FROM THE JAMES LIND LIBRARY Hippocrates: timeless still

Eleni Tsiompanou1 . Spyros G Marketos2 1Health-Being, London, UK, www.healthbeing.co.uk; 2Professor Spyros Marketos, Past President of the International Hippocratic Foundation of Kos, died between finalising and publication of this article. Correspondence to: Eleni Tsiompanou. Email: [email protected]

DECLARATIONS In 1868, Charles Darwin, already famous for his legends surrounding the life of Hippocrates, ‘The radical theory on evolution, made a surprising Father of Medicine’. Competing interests admission, acknowledging the similarities None declared between his theories and those of Hippocrates, The historical Hippocrates the famous Greek physician of the fifth century Funding BC. In reply to a letter, now unfortunately lost, Anyone attempting a biography of Hippocrates None declared sent by Dr William Ogle (Superintendent of would find very little to be certain about, espe- Statistics to the Registrar-General) Darwin cially following the more recent historical biogra- Ethical approval declares the following: phies that follow the modern iconoclastic trend, Not applicable rather than the older, often hagiographic one. Very ...I wish I had known of these views of Hippocrates little information has passed down to us about his Guarantor before I had published, for they seem almost identi- life. We do not even know what he looked like, as

ET cal with mine - merely a change of terms - and an it is almost definite that the statues purported to application of them to classes of facts necessarily represent him are a fictional depiction and not a Acknowledgements unknown to the old philosopher. The whole case is true image. Some of the stories recounted by Both authors are a good illustration of how rarely anything is new. ancient writers and historians have been investi- grateful to ...Hippocrates has taken the wind out of my sails, gated by modern scholars and may be true, while Professors Emily but I care very little about being forestalled. I others are shrouded in myth. Yet, there is no doubt Savage-Smith and advance the views merely as a provisional hypoth- that he existed and was indeed the most success- Ulrich Tro¨hler for esis, but with the secret expectation that sooner or ful physician of his time. Plato, the founder of the later some such view will have to be admitted. Academy of Athens, who often criticized the work comments on an ...I do not expect the reviewers will be so learned as of doctor-practitioners in Ancient Greece, calls earlier draft of this you otherwise, no doubt, I shall be accused of wil- Hippocrates: ‘the famous physician of Kos’ in his article. Professor fully stealing Pangenesis from Hippocrates, for this dialogue ‘Protagoras’. Spyros Marketos, is the spirit some reviewers delight to show.1 ‘The Great Hippocrates, the wise physician’ as Past President of Aristotle calls him in his book Politics, was obvi- the International Having grown up in a family of doctors and ously an unusual man, even for the enlightened Hippocratic having attended medical school only to drop out era in which he lived. Born into a family of priests- Foundation of Kos, after a couple of years, Darwin may have had doctors, he was taught by his physician-priest died between fina- some knowledge of the Hippocratic writings. He father Heraclides and his grandfather lizing and publica- however denies it in his letter, leaving us only to Hippocrates. At that time, anyone could become 0 tion of this article. guess whether he had read any of the books in the a self-proclaimed physician ( &) without Eleni Tsiompanou Corpus. having to go through any kind of structured train- It is not only Darwin, though, who is witness to ing, provided he was born into a family of doctors. expresses her the richness of Hippocrates’ work and personality. Medicine was a ‘closed occupation’, practised indebtedness to her His reputation has been such that, over the aeons, mainly by priests in the temples, the Asklepeiia. deceased co-author people have repeated stories of his achievements Consequently, medical practice was, more often as follows: and abilities. One story describes how on his tomb than not, mixed with magical, supernatural and My interest in in Larissa in central Greece, bees gathered to form superstitious elements. Hippocrates did not Hippocrates was a beehive.2 Their honey had exceptional healing believe that illnesses were God-sent. Furthermore, first stimulated by properties and local people used it to treat colds, he was not content to just preserve the traditional ‘Galen’, not the great wounds and weaknesses. This is only one of the practice of his ancestors. He was exceptional in

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physician philoso- that he broke the longstanding tradition of keep- ...full discovery will be made, if the inquirer be pher of ancient ing the occupation within the family. He estab- competent, conduct his researches with knowledge 3 times, but a ‘modern’ lished the School of Kos where he taught of the discoveries already made, and make them his version who, for me, medicine for a fee to outsiders who wanted to starting-point; but anyone who, casting aside and learn ‘the Art’ and were prepared to abide by the rejecting all these means, attempts to conduct was no less inspir- rules described in the Hippocratic Oath. research in any other way or after another fashion, ing. ‘Galen’ was the Between 440 and 360 BC (approximately) and asserts that he has found out anything, is pseudonym used by Hippocrates wrote a number of medical treatises and has been, the victim of deception. Ancient Dr Spyros Marketos, and his pupils probably wrote many more.4,5 Only Medicine 1.26 a professor of the 60 treatises were saved from the fire that des- history of medicine troyed the Great Library of Alexandria around This clear Hippocratic instruction brings to mind in Athens, when he the end of the second century AD. The surviving today’s call for systematic reviews, a necessary wrote for texts were compiled, possibly by an Alexandrian first step to establishing what is already known Kathimerini, a daily librarian, and published under the title Corpus and uncovering areas that need further explor- newspaper. Every Hippocraticum. The authorship of the books in ation. A plethora of research studies and publica- Sunday, I was the Corpus continues to be the subject of archaeo- tions in a large number of journals means that inspired by his logical and historical research and debate. systematic reviews are more important nowadays Although some of the books may not be than ever before. Modern scientists agree that fail- words, particularly Hippocrates’ own writings, it is nevertheless ure to review pre-existing data can have negative his accounts of the agreed that all display his influence.3 consequences, sometimes fatal.7 lives and work of great medical sci- The need to review the First and foremost, the people entists. In 1987, evidence while still a medical In Ancient Medicine Hippocrates stresses that doc- student in Northern In his text Ancient Medicine Hippocrates was crit- tors’ duty is to help alleviate the suffering of the Greece, I wrote to ical of his predecessors for being inadequately people «0!o» (he does not use the word ‘Galen’ asking to prepared to practise medicine: patient). He emphasizes that doctors must be meet him. Professor able to communicate their knowledge of the Marketos replied, All those who have taken as their task to speak or causes and treatments of diseases in a way that inviting me to visit write about medicine and are using a hypothesis for is understandable and beneficial to people: their thesis, such as hot or cold, wet or dry or any- him. Travelling over- thing else similar, being the cause of illness and But it is particularly important I believe that when night in the sleeper death in human beings, clearly are wrong in what one discusses this art one says things ina way that can of a slow train from they say, as they reduce the causes of diseases to one be understood by lay people. For the subject of our Thessaloniki to or two factors. But their fault is especially grave, as research and discussion should be simply and solely Athens, I arrived as their mistakes have to do with a real art, which the sufferings and illnesses of people. It is not easy for the sun appeared on people use in the most important circumstances lay men to understand how illnesses appear and pass the horizon. I stayed and whose good practitioners are especially honored away and what causes them to get better or worse; but in a small hotel near by all. Some of these practitioners are bad, while when someone else has discovered these things and 6 the Acropolis and others are much better. Ancient Medicine 1.1 explains them then it is easy ...But if he fails to be walked to his office clear to lay people and does not succeed in making his in Kolonaki. However, he acknowledged that not everything listeners understand, then he misses what is truly 4 This was to be was wrong and that there had been useful discov- important. Ancient Medicine 3, my translation the first of count- eries made before him. He therefore instructed less trips over the doctors to review and analyze all pre-existing Choosing the right treatment data before embarking on any research. This next few years. method of inquiry, he said, was and always had Hippocratic doctors considered each person to be Professor Marketos been the only acceptable way of finding answers unique and therefore adapted their advice, paying had invited me to in medicine, as it helped physicians with good particular attention to the characteristics of each join his circle of training and inquisitive mind focus their attention person (age, gender, appearance and physique), young medical on what had not been discovered: their daily habits, the place they lived in and the

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students studying season of the year. They were helped to decide on trust in writing, they will recall to memory things the history and phil- their prescribed treatment by their past experi- from outside, by means of external marks; not from osophy of medicine. ence of treating similar cases: inside themselves, by themselves. You have And so my journey invented a pharmakon not for memory, but for ...the physician sets about his task (of prescribing reminding.10 began. Studying the treatment) with healthy mind and healthy body, books in the having considered the case and past cases of like Perhaps these records were used for teaching pur- Hippocratic Corpus, characteristics to the present, so as to say how poses. We do not really know what their purpose I discovered that, they were treated and cured. The Art 2.76 was. Hippocrates challenged the then oral trad- despite the fact that ition, by recording his observations. When a they did not have Then, as today, physicians often had to face uncer- person came to see him about their illness, he our anatomical, bio- tainty in their practice when choosing the right examined details about their habits, lifestyle, chemical and treatment for their patients. During a historical food intake and their symptoms and signs of dis- physiological under- period of very limited access to written literature, ease. With his companions and disciples, he rec- standing, Hippocratic doctors used what we would now orded his findings, analyzed them and later Hippocrates and his call grade IV evidence (that is, anectodal, based developed his theories. Through this system, followers knew how on personal experience) to guide their clinical which was based on clinical observation, he decisions. In the 21st century, modern doctors drew original conclusions and pushed medicine to use diet to restore can rely on more robust evidence in their daily forward to a new era, influencing physicians more health in ill people. practice.8 Even so, they continue to be influenced than anyone else before him. My interest in by their clinical experience, not least in avoiding The case histories written in some of the books, Hippocrates led me doing harm to patients.9 such as the Epidemics, are only epigrammatic recol- to study for an MSc lection of certain patients. It is possible that the infor- in Nutritional The art of medicine and writing mation presented was only a summary of the actual Medicine at the casesanditspurposewasprimarilyforteaching. University of Surrey. A doctor’s aim, Hippocrates argues, should be to Yet, what these writings show is a discrimination I am indebted to push medicine forward, taking what has already of cases and a search for understanding of what Professor Spyros been discovered and improving it further, to determines disease progression and prognosis: Marketos whose advance The Art of medicine: writing and encour- The most acute diseases, the most severe, difficult In my opinion, however, to discover what was and fatal belong to the continuous fevers. The least agement inspired unknown before is the ambition and task of intelli- fatal and least difficult of all, but the longest of all, me at the beginning gence, and so is to bring to completion what was is the quartan ...It is necessary also to consider the of my medical already accomplished in part. The Art 2.16 person’s mode of life and to take it into account career when prescribing. Many other important symp- Provenance Hippocrates called for physicians to engage with toms there are which are akin to these ...These Invited contribution research in health and disease, as today. Every must be duly weighed when considering and decid- from the new discovery opens up another level of inquiry ing who is suffering from one of these diseases in an James Lind Library that goes deeper into understanding how the acute, fatal form, or fatal illness, or one from which human body functions. he may recover ...Epidemics I 1.XXIV-V6 An aspect of Hippocratic Medicine that was The woman suffering from angina who lay sick in innovative at the time relates to the practice of col- the house of Aristion began her complaint with lecting detailed records of the patients Hippocrates indistinctness of speech. Tongue red, and grew cared for. This practice marked a significant shift parched. First day: Shivered, and grew hot. Third from the then traditional oral transmission of day: Rigor; acute fever; a reddish, hard swelling in knowledge. Plato commented on this new move- the neck, extending to the breast on either side; ment of the written word, in his work Phaedrus: extremities cold and livid, breathing elevated; drink returned through the nostrils –she could not For this [the art of writing] will cause forgetfulness swallow- stools and urine ceased. Fourth day: gen- in the minds of those who have learned, because eral exacerbation. Fifth day: Death. Epidemics III, they will neglect their memory. Having put their 1. Case VII6

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Personalized medicine based suggesting that the Hippocratic methods of on diet and lifestyle inquiry were appropriate and on the right track. For example, in Airs, Waters and Places the author The special interest in each person’s particular describes the tribe of Scythians in whom, he says, characteristics distinguishes Hippocratic medi- overweight and obesity was prevalent due to the cine significantly from modern medicine. fact that they were leading sedentary lives. The Hippocrates put the person at the center of his relationship between reduced energy expenditure attention, while modern medicine focuses on the and overweight is therefore correctly observed: disease. Hippocrates was first and foremost inter- ested in finding out what led to the development ...Their bodies grow relaxed and squat, firstly of the symptoms experienced by the person. He because, unlike the Egyptians, they do not use distinguished lifestyle patterns and personal char- swaddling clothes, of which they have not the acteristics that predisposed to certain conditions. habit, for the sake of their riding, that they may Although modern medicine is increasingly sit a horse well; secondly, through their sedentary accepting the importance of lifestyle in the devel- lives. For the boys, until they can ride, sit the great- opment of chronic diseases, it continues to give est part of the time in the wagon, and because of the priority to examining the illness and treating the migrations and wanderings rarely walk on foot; symptoms. Hippocratic therapies involved pri- while the girls are wonderfully flabby and torpid marily changes in food, exercise and other life- in physique ...[my emphasis]. Aer. 1.206 style patterns while modern medical treatments concentrate on pharmacological and surgical In addition, the Hippocratic author describes the interventions. causes of their infertility: In The Art, the writer gives general advice on how a patient should be treated. He explains that A constitution of this kind prevents fertility. The men medical treatment consists of much more than have no great desire for intercourse because of the drugs: moistness of their constitution and the softness and chill of their abdomen, which are the greatest checks The most famous doctors cure by changing the diet on venery. Moreover, the constant jolting on their and lifestyle of their patient and, by using other sub- horses unfits them for intercourse. Such are the stances. Such capable doctors have the knowledge causes of barrenness in the men; in the women they and ability to use the therapeutic properties of most are the fatness and moistness of their flesh,which natural or man-made products. The Art 2.6 6 are such that the womb cannot absorb the seed. For neither is their monthly purging as it should be, but The word diet (d0aia – diaita) in Ancient Greek scanty and late, while the mouth of the womb is closed had a much broader meaning; it meant ‘mode of by fat and does not admit the seed. They are person- life’ and it encompassed the various aspects of life- ally fat and lazy, and their abdomen is cold and soft. style: food and drink, physical exercises, baths and These are the causes, which make the Scythian race massage, sun-therapy, sleep and sexual practice, infertile. A clear proof is afforded by their slave- ‘passions of the soul’, habits and generally the girls. These, because of their activity and lean- whole way of leading one’s life. Modern medi- nessofbody,nosoonergotoamanthantheyare cine’s re-discovery of the importance of lifestyle with child [my emphases]. Aer. 1.216 in disease prevention and treatment resonates with the approach taken by Hippocrates. The author observes correctly that obesity and a sedentary lifestyle have a negative impact on Timeless observations women’s reproductive health, as has also been reported in contemporary studies.11–13 He Although the physiologic explanations found in attempts a physiological explanation for male fer- the Corpus differ from contemporary knowledge, tility problems, which differs from modern under- many of the Hippocratic comments, aphorisms standing but which connects the act of horse and treatments, reveal a clear understanding of riding to sexual and reproductive dysfunction in disease prevention, causes and prognosis, men. Current studies suggest that activities

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similar to horse riding, such as cycling, can impair This timeless statement and other ‘unchanging male fertility by increasing scrotal temperature14 truths’ in the Hippocratic Corpus, written and increase the risk of erectile dysfunction by around the fourth century BC, continue to perineal compression causing vascular, endothe- ring true today. What will remain of the lial and neural abnormalities.15 medicine we practice today in 25 centuries, we As a final example of the timelessness of wonder? Hippocratic observations, the modern doctor can look at what is said about the relationship References between body weight and longevity in the book 1. Darwin F, ed. The Life and Letters of Charles Darwin, Vol II. of Aphorisms: London: John Murray, 1887 2. Pinault JR. Hippocratic Lives and Legends – translation of ‘The Those who are constitutionally very fat are more apt Origins and Life of Hippocrates, According to Soranus’. Leiden: Brill, 1992 to die quickly than those who are thin. Aphorisms 3. Jouanna J. Hippocrates. Baltimore: John Hopkins University 6 2.44 Press, 1999 [DeBevoise MB, transl.] 4. Hippocrates (5th century BCE). Ancient medicine. In: Littre´ Numerous modern studies show reduced life MPE, ed. Oeuvres completes d’ Hippocrate, vol 1. Traduction expectancy as a result of overweight/obesity Nouvelle Avec le Texte Grec en Regard, Collatione Sur Les Manuscrits et Toutes les Editions; Accompagnee d’ une being the number one public health issue for Introduction, de Commentaries Medicaux, de Variants et de 16 most industrialized countries. Notes Philologiques; suivie d’ une Table Generale des Matieres. Paris: J-B Bailliere, 1839:572 5. Nutton V. Ancient Medicine. London, New York: Routledge, A medical legacy 2004 6. Jones WHS. Hippocrates. Volume I. With an English Translation by WHSJ. Cambridge, MA, London: Loeb The words that the writer uses in Ancient Medicine Classical Library, 1923 to describe the medicine of older generations 7. Chalmers I. The lethal consequences of failing to make full could be used today to describe Hippocratic use of all relevant evidence about the effects of medical Medicine itself: treatments: the importance of systematic reviews. In: Rothwell P, ed. Treating Individuals: From RandomisedTrials to Personalised Medicine. London: Elsevier, we ought not to reject the ancient art as non- 2007, pp.37–58 existent, or on the ground that its method of inquiry 8. Darzi A. Evidence-based medicine and the NHS: a com- is faulty, just because it has not attained exactness mentary. JRSocMed2008;101:342–4 in every detail. Having been able by reasoning to 9. Stuebe AM. Level IV evidence–adverse anecdote and clin- ical practice. New Engl J Med 2011;365:8–9 rise from deep ignorance to approximately perfect 10. Totelin LMV, ed. Plato. Hippocratic Recipes: Oral and Written accuracy, I think we ought to admire the discoveries Transmission of Pharmacological Knowledge in Fifth- and as the work, not of chance, but of inquiry rightly and Fourth-Century Greece. Leiden: Brill, 2009, p.1 correctly conducted. Ancient Medicine 1.126 11. Rich-Edwards JW, Spiegelman D, Garland M, et al. Physical activity, body mass index, and ovulatory disorder infertility. Epidemiology 2002;13:184–90 Despite today’s advanced knowledge though, it 12. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. seems that contemporary medicine can still turn Diet and lifestyle in the prevention of ovulatory disorder to Hippocrates for inspiration and understanding. infertility. Obstet Gynecol 2007;110:1050–8 And the complexity of medical practice, which is 13. Zain MM, Norman RJ. Impact of obesity on female fertility accurately described in the first Hippocratic and fertility treatment. Women’s Health 2008;4:183–94 14. Jung A, Strauss P, Lindner HJ, Schuppe HC. Influence of Aphorism, still applies to modern healthcare moderate cycling on scrotal temperature. Int J Androl professionals: 2008;31:403–7 15. Sommer F, Goldstein I, Korda JB. Bicycle riding and erectile Life is short, the Art long, opportunity fleeting, dysfunction: a review. J Sex Med 2010;7:2346–58 experience false, judgment difficult. Aphorisms 4 16. Thompson D, Edelsberg J, Colditz GA, Bird AP, Oster G. 6 Lifetime health and economic consequences of obesity. Arch 1.1 Intern Med 1999;159:2177–83

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