Thank you very much.
Count Bernadotte, Nobel Laureates, ladies and gentlemen.
It is a great pleasure to be present on this occasion and an honour to have received an invitation to participate.
That someone who is only a physician, with severely limited classical as well as scientific background,
should venture to bring once more to your attention the time-honoured theme of Hippocrates and history.
It is the result not so much of new discoveries concerning Hippocrates as it is of certain new and massive
and to some extent rather frightening trends that we find in present day physical and biological affairs, including medicine.
What I shall try to show is, first, the position originally taken by Hippocrates regarding man and nature.
Second, how this position has waxed and waned in its validity and acceptability over vast centuries of time.
And third, the urgency now for a new consideration of what may fairly be called Hippocratic doctrine.
We need to know about Hippocrates himself as well as his ideas and must first establish that he was a man and not a fable.
Like every great man all kinds of fables gathered around and about him, but these must be recognised and discarded.
There are 2 clear references by Plato, Hippocrates' contemporary.
In the Protagoras one of Plato’s characters, also named Hippocrates, is going to Hippocrates of Kos, the Asclepiad, to be instructed in medicine.
And Asclepiad was a term apparently used to describe the general guild of physicians.
In the Phaedrus of Plato it is recorded that Hippocrates, the Asclepiad, teaches
that an understanding of natural events is the necessary approach - not only to medicine, but to all knowledge.
Aristotle in his politics has an interesting comment.
When one says the great Hippocrates, he writes, one means not the man but the physician.
From this brief but authoritative statement one can deduce that Hippocrates was a man;
that he was well known to Aristotle; and that then, a generation after his death, he was already a great figure.
Some have even thought that there is here an implication that Hippocrates was a man of small stature.
But this seems debatable.
The pertinent question is raised, however, what indeed did Hippocrates look like?
This question has occupied archaeologists for more than 3 centuries.
The first evidence that was found early in the 17th century was a Roman coin of the first century AD
on which were depicted a head in profile, the Greek letters iota pi, hip and a serpent staff.
The head was rounded, bald, with a short beard, the nose large with broad nares.
The design is of course crude, but gives a definite idea of the kind of head and countenance the man had.
There was much interest through the latter 18th and 19th centuries in finding an antique sculptured head or other portrait
which would be sufficiently like that on the coin, so as to call the head Hippocrates'
On the next slide is one familiar in the Capitoline Museum in Rome.
And here of the same person, that in the British museum.
The fit, as you will see, is not good: the face being much narrower than that on the coin.
Half a century or so ago with much additional evidence this head was identified as that of the stoic philosopher Chrysippus and not Hippocrates.
There was then at this point no accepted representation of Hippocrates except the coin.
In 1940, in the excavation of a burial ground near Ostia Antica, the ancient seaport of imperial Rome,
there was found within the family tomb of a distinguished Greek or Roman physician of the first century AD,
a pedestal, on which was an inscription beginning, ‘Life is Short’.
Near the pedestal on the ground was the sculptured head or herm of an elderly bearded man, the right side of the face much damaged.
The contour of the head and details of the face were found to correspond closely with those on the old Roman coin of Kos.
This with the inscription ‘Life is Short’ and other evidence have lead most archaeologists to believe with some confidence
that the head is indeed an ancient representation of Hippocrates, a fine Roman copy of an earlier Greek original.
This is the side view.
This is from one side and this from the other.
It is seen to be a head and countenance of great power, its expression a curious blend of strength and sorrow.
The Hellenistic style places the Greek original at about 280 to 300 BC or somewhat less than 100 years after Hippocrates' death.
What were the enduring creations that came out of the life of this remarkable man?
As in all history there are not many certainties, and we must deal with records of greatly varying probability.
One certainty is the Hippocratic corpus.
The whole mass of medical treatises, some 70 or 80 of them still surviving,
that were gathered over a period probably of some 400 years and that have survived over a period of 24 centuries.
This in itself is an astonishing product.
We have, of course, writings on religion collected over much longer periods, and still with us.
But where else in either ancient or modern times have we a collection of objective and interpretative writings in a scientific field
assembled in one man’s name, so sedulously protected and so earnestly studied and used over so great a span of time?
Plato, Aristotle and, of course, Galen wrote more extensively, but within 1 or 2 generations they and their schools had completed their work.
The stoics continued teaching and writing for centuries, but their works were scattered,
never held together by one dominating personality and in great part lost.
It is fairly certain that there existed a school of medicine at Kos before Hippocrates the Great:
his biographer, Soranus, mentions his grandfather, Hippocrates the First,
and at least 2 of the writings in the corpus have been dated before Hippocrates.
What were the truly fundamental contributions to medicine of Hippocrates himself?
The evidence is largely internal, and authorities naturally vary as to which treatises are genuine –
meaning by this: either written by himself or his immediate students or associates.
I believe that by reference to a few of these one can reach the primary features of his teaching.
One of the severer critics, Deichgräber, admits only one, the Epidemics, books I and III, as surely by Hippocrates himself.
These, as I suppose everyone knows, are simple in form.
They consist first of a brief discourse on constitution - that is the meteorological conditions –
and the kinds of disease occurring in a particular season.
And second, 3 series of most detailed and exact descriptions of individual clinical cases.
These are, moreover, complete; there are no single visits to a prestigious patient by a prestigious consultant.
The physician here sees every kind of patient, from the wealthy aristocrat to the artisan, the domestic, even the slave.
And he follows the patient from the beginning of his disease to its end - whether recovery or death.
And whether the disease lasts 2 days or 4 months.
He is concerned about the patient’s mental and emotional state as well as the physical strains or excesses that led up to his illness.
I venture to state that this kind of exact description was new.
Here is an exact and accurate observer of natural events, here is no philosopher proving a system.
As Hippocrates himself insists over and over again: he is a practitioner of his 'techne' or craft.
And craft is probably a better name for Hippocratic medicine than the traditional word art.
What further does he think and do in the broad field of medicine?
There are a number of other works which are considered by most authorities to have been written by Hippocrates
or one of his colleagues associated in contemporary practice and teaching.
The treatise Regimen in Acute Diseases indicates the broad principles of therapy, using the means then available:
diets, purges, emetics, bleeding and general daily regimen.
The prognostics give the evaluation of symptoms and signs 'favourable' and 'unfavourable'.
The surgical treatises on fractures, dislocations and wounds of the head are an extraordinary group,
detailing most accurately the anatomy and signs of these various injuries: when to use the knife; how to reduce the fracture or dislocation;
precisely how to dress or bandage the injury; what will happen on succeeding days and how to deal with these events.
Significant here is that Hippocrates included all branches of medicine and surgery on the same terms.
There was no downgrading, for example, of surgery - this came centuries later.
In the chapter on airs, waters and places Hippocrates reaches out further
and endeavours to place man in relation with his environment – man and nature, as it were, together:
what kind of human beings develop in such-and-such a climate or ecologic state as well as what diseases they will have.
While he describes accurately malarial climates and the chronic malarial state in man,
other sections are wide off the mark, as we would interpret them now.
But the point here is the breadth of Hippocrates' conception of medicine and the identification of man,
both in health and disease, as a part of nature.
Hippocrates’ attitude, his philosophy at the foundation of his medical art or craft,
is perhaps best set forth in a very early chapter called ‘Ancient Medicine’.
In this he begins by stating that medicine has no need of hypothesis.
Here one must distinguish, as W. H. S. Jones notes, the ancient from the modern notion of hypothesis.
In the modern, a hypothesis is a postulate which once stated can be investigated.
Not so in ancient times; then a hypothesis was a thesis, a declaration of underlying truth to be accepted
and thereafter used to explain phenomena but never questioned.
To such a hypothesis Hippocrates was opposed.
He does not accept for example Empedocles’ proposition that in order to know nature one must first know the origin of man,
how he came into being and out of what elements.
Medicine is concerned, says Hippocrates, with the sufferings of ordinary folk and does not require ultimate cosmologic theory.
He admits of certain general processes and forces, which can be derived from the study and observation of man himself.
As one would expect, these are not especially original, but relate to a number of philosophic generalities current in the 5th century BC.
The state of health is one of harmony or balance of forces.
An acute disease, for example, with sharp acrid discharges is caused by an imbalance of forces to be restored by coction, the Greek word 'pepsis',
into thicker, more purulent secretions that lead to healing, and this through mixture or blending, the Greek word 'crasis'.
The so-called humours in this early era were recognised but numerous and of various kinds; the fixed doctrine came later.
In all cases the basis of medical care is to understand nature, the Greek word 'physis', that is the natural order.
The function of medicine is to assist nature to restore this balance of forces, which is the state of health.
It is necessary now to define our terms even more precisely, if we are to know what Hippocrates is talking about.
The Greek word 'physis' or nature comes from phylon: to grow, spring forth, come into being.
And so physis, as Hippocrates uses it, means both nature and the natural order in the large, and also the nature or constitution of man himself.
The term differs from the Aristotelian epistemei, which is to know how or understand,
and thus denotes man’s own definition of scientific knowledge.
Neither one includes the notion of experimentation as a planned action to demonstrate a process.
It should be noted, however, that Hippocrates was very much aware of the experimental aspect of medicine.
The word 'pira' or trial, which he uses in the first aphorism,
shows that for him every therapeutic effort in medicine is an experiment - as indeed it is.
The other word of importance is 'iatrica', medicine or the art of healing, and this too is very broad.
In Hippocrates' conception it signifies the guidance of man by the physician in health and disease, and in all man’s relations with nature.
In this same treatise, that is ancient medicine, Hippocrates makes the boldest and most inclusive statement of all.
‘I hold’, says he, ‘that clear knowledge about nature can be obtained from medicine and from no other source’.
This is presumptuous indeed.
It may be no more than a naïve statement by a craftsman trying to advance the prestige of his own trade, perhaps.
But I believe that it is more than this.
Since man and nature are one, we must seek this knowledge through the study of man, and man in nature.
This is medicine or iatrica in its broadest sense.
It is in fact humanism, also in the broadest sense.
I am inclined to think that Hippocrates had this large concept in mind,
though the language was not then available to give it more precise expression.
I should mention the Hippocratic aphorisms.
These terse statements, some 400 of them, are of variable quality and origin: many brilliant clinical observations;
many obscure and hard to interpret; many of post-Hippocratic and some of pre-Hippocratic origin.
They were revered and memorised in later ages by scores of generations of Greek, Roman, Hebrew, Arabic and medieval physicians.
We must examine one more Hippocratic or early post-Hippocratic treatise:
that on the sacred disease or epilepsy, in which he contrasts medicine with religion and magic.
The name 'sacred disease' for epilepsy came out of the tradition of some past age.
But why this, asks Hippocrates, more than any other?
All diseases are divine, he insists, and all are human.
Each has a nature and proceeds according to its natural order.
Hippocrates is opposed to non-rational magic but not at all opposed to religion in and for itself.
‘Bring the sick man to the sanctuary’, he says, ‘at least it is god head that purifies and cleanses us from the greatest of our sins.'
While thus not denying religion he holds as absolutely to the mechanical order in his description of nature as Democritus himself.
Incidentally while there is multiple evidence that Hippocrates and Democritus of Abdera were friends over many years,
Hippocrates did not use, or appear to need, atomistic theory in all its detail.
He might have been interested in Aristotle’s biology but not his cosmogony.
Plato’s idealism was the opposite of Hippocrates' primary concern with objective living events.
Least of all would he have accepted the Judaic belief of man under a beneficent Jehovah
as Lord and Master of created beings, both living and non-living.
Man belongs to nature, according to Hippocrates, but nature does not belong to man.
We shall come back to this later.
So much for Hippocrates, the man and the physician and his teaching.
It has been a long introduction.
Now to pursue the adventures, misadventures and distortions of himself and his doctrines through the course of history,
we must keep separate at all times 2 main features of this teaching - one is the actual clinical instruction in practical medicine,
the other is the larger philosophical scheme of man in nature - because they have very different histories.
Let us examine first the course of Hippocratic medicine within his school itself,
as more and more medical writings came to be added to the collection.
These were from many sources and with many different philosophic backgrounds: Pythagorean, Aristotelian, Epicurean and so forth.
The whole, as we have it now, is actually probably a part of a library of the Hippocratic school.
As is so often the case with a leader of thought, the wide-ranging philosophy of Hippocrates became increasingly restricted and dogmatised
as time went on, to end eventually, and unhappily, in that rigid rubric which continued down the ages
as the Hippocratic doctrine of the 4 humours, combining these with the 4 elements and 4 forces or powers.
These, as we have noted, Hippocrates himself had been at much pains to denounce as the wrong way
by which to approach the art and science of medicine.
This figure, familiar I suppose to all of you, gives the pattern.
We have the 4 elements: fire, earth, water and air.
And associated with them the Hippocratic humours: yellow bile, black bile, phlegm and blood.
And acting upon them the 4 dynamis or forces are: hot, dry, cold and moist.
Like so many theories, it is so neat that it ought to be true even if it is not, and therefore was thought worthy to be perpetuated.
Even more, perhaps, than his scientific attitude, Hippocrates as a man was stripped of his human qualities
and made into a figurehead if not a semideity.
He was solemnly pronounced 19th in lineal descent from Asclepius and 20th in lineal descent from Hercules.
He was set up as an actual disciple of Asclepius, as for example in the so-called Hippocratic, actually post-Hippocratic, Oath,
when in his life he scorned the use of magic in medicine and in his own writings never once mentioned Asclepius name.
In the later works of the Corpus, if one leaves aside the medical philosophy and looks only at the medical and surgical observations,
one finds that there is much of value and of the widest range.
This solid foundation of practical clinical medicine is what continued to be valued by successive generations of physicians,
and what therefore held the corpus together as a sort of text book on a grand scale.
The long list of commentators provides abundant proof of this: Aristotle comments on one.
His student Menon lists a number of the writings.
Herophilus, the anatomist of the Alexandrian school around 300 BC, was a commentator, and more extensively his student Bacchius.
Eoritan, in the time of Augustus, listed the works known to him.
To complete our story, the renaissance compiler and editor Anutius Foesius assembled over 250 commentators on the works of Hippocrates,
most of them Greek, Roman, Hebrew or Arabic.
But it was, of course, Galen at the end of the second century AD
who truly and authoritatively brought to life again the major writings of the Hippocratic School.
It is extraordinary how absolute the devotion which this arrogant and overweening man paid to the father of medicine.
To be sure, if Galen did not agree with the Hippocratic writing, he either reinterpreted it to suit himself
or else discarded it as a miscopying or a later interpolation.
He wrote commentaries on or mentioned over 30 chapters, including all but one of those that we now accept as 'genuinely' Hippocratic.
But Galen also accepted, and made his own, that same rigid humoral philosophy worked out in a post Hippocratic period.
And he successfully passed this on to later Roman and medieval times.
We can skip now over vast centuries.
With medical theory and philosophy fixed and with experimental enquiry as yet unborn,
practical medical knowledge was derived largely from the ancients and even this in fragmentary form.
Some of Galen’s medicine and physiology survived: much of his materia medica.
Greek medicine was delivered largely through Arabic sources,
though Hippocrates' Aphorisms, Prognostic and Dietetics were available in Latin translation.
These sources formed the textbooks in the better schools for 1000 years.
Surgery declined to the level of barber surgeon practitioners.
Medicine as a practical healing art was reduced to empirical formulae mixed with astrology, superstition and magic.
Its total impotence during the ravages of the Black Death from the mid-14th century on diminished its standing still further.
Medicine was late in joining the revival of learning, slumbering on in Galenic tradition for nearly 2 centuries
after the first flowering of art and literature in Italy.
This was only partly because of the stubborn adherence of medical leaders to Galenic doctrine, partly because other science was late in starting,
and partly also because the full texts of the medical knowledge of the ancients
arrived from the east only toward the end of the 15th and early 16th centuries.
The Hippocratic corpus was a part of this new or newly restored knowledge.
The first editions of the corpus with Latin translations were published in 1525.
This was a time of great events, in which, as it turned out, Hippocrates and his doctrines played a diminishing role.
Let us consider again the 2 aspects of this doctrine: on the one hand the clinical descriptions and teaching,
and on the other the broader ideas of medicine and philosophy.
In the former, as one would expect, it was the clinicians who seized avidly upon the newly discovered writings,
whereas the anatomists and physiologists such as Vesalius and William Harvey stayed with Galen and Aristotle - at least as long as they could.
Outstanding among the clinicians were Ambroise Paré of France in the 16th century,
Thomas Sydenham of England in the 17th, and Hermann Boerhaave of Holland in the early 18th.
Paré, the surgeon, contemporary of Vesalius, was a man of humble origin and no learning.
He has been thought to have hired some assistant to put into his writings Hippocratic quotations, but actually Paré did more than this.
In his great textbook of surgery, the section on fractures and dislocations is modelled exactly after the Hippocratic treatises,
in fact reads like an extension of these.
Paré was a true disciple of the father of medicine.
Thomas Sydenham went further.
Not only did he follow in his textbook, Processus Integri, the Hippocratic method of exact clinical description,
but he accepted also his broader ideas of health and disease in the natural order, and made explorations in the field of epidemiology.
These, however, were not taken up by his successors and were soon forgotten.
But these more or less isolated events in clinical medicine over this 2-century span were small indeed
beside the momentous discoveries and revolutions in the whole realm of science.
I realise that these are familiar to all of you.
But I must look at them briefly in their relation to medicine, both looking backward to the ancients
and also forward as they transformed all science, philosophy and society in the generations ahead.
The dominant force, of course, was the discovery and elaboration of the methods of experiment,
which had been absent from the work of almost all in ancient times.
In the physical sciences in this brave new world, man was all but overwhelmed by his own success.
A. N. Whitehead has said that the Middle Ages were the age of faith based on reason, the 18th century the age of reason based on faith.
It was faith in science and its limitless possibilities.
It was faith also in man and his limitless capability.
There was a resurrection of the old Judaic and now Judeo-Christian doctrine of man under a beneficent deity as Lord of Creation.
Sometimes the deity was called providence, sometimes he was dropped out, but the principle was the same.
Man was the master, nature in its limitless profusion was his servant.
There was something also of the crusader added to the conception.
Man conquering the infidels of a baleful nature, or at least of the baleful and antihuman features of man’s environment.
In any event, the prospect was pleasing.
By taking thought and exerting himself, man would soon learn to live forever in prosperity and peace.
The immense achievements of science and technology through the 17th, 18th and 19th centuries
could not but serve as proofs of the validity of this conception.
In the new scheme of things, it is only fair to say, that our friend Hippocrates lost out completely.
As emphasised recently by Galdston, whatever was left of the Hippocratic idea of medicine assisting nature in the restoration of health
gave way before the experimental approach and its consequences.
Diseases became specific entities with etiologic agents, cures and preventions.
And in the ever-strengthening anthropocentric philosophy of our age they came to be looked upon as enemies,
to be put down and stamped out under the foot of the Lord of Creation.
Each discovery was another battle won in man’s total conquest of nature.
One by one infections, deficiency states, metabolic defects have been brought under control by miracle drugs or other agents;
even persisting chronic diseases alleviated.
In our environment pests unfavourable to our food products, animal or vegetable,
have been destroyed by powerful poisons, predatory animals wiped out.
Heredity in plants and animals have been rearranged to man’s benefit.
And even in man, heredity is about to be placed under favourable control - at least in the minds of some.
Man has, in fact, all but reached his goal as Lord of Creation.
Even 2 world wars with their insane and ghastly devastation did not disturb the dream
still resting in the confident scientific philosophy of the 18th century.
Then, at first slowly, afterward with increasing momentum, something happened.
God disappeared from his Heaven and all was not right with the world.
It began to be apparent that the world no longer has a physical frontier and never again will have.
It has changed or has been changed from an open to a closed system.
One physical event can reach around the world - there is no place to hide.
This is something altogether new in history - at least so far as the small species, homo sapiens, is concerned.
Some things have happened by slow degrees, others suddenly.
One is reminded of the moment in the life of Niels Bohr, that great and good man,
when he awoke to the sombre realisation that the true and the good are not the same, that the true in fact can be appallingly evil.
I refer obviously to the explosion of the first atomic bomb.
There is no need to continue this story.
The subsequent distruction, all the radiation that up to now has been loosed upon the world, the grim threat of annihilation –
but the list piles up: we have the ravages upon our forests and mineral resources; water pollution, air pollution from many sources –
the most overwhelming from all the effluent of the burned carboniferous fuels produced by our flourishing industries;
pesticides with their lethal track down our streams into the sea, taken up into animal, aquatic and bird life,
destroying countless millions, if not whole species - and so back into man himself.
Most ironical has been the progress in medicine.
Simultaneously with the conquest of disease has come the enormous increase in population.
The statisticians telling us that the world population, if not checked, will double in 35 years,
with its inevitable threat of increased starvation and the rest.
Our death control, as someone has said recently, has been admirable; our birth control, when looked at over the whole world, small indeed.
In our wanted conquest of nature it appears, as so often with other conquests,
that the conquered and even the means of conquest return to plague the conquerors themselves.
If one proposes to be Lord of Creation, one must think of everything and one must not forget.
And the trouble with man is, he has not thought of everything and he does forget.
It is a sad reflection on our miscalculations to consider now, if we are to survive,
how much of our time will have to be spent correcting our own mistakes.
In all of this, where does Hippocrates come in?
He comes in most vigorously.
You will remember some 24 centuries ago, his general position that man belongs to nature, but nature does not belong to man.
Although the context has changed, it seems reasonable to suppose that Hippocrates would argue
that man must now abandon the notion of conquering nature and become once more nature’s servant.
Nature must be protected more than exploited.
And this must be man’s primary concern.
This argument is set forth by Galdston in his paper, which I have already referred to, in which he claims a resurgence,
or perhaps one should say a hoped-for resurgence, of Hippocratic medicine.
There is nothing new, to be sure, in this general proposition about the world today.
You will say, as Horatio said to Hamlet, ‘There needs no ghost, my Lord, come from the grave to tell us this.'
But the question is not one of novelty but of urgency.
It is true that remedial measures are at hand if we will use them, and on a large enough scale.
Birth control is possible and feasible.
Mineral and forest sources can be conserved, fuel consumption reduced, air and water pollution controlled,
metabolisable pesticides discovered and applied, the nuclear arms race stopped, and dangers from radiation curbed.
It is true also that in some countries, as in Europe and Japan, much of this control is exercised, but the world picture is disturbing.
In the heavily industrialised United States, politics and industry are in command,
and the military pressures by the one and the primary urge for profits by the other prevent essential reform.
Over the world at large, population control is of course the most urgent of all considerations.
But the ignorance of the people and the incapacity or unconcern of most governments leave little to hope for and everything to be done.
Yet if man is to survive, somehow these huge obstacles must be overcome - and soon.
There is much to do and not very much time.
As I listened yesterday to my friend and colleague André Cournand - this remark, by the way, is not in my prepared text –
as I listened to Doctor Cournand, it occurred to me that I might at this point call in the prophet Daniel, as he did, and invoke his aid.
But then I realised that Daniel was a prophet.
And this is not prophecy but only history.
So I shall rest with Hippocrates.
Hippocrates also had the right word to describe where we now are: The art is long, he said, and life is short.
Applause.