Hippocrates

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In ancient Greece many men shared the name 'Hippocrates' — a common Greek name like ‘Edward’ or ‘Lawrence’ in English — and many of them distinguished themselves in Greek history in one way or other. But one man, Hippocrates of Cos (ca. 460 – 370 bce), earned such respect and honor for the revolution he initiated in the principles and practice of medicine that his ideas flourished throughout Western history to the present day. His revolutionary ideas so changed the course of the development of medicine in Western civilization that the health and welfare of all humanity has benefited.

Hippocrates. Engraving by Peter Paul Rubens, (S.L., 1638).

Prologue

Hippocrates of Cos revolutionized the practice of medicine by transforming it from its mythical, superstitious, magical and supernatural roots to a new set of roots based on logical reasoning applied to methodical observation — the roots of scientific objectivity — roots that have nourished an ever-growing evolutionary tree of Western scientific medicine still flourishing. For that reason History has honored Hippocrates of Cos as "The Father of Medicine", medicine’s progenitor. We might bestow on him the more precise cognomen, "The Progenitor of Western Rational Medicine". Historian Charles Singer goes a step further:

We must remember that all the biological sciences were first studied because of their bearing on medicine. Hippocrates, therefore, might well be called also 'the father of biology'.

Because historians know only a little of the details of the life of Hippocrates, and because of the great influence the works associated with his name have had on medicine for millennia, his fame has led to a plethora of writings about him that have the character of legend:

We still know very little about Hippocrates. And yet, like the physicians of Imperial Rome, the doctors of our days want to know all about the life of the "Father of Medicine." Where there are no historical sources available, imagination will step in, and the poet will replace the historian.

The details — even basic facts — of Hippocrates' life remain contentious among modern classics scholars. An unfortunate dearth of contemporary 5th and 4th century bce historical information makes many questions about about the historical Hippocrates particularly knotty, and vexes the question of the relationship between the writings that have come down in Hippocrates' name, the Hippocratic corpus, and those works among the corpus that Hippocrates himself, rather than his followers, may have written.

The legends about Hippocrates, whether completely imagined or evolved elaborations of reality, by their hero-generative nature, attest to the esteem bestowed on Hippocrates for nearly two and one-half millennia.

In the modern age of Western medicine — beginning perhaps with the corrective emendations of the dogma of Hippocrates’ self-proclaimed scientific heir, Galen, by the anatomists and physiologists, Andreas Vesalius and William Harvey, in the 1500s and 1600s ce, respectively — the writings of the Hippocratic physicians no longer serve as 'chapter and verse' for the practice of medicine. Yet, as articulated by Professor Sir Geoffrey Ernest Richard Lloyd, former Professor of Ancient Philosophy and Science in the University of Cambridge, ....Hippocrates still represents an ethical ideal, the ideal of the compassionate, discreet and selfless doctor…. Accordingly, graduating medical students in many Western medical schools continue to swear some form of the Hippocratic Oath that represents the ethical ideals articulated by Professor Lloyd.

Sources for the life of Hippocrates

Excerpt from Plato's Protagoras  The Project Gutenberg Etext of Protagoras, by Plato. Socrates, in speaking to a man by chance named Hippocrates wonders why the man exhibits excitement over the impending visit of a famous Sophist, Protagoras. In the dialogue, he reveals the existence of the physician, Hippocrates of Cos, the Asclepiad, implying that the latter’s fame as a physician and teacher had reached Athens during his lifetime: “Tell me, Hippocrates, I said, as you are going to Protagoras, and will be paying your money to him, what is he to whom you are going? and what will he make of you? If, for example, you had thought of going to Hippocrates of Cos, the Asclepiad, and were about to give him your money, and someone had said to you: You are paying money to your namesake Hippocrates, O Hippocrates; tell me, what is he that you give him money? how would you have answered?” “I should say, he replied, that I gave money to him as a physician.” “And what will he make of you?” “A physician, he said.

Though Hippocrates looms large in the imagination and in historical tradition, unambiguous evidence for a satisfactorily full account of his life remains elusive. The evidence closest in time to Hippocrates' life comes to us from the writings of the philosopher Plato (429-347 bce), a contemporary of Hippocrates. Plato has Socrates mentioning Hippocrates in his works, Protagoras and Phaedrus. These passages help us to locate Hippocrates in the context of Greek culture in the 5th century bce. The latter reference (which has inspired a large body of scholarship) comments on Hippocrates' methodology. Together, Plato's works give us reliable evidence of the existence of Hippocrates as a physician and teacher, as a citizen of Cos, of the Asclepiad family, who had achieved fame beyond his homeland during his lifetime.

Excerpt from Plato's Phaedrus  The Project Gutenberg Etext of Phaedrus, by Plato. Socrates, in dialogue with Phaedrus, confirms the existence of Hippocrates the Asclepiad, indicating Hippocrates’ holistic approach to medicine, and implying that Hippocrates’ thought relating to medicine influenced philosophical thinking about such things as the nature of the soul: SOCRATES: And do you think that you can know the nature of the soul intelligently without knowing the nature of the whole? PHAEDRUS: Hippocrates the Asclepiad says that the nature even of the body can only be understood as a whole. SOCRATES: Yes, friend, and he was right:--still, we ought not to be content with the name of Hippocrates, but to examine and see whether his argument agrees with his conception of nature. PHAEDRUS: I agree.

A passage in the Politics of Aristotle, a near contemporary of Hippocrates, also attests to Hippocrates' existence in a way that suggests his fame as a scientist physician.

Hippocrates' life and work are discussed in the writings of Aulus Cornelius Celsus (d. ca. 50 ce). An anonymous, mystifying papyrus tries to differentiate the real teachings of Hippocrates from those merely attributed to him.

Furthermore, it was recognized in antiquity that the Hippocratean corpus, the collection of writings attributed to Hippocrates, could not be the writings of one man. Later commentators, including the influential Galen, attempted to separate the genuine Hippocratean teachings from the spurious and included biographical detail when they did so.

One Life of Hippocrates, a short work attributed to Soranus of Ephesus (a 2nd century ce physician), provides many details concerning Hippocrates' life. French Classics Professor, Jacques Jouanna, who has written a major work on Hippocrates and the Hippocratic Era, refers to it as "the canonical source", as it appears introductory to the earliest compiled editions of the Hippocratic corpus. Jouanna asserts that it "draws upon more ancient sources, the most outstanding of which is the director of the library of Alexandria during the Hellenistic era, Eratosthenes of Cyrene.

Given the lack of unambiguous contemporary evidence, many modern scholars have concluded that the real, historical Hippocrates is unknowable. In recent years, the research of Jacques Jouanna has re-opened the debate on the life of Hippocrates, and on many points of Hippocratean scholarship.

Hippocrates’ life on the island of Cos

Ionia (in Asia Minor) and the island of Cos, Hippocrates' birthplace.

Hippocrates entered the world into an aristocratic family on the Ionian island of Cos (or Kos), located in the Aegean Sea off the southwest coast of then called Ionia (Asia Minor, present day Turkey).

Hippocrates' father, Heraclides, and his father's father, also called Hippocrates, practiced medicine employing ancient ideas of supernatural causation and treatment of disease according to the tradition linked to Asclepius, considered a deity.  In fact, Heraclides traced his ancestry through the male line back to Asclepius in the era of the Trojan war, when Asclepius, a physician, had not yet received divine status. Heraclides descended through the male from Asclepius’s son, Podalirius, who fought in the Trojan war, moved to Asia Minor, and whose descendants eventually settled on Cos. The tradition of Asclepian medicine passed from son to son down the generations, eventually reaching Heraclides. The family from Podalirius onward called themselves Asclepiads, their family name. Hippocrates belonged to the Coan branch of the family, settling on Cos; a second branch, splitting off from from Podalirius, settled on the nearby peninsula of Cnidus, referred to as the Cnidian branch, also continued to practice medicine.

At the time of Hippocrates’ birth, Cos paid tribute to Athens as a member of the Athenian federation created to defend against Persian aggression.

Hippocrates, though known also as 'Hippocrates of Cos, the Asclepiad', and though reared in the family tradition of Asclepian medicine, rejected the supernatural ethos, substituting a naturalistic ethos, thereby sparking a revolution of principles and practice in medicine that present day non-supernatural Western scientific medicine acknowledges as its parentage and heritage. Scholars have found no evidence of Hippocrates ever practicing as a physician priest of Asclepius.

Hippocrates’ education within the family probably included, in addition to medicine, philosophy and rhetoric and other subjects that gave him knowledge of the world of reality. He remained on Cos well into maturity, married and had two sons and a daughter. His new practice of medicine according to the tenets of observation and reason gained him fame in and beyond Cos. One plausible story has him rejecting an invitation to court of the current king of Persia.

The emergence of Hippocratic medicine

The Greeks invented rational medicine. —James Longrigg

Hippocratic medicine reflected the emerging philosophy that things and events in the world resulted from natural causes, a philosophy that began with the Ionian philosopher, Thales of Miletus (c. 625-546), whose speculation about the natural world philosophers regard as an important turning point in Western scientific thought. Classicist and historian of medicine, James Longrigg elaborates that point in the accompanying sidebox to the right.

The Hippocratic treatise, On Ancient Medicine, asserts that the practice of medicine does not derive from a priori first principles, as does the practice of some branches of philosophy, but from the findings in individual cases.

Medicine does not qualify as philosophy, but as an observational science challenged by specific diseases arising from specific natural causes, the challenges met only by detailed observation leading to cumulative knowledge undergirded by rational reasoning.

Our earliest evidence of Greek medicine reveals, then, that, as in ancient Egypt and Mesopotamia, the causation of disease and the operation of the remedies applied to the sick were so linked with superstitious beliefs in magic and supernatural causation that a rational understanding of disease, its effect upon the body, or of the operation of remedies applied to it was impossible. The sixty-odd works of the Hippocratic Corpus, however, provide a striking contrast and are virtually free from magic and supernatural intervention.[citation] Here, in this collection, for the first time in the history of medicine complete treatises have survived which display an entirely rational outlook towards disease, whose causes and symptoms are now accounted for in purely natural terms. The importance of this revolutionary innovation for the subsequent development of medicine can hardly be overstressed. This emancipation of (some) medicine from magic and superstition, was the outcome of precisely the same attitude of mind which the Milesian natural philosophers were the first to apply to the world about them. For it was their attempts to explain the world in terms of its visible constituents without recourse to supernatural intervention which ultimately paved the way for the transition to rational explanation in medicine, too. —James Longrigg

"Whoever having undertaken to speak or write on Medicine, have first laid down for themselves some hypothesis to their argument, such as hot, or cold, or moist, or dry, or whatever else they choose (thus reducing their subject within a narrow compass, and supposing only one or two original causes of diseases or of death among mankind), are all clearly mistaken in much that they say…. Wherefore I have not thought that it stood in need of an empty hypothesis, like those subjects which are occult and dubious, in attempting to handle which it is necessary to use some hypothesis; ; as, for example, with regard to things above us and things below the earth; if any one should treat of these and undertake to declare how they are constituted, the reader or hearer could not find out, whether what is delivered be true or false; for there is nothing which can be referred to in order to discover the truth." —Hippocrates, Ancient Medicine

In my view, there is no beginning in the body; but everything is alike beginning and end. For when a circle has been drawn, its beginning is not to be found. And the beginning of ailments comes from the entire body alike. . . . Each part of the body at once transmits illness one to the other, whenever it arises in one place or another; belly to head, head to flesh and to belly, and all other parts thus analogously, just as belly to head and head to flesh and to belly. For when the belly fails to make proper evacuation, and food goes into it, it floods the body with moisture from the ingested foodstuffs. . . . .This moisture, blocked from the belly, travels en masse to the head. When it reaches the head, not being contained by the vessels in the head, it flows at random, either around the head or into the brain through the fine bone. Some penetrates the bone and some the region of the brain through the fine bone. And if it returns to the belly, it causes illness in the belly; and if it happens to go anywhere else, it causes illness elsewhere; and in other cases similarly, just as in this case, one part causes illness in another. . .. The body is homogeneous (lit. the same as itself) and is composed of the same things, though not in uniform disposition, in its small parts and its large; in parts above and parts below. And if you like to take the smallest part of the body and injure it, the whole body will feel the injury, whatever sort it may be, for this reason, that the smallest part of the body has all the things that the biggest part has. —Hippocrates, Places in Man;

Hippocrates’ life overlapped that of the great Greek natural philosophers Empedocles (ca. 495-435 bce), Socrates (469–399 bce), Plato (429-347 bce) and Aristotle (384-322 bce). Thus he lived during the Golden Age of Greece (c. 500  – 300 bce). Disease, so central a continuing problem in human lives, not surprisingly would come under scientific scrutiny in the environment of such thinkers. Historians know that Hippocrates observed keenly ("infinite in faculty"), reasoned rationally ("noble in reason"), and taught and practiced a holistic ideal of medicine ("what a piece of work is Man") that regarded health and disease as manifestations of body and mind as a whole — though centuries later Margagni would offer a qualification. An excerpt from one of the Hippocratic Treatises, Places in Man, aptly illustrates the Hippocratic holistic view. See sidebox at lower right.

"Why do modern day researchers keep going back to Hippocrates?....although ancient, some notions expressed in the Hippocratic works are still applicable today. What is more important though, is a reason easily recognized to anyone familiar with Hippocratic descriptions of infection: the clarity of presentation of the clinical course and the astute inclusion of infection in a broader environmental and social context are still unparalleled by modern thinking." —Georgios Pappasa, Ismene J. Kiriazea, and Matthew E. Falagas

Hippocrates founded a school of medicine known by his name, and advocated a basic approach to the diagnosis and treatment of disease that still has applications in modern medicine. [For example, see Pappas et al., Chang et al., and Ghaemi]

History gave his name to an oath of medical ethics called the Hippocratic Oath. "The code of conduct for doctors outlined in the Hippocratic Oath, a vow commonly taken by modern doctors", remains an ethical guideline in medicine. One can begin to appreciate the influence of Hippocrates to the present day by his presence in the World Wide Web since the year 2000, where the scientific search engine, SCIRUS, reveals 74,523 entries, and Google search reveals ~172,000 entries for the twelve months preceding April 2008.

(PD) Image: Ed Snible
Ancient Greek World

Early Greek medicine operated as a supernatural, magical art. The god of healing, Asclepius (Aesculapius in Roman terminology), whose priests and temples flourished in ancient Greece at least from the Homeric era, appeared in the dreams of the sick who came to the temple for 'sleep therapy'. Asclepius gave advice to the dreamer, which the priests interpreted. The priests prescribed baths, diets, exercises, changes in occupation or living locales, and other routines, and those prescriptions received credit when cures occurred. The cult of ‘therapeutic dreaming’ persisted in various places even into Christian times.

Hippocratic medicine developed as the "naturalistic counterpart" of the Asclepian supernaturalistic tradition. By the 6th century bce (the 500s bce) Greek philosophers emerged and began to theorize about the natural causes of the way the world worked. Empedocles (ca. 495-435 bce), characterized as a physician and philosopher, postulated earth, air, fire and water as the primordial elements of which everything in the world consisted, in differing combinations and kinds of combinations, including the human body. 

"The development of Hippocratic medicine, its [Aesculapian medicine’s] naturalistic counterpart, is considered a turning point in the history of the healing arts although, as we have seen, at about the same time, naturalistic medical paradigms were developing in other ancient civilizations as well. The importance of Hippocratic medicine rests on the fact that it is the first comprehensive naturalistic medical system of the Western world and therefore the source from which scientific medicine would eventually originate." —Plinio Prioreschi

Indeed, the development of Hippocratic medicine may have influenced changes in the persisting Asclepian practice.

For its objectives of seeking classification, causes and remedies of disease, medicine requires reason, but not only reason. Considering that knowledge emerges from information processed by reason, not only does the quality of reason count, but also does the quality of the information fed into reason count. Reason will yield a formally valid conclusion, but if fed flawed information, it will not yield a reliable conclusion. For the latter, reason requires information ultimately based on empirically sound observation. If based on wishful thinking, imagination, unquestioned assumptions, believed revelations by deities, guesswork and the like, reason yields at best dubious knowledge and at worst false knowledge. Hippocrates appears to have understood that, and as a physician considered to epitomize the art of medicine, as Socrates did, he inspired many likeminded and knowledge-seeking followers.

In her blog, “Well: Tara Parker-Pope on Health”, Parker asks, What Would Hippocrates Do?, and in the process of reviewing physician Daniel H. Newman’s book, Hippocrates’ Shadow: Secrets from the House of Medicine, gives us an excerpt from Newman’s book that elaborates revealingly on the methods of the Hippocratic physicians:

By today’s standards, Hippocrates was a profoundly abnormal physician. Medicine’s founding father routinely tasted his patients’ urine, sampled their pus and earwax, and smelled and scrutinized their stool. He assessed the stickiness of their sweat and examined their blood, their phlegm, their tears, and their vomit. He became closely ac¬quainted with their general disposition, family, and home, and he studied their facial expressions….In deciding upon a final diagnosis and treatment, Hippocrates recorded and considered dietary habits, the season, the local prevailing winds, the water supply at the patient’s residence, and the direction the home faced. He absorbed everything, examining exhaustively and documenting meticulously. </ref>

Likely inspired by Empedocles’ concept of four elements making up natural things, the concept of four humours (blood, yellow bile, black bile, phlegm) as constituent elements of the human body emerged as part of the Hippocratic tradition, the individual humours in various combinations determining state of health and personality:

• excess blood makes a person ‘sanguine’, full of energy, optimistic, ruddy complected
  
• excess yellow bile makes a person ‘bilious’, ‘choleric’, bad tempered, quick to anger, irritable
  
• excess black bile makes a person ‘melancholic’, deeply and long-lastingly sad
  
• excess phlegm makes a person ‘phlegmatic’, unemotional, temperamentally slow, calm
  

Historians have not identified an individual who originated the four humours theory, nor have they excluded the possibility that the theory emerged into a formal theory only gradually.

The medical corollary of Empedocles' theory is the identification of the traditional humours with constituent elements: what made this possible was the presence, in the traditional view of humours, of positive characteristics. Because of these characteristics it was easy to conceive the humours as the ingredients of man, upon which his normal or healthy state, as well as his very existence, depended….It is not the recognition of this or that humour as existing which counts, but the theoretical use to which that humour is put. One would therefore also have to find evidence….that the humours were regarded as constituent parts of the human body. There seems no a priori reason why this should not have been the case, in any writer working after say 450. But in the absence of such evidence, the question of the precise originator of the four-humoral theory is formally insoluble….What is perhaps of more interest is the way in which the theory of four humours exemplifies the stimulating effects of Greek philosophy on Greek medical science. It may be described in this way: the philosopher provides the categories within which the medical scientist can order his experience. (Page 61.)

The Hippocratic physician: scientist or craftsman?

H.J.F. Horstmanshoff argues that the Hippocratic physicians qualify as craftsmen, and not as scientists:

Ancient physicians did not receive scholarly, scientific training. The intellectual attitudes and social status which we are inclined to attribute to them are anachronisms nourished by the Hippocratic tradition from Galen to Littré. Physicians who had scholarly ambitions steered toward philosophy and rhetoric rather than to empirical disciplines. As a consequence of the prevailing social and economic outlook, the image of the rhetor [teacher of rhetoric, or orator] and of the philosopher were considered to be far better than that of the engineer or of the artisan, or that of those devoted to applied knowledge in general. Ancient physicians were above all craftsmen. Nevertheless the more ambitious among them cloaked over the manual aspects of their art and explained away the remuneration for their services with the help of rhetoric [persuasive public speaking].

....

The Hippocratic physicians and women patients

In his study of the Hippocratic treatises, ancient Greek theatrical productions, the works of Plato, and the comments of Herodotus, Jacques Jouanna discusses the practice of the Hippocratic physicians in respect of women. He makes the following points:

• Hippocratic physicians treated women as well as men.
• Commonly the physician treated women who had genital tract disorders.
• Although the Hippocratic physicians did not dismiss the importance of the gynecological disorders, that did not automatically remove the barrier of women’s modesty and their eagerness to request a physicians‘s help.
• Hippocratic physicians did not approve of the women’s reluctance to call on them, as that could have serious consequences for the women.
• Nevertheless, physicians could not always be counted on to have the requisite knowledge and experience of conditions specific to women.
• Women could not call upon women physicians, because in Hippocrates’s era no woman could assert herself a physician.
• Women preferred to seek the help of other women for disorders specific to women — especially women who had similar disorders or who attended those with similar disorders.
• Certain women could serve as midwives, — Socrates’ mother, for example.
• Though not physicians, midwives were referred to as ’healers’ and ‘she who treats’, and were considered professionals.
• Hippocratic physicians sometimes worked directly with midwives, and sometimes instructed them how to proceed, as in a difficult childbirth.
• In general, the Hippocratic physicians tasked themselves to maintain complete respect for a woman’s modesty and dignity.

The Hippocratic physicians as novices in preventive medicine

As Jouanna notes, none of the treatises of the Hippocratic collection of writings devotes itself exclusively to preventive medicine, suggesting lesser development of preventive than curative medicine among the Hippocratic physicians.

Yet the Hippocratic physicians recognized that certain practices tended to preserve health, and wrote about them within the treatise collection. Jouanna notes that the Hippocratics prescribed evacuations (vomiting, bowel evacuations) as preventive: "According to the author of Nature of Man, good hygiene required that vomiting be induced in winter and bowel evacuations in summer." The author explained the reason for the preventive regimen based on the effects of seasonality on the balance of humors in the body.

The Nature of Man writes of other preventive measures based on diet, exercise and baths, and cautions to design preventive regimens in keeping with seasons and many other factors. A more elaborate description of such a regimen also appears in the treatise Regimen. The author of Regimen also stressed looking in healthy people for signs, not so much of a disease, but of indicators that the true symptoms of disease will soon appear. We do that today using blood tests like those of lipid types and concentrations as harbingers of heart disease and stroke.

To protect oneself from the 'miasmas' believed the cause of plagues, the rationalist Hippocratics advised reducing one's respiratory cavity, through weight loss, and getting out of town.

Preventive medicine has advanced along with the advances in curative medicine, perhaps not as rapidly or successfully. Interested readers might consult some of the journals devoted to the subject and visit the website of the American College of Preventive Medicine:

• Preventive Medicine
• American Journal of Preventive Medicine
• The Journal of Primary Prevention
• American Society of Preventive Medicine

Social and economic roles of the Hippocratic physicians

The Hippocratic Corpus records a wealth of information about classical Greek medicine, yet records little details about the lives of the Hippocratic physicians. In part to remedy that gap, or compensate in a way for it, classical scholar, Hui-hua Chang studied the Greek cities in the northern regions of the Aegean where the Hippocratic physicians spent time, as recorded in the Hippocratic treatise, Epidemics.  The express purpose of the study, according to Professor Chang, “…is to determine how such places may help us define the social and economic roles of Greek physicians in the Classical period.”

Professor Chang's analysis reveals that the Hippocratic physicians were not mere aimless itinerants, as sometimes implied by writers. Rather, more objectively, Chang characterizes them as physicians visiting targeted towns and villages to seek employment and financial support as opportunity presented. They found more job opportunities in the larger urban centers where division of labor accompanied by specialization of occupation had evolved. Moreover, such centers housed wealthy individuals and families who could support the renown Hippocratic physicians of burgeoning repute.

The Athenian Empire at its height about a decade before Hippocrates' birth. Public domain. Courtesy of the University of Texas Libraries, The University of Texas at Austin, http://www.lib.utexas.edu/maps, and the Perry-Castañeda Library Historical Atlas by William R. Shepherd, http://www.lib.utexas.edu/maps/historical/shepherd_1911/shepherd-c-013.jpg . Modified slightly from original, for ease of study.

Professor Chang provides detailed descriptions of the cities visited by the Hippocratic physicians, their location on trade routes, their chiefs sources of trade, their resources for their daily lives — revealing most of them as wealthy commercial centers or the major cities in the region. He describes:

• Cyzicus on the southern coast of Propontis (now the Sea of Marmara) — visible upper right on the accompanying map south of Thrace and North of Asia Minor (Anatolia) — acquiring its wealth from its location on the trade route between the Black Sea to the northeast and the Aegean Sea to the west, its exports of wine, fish and marble, and it supply of wheat to the Aegean from Russia.
• Perinthis on the northern coast of Propontis, also depicted on the map, a trade city with abundant territory to produce corn, cattle and timber.
• Abdera and Ainos, on the Thracian coast near the island of Thrasos in the north Thracian Sea. Ainos acquired its wealth from its location at the mouth of the major river in the northern Aegean, supplying the Aegean with the products fertile Thracian fields in return for Greek merchandise. Abdera — home of the geometer and atomist, Democritus, whom legend has it Hippocrates visited because of accusations of mental dysfunction and declared Democritus the sanest man in town — became “the emporium of the silver trade”.
• Thrasos, the island and its Thracian mainland colonies, wealthy from gold and silver mining and producing wine considered the finest in Greece. The Hippocratic physicians spent much time there.
• Olynthus, the largest city on the peninsula of Chalcidice, visible on the map in the southern part of Macedonia, destroyed after Hippocrates’ death because Phillip II considered it a threat to his rule of Macedonia. The Hippocratic physicians practiced their art there prior to its destruction, when its large population displayed their wealth and power.
• Larissa, in Thessaly, south of Macedonia and left of center on the map, shows up in Epidemics with many descriptions of medical cases. It had much fertile land and control of the mountain passes to Macedonia.

Possibly the Hippocratic favored those cities both because their wealth and the undoubted wealth of patients in cities with dense populations of people living luxuriously. Large populations also usually meant labor division and thus opportunities for physicians to concentrate on practicing medicine. Professor Chang closes thus:

It was in such places as those described above, where wealth was concentrated and people with open minds resided, that they [the Hippocratic physicians] would find clients and patrons who were ready to accept untraditional [non-supernatural] ideas and who would support the art of the Hippocratic doctors.

Coan vs. Cnidian schools of medicine

Many historians of medicine contrast schools of medicine of the Coan branch of Podilarius's family, to which Hippocrates of Cos belonged, and the Cnidian branch that settled nearby Cos, on a peninsula off Asia Minor. By 'schools of medicine' they refer to different philosophies and practices of the earliest rationalist Western medicine. Other historians have regarded the two schools "....self-inflating and self-generating myths...." in part the result of misrepresentations by Galen and in part the result of misinterpretations of Galen by historians.

Yale medical historian and clinical professor of surgery, Sherwin B. Nuland, attributed distinguishing features to the two schools. ....

The Hippocratic treatises

Emile Littré's translations of the writings of the Hippocratic physicians

Writings attributed to Hippocrates, about sixty volumes in number, written in the Ionian dialect of Greek, have survived to the present, with accompanying translations in French, residing in a 19th century ten-volume work by the French scholar, Émile Littré, completed in 1862.  Littré ((Maximilien-)Paul-Émile Littré) received education in medicine (but received no degree), and in numerous languages, including Greek, Latin, German, English and Sanskrit. He gained repute for his lexicographic work, a scholarly dictionary of the French language, considered “….one of the outstanding lexicographic accomplishments of all time.”  Jouanna states that ".... Despite the progress made by Hippocratic philology over the last one hundred years, the Littré edition [of the Hippocratic writings] has not yet been entirely superseded. "

One can read Littré’s French translations of the Hippocratic writings at the website of the Bibliotheque interuniversitaire de medecine (Paris). The links to each of the 10 volumes are given here:

Listing of Hippocratic treatises

This listing as in Jouanna's Appendix 3.  Jouanna states: "The principal editions given here are based on the Greek-French edition of Émile Littré (10 vols., 1839-1861).

The Editors have inserted brief excerpts from some of the treatises, to give the reader some flavor of the works.

• Address from the Altar (=Epibomios)
  
• Affections
  
• Airs, Waters, Places
  

Especially one treatise among the Hippocratic writings has attracted attention as a celebrated example of geographical or meteorological medicine (Nutton 2005, 75). An unknown Greek physician wrote in the second half of the fifth century BC (Jouanna 1999, 375) the famous treatise called Airs, Waters, Places, which starts by describing what circumstances an itinerant physician must consider when he comes to an unfamiliar town. The treatise contains several passages about the health effects of water, and the ancient Greek author deals with the different sources, qualities and health effects of water in length. Translations of ancient texts are from the Loeb Classical Library editions, as listed in the references.

"He (the itinerant doctor) must also consider the properties of waters; for as these differ in taste and in weight, so the property of each is far different from that of any other. […] He must consider with the greatest care both these things and how the natives are off for water, whether they use marshy, soft waters, or such as are hard and come from rocky heights, or brackish and harsh. [...]" (Airs, Waters, Places. 1) "I wish now to treat of waters, those that bring disease or very good health, and of the ill or good that is likely to arise from water. For the influence of water upon health is very great. Such as are marshy, standing and stagnant must in summer be hot, thick and stinking, because there is no outflow; and as fresh rain-water is always flowing in and the sun heats them, they must be of bad colour, unhealthy, bilious. In winter they must be frosty, cold and turbid through the snow and frosts, so as to be very conducive to phlegm and sore throats. Those who drink it have always large, stiff spleens, and hard, thin, hot stomachs, while their shoulders, collar-bones and faces are emaciated; […] This malady is endemic both in summer and in winter. In addition the dropsies that occur are very numerous and very fatal. For in the summer there are epidemics of dysentery, diarrhoea and long quartan fever, which disease when prolonged cause constitutions such as I have described to develop dropsies that result in death. These are their maladies in summer. […] Such waters I hold to be absolutely bad. The next worst will be those whose springs are from rocks – for they must be hard – or from earth where there are hot waters, or iron to be found, or copper, or silver, or gold, or sulphur, or alum, or bitumen, or soda. For all these result from the violence of heat. So from such earth good waters cannot come, but hard, heating waters, difficult to pass and causing constipation. The best are those that flow from high places and earthy hills. […] They would naturally be so coming from very deep springs. […] Spring waters should be used thus. A man in health and strength can drink any water that is at hand without distinction, […]" (Airs, Waters, Places. 7) "Rain waters are the lightest, sweetest, finest and clearest. […] Such waters are naturally the best. But they need to be boiled and purified from foulness […] Waters from snow and ice are all bad. […] I am of opinion that such waters derived from snow or ice, and waters similar to these, are the worst for all purpose." (Airs, Waters, Places. 8) "Stone, kidney disease, strangury and sciatica are very apt to attack people, and ruptures occur, when they drink water of very many different kinds, or from large rivers, into which other rivers flow, or from a lake fed by many streams of various sorts, and whenever they use foreign waters coming from a great, not a short, distance. […] Such waters then must leave a sediment of mud and sand in the vessels, and drinking them causes the diseases mentioned before. […]" (Airs, Waters, Places. 9)

Ideas expressed in the Airs, Waters, Places had a definite influence during antiquity and later. The philosopher Plato (428/427–348/347 BC) most probably knew the legendary Hippocrates and was familiar with Hippocratic medicine and the ideas of environmental influences on health. He advised a lawmaker who was about to found a city to take into account several factors, among them water: “Some sites are suitable or unsuitable because of varying winds or periods of heat, others because of the quality of the water.” (Plato Laws. 5.747d) The ideas on climate, place and water expressed in Airs, Waters, Places are seen in the manual of architecture De Architectura by Vitruvius in the late first century BC. ”[…] he must know the art of medicine in its relation to the regions of the earth (which the Greeks call climata); and to the characters of the atmosphere, of localities (wholesome or pestilential), of water-supply. For apart from these considerations, no dwelling can be regarded as healthy.” (Vitruvius De Architectura. I.i.10.) Columella (1st century AD) and Palladius (5th century AD), who both wrote about agriculture and Roman officer and administrator Pliny the Elder (23/24–79 AD), who dedicated his encyclopaedic Natural History to the emperor Titus in 77, were also clearly influenced by the same ideas. The most famous physician in antiquity (second after the mythic Hippocrates), Galen, (129–199/200/216 AD) wrote a commentary on Airs, Waters, Places, and it was among the few Hippocratic treatises to be translated into Latin in late antiquity (Jouanna 1999, 356, 361, 375, 478).

• Anatomy
  
• Ancient Medicine
  
• Aphorisms
  
• The Art
  
• Breaths
  
• Coan Prenotions
  
• Crisis
  
• Critical Days
  
• Decorum
  
• Decree of the Athenians
  
• Dentition
  
• Diseases I
  
• Diseases II
  
• Diseases III
  
• Diseases IV
  
• Diseases of Girls
  
• Diseases of Women I-II/Sterile Women
  
• Eight Months' Child (contains Seven Months' Child)
  
• Epidemics I and III
  
• Epidemikcs II, IV, and VI
  
• Epidemics V and VII
  
• Excision of the Foetus
  
• Fistulas
  
• Fleshes
  
• Generation/Nature of the Child
  
• Glands
  
• Haemorrhoids''
  
• The Heart
  
• Humours
  
• Internal Affections
  
• In the Surgery
  
• Law
  

"For a man to be truly suited to the practice of medicine, he must be possessed of a natural disposition for it, the necessary instruction, favourable circumstances, education, industry and time. The first requisite is a natural disposition, for a reluctant student renders every effort vain. But instruction in the science is easy when the student follows a natural bent, so long as care is taken from childhood to keep him in circumstances favourable to learning and his early education has been suitable. Prolonged industry on the part of the student is necessary if instruction, firmly planted in his mind, is to bring forth good and luxuriant fruit."

• Letters
  
• Mochilicon (=Instuments of Reduction)
  
• Nature of Bones
  
• Nature of Man
  
• Nature of Women
  
• Nutriment
  
• The Oath
  
• On Fractures/On Joints
  
• On Wounds in the Head
  
• Physician
  
• Places in Man
  

"The treatise has everything: 'factual' information, scientific reasoning, clinical practice, ideological statements. It represents in miniature the entire HC. Despite its wide and varied scope, the work is consistent both in content (doctrinal views, therapeutic strategy, didactic tenor) and expression (syntax and style). The content may be summarized as follows: Introduction; Anatomy: senses of hearing, smell, sight; vessels; cords; bones and joints; digestion; Physiology: theoretical aetiology of fluxes; seven fluxes in practice; Pathology and nosology: causes and treatment of various diseases; Precepts: practical and surgical guidance; Ideology: views on medicine and medical education; Gynaecology."

• Precepts
  

"This piece of advice is of importance. Do not begin by worrying the patient about your fee. If you do, you will arouse in the patient a suspicion that unless he agrees to your terms you will go away and leave him to his fate. So do not concentrate your attention on fixing what your fee is to be. A worry of this nature is likely to harm the patient, particularly if the disease be an acute one. Hold fast to reputation rather than profit. It is better to reproach patients you have saved than to distress men who are at death's door."-Chapter IV.

• Prognostic
  
• Prorrhetic I
  
• Prorrhetic II
  
• Regimen
  
• Regimen in Acute Diseases
  
• Regimen in Acute Diseases (Appendix)
  
• Remedies
  
• The Sacred Disease (See: Epilepsy)
  
• Sevens
  
• Sight
  
• Speech of the Envoy (=Presbeutikos)
  
• Superfoetation
  
• Testament of Hippocrates (=Qualem Oportet Esse Discipulum)
  
• Ulcers
  
• Use of Liquids
  
• Other Apocryphal Treatises
  

....

Aphorisms

The first aphorism

"....the First Aphorism is medicine’s whole law; the rest is commentary."        —Sherwin B. Nuland, The Uncertain Art

Of the more than 400 aphorisms attributed to Hippocrates, the first has received the most attention. In the Francis Adams translation, it reads:

Life is short, and the Art long; the occasion fleeting; experience fallacious; and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals cooperate.

Another 19th century translation:

Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.

The same aphorism as translated in the Hippocratic Writings edited by G. E. R. Lloyd reads:

Life is short, science is long; opportunity is elusive, experiment is dangerous, judgement is difficult. It is not enough for the physician to do what is necessary, but the patient and the attendants must do their part as well, and circumstances must be favourable.

In the Adams translation, the "Art", always with an capital 'A', refers to medicine — the art of medicine. In the Lloyd text, the 'Art of medicine' becomes 'science'. In either case, the first clause of the first aphorism seems to say that the lifespan of a physician does not suffice for learning the Art of medicine, all of its science. The implication would seem to exhort awareness to physicians that they cannot expect learn all of medicine in a lifetime, an exhortation to humility and avoidance of overconfidence. Can any physician even two and a half millennia later deny the aphorism, especially in respect of the enormous amount and intricate complexity of the knowledge base of medicine in the early 21^st century. Perhaps the complete Art of medicine will always overwhelm any one physician's lifetime of learning and practice.

Sherwin Nuland puts it this way:

Although life expectancy is currently well more than twice what it was during the golden age of Greece, it will never be endowed with years enough for anyone to master the vast expanse of medical knowledge, or even that part of it sufficient for an individual doctor to care for all of his patients.

The aphorism continues with the occasion fleeting, alternatively opportunity is elusive, generally interpreted as indicating the need for timely diagnosis to achieve the best results of treatment — a narrow window of opportunity.

[E]xperience fallacious, or experiment [in the sense of experience] is dangerous, seems to warn of misinterpreting the patient's symptoms and signs by relying on experience that might apply generally but not to the specific patient at hand owing to that patient's particular circumstances, internal or external, physiological or psychological. Sherwin Nuland applies that to the non-personal 'experience' that statistics offers, unless it takes into consideration individual variability and the factors that go into generating it.

[J]udgment is difficult seems to follow given that life is short and the art long, and that experience of other cases cannot always be counted as reliable when applied to an individual patient at hand.

21st century scholarly interest in and diversity of views of Hippocrates

Some Abstracts paragraphed or otherwise reformatted for ease of reading

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• Astyrakaki E, Papaioannou A, Askitopoulou H.

The Hippocratic Collection, containing 60 medical texts by Hippocrates and his pupils, was searched using the electronic database Thesaurus Lingua Graeca to identify the words "anaesthesia" and "analgesia," their derivatives and also words related to pain. Our purpose was to investigate the special use and meaning of these words and their significance in medical terms. The word "anaesthesia" appears 12 times in five Hippocratic texts to describe loss of sensation by a disease process. This observation reveals Hippocrates as the first Greek writer to use the word in a medical rather than a philosophical context. Hippocrates was also the first Greek physician to keep an airway open by bypassing a pharyngeal obstruction with the insertion of narrow tubes into the swollen throat of a patient with quinsy, thus facilitating the airflow into the lungs. In the Hippocratic texts, "analgesia" is related to "anaesthesia" for the first time, when it is pointed out that an unconscious patient is insensitive to pain. Hippocrates and his followers rationalized pain as a clinical variable and as a valuable diagnostic and prognostic tool. They used expressive and precise adjectives and well-defined characteristics of pain, such as location, duration, or relation to other symptoms, to elucidate a disease process. They also had a wide terminology for the various types of pain, still in use today. Many cures were described for the treatment of pain, including incisions, effusions, venesection, purges, cauterization and, most interestingly, the use of many plants, such as opium or the application of soporific substances. In particular, Hippocrates refers to opium poppy as "sleep inducing."

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• Grammaticos PC, Diamantis A. (2008) [From Emeritus professors, Thessaloniki, Macedonia, Greece] 

“Hippocrates is considered to be the father of modern medicine because in his books, which are more than 70. He described in a scientific manner, many diseases and their treatment after detailed observation. He lived about 2400 years ago. He was born in the island of Kos and died at the outskirts of Larissa at the age of 104. Hippocrates taught and wrote under the shade of a big plane tree, its descendant now is believed to be 500 years old, the oldest tree in Europe-platanus orientalis Hippocraticus- with a diameter of 15 meters. Hippocrates saved Athens from a plague epidemic and for that was highly honored by the Athenians. He considered Democritus-the father of the atomic theory- to be his teacher and after visiting him as a physician to look after his health, he accepted no money for this visit. ome of his important aphorisms were: "As to diseases, make a habit of two things -to help or at least to do no harm". Also: "Those by nature over weight, die earlier than the slim.", also, "In the wounds there are miasmata causing disease if entered the body".He used as a pain relief, the abstract from a tree containing what he called "salycasia", like aspirin. He described for the first time epilepsy not as a sacred disease, as was considered at those times, but as a hereditary disease of the brain and added: "Do not cut the temporal place, because spasms shall occur on the opposite area". According to Hippocrates, people on those times had either one or two meals (lunch and dinner). He also suggested: "...little exercise...and walk...do not eat to saturation". Also he declared: "Physician must convert or insert wisdom to medicine and medicine to wisdom". If all scientists followed this aphorism we would have more happiness on earth.”

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• Totelin LM (2007) [From: Department of History and Philosophy of Science, University of Cambridge, Cambridge, UK.] .

The author asserts in the Introduction: "The compilers of the Hippocratic gynaecological treatises, active at the end of the fifth century bc or at the beginning of the fourth century bc [citation] considered that too little intercourse could only damage the health of women. In their opinion, women are never healthier than when they are pregnant.[citation]. When women do not have enough sex, they do not get the beneficial moisture that is sperm; their wombs risk drying up and start moving around their bodies, wreaking havoc.[citation]. Diseases caused by a displaced womb mostly affect women who do not have frequent sexual intercourse: virgins, young widows and old women.[citation] For the Hippocratics, the 'obvious' treatment for displacements of the womb and for many other gynaecological ailments is sexual intercourse.[citation] —Totelin's Abstract reads: The compilers of the Hippocratic gynaecological treatises often recommend sexual intercourse as part of treatments for women's diseases. In addition, they often prescribe the use of ingredients that are obvious phallic symbols. This paper argues that the use of sexual therapy in the Hippocratic gynaecological treatises was more extended than previously considered. The Hippocratic sexual therapies involve a series of vegetable ingredients that were sexually connoted in antiquity, but have since lost their sexual connotations. In order to understand the sexual signification of products such as myrtle and barley, one must turn to other ancient texts, and most particularly to Attic comedies. These comedies serve here as a semiotic guide in decoding the Hippocratic gynaecological recipes. However, the sexual connotations attached to animal and vegetable ingredients in these two genres have deeper cultural and religious roots; both genres exploited the cultural material at their disposal.

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• Smith CM. (2005) [From School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York] 

—Author asserts: "Many writers, if not the majority, believe incorrectly that the author of this aphorism was Hippocrates; many believe, also incorrectly, that it will be found in the Hippocratic Oath."  [For example see Introduction section of article by Pappas et al. , who assert "....(primum non nocere) Hippocrates’ advice, meaning "first do no harm"."]. —Smith's Abstract reads: The so-called Hippocratic injunction to do no harm has been an axiom central to clinical pharmacology and to the education of medical and graduate students. With the recent reexamination of the nature and magnitude of adverse reactions to drugs, the purposes of this research and review were to discover the origin of this unique Latin expression. It has been reported that the author was neither Hippocrates nor Galen. Searches of writings back to the Middle Ages have uncovered the appearance of the axiom as expressed in English, coupled with its unique Latin, in 1860, with attribution to the English physician, Thomas Sydenham. Commonly used in the late 1800s into the early decades of the 1900s, it was nearly exclusively transmitted orally; it rarely appeared in print in the early 20th century. Its applicability and limitations as a guide to the ethical practice of medicine and pharmacological research are discussed. Despite insufficiencies, it remains a potent reminder that every medical and pharmacological decision carries the potential for harm.

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• Ventegodt S, Clausen B, Omar HA, Merrick J. (2006) [From: the Nordic School of Holistic Health and Quality of Life Research Center in Copenhagen, Denmark; Nordic School of Holistic Medicine; the Kentucky Clinic University of Kentucky in Lexington.; Center for Multidisciplinary Research in Aging, Zusman Child Development Center, Division of Pediatrics and Community Health at the Ben Gurion University, Beer-Sheva, Israel] .

—Excerpts from the article: Studies from different western countries indicate an incidence of about 15% of girls being assaulted sexually in childhood[8,9,10] and many of these girls are likely to demonstrate severe pelvic problems in their youth. Sexual and gynecological problems resistant to standard therapy are typically problems with acceptance of own sex and sexuality, which do not have to originate from abuse. As originally suggested by Masters and Johnson, they can be a result of not having received the loving acceptance and touch needed in childhood[2,11].....The Hippocratic (Hippocrates, 460–377 bce) physician was aware of these diseases and his treatment included different physical procedures focused on the female pelvis, like smoking the vagina and massaging the pelvis[12]. The reason why these treatments were later condemned are debated; some authors find it a form of sexual abuse of the woman by the medical profession with an insufficient ethic[13].....When it comes to the practice of pelvic massage, we might be at the essence of medical ethics and the ability to perform this procedure place.

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References and notes cited in text

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