On January 17, the Great Books and World Classics discussion group cosponsored by Northern New Jersey Mensa and Mensa in Georgia focused on two works by Hippocrates: On the Sacred Disease and the Hippocratic Oath. The former text shows why Hippocrates was considered the Father of Medicine: in particular, how medicine broke away from theology. The latter deals with medical ethics in general and (possibly) the ethics of abortion. Today’s physicians still take a modified version of the Hippocratic Oath.

Who Was Hippocrates?

When medical historians cite “Hippocrates,” they really mean “the anonymous author of one or more of the unsigned texts that are included in the Hippocratic Corpus because they seem to come from the right place and time and express a particular attitude toward medicine.” Hippocrates was almost certainly a real person, and probably from the Island of Cos, which is one of the Dodecanese Islands in the Aegean Sea. It lies just off the coast of what is now Turkey.

Hippocrates supposedly was born around 460 BCE, which would have made him about 60 years old at the time of the death of Socrates. Hippocrates was mentioned in passing in the two of Plato’s Socratic dialogues (Protagoras and Phaedrus) and in Aristotle’s Politics. Aristotle, who was born about 15 years after the death of Socrates, was the son of a physician who was believed to be trained in the Hippocratic tradition. Nevertheless, the earliest surviving biography of Hippocrates, by Soranus of Ephesus, dates from the second century CE. Thus, few details of the life of Hippocrates are known for certain. Nevertheless, it is reasonable to presume that Hippocrates had been trained at the Asclepieion (healing temple) on the island of Cos.

The Ascplepieion at Cos

The asclepieia were temples dedicated to Asclepius, a demigod who had such great healing powers that he sometimes raised people from the dead. Asclepius had five daughters, each associated with some aspect of health or healing:

• Hygieia (the goddess of health, cleanliness, and hygiene)
• Iaso (the goddess of recovery from illness
• Aceso (the goddess of healing)
• Aegle (the goddess of good health)
• Panacea (the goddess of universal remedy)

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Treatment at the asclepieia focused on promoting healthy lifestyles as well as meeting the client’s spiritual needs. One common practice was incubatio, which meant that the client would sleep in the temple. Asclepius or one of his daughters would appear in the client’s dream, to reveal what the client needed to do to restore health. The interventions were generally conservative (diet and exercise). However, some surgical procedures were performed, typically with the patient heavily doped with opium.

Natural versus Supernatural

Hippocrates is regarded as the Father of Medicine because the Hippocratic writings focus on purely natural (as opposed to supernatural) explanations of disease. Natural explanations are derived from the observable nature of the physical world, including the patterns of cause and effect (laws of nature), that natural phenomena tend to follow. In contrast, a supernatural being (e.g., a god or spirit) would not be restricted by the laws that govern ordinary physical phenomena. Thus, Hippocratics focused on physis (often translated as natura in Latin) which meant the things that could be perceived through the senses.)  Belief in the supernatural is related to, but not identical to, the concept of superstition. Superstition can mean any false belief about cause and effect, not just a false belief about the supernatural.

The earliest societies had animistic religions. Animism is the belief that animals, plants, rocks, meteorological phenomena such as the wind, and celestial bodies such as the sun have thoughts and feelings, just like human beings, and can do things on purpose. This kind of belief is natural among children. The Greek gods can be seen as personifications of things such as the sun or the wind. As individuals learn more about how things work, they gradually discard the notion that natural phenomena are the work of gods and spirits. The Hippocratics discarded it entirely. Other medical traditions maintained that disease could be divine punishment or the work of evil spirits, and that the treatment must be at least partially spiritual. In contrast, the Hippocratics never blamed gods or spirits, and the interventions they used were entirely physical.

On the Sacred Disease

On the Sacred Disease deals with epilepsy, which was often called the falling sickness. In ancient times, epilepsy was often regarded as a supernatural phenomenon: either communion with the divine or demon possession. Julius Caesar was reputed to suffer from epilepsy. Modern medical historians have speculated about the possible cause of his reported attacks. Yet there is also the possibility that he faked the attacks for political reasons: to persuade his fellow Romans that he was in communication with the divine. Note that the Hippocratic author of On the Sacred Disease was contemptuous of such superstition:

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 the 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. … They who first referred this malady to the gods appear to me to have been just such persons as the conjurors, purificators, mountebanks, and charlatans now are, who give themselves out for being excessively religious, and as knowing more than other people. Such persons, then, using the divinity as a pretext and screen of their own inability to afford any assistance, have given out that the disease is sacred, adding suitable reasons for this opinion, they have instituted a mode of treatment which is safe for themselves, namely, by applying purifications and incantations, and enforcing abstinence from baths and many articles of food which are unwholesome to men in diseases.  [translated by Francis Adams]

The other Hippocratic writings align with this sentiment. They never blame illness on divine punishment or the work of evil spirits. Nor do these writings recommend spiritual interventions to address physical problems. In practice, of course, a Hippocratic physician might have accommodated a patient’s religious beliefs.

The Hippocratics’ Approach and Achievements

The Hippocratic approach to patient care involved the following important concepts:

• Physical examination
• Case histories (dozens survive; thus, the Hippocratic writings provide the oldest surviving description of many modern disorders, such as migraine headache)
• Diagnosis, which meant the conclusion about what is wrong with the patient. This conclusion was based on assessment of the physical examination and numerous other factors, such as environment and diet.
• Prognosis means a prediction of what is likely to happen next.
• Prorrhetics meant the art and science of making an accurate prognosis.
• Cautious yet multipronged approach to therapeutics. They emphasized gentle interventions, such as diet and exercise. Surgery could be used, but only if desperately needed and performed by a qualified surgeon

Here are some of the Hippocratics’ contributions:

• Uroscopy (visual examination of the urine for color, blood, particles, etc.) and the recommendation to increase fluid intake to prevent urinary stones
• Description of Hippocratic facies, which means a change in facial appearance that is associated with serious disease or impending death
• Description of Hippocratic fingers, which is an enlargement (clubbing) of the fingertips, often found in someone with lung disease.
• Recognition that epilepsy results from disease of the brain. They recommended conservative treatment (herbal remedies) in most cases but trepanning (drilling into the skull, which released pressure) in serious cases.
• Documentation of many kinds of surgical procedures

The Hippocratics’ Superstition

Although the Hippocratics ignored the spirit world, they still were laboring under some false understanding of cause and effect because they had a limited understanding of chemistry and biology. Greek philosophers came up with the idea that there was a lower limit to how small a particle could be. They coined the term atom (indivisible) to refer to the smallest possible particle. However, they assumed that there were only four elements (i.e., four types of atoms): earth, water, air, and fire. These concepts align with the modern concept of the three phases of matter (solid, liquid, gas) and energy. Other ancient peoples came up with practically the same idea. The Chinese split “earth” into two elements: wood and metal, which correspond to organic and inorganic chemistry. The ancient Indians likewise had five elements: earth, water, air, fire, and akash (often translated as aether), which represented space and the spiritual realm. Modern chemistry has retained the concept of the atom but has identified more than a hundred elements. Organic chemistry deals with molecules that consist mainly of carbon and hydrogen, and often oxygen and nitrogen.

The pre-Socratic philosopher Empedocles argued that the four elements represented two pairs of opposites: hot-cold, wet-dry. This led to the Hippocratic notion that the body contained four different fluids, which had to be kept in proper balance:

Humor	Season	Age	Element	Organ	Temperaments
Blood	Spring	Infancy	Air	Liver	Warm and moist	Sanguine
Yellow bile	Summer	Youth	Fire	Gallbladder	Warm and dry	Choleric
Black bile	Autumn	Adulthood	Earth	Spleen	Cold and dry	Melancholic
Phlegm	Winter	Old age	Water	Brain/Lungs	Cold and moist	Phlegmatic

Thus, the goal of therapeutics in Hippocratic medicine was to balance the patient’s temperament, mainly through diet. The Hippocratics insisted that physicians should avoid harming their patients. However, later physicians who embraced humoral theory (which was central to European medicine until the 19^th century) sometimes applied this theory in harmful ways. For example, during former President George Washington’s fatal illness, his physicians drained a dangerous amount of blood from him, when what he probably really needed was a tracheotomy. (He apparently had a “textbook case” of epiglottitis, which is a dangerous swelling of the flap that closes off the windpipe when you swallow.)

What None of the Ancients Knew

Modern medical researchers still study ancient medical texts for remedies that may remain useful today. For example, ginger was highly regarded by ancient Hindus for its value in relieving pain and nausea. Modern research showed that it was at least as good as sumatriptan for relieving a migraine attack. However, no ancient healers knew the following basic facts, which guide modern medicine.

• Blood circulates (reported in Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus by William Harvey in 1628)
• There are more than four or five elements (explained by Lavoisier’s 1789 Elementary Treatise on Chemistry)
• All living things are made up of cells and the materials made by cells (Microscopical researches into the accordance in the structure and growth of animals and plants)
• All cells come from other cells (asserted in Rudolf Virchow’s Cellular-Pathologie  in 1855)
• Green plants capture energy from sunlight to sugar out of carbon dioxide and water, releasing oxygen in the process (the result of a series of discoveries starting in the 17^th century).
• Animals can use oxygen to break down the sugar into carbon dioxide and water, releasing energy in the process (the chemistry of combustion was demonstrated by a series of experiments by Lavoisier and others starting in the 1770s).
• Many diseases result from germs (bacteria or viruses), established beyond a shadow of a doubt by Louis Pasteur and Robert Koch in the late 19^th century.
• All living things store information encoded in DNA (worked out by a series of workers in the 20^th century).

These basic facts inform the modern practice of medicine. So, it pays to be skeptical of anyone who is peddling some ancient healing system, such as Ayurveda or Traditional Chinse Medicine.

The Hippocratic Oath and Medical Ethics

Ethics is the study of morality and choices (where people have no choices, what does it mean to talk about what they should do?). Medical ethics poses lots of thorny issues, partly because it deals with matters of life and death but also because it often involves a conflict between commercial interests and human rights. To address these issues, it helps to start with an ethical framework that was worked out by Hindu sages a few thousand years ago. They recognized that in any society that is large enough to have a division of labor, people will have many different occupations. However, those occupations can be sorted into four broad categories, each of which has a particular kind of political power and social responsibility. The four varnas correspond to the four suits of European playing cards, as well as the four men on Gilligan’s Island and the four colleges at Hogwarts. As you can see, the medical profession is spreadeagled among all four varnas:

Varna	Varna Dharma	Medical Responsibility
♥ Brahmin	Have the power of knowledge and wisdom. Seeks knowledge for its own sake. Selflessly teaches and preaches.	Must have scientific training
♠ Kshatriya (ruler)	Has the power to command the army and police. Selflessly holds the responsibility to ensure national defense, public order, and public health	Sometimes perform surgery
♦ Vaishya (businesspeople)	Have the power of wealth. Are expected to seek wealth but also give to charity. Are responsible for organization of large-scale production and distribution of goods and services	Often must run their own medical practice as a business
♣ Shudra (servants and laborers)	Collectively have the power of number. Are expected to work and to serve selflessly	Must provide care to the sick

The concept of varna provides an analytical framework for figuring out why any given society is dysfunctional. For example, if the kshatriya is weak or absent, you have the wild wild West. Marxist societies suffer from poor productivity because they destroy their vaishya varna. Conversely, capitalist societies can suffer if they allow the vaishya to buy off the government. Meanwhile, great social advances (e.g., the Civil Rights Movement) occur when the Shudras unite under the guidance of some brahmins.

Physicians can become dysfunctional if they are poorly educated or are seeking wealth at the expense of their patients’ health. How did the Hippocratics address these age-old problems? Here are some notes on the English translation of the original Hippocratic Oath.

English translation	Varna Dharma
I swear by Apollo Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.	Brahmin: truth telling Shudra: service
To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the Healer’s oath, but to nobody else.	Shudra: serve the teacher Brahmin: teach, but only to students who have taken the Healer’s Oath. Note that trade secrets something that businesspeople do, whereas brahmins teach everyone. Note that this vow to teach only to those who have taken the Healer’s oath is an ethical stance, not an attempt to protect trade secrets.
I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them.[4] Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein.	Shudra: provide care. Note that the original Greek does not really mention abortion. It means “harmful pessary” (which could mean harmful to the woman). The text does not mention pregnancy or fetus or abortion. (Revisiting the evolution of the Hippocratic Oath in obstetrics and gynecology – American Journal of Obstetrics & Gynecology) This injunction is in line with the injunction not to harm someone by cutting to relieve bladder stones.  Pessaries could be used to manage pelvic organ prolapse or for contraception. A dangerous pessary could do more harm than good
Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.	Shudra: serve selflessly
Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I break it and forswear myself, may the opposite befall me.

Ironically, the Hippocratic Oath starts with mention of all the gods (a very serious oath!), even though Hippocratic medicine ignored all the gods in practice. Nevertheless, it is easy to see why some version of the Hippocratic Oath is still used today. Hippocratic physicians swear to help their patients, not to harm them or do injustice.