The Greatest Benefit to Mankind: A Medical History of Humanity. Roy Porter

openness followed from the fact that Greek civilization developed in multiple centres from Asia Minor to Sicily, and no single sect of doctors possessed a state or professional monopoly. Athens was the first city to support a fair number of full-time healers making a livelihood out of fees, and, according to his younger contemporary Plato (427–347 BC), the great Hippocrates taught all who were prepared to pay.

      HIPPOCRATES

      All we know about Hippocrates (c. 460–377 BC) is legend. Early hagiographers say he was born on the island of Cos and that he lived a long and virtuous life. The sixty or so works comprising the Corpus were penned by him only in the sense that the Iliad is ascribed to Homer. They derive from a variety of hands, and, as with the books of the Bible, they became jumbled up, fragmented and then pasted together again in antiquity. What is now called the Corpus was gathered around 250 BC in the library at Alexandria, though further ‘Hippocratic’ texts were added later still. Scholarly ink galore has been spilt as to which were authentic and which spurious; the controversy is futile.

      The Corpus is highly varied. Some works like The Art are philosophical, others are teaching texts; some, like the Epidemics, read like case notes. What unites them is the conviction that, as with everything else, health and disease are capable of explanation by reasoning about nature, independently of supernatural interference. Man is governed by the same physical laws as the cosmos, hence medicine must be an understanding, empirical and rational, of the workings of the body in its natural environment. Appeal to reason, rather than to rules or to supernatural forces, gives Hippocratic medicine its distinctiveness. It was also to win a name for being patient-centred rather than disease-oriented, and for being concerned more with observation and experience than with abstractions.

      Hippocratic medicine did not offer all the answers. The workings of the body and the springs of disease remained thorny issues dividing physicians. This was partly because knowledge was limited. Hippocratic doctors had a sound grasp of surface anatomy, but first-hand knowledge of the innards and living processes depended heavily on wound observation and animal dissection, for in the classical period the dignity the human body enjoyed forbade dissection.

      Analogy might help – hens’ eggs offered models for human foetal development, and the digestion of food could be compared to cooking over a fire – but even animal experiments were rare, and the body’s hidden workings had to be deduced largely from what went in and what came out. With internal physiology hidden, disease might be conjecturally explained: On the Sacred Disease argued that epilepsy, as natural as any other disease, was caused by phlegm blocking the airways, which then convulsed the body as it struggled to free itself.

      The cardinal concept in the Hippocratic Corpus was that health was equilibrium and illness an upset, an explanation probably owing much to pre-Socratic attempts to understand the stability yet changeability of nature. On Regimen pictured the body as being in perpetual flux: health was a matter of keeping it within bounds. More commonly, notably in On the Nature of Man, the body was viewed as stable until illness subverted it. Imbalance would produce illness if it resulted in undue concentration of fluid in a particular body zone. Thus a flow (defluxion) of humours to the feet would produce gout, or catarrh (defluxion of phlegm from the head to the lungs) would be the cause of coughing. It was the healer’s job to apply his skill to preserving balance or, if illness befell, to restoring it.

      What was being kept in balance or upset were bodily fluids or chymoi, translated as ‘humours’. Sap in plants and blood in animals were the fount of life. Other and perhaps less salutary bodily fluids became visible only in case of illness – for example, the mucus of a cold or the runny faeces of dysentery. Two fluids were particularly associated with illness: bile and phlegm, though naturally present in the body, seemed to flow immoderately in sickness. Winter colds were due to phlegm, summer diarrhoea and vomiting to bile, and mania resulted from bile boiling in the brain. Airs, Waters, Places also attributed national characteristics to bile and phlegm: the pasty, phlegmatic peoples of the North were contrasted with the swarthy, hot, dry, bilious Africans. Both were judged inferior to the harmonious Greeks in their ideally equable climate.

      Bile and phlegm were visible mainly when exuded in sickness, so it made sense to regard them as harmful. But what of other fluids? Since Homeric times, blood had been associated with life, yet even blood was expelled naturally from the body, as in menstruation or nose-bleeds. Such natural evacuation suggested the practice of blood-letting, devised by the Hippocratics, systematized by Galen, and serving for centuries as a therapeutic mainstay.

      The last of the humours, black bile (melancholy), entered disease theory late, but in On the Nature of Man it assumed the status of an essential, if mainly harmful, humour. Visible in vomit and excreta, it was perhaps thought of as contributing to the dark hue of dried blood. Indeed, the idea of four humours may have been suggested by observation of clotted blood: the darkest part corresponded to black bile, the serum above the clot was yellow bile, the light matter at the top was phlegm. Black bile completed a coherent, symmetrical grid in binary oppositions, and the four humours – blood, yellow bile, black bile and phlegm – proved wonderfully versatile as an explanatory system. They could be correlated to the four primary qualities – hot, dry, cold and wet; to the four seasons, to the four ages of man (infancy, youth, adulthood and old age), to the four elements (air, fire, earth and water), and the four temperaments. They thus afforded a neat schema with vast explanatory potential. On the assumption, for example, that blood predominated in spring and among the young, precautions against excess could be taken, either by eliminating blood-rich foods, like red meat, or by blood-letting (phlebotomy) to purge excess. The scheme (which finds parallels in Chinese and Indian medicine) could be made to fit with observations, and afforded rationales for disease explanation and treatment within a causal framework.

      The Hippocratics specialized in medicine by the bedside, prizing trust-based clinical relations:

      Make frequent visits; be especially careful in your examinations, counteracting the things wherein you have been deceived at the changes. Thus you will know the case more easily, and at the same time you will also be more at your ease. For instability is characteristic of the humours, and so they may also be easily altered by nature and by chance.

      … Keep a watch also on the faults of the patients, which often make them lie about the taking of things prescribed. For through not taking disagreeable drinks, purgative or other, they sometimes die. What they have done never results in a confession, but the blame is thrown upon the physician.

      Their therapeutic stance was ‘expectant’: they waited and watched their patients, talking, winning trust and giving a helping hand to the ‘healing power of nature’ (vis medicatrix naturae) emphasized in the text On Ancient Medicine. Believing that ‘our natures are the physicians of our diseases’, they scorned heroic interventions and left risky procedures to others. The Oath forbade cutting, even for the stone, and other texts reserved surgery for those used to handling war wounds. That was a sensible division of labour, but surgery was also regarded as an inferior trade, the work of the hand rather than the head – a fact reflected in its name: ‘surgery’ derives from the Latin chirurgia, which comes from the Greek cheiros (hand) and ergon (work). Surgery was handiwork.

      The Hippocratic doctor might disown the knife, but he prided himself on his knowledge of surgical matters – indeed the Corpus contains much now regarded as such, including a treatise On Head Injuries. Hippocratic advice proved highly influential: wounds should be kept dry, but suppuration was deemed essential to healing; the pus supposedly derived from vitiated blood which needed to be expelled from the body: pus was thus a desirable evacuation. Fractures were to be reduced and immobilized with splints and bandages. For bladder stones, catheterization was advocated, never lithotomy – such operations were left to ‘such as are craftsmen therein’; and, as a last resort in case of gangrene, amputation might be performed (vascular ligature was unknown).

      Hippocratic surgical texts were thus conservative in outlook, encouraging a tradition in which doctors sought to treat complaints first through management, occasionally through drugs and finally, if need be, by surgical intervention. Hippocrates