[INTRODUCTORY NOTE. — Maximilien-Paul-Émile Littré was born and lived in Paris (February 1, 1801 - June 2, 1881 †). His parents, freethinkers, never tried to inculcate him with anything or to affect in some way his mind, but they were only worried that he learned freely everything he wished; the little Émile had a fairly good library at his disposal and soon showed both his thirst for learning and his uncommon gifts. After completing his secondary education, already he spoke and wrote in English, German, Italian, Latin and Greek. Then, he opted for medicine. Having completed the entire cursus of studies, as a day pupil and a boarder, immediately after he renounced to send in his thesis, in order to help his mother, who was left without a penny owing to his father's death. Perhaps the renunciation of the academic qualification could have been favoured, too, by fear that a full time job as a physician would have forced him to neglect his classical studies. Anyhow, he was a great physician, even if he was not “doctor”. Nevertheless, he never abandoned his medical studies. On the other hand, a degree certificate could not add anything to his knowledge, except in the mind of bigoted people who like to show off their paper certificates to conceal an embarrassing inadequacy.
Like all great scholars, he was concerned above all to learn his own language. The fruit of studies in French language is beautifully witnessed by his great Dictionnaire de la langue française, which was completed in 1872 and printed by Louis Hachette, a fellow student of Littré. As to medicine, the publisher Baillière-having to prepare the tenth edition of Joseph Capuron's Dictionnaire de médecine (1806, later updated by Pierre-Hubert Nysten)-asked the contribution of Littré, who, with Charles Robin's assistance, reframed the whole project (1855), leaving his original mark on it. Of this excellent dictionary Littré edited the subsequent editions too, till the fourteenth.
Many years before, the same publisher Baillière had asked the thirty-year-old Littré for preparing a full translation of Hippocrates' works. The first volume of this splendid edition, which was not just a simple translation, was printed in 1839; the last one, the tenth, came out in 1863. In such an edition Littré shows his rare skills of a linguist, physician and philologist. Still irreplaceable, it was taken as basic text for the compilation of the Index Hippocraticus (Göttingen 1989).
As to the philosophical thought of Littré, suffice it to say that he was a positivist, who was content to express his thoughts clearly, without impositions, crusades, dogmatisms, animosity, conveniences.
In short, Émile Littré was a great man, whom France may be very proud of.
* * *
In the chapter we present here, Littré outlines clearly and precisely, like nobody else, the medical theory of Hippocrates. To judge by what encyclopaedias and literatures tell about that, we hope to have done something useful.
Today Littré would be much less cautious in pointing out the differences between Hippocratic medicine and modern one, as it is not just a matter of different times, but of antipodean conceptions. For example, if Hippocrates were to return from the past, he would remain dismayed at the inability of modern doctors—in spite of all the most expensive tests possible—to understand what is the problem, since it would be enough to observe carefully the patient: they should not need anything else. But our times made every human concern converge in money, which grants all powers; very likely the rest does not interest anybody any more.]
A BRIEF ACCOUNT OF HIPPOCRATES' MEDICAL DOCTRINE.[*]
If, before having investigated to recognize what of Corpus Hippocraticum belongs to the only Hippocrates, I had tried to expose his medical doctrine, it would have been a tough job for me to draw up a clear account of this ancient doctrine, and the reader would not have been able to follow the thread of my speech, which would prove to be contradictory and incoherent: he would have found references to hypothesis, here, of four humours, there, of elementary heat and cold, elsewhere, of pneuma, without being able to find, among these different conceptions of the oldest Greek medicine, a link that does not exist, since those conceptions belong to different systems.
Through the study and comparison of testimonies that have nothing to do with a possible or probable system of Hippocrates, I came to discern in Corpus Hippocraticum a number of writings, which I consider as his. Now, for a coincidence, which I have frequently found and ultimately confirms the results of my work, it happens that these writings, designated as a work of Hippocrates himself on the basis of reasons unrelated to the inquiry of his doctrine, present a whole where only one thought prevails, where everything gets on well, where there are no discrepancies, no inconsistencies, no contradictions. So, the long research I had undertaken, came back, so to speak, to itself like a circle. Then, with regard to such agreement of arguments, turning the meaning of a sentence of a Hippocratic author, I may say: having drawn a circumference, the beginning can not be found.
Therefore, outlining the principles of the ancient medicine of Hippocrates is possible. I will exclude from the object of this account both anatomy and physiology, since at that time these two parts of medical science were still ignored, and doctors had only vague ideas about—although sometimes profound—whose evaluation would get me too much far.
The fact that Hippocrates' medicine gave ample space to theory; that it devoted itself to the research of the causes and how to explain them; that it has deserved the appellation of "dogmatic", the antiquity gave to its school and its immediate successors, can not be questioned, when you read the following passage from Plato: «Medicine researches the nature of what it deals with, and the cause of what it does, and it knows how to give an account of each of these things. Now, with the help of theoretical ideas entrusted to the writings attributed by the critics to Hippocrates himself, it is not difficult to fill the program indicated by Plato.
In ancient medicine a first point to consider regards the causes of the diseases. Hippocrates recognizes two main orders of causes, to which he attributes the genesis of pathological disorders. The first order includes the influence of the seasons, water, temperature, dwelling place; the second order is more individual and is linked to both the diet peculiar to each man, and exercise he takes. These two orders of causes are treated mostly in the writings De aëre aquis et locis and De prisca medicina.
Taking into account the atmospheric modifications in connection with seasons and climates was a fruitful idea that Hippocrates successfully developed, and following science has not yet exhausted. As the year passes through its subsequent periods of heat, cold, humidity and dryness, the human body undergoes modifications, from which diseases derive their characters. It is on this basis that the doctrine of pathological constitutions in accordance with certain atmospheric conditions is founded; such a doctrine was renewed several times and studied with great care. According to Hippocrates, when a year or a season had a particular feature and was dominated by this or that temperature, a series of diseases bearing all the same mark showed among the people subjected to those conditions. There is here a deep intuition that moderns have caught and on which they still debate: it is the genius of pathological constitutions and epidemics.
The theory of climates' influence, developed with such acumen by Hippocrates, and on which it has been so often drawn, is the result of all he thought about seasons and temperature of the years. In fact, a climate is not, so to speak, but a permanent season, and its stamp has to be much deeper, since it exists and incessantly makes itself felt. Hippocrates hardly set limits there. Shape of the body, mood, courage, love of freedom, all, according to him, depends on the law of climates. If the Greeks are brave and free, whereas Asians are effeminate and slaves, this difference is due to the climate under which these people live.
Ages were obviously regarded as seasons and, for the same reason, exposed each to specific diseases, which were compared with the ones caused by yearly changes of atmosphere. This assimilation was much easier because it rested on one of the main theories of Hippocrates. According to him the human body is penetrated by a heat which he calls innate, whose quantity is at its highest in childhood and it is constantly running out as life goes on until old age, where it reaches its minimum. Such continuous changes of the innate warmth which undergoes the same phases of the sun during a year, led to consider the ages like seasons, and consequently to ascribe to each age an order of diseases similar to the one ascribed to each season.
The second part of general aetiology included the action performed by nutrition and exercise. All sorts of trouble are charged to a badly regulated diet. Both glut and scarceness of food generate diseases, and it is remarkable when Hippocrates picks out the troubles an excess of health, stemming from an excess of power and strength, brings on the athletes. The exercises, which are destined to consume too much due to food, determine when they are excessive or entirely overlooked, opposite damages, that are detrimental to preservation of health.
Such aetiology, taken as a whole, is big and beautiful: the train of times and the progression of science have complied with its basics. It is the first essay-indeed clear and profound-of Greek medicine on the causes of diseases. Even today, the aetiology is one of the most important and difficult subjects. It was natural for the early doctors-among them for Hippocrates-to understand and observe firstly the great and universal influence of the outside world: climate, seasons, way of life and feeding. These influences were all sketched out. The method of observing things all together is not only peculiar to ancient medicine, but it is its distinctive character too, and determines its greatness, when what has been grasped is true. The method of scanning things in detail in order to go back, this way, to general ideas is peculiar to modern medicine. Today it would not be possible to construct a so comprehensive aetiology as required by the doctrine of Hippocrates. Many influences the physicians at the time of Cos ignored, have been identified; everything concerns contagion, viruses, infections has taken an important place in teaching; then, what you believed to know, it was found that it was not known. Typhoid fever, for example, which is the great endemic fever, at least in a part of Europe, has seen the crumbling of all its aetiology thanks to recent work; in fact, both external agents and feeding do not explain why one catches it, so its cause has gone back to the field of unknown things.[a] On the other hand, however, in no other case the influence of the age makes itself more conspicuous, since, for a singular privilege, the old age is immune from such a fever.
Apart from both the influence of the innate heat and the ages—influence whose admission is evidence that Hippocrates was no stranger to the doctrines which compared the man to the world, the microcosm to the macrocosm—it is clear that his aetiology is all in study of external causes; likewise—and we shall see later—his pathology lies in the action of injurious humours. What Hippocrates knew better, were the effects on the body caused by feeding, way of life and dwelling place; what he knew less, was the mechanism of functions. Hence, his aetiology is completely directed to the outside. He asserted that, in order to understand the medicine in its true generality, one must study the action of every food, every way of life, everything surrounds the man; certainly, this is one of the largest programmes about aetiology that have been ever drown up, and one of the deepest indications that have been ever given to medicine. This program, which leaves out only the movement and the spontaneous development of life, came down for Hippocrates to the aetiology I have just outlined. We must, however, add that it has not been exhausted and that completing it is still one of the main tasks of science. I will come back to this thought that Hippocrates left in one of his most notable books. We need only to observe that a plan of researches so conducted, involving the living being in its relations with the surrounding world, includes mainly hygiene and pathology; consequently, in spite of gaps, it proposes a solid and immense base of study, and we understand how the medicine of Greece and Hippocrates, animated by a so fair and fruitful thought, made a so much happy choice in observing the nature, and delivered to the posterity, together with a wealth of experience, a method which exerted in some way a powerful and healthy influence.
Medicine has often tried to discover the organic medium through which the true or presumed cause produces the disease. In this case Hippocrates did not escape the influence of the doctrines, which had preceded him and were prevailing at the time. Just before him, Anaxagoras had attributed the diseases to the bile; Hippocrates attributed them to the quality of humours and inequalities of their mixtures. Necessarily, pathology of humours had to precede that of solids. In fact, long before seeing the hepatization of the lungs in pneumonia or alteration of the pleural membrane in pleurisies, they had noticed the modifications, which during a disease underwent urine, sweat, expectoration and alvine discharges. Nevertheless, Hippocrates, in his treatise De prisca medicina, at the side of humours' action places that of organs' shape and arrangement (σχήματα), but this aspect was little followed, even by him, and the theory of humours remained prevalent.
According to Hippocrates, health is due to the regular mix of humours: it is what he calls crasis; and the disease proceeds from the disorder of the humours' crasis. To this opinion refers back a doctrine, which is one of the cornerstones of Hippocratic medicine: it is the doctrine of coction,[b] and we should discuss this with some detail. It depends indisputably on another theory, namely that of the innate heat: one is a consequence of the other, but both are based on the observation of physical phenomena. The innate heat is founded on the fact that the living body possesses its own temperature; the coction is founded on another observation, that is, as the disease is drawing to its end, the humours alter, get heavier and change colour, and all these alterations coincide with getting better.
But what does coction actually mean? When at the beginning of a cold the nose is runny, the dripping humour is thin, liquid and acrid; as the sickness is on the way to recovery, that humour turns yellow, viscous, dense, and stops to irritate the parts with which it is in contact. In an inflammation of the conjunctiva the humour the eyes produce, at the beginning is warm and acrid, and then turns dense and sweet. In pneumonia the sputum, which at first is frothy, viscous and slow-bleed, turns yellow and dense when the disease approaches to a favourable solution. Here is what the ancients observed and called coction. Therefore, the coction is the change that humours undergo during a disease, and it, removing thinness, liquidity and acridity, gives them more consistency, a darker colouring and some characters that metaphorically have been assimilated to changes caused by baking of substances.
Generalizing these observations, which in several diseases do not present any difficulty, the ancients admitted that the majority of diseases undergo a coction, that is a processing of the humours, which ends with an expulsion. Having described the coction, it is useless to explain what is the rawness of the humours, since within such a theory it is understood by itself. Likewise, when the urine comes to coction, it shows sediment. As long as the humours are raw and light, they are floating in the body, and evil is in its most intense phase; nothing can determine the expulsion of such injurious substances. But, when the nature's activity leads them to maturation, then they become fixed and are carried away by spontaneous evacuations or artificial ones. In this theory it is always a substance that hampers the organism's economy, and it is necessary to eliminate that for defeating the disease; in order to be successful, nature employs always the same procedure, i.e. the coction, which causes the transition of the raw matter to a state where it can no longer harm, and directs it there where its evacuation can be done without damage. So, all the diseases, which cannot admit such a resolution, are deemed incurable, like for example cancer.
We have just stated the meaning and the value of Hippocrates' doctrine of coction. Now, we can make some remarks on the march of sciences, and also a curious comparison with the doctrines still prevailing nowadays. This Hippocratic doctrine has a significant point of contact with what the research of pathological anatomy has recently suggested to someone. In spite of the very different consequences, it starts from a common principle, namely that there is no disease without alteration of matter. According to Hippocrates that alteration depends on a humour which disturbs the body's economy; according to the school which wanted to rely solely on pathological anatomy, the same alteration depends on an appreciable lesion of organs; therefore, from its beginning up to a quite distanced term in time, the medicine rests on the same principle. The idea of disease without matter, as some schools have understood, is alien to Hippocrates. In the Argument of De prisca medicina I shall try to explain what we might call "vitalism" of the doctor of Cos: he conceived it in its reality—it must be bluntly said—with both strength and depth.
Besides, I cannot help but consider the coction from another point of view, comparing it with modern medicine in another way. Actually in many diseases, acute and chronic, the Hippocratic coction corresponds to what we call “resolution”. Take for example pneumonia: ancient medicine, observing that sputum, at first frothy and slow-bleed, turns dense and yellowish, sees therein the work of coction which matches with the recover; a modern doctor, auscultating the diseased lung, recognizes the patient is getting better from both the crackling gasp following the bronchial murmur, and the normal breathing following the crackling gasp. In this case, the coction is the external sign of the activity inside the lung: the ancient doctor kept a check on external signals, whereas the modern doctor pays attention to the internal activity. There is nothing more instructive than the study of different solutions that at different times the sciences gave to the same problem. The expectoration's coction and the hepatization's resolution are two answers—separated by more than twenty-two centuries[c]—to the following question: how can you recognize the pneumonia is on the way to get better?
On the coction, considered in itself, three main observations can be made: —in first place, it is based on a datum certainly too much generalized, according to which every disease is caused by an injurious humour; —secondly, there where ancient physicians observed it, namely there where a humour, draining, undergoes several changes in consistency and colour, the coction is only a fact concomitant with the resolution, which is working in the body or a part of it; —third, the coction system was by assimilation extended to many diseases, where such a process escaped the observer's eyes, for example in continuous fevers. Nevertheless, it should be added here, in terms as general as possible, that the issue is not under judgment at all; and, moreover, in most of affections, for which one goes back to humours' alteration, and in those caused by virulent and destructive principles, the pathological phenomena show a certain development, which authorizes the Hippocratic coction or, at least, the idea, included therein, of an elimination process.
The expulsion of humours by means of coction requires efforts, which in Greek medicine received a specific name, i.e. crisis. There are several outflows, which most commonly are represented by sweat, urine, alvine excretions, vomiting and expectoration.
Hippocrates often points out another kind of crisis, that is the “sediment” (ἀπόστασις). The theory of sediment is closely linked to that of other crises, of which it is but an extension. When the morbid matter does not find a convenient outflow, nature conveys and fixes that in a particular point. The sediment, however, should not be confused with an abscess; sometimes, it is an external inflammation like erysipelas; other times, it is a swelling of an articulation; other times again, it is a gangrene of a part. Hence, you have the distinction—at first sight obscure, but real—between the diseases, which are a true sediment and imply a resolution, and the diseases, which appear like that, but are not, and do not play any role in the recovery. A good example of that distinction is given by those pernicious erysipelases—you may see them in some typhoid fevers—which not only are far from alleviating the effects, but worsen such fevers. We must also mention a statement of Prognosticon, considered by some as incomprehensible and by others as futile; nevertheless, that statement is not only in accordance with the Hippocratic doctrine, but, again, it is founded on facts. According to that statement, a patient runs less danger when a body part is completely black than when it is livid. Sprengel (Hist. pragmat. de la Médecine, t. I, p. 339) wonders why should it be like that. Here is why: the blackening of a part announces gangrene, namely the formation of sediment, which is an auspicious effort of nature; in this case, if the mortification is circumscribed, a recovery is possible. On the contrary, the lividity of a part is not sediment and can be considered as an evidence of a general weakening, so that it is a sign of bad omen.[d]
The doctrine of “critical days” is the complement of that of crisis. According to ancient doctors crises do not turn up at random, because the timing of a disease is regulated. Actually, the phenomena, which diseases show, are subject to an order; therefore, depending on patient, disease and season, certain days undergo critical efforts. In the framework of such a doctrine Hippocrates has signalled the days, which in his judgment are worthy of observation, what will delay or speed up them, what indicates their regularity or their irregularities, and the danger of those critical days, which do not offer any signal.
From general considerations on the causes of diseases, from theory of humours, their coction, the crisis and critical days, turned out a quite different way from ours of judging the patient and the disease. It is what at the time of Hippocrates they called “prognosis”. This is a very important point, because it constitutes one of the most essential differences that separate Hippocratic medicine from modern one. For the school of Cos the prognosis was not what we mean by semiotics. The semiotics, in fact, is a chapter of medical knowledge, by which we learn the value of signs, but it does not stand out above all the other chapters; on the contrary, it is even subject to diagnosis when this is accurate, and in higher teaching it occupies a position much minor compared to one of diagnosis. By contrast, the prognosis of Hippocrates dominates the whole of science, of which it is the culminant point; it lays down the rules to medical practitioners; there is nothing that it might not consider and contemplate. Therefore, we have to well understand its significance and importance, as it is, so to speak, the key of Hippocratic medicine.
The prognosis is clearly connected with the theories on coction, crisis and critical days. I will not inquire if it was born from those theories, or if, on the contrary, those ones were a consequence. If prognostic, coction, crisis, critical days go on naturally together, what was subordinate to rules, had to be foreseeable, or, conversely, what you could foresee, followed rules. It seems more philosophical to consider the prognosis and the doctrine on coction and crisis not as born one from another, but rather as two sides of the same scientific conception. These two ideas grew up together; they were worked out simultaneously and explained by the same works on the ground of the same experiences. Although they did not receive a systematic form, they constitute the doctrine of Hippocrates and the rule, with which he connected everything.
What then is the prognosis of Hippocrates? Do not believe, by appealing to etymology, that it aims at the forecast of what is going to happen: the prognosis (in this respect Hippocrates is formal) informs about the past, the present and future of the patient.[e] It informs about the past, because it offers the means to supplement what the patient does not know or cannot tell, and provides information about the accidents he suffered, the causes which took effect on him, and the nature of the affection, for which he is seeking relief. It informs about the present, because it teaches the difference that exists between the state of health and that of disease, by showing—from the degree that affection has reached—the danger the patient is running, the possibilities of recovery, which are left for him, and the intensity of the disease that plagues him. At last, it informs about the future, because it interprets the signs announcing the crudity or the coction of humours, the crises' approach, the days when they are going to occur, the outcomes they will have, and the parts where critical sediments will be formed. This is in its entirety the performance of the Hippocratic prognosis, this is the field it takes in, and this is the teaching it gives.
We have just seen: —since health is the right mixture, i.e. crasis, of humours, the disease is caused by the disorder of such a crasis; —during the disease, caused that way, an intense activity is operating, which has been metaphorically compared to coction and, being fulfilled, drives on the way of recovery, or, not being fulfilled, allows the evil to last or the death to come; —as a result of such an intense activity crises arrive characterized by evacuations or sediments; —since these phenomena are regulated in time, hence we have critical days;—finally, the doctor, led by this series of observations and reasoning, comes to consider the disease in a more comprehensive doctrine, that is the prognosis. Now, which is the final idea of this doctrine? Well, it is that the disease, quite apart from the organ affected or the form it takes, is something that has its own path, development and end. In this system, what diseases have in common is more important than their distinctive features; and it is precisely these common parts that must be studied and which form the fundamentals of prognosis. In other words, the prognosis is—if I may express myself this way—the diagnosis of the general state, diagnosis in which the doctor pays only a very little attention to the affected organ or, as Hippocrates says, to the disease's name. In Hippocratic prognosis, both what we call diagnosis and what we call prognosis, are merged and combined. This union derives from the fact that the doctor of Cos, concerned above all to detect the patient's general state, diagnoses—it is true—a certain condition at a given time, but at the same moment he foresees, according to the rules of his art, a particular course of the illness, and he is able even to go back to some past circumstances: these are the terms Hippocrates gave to prognosis. What we have just stated, implies the acknowledgment of a deep doctrine, i.e. that in every disease the pathological work is only one, and passes, from beginning to end, through a development, in which all phases are connected to each other. So, the school of Cos—mastering the idea of unity or, in other words, the development of a disease, and being little informed about peculiarities, namely seat, anatomical condition and extent of every affection—went in completely for researching into the common aspects of the diseases. It is the result of such a study that Hippocrates handed in the excellent writing entitled Prognosticon.
So, for the ancient medicine, the prognosis is the source of all true knowledge; at the time it was the philosophy of science; without it there is nothing but empiricism and blind training. If you delete the prognosis as the school of Cos conceived and arranged it, —I repeat— if you delete it in a time when the anatomy had so little progressed, the study of the functions took its first steps, the pathological anatomy did not exist, the differential diagnosis was deprived of its most precious elements, well, which guiding light was remaining to medicine? What could prevent it from losing in a labyrinth of single, unrelated facts, and from flagging in an endless infancy, where everything gets bogged down for lack of a scientific work and method, and inevitably ends up in the empirists' hands without progressing any more if not at random? The prognosis is the first scientific framework we know of medicine. For this reason it deserves our attention, mostly because it is not based on speculations and hypotheses, but because it starts from observations and real experiences. The changing of humours' qualities during a disease, the signs announcing a worsening or a bettering, the survey of both evacuations and critical periods, all this forms a whole that the school of Cos judged worth studying and theorizing.
The scientific talent of the Greeks made itself known, here as elsewhere, with great confidence and great superiority. On the one hand, the intuition that there were not only individual facts, disjoint from each other, protected them against empiricism; on the other hand, by framing those facts in a general system, medicine turned into science. Without testing the peculiar characters of every disease; without trying to bring the different diseases together in a framework and to classify them; without even dreaming of it, the school of Cos has got a fruitful idea, which sums up everything and—by an abstraction that does not lack of importance or greatness—gives the physician a doctrine, which has him trained up in scientific researches and practise of the art. According to this school—and it is the experience, not an hypothesis, that supplies these data—the human body shows during a disease a series of phenomena, which do not necessarily need to be related to this or that disease; in fact, they have got their own meaning, foretell what is about to happen, indicate the most likely outcome of the struggle, the efforts made by nature, the ways through which it will relieve itself, and the relief to which the art can and must resort. Thus, the disease being regarded as something general and indefinite, the knowledge of every disease—actually a knowledge very limited at that time—is not so essential. The prognosis studies the faithful expression with which the economy of the body betrays the pain it feels, and it is that expression you need to catch. To prefer the observation of the whole organism rather than of a specific organ, the study of general symptoms rather than of local ones, the idea of diseases' common aspects rather than of their peculiarities, this is the medicine of the school of Cos and Hippocrates.
As I have already pointed out in this Introduction, sciences do not proceed differently from human history; discoveries and systems do not arise without precedent and in a more spontaneous way than empires and social revolutions. The Hippocratic prognosis, as I just described, is certainly a nice result of ancients' work, but it was not suddenly born into the head of Hippocrates or, to be more exact, within the school of Cos; its elements were already ready, and the derivation is simple and natural. We know what were the temples of Asclepiades; the physician-priests who gave their service in there, received the patients and jotted down the observations the diseases' course suggested them; so, they formed a collection of notes, which we have got in both the Coa praesagia and the first book of Prorrheticon. The priests showed interest in, it was in their character to, it was in the habit of any priestly order of trying to raise the veil of future and, in Asclepiades' temples, to foresee the pathological events of which the patient's body was going to be the theatre. Hence derives the previsional and, so to speak, predictive side the ancient medicine of Asclepiades' priests shows. But divination does not apply only to future, but also to present and a past you might ignore. This is why the word prognosis (προγινώσκειν) was employed to express such a mental work and medical judgment, whose aim was to evaluate the patient's past, present and future. Up to that point it was a craft; but, when the school of Cos, bringing together these three periods, realized that a disease was not a succession of freakish, disorderly and lawless phenomena any more, but a chain where every event was justified by the previous one, that craft became a science. Here is, I think, the transition from temples' empiricism to the doctrine of the school, and perhaps this progress has to be attributed to Hippocrates himself, whose clear trace you can recognize in the word prognosis (προγινώσκειν), which was attached to his chief writing. It is, therefore, from the medical divination in the temples and the notes, on which it was founded, that the prognosis of Hippocrates was born; a profound doctrine, according to which every disease is one and at the same time common: it is one because of its development; it is common because of certain phenomena that I shall call here, in short, general state, and Galen, explaining Hippocrates, calls diathesis. We do not know what was the medicine of Egyptians and other people of East, and we do not know too if it ever left the circle of particular annotations, unconnected facts and observations without philosophical method. The Hippocratic School broke this circle, and this way it impacted on the whole future of medicine in the West.
The elements, upon which rested the study of the general state so conceived, had nothing arbitrary: it was the comparison between health and disease. After studying the regular workings of the living body, that gymnastics taught them with such precision, the doctors of the school of Cos confronted the various phenomena, which came about in different diseases; the state of health was the standard, according to which they weighed up the importance of those phenomena and reckoned the damages too. Throughout the Prognosticon Hippocrates has not got any other rule to analyse the face's look, the sweat, urine, alvine evacuations, breathing, etc. In truth, every pathological study is based on the comparison between the state of health and that of disease. But such researches were not done like the school of Cos did. This school conceives everything it knows about the functions, checked in their regularity, like a whole, and it compares them en bloc with what it notices in patients; from such a comparison it draws a picture rather than a series of symptoms, a study of the man as a whole rather than of an injured organ, a research in great functions' pains and efforts rather than of alterations hidden in an internal part, a report of patient's general state rather than of a particular apparatus, membrane or tissue. I do not want to praise the school of Cos for having acted that way, because at the time it could not act otherwise, nor I blame the modern insistence on local diagnosis, without which no precision would be possible. Nevertheless, what I point out as a genius feature in the Hellenic ancient medicine is that they had got a so great power of generalizing, that they could build, with the data at their disposal, a system that was able to understand those data, linked them up in a logical way, so that it became a science.
I am not attributing to Hippocrates and his masters what was not in their mind, I just want to tell openly through my analysis what is hidden in the synthesis of their views. Actually, such a theory, as stated above, was his own to the point that he defended it against the Cnidian doctors, who were guilty of both multiplying the kinds of diseases and neglecting the general state. It was his own, because all the Prognosticon is a statement of what acute diseases have in common; and he ends that work by saying that his reader should not regret the name of not mentioned diseases, since what has been explained applies to all affections which have the same course.[f] At last, it was his own, because the particular cases, with which he dealt in De morbis popularibus, have been compiled by this very rule.
Hippocrates was the first who handed down diseases' particular cases to us, a remarkable example, which afterwards was not followed enough. Such cases have got a special feature and were very often boasted without understanding the spirit, which had inspired them. They are the direct product of the system by which the ancient medicine was a whole, i.e. the result of the prognosis I have just explained.[g] If you judge them by ancients' standards, everything will become clear: actually, there is nothing but a strict application of the prognosis, namely of the system which was the foundation of this medicine. Everything about the characters of a particular disease, local symptoms, lesions of an organ, is missing, because from the Hippocratic point of view all that is of a secondary importance. But, the usual diet, the alterations, which preceded the disease, the critical and not critical evacuations, the days on which they occurred, the state of breathing, sweat and urine are annotated with perfect accuracy, so that, actually, in Hippocratic observation the individual disease disappears to make room to the general picture of suffering and efforts of the great functions.
It would certainly be curious and useful looking in the history of science how the various medical doctrines influenced the way of drawing up a medical report. We have a striking example under our nose. The "numeric method" of Mr Louis[h] has changed—for those who use it and, we might add, for those who do not use it—the plan according to which the individual events are described. Such an influence of medical system on reports is no less evident in De morbis popularibus, where Hippocrates avoids mentioning diseases and their peculiar symptoms; he strictly stands within the prognosis' limits; in brief, he faithfully follows what he states in another of his writings, and this idea is for him a so fundamental point that he in the Prognosticon exculpates himself for not having mentioned a greater number of diseases, making sure that the collection of their common signs is enough for his plan. Whatever opinion you have about Mr. Louis' method, it certainly meets modern medicine's need of more and more detailed observations. Therefore, we may uphold that, as the way of drawing up a disease's account fulfils the spirit that nowadays breathes through the study of medicine, so the particular cases you read in De morbis popularibus bear the seal of Hippocrates' doctrine. This simple comparison is enough to characterize one age and the other. Just as the modern doctor researches and explains what is specific and distinctive in every disease, in order to can make an exact diagnosis of any affection, so the ancient doctor is concerned about what the diseases have in common, so that any individual affection leaves room for the study of the general state.
About the therapeutics of Hippocrates we have only the book De diaeta in morbis acutis. Here, again, it is the idea of coction, crisis, general state's assessment, i.e. prognosis, to teach when and how you have to resort to diet, exercises and remedies for treating an illness. The prognosis contains the general therapeutics, namely the formula of any instruction necessary to a physician, who has to use the means at his disposal neither at random nor without a definite purpose. A therapeutics so founded, therefore, endeavours to realize its own reasons, the result it wants to get, the time which is to be chosen, the crisis to be assisted or imitated; it corresponds with the definition, referred above, that Plato gave of medicine of his time.
From the point of view of prognosis the study of health, disease and treatment formed a very simple whole. Eresistratos (cf. Gal. vol. V, p. 40, ed. Bas.) tells a certain Petronas, a little later than Hippocrates, took into his head to treat the feverish patients by giving them wine and meat.[i] Surely, Petronas was not a member of the school of Cos: the Hippocratic doctrine would never allow a so serious aberration. It had studied the health man and the sick one and the nature's efforts during a fever so much, that it was not possible to suppose that such a treatment could grasp beneficial results, and an experiment like this should never be attempted. The prognosis, as that school had set up and taught, preserved it from the dangerous deviations of a blind empiricism. Petronas roughly wondered if wine and meat could cure fevers: let us have a try! Such a practice did violence to all the prognosis' rules.
We must forgive Hippocrates' supporters for their admiration for both the great school, which gave a ground to the science, and the great man who was the interpreter of that. This unity that appears in the conception of the most ancient Greek medicine, has something singularly beautiful and remarkable, all the more because it did not happen again, or, at least, the systems, which pretended to replace the Hippocratism, did not prove so well-founded, did not last so much time, and, obviously, were not of so much intrinsic value. In truth, those systems were founded on "hypotheses", whereas Hippocrates judged by "facts". Here, again, I use his own words: what in De prisca medicina he is fighting with, is hypothesis (ὑπόθεσις); what he is urging is the truth, that is the study of facts (τὸ ἐόν).
As you can see, then, the ancient method of Hippocrates and the modern one do not differ in their essence, since both are experimental methods. Hippocrates—as we do—wanted the nature to be observed, and—as we do—used the induction in order to extend the scope of his observations and find a link between the individual facts. He admits that such a link is the study of the common signs of diseases, and on this study he establishes without hesitation his general pathology. But, we have gone so far as the common signs, which were enough for Hippocrates, are no sufficient any more to guide the doctor in the vast field of pathological phenomena. If we apply the Hippocratic programme to the letter and notice in every disease the common signs and nothing but the common signs, we would get a so little result and go down into a so far generality, that we would not reap anything fruitful for both theory and practice. So what? It is that we are sinking, day-by-day, into details, local observations, and researches more and more subtle and meticulous. Hippocrates, because of the nature of his knowledge, held to the surface of the sick body, whereas the modern doctor has penetrated inside; and such a penetration, so to speak, into the intimacy of organs and tissues, has been the work of the centuries elapsed between us from Hippocrates.
The doctor of Cos states in his Prognosticon what the diseases have in common, namely the value of patient's general state; in the book De morbis popularibus he goes again along what he observed, that is those common features; in the writing De diaeta in morbis acutis takes into account the therapeutics in accordance with the rule he illustrated in Prognosticon and followed in De morbis popularibus. In the treatise De prisca medicina he fights the hypotheses, refers solely to the facts observed and declares that the living body, for being known, must be studied in its relationship with the surrounding environment. Here is the doctrine Hippocrates explains in his books. His method is experimental; his medical theory rests on the idea of both the regularity of diseases' course and the common features; at last, what I shall call his philosophy or metaphysics, is all in his opinion of the living body, which, to his mind, subsists thanks to its relationships and must be studied in its relations with everything else. Such a thinking of Cos' doctor is completely opposite to that of contemporary philosophers, who tried to know the living body in itself, and is essentially connected with hygiene and pathology. It was undoubtedly the result of his vast knowledge in these two branches of medicine, but, in return, it made him realize how impotent and empty any hypothesis is; so that in De prisca medicina he could proclaim there was but one way for the progress of this science, and the way was that of reasoning based on experience.
It is not surprising that, ending this brief essay on the doctrine of Hippocrates, I recalled the writings it has particularly inspired. Actually, those writings betray the same taught and, therefore, must be of the same hand, and that hand is Hippocrates'. The confirmation, this way, of all the results of my work was so crushing, that I did not want the reader to remain unnoticed.
[*] The notes numbered—where we have updated the quotations and added a Latin translation of Greek passages—are Littré's; the ones marked by letters are ours. The Latin titles of Hippocrates' works are the same you find in whatever edition of Canon of Greek Authors and Works (Oxford University Press). Last but not least, we apologize to readers for our bad English: every suggestion will be welcome.
[© Franco Luigi Viero]