HISTORY OF MEDICINE
Spyros G. Marketos
Department of History of Medicine, Athens University Medical School, Athens
The medical school of Kos is connected with the first creative period of scientific medicine: Hippocratic medicine. Hippocrates, the "father" of rational medicine, worked on the island of Kos before the founding of the Asclepieion. He came from an old local priestly family and travelled extensively Hippocrates was a famous practitioner and a teacher of the art of healing, so his outlook was necessarily pragmatist, and the view which he took of his patient's case tended to be essentially of a prognosis through to treatment. The Hippocratic diagnostic system, based on observation and logical reasoning, provided the fundamental principles of medical practice. The medical school of Kos had a profound understanding of human suffering and emphasised that the place of the physician is at the patient's bedside and that each disease has a natural cause. Hippocrates believing 1n "the healing power of Nature" was directed toward the patient as a physical, mental and spiritual whole and denied supernatural explanations and removed the art of medicine from the realm of superstition and magic. He crystallised the existing knowledge of the Koan and Knidian medical schools into a systematic science and he made physicians understand the high ethical and moral inspiration of their profession Hippocrates was respected not only as a great physician and teacher, but also as an inspired philosopher and thinker. Under his leadership the medical school at Kos produced many fine scholars and pupils who added their experience and other writings to the works of the master himself.
The history of Hellenic medicine is chiefly concerned with two main invading streams of Greek tribes: that of the Dorians, who travelled to Crete and to the Island of Kos and the opposite peninsula of Knidos, and that of the Ionians, who colonised most of the remaining; part of western Asia Minor. These two populations were responsible for the main intellectual output of the Greeks of those early times. The medical system, which they initiated first, took shape in western Asia Minor, and hence spread over the whole of the Greek world. The Greek system of medicine which thus arose in Asia Minor had various roots and a variety of influences as indeed could be expected of the medical practice of a mixed people, living under very complex social conditions. In the first place, Miletus itself an Ionian Greek city on the west coast of Asia Minor, was a place of tremendous activity. According; to tradition, being a colony itself, it founded no less than ninety new colonies and through these colonies, one at which was the settlement at Naucratis in Egypt, was brought into contact with older neighbouring cultures and became extremely wealthy.
It is obvious that early Greek Medicine derived knowledge from many older sources (1-7) and had wide connections with other lands and cultures. Due to their geographical location, the Greeks were exposed to the influence of Egyptian, Assyro-Babylonian, Mesopotamian, Phoenician and Minoan (Cretan) civilisations (1-3). Greeks also learned a great amount from lay medicine and from ancient Jewish medicine, especially in the fields of sanitary laws, prevention and prophylaxis (3).
The birthplace of Hippocrates is the island of Kos. It is the second-largest island of the East Aegean Sea (Dodecanese), second in size to Rhodes, with an area of 112 square miles. It is approximately 27 miles long and six miles wide at its points, and is only 2.5 miles from the mainland, opposite to the ancient town of Halikarnassos, which is now Bodrum and 10 miles from Knidos (Figure 1). During the 6th century BC, Kos belonged to the league of six cities (Hexpolis) along with Halikarnassos, Knidos and Rhodes. It is a fertile, hilly island covered in vegetation, and has been a popular destination since Roman times. The taproot of western civilisation, as William Osler wrote, "sinks deep in Greek soil, the astounding fertility of which is one of the outstanding facts of history" (8).
The main difference between the medical school of Knidos and that of the homeland of Hippocrates (8-10) lies in the fact that the latter was more interested in disease in general and the former in particular diseases. In Knidos, diseases were supposed to have been elaborately categorised according to the organ affected, a system with some resemblance to the practice in the Mesopotamian lands east of Knidos. To use modern terms, we might say that the doctors of Kos dealt chiefly with general medicine and their Knidian colleagues with medical specialities. Both tendencies were justifiable and one might argue that the second was at least as necessary as the former, but even so it was premature. According to Galen, Knidian doctors recognised seven diseases of the bile and twelve of the bladder; this was obviously artefactual. The means of exact diagnosis were utterly insufficient to characterise symptoms, that is, to distinguish between symptoms that have differential value and those that do not. In other words, Knidian medicine concentrated on the disease rather than on the patient and multiplied the disease entities, while on the other hand, Hippocratic medicine emphasised the patient rather than the disease, with great attention paid to observing and evaluating the physical findings (5-17).
It is interesting to note that the two places where medical thought matured, the peninsula of Knidos and the island of Kos (17), were both in the same region and appeared over the horizon at about the same time. The occurrence of the two famous medical schools in that small corner is not accidental. A look at the map depicts that if one were to sail northwest from the island of Kos, one would reach the Ionian islands, or on steering southwards, a short journey would take one to Rhodes.
From Rhodes one can sail in a circle to Cyprus, Phoenicia, Egypt, Cyrenaica, sail across the Aegean and the Mediterranean almost without ever losing sight of land. The main point is that the coast of Caria, with its back to Asia, was relatively near to Crete, Cyprus and Egypt, and hence was a strategic location for intellectual exchanges. Knidos and Kos may not have been as close to each other as depicted, and this we cannot yet explain. It may be that one was the offshoot of the other.
The Asclepieion of Kos, approximately 4 km southwest of the city, is the famous Sanctuary of Asclepios, (18-22) which dates from the 4th century BC and was built on the site of a still older temple to Apollo. It is one of the most beautifully appointed island shrines in the Aegean; it was discovered by the German archaeologist Rudolf Herzog in 1901 (8, 9) and was systematically excavated by the Italians. The German excavations brought to light more than twenty inscriptions concerning physicians, giving evidence of the flourishing condition of the medical school of Kos in the 3rd and 2nd centuries BC, and of its relationship with the Asclepieion. Herzog believes that an inscription that he found should be considered as the sepulchral inscription of Thessalus, son of Hippocrates the Koan.
Asclepios, was the son of the God Apollo and the father of a large family, most of whom had health and medical functions: his wife, Epione, caretaker of the sacred snakes, soothed pain; his daughter, Panacea, had a cure for everything; Hygeia, another daughter, whose domain was public health and the prevention of disease, fed the temple serpents; Telesphorus, always represented as a child, cared for convalescents; Podalirius was the army surgeon and psychiatrist, and lastly Machaon was the famous surgeon of whom Homer writes in a famous line of the greatest epic in every European language Iliad (II. XI:514): "A physician is a man worth many others" (2). The latter two sons achieved great fame as military medics during the Trojan war (2, 18-22).
It is important to clarify that traditional medicine began with the God of the Sun, leader of the Muses and patron of physicians, Apollo. It was continued by his son the God of healing art and ancient hero of medical care Asclepios (22) who was taught the art of medicine by the wise surgeon and kind medical Centaur Chiron, and accomplished by Hippocrates. It is also very important to note that rational medicine did not exclude a parallel to-existence both of Hippocratic (rational) and of Asclepian (religious) medicine ( 19, 20, 23-26). Furthermore, there are traces of scientific method in the treatment of patients in the Asclepian culture. There was, indeed, a relationship between the practice of some of the physicians and that of some of the priests, but the actual extent and nature of this relationship is not yet known (7, 25). It is interesting to note however, that the two systems were parallel, but quite distinct in their most typical developments and that religion and medicine, priest and physician, both worked towards the same aim: the healing art (26). Priestly and rational medicine were a common practice on the island of Kos, up to the 5th century AD, when the cult of Asclepios is found mingled with that of Christian churches.
To conclude, the Greek island of Kos was well known to the ancient Greeks for its wealth and its settlements, but its greatest fame was due to Hippocrates who was born there and to its Asclepieion which, for hundreds of years after the death of Hippocrates, was operating on the basis of some of the Hippocratic principles in matters of therapy and training and had become the most famous medical centre of the Hellenic and the Roman Empires.
For practical purposes, the history of rational Greek medicine begins with the schools of Knidos and of Kos, as it is directly from these, and especially from the latter, that the father of Medicine arose (11-14, 18, and 24). From the writings of these medical schools, however, they were much influenced by earlier or contemporary philosophies, such as those of the Ionian and Sicilian schools, usually known as "pre-Socratic" (27). Hippocrates and Socrates were practically contemporary, both belonging to the classical or Porcelain age of Greece. They were acquainted with the same culture conditions, and both, in their own spheres, made a somewhat similar advance therefrom. Hence pre-Socratic thinkers may in a history of medicine be also termed pre-Hippocratic (4, 27-30).
Philosophical speculation seems to have begun on the periphery rather than at the centre of the Greek world (27-29). At any rate the early cosmological speculators hailed from ancient Asia Minor and from southern Italy or Sicily.
The precursors of rational medicine were early Greek philosopher-physicians (2, 5, 27): the Milesians, the Pythagoreans, the Sicilians, who sought to explain the universe by pure reason. Some explained the world process by monistic theories; others projected a dual or multifaceted version of phenomena. For example:
i. Thales of Miletus propounded the primary principle that water was the cause of all things;
ii. Pythagoras of Samos constructed an orderly universe base on the harmony of numbers, combining this mystic concept with scientific experiments in music theory and acoustics, and;
iii. Empedocles of Agrigentum explained the world in terms of four elements: earth, water, air and fire which he called the root of all things ( 18, 26-29).
The Hippocratic writings clearly reveal much evidence of philosophical influences (11, 19, 29). Whereas some treatises manifest the strong influence of a single philosopher, others are eclectic and select from different philosophers' theories, which suit their particular need. Others again, while adopting no particular philosophical theory, reveal themselves to be none the less deeply influenced by the concepts and categories of pre-Socratic philosophy generally. Although Hippocrates was more interested in recording his clinical observations than philosophising, the "Aphorisms" and the "Oath" (31-32) are exemplary of a blending of the thoughts of a reflective philosopher and the wisdom of an experienced practitioner.
Hippocrates considered ethical behaviour the foremost characteristic of a physician. His ethical concepts are described in five books, namely, the Oath, the Physician, the Law, Medical Decorum, and his famous Aphorisms (12-14). They explore the ethical attitudes necessary in medicine and underscore the many difficulties inherent in medical practice. The "Hippocratic Oath" (4-6, 31, 32) has been adopted as a pattern by the medical community throughout the ages. It is a code of ethics (not a legal text as some insist) and an ethical guide for those who practise medicine, a one-page text about which hundreds of thousands of pages have been written throughout the ages. It was written "to inspire human feelings in the mind of the students and the younger physicians" as firstly stated by the Latin author Scribonius Largus.
Hippocratic medicine and philosophy combined the 6th century BC concepts of the Ionian philosophers of Asia Minor with Pythagoras' concepts and the theory of his pupil Alcmaeon (School of Croton in southern Italy) and Empedocles (4, 29, 33), regarding the equilibrium of dissimilar elements and of opposite quantities, thus establishing the humoral theory for human physiology and pathophysiology. According to this theory, human beings are made of a soul and a body, which contain four humours (fluids): blood, phlegm, black and yellow bile, that correspond to the four organs of the body, the heart, the brain, the liver and the spleen. These four humours are in continuous motion through the circulation. The equilibrium (the balance) and the harmony of the four (4) humours (eucrasia in Greek terminology), is identified with health. The disequilibrium (the imbalance) and disharmony (dyscrasia in Greek terminology) produces disease. Sickness was considered to be an imbalance between the four fluids caused by an influence from the environment, seasons, weather, diet, nutrition or other factors, and treatment was thus an effort to restore the balance (6, 12-16, 34).
During the twenty-five centuries that separate us from Hippocrates, his theory of the four humours has influenced several medical theories, even modern biology and medical philosophy (33). It is important to emphasise that the four basic elements of Empedocles' doctrine (water, air, fire and earth), each with its specific quality (moist, dry, hot and cold), giving emphasis on the number four (Figure 5) led to the Hippocratic hypothetical system (Figure 6) which explains health and illness. Modern advanced technology in molecular biology and genetics have proven experimentally that the Hippocratic model (pattern) of the four humours is compatible with the structure of the double helix (DNA) hypothesis (Figure 7). As proposed by the two Nobel prize-winners, Watson and Crick, the genetic code of men, animals, plants, bacteria and viruses is the result of the mixture of four nucleic bases of the DNA. The different combinations of these four bases (adenine, guanine, cytosine and thymine) which we abbreviate A, G, C, T, describe most of the characteristics of the "code of life" (25). In addition, each one of these four nucleic acids is constituted from a mixture of four vital elements (carbon, oxygen, hydrogen and nitrogen) which have a lot of similarities with the Hippocratic hypothesis (Figures 6 and 7). The extrapolation of the adenine-thymine and guanine-cytosine pairs system, used to construct the double helix, is not related but reminds one of the Hippocratic hypothetical system which explains the healthcare medical system.
No account of Hippocrates' philosophy would be complete without referring to three Hippocratic messages which contain the essence of his medical philosophy (3, 4, 11, 19, 22, 30):
"Life is short; and the art long; and the right time an instant; and treatment precarious; and the judgement difficult. It is necessary for the physician not only to provide the needed treatment but provide for the patient himself and for those beside him and to provide for his outside affairs" (Hippocrates
Aphorisms, L. IV, 458).
"What drugs will not cure, the knife will; what the knife will not cure, the cautery will; what the cautery will not cure must be considered incurable" (Hippocrates Aphorisms, L. IV, 609).
"For where there is love of man there is love of the (medical) art" (Hippocrates Precepts , L. IX, 258).
To conclude, the philosopher-physicians of ancient Greece were a bridge between the medicine of the Asclepian (Homeric) age and Hippocratic medicine, which developed in close company with natural philosophy. Hippocratic writings strongly support that in order to be a good physician, one must first of all be a good human being.
The name of Hippocrates is synonymous with the medical school of Kos and is connected with the most creative period of scientific medicine in antiquity (6, 34, 37). Hippocrates himself was an ardent traveller throughout almost all the East Mediterranean countries. Under his leadership the medical school of Kos produced many prominent scholars and pupils who added their experience and writings to the works of the master himself.
In the present article the term "school of Kos" (σχολή της Κω) is used, meaning the place where Hippocrates taught and practised the rational medicine and established the ethical principles both in theory, as well as in clinical practice.
The writings of the Koan teachers, presumably by Hippocrates or by his pupils, during or shortly after his time, were collected in the 3rd century BC for the
Alexandrian library by Alexandrian scholars under the title "Corpus Hippocraticum" (38). On the other hand, the "Knidian Sentences" was a collection of medical treatises which has not survived and is only known by mention in the "Corpus Hippocraticum" and through later commentators on Hippocrates, especially Galen in the 2nd century AD (17). Although both Kos and Knidos, where the treatises in the Hippocratic Collection originated, were Dorian settlements, the "Corpus Hippocraticum" itself is written in the Ionic dialect, which became the standard literary medium not only for expounding philosophy, medicine and science generally, but also, initially, for the world history (27).
Some of the most important medical treatises in the "Corpus Hippocraticum" are the following: The Sacred Disease, On Prognostic, On Prorrhetics (book I and II), On the Nature of Man, On Regimen, On Humors, On Affections, On Diseases, On the Physician, On Wounds and Ulcers, On Fractures, On Joints, On Instruments of Reduction (Mochlicon), On Airs, Waters and Places, On Epidemics (book I and III), On Ancient Medicine, On Precepts, On the Surgery, On Law, On Decorum, On the Art, On Nutriment, The Monumental Oath and the Famous Aphorisms (12, 13, 23, 38).
The medical terminology of the "Corpus Hippocraticum" is almost identical with the one today: carcinoma, oedema, hydrops (dropsy), nephritis, hepatitis, arthritis, herpes, erysipelas, cholera, pneumonia, pleurisy, apoplexy, melancholy, tetanus, mania, empyema, emphysema, ileus, thorax, paralysis, ulcus, diarrhoea, dysury, dysentery, cachexia, hydrocephalus, epilepsy, lethargy, cystitis, leprosy, haematuria, crisis, coma, paroxysm, dyspnoea, orthopnea, asthma (38, 39), and several other scientific words of Greek origin. Unfortunately, no Greek
medical literature prior to the "Corpus Hippocraticum" has survived. The only preHippocratic Greek medical writer, whose views have survived in any form, was Alcmaeon of Croton.
Hippocrates (460-377 BC), about whose life we have sparse information, worked on the island of Kos before the founding of the Asclepieion (16). He came from an old local priestly family and travelled extensively before dying in Larissa, Thessaly. His pupils established a centre of healing here after his death, using the old Hippocratic methods (clinical ' examination, prognosis and therapy).
The greatest teacher of Kos classified clinical and physical observations (6, 13-16, 34-36), and formulated principles as he taught his pupils under the famous plane-tree which still stands in the main square of Kos (Figure 9). He observed diseases with the eye of a naturalist and established rules by which the physician would know what to expect and what to do at the right time. He had a profound understanding of human suffering and emphasised on many occasions that "the place of the physician is at the bedside of his patient". Hippocrates and his disciples collected scientific case histories as no-one had done previously; for example in "Epidemics" he described the events of illness with cool detachment and in a truly scientific way he declared: "State the past, diagnose the present and foretell the future". He observed pneumonia, pleurisy, tuberculosis, malaria and many other diseases. In "Airs, Waters, Places" appeared the first treatise on public health and environmental medicine. It constitutes the first known systematic endeavour to present the causal relations between environmental factors and disease (23). Hippocrates stressed the meteorological variations and the character of the seasons as the main elements determining the rise and fall of epidemic diseases and their seasonal and annual incidence (22).
In studying the works of Hippocrates no-one can fail to remark on his accuracy of clinical observation, his fundamental skills of recording patient history and his famous doctrine that the pathology of an organ reflects the illness of the whole body (3-12). He was one of the most significant figures in the history of science because he separated the art of healing from the notion of demons, superstition and magic (3, 16, 19, 40). Diseases had a logical interpretation, they were no more a curse of the gods or a punishment to man due to divine wrath. The Hippocratic diagnostic system, based on logical reasoning, observation and belief in the "healing power of Nature" (6-16, 34), formed the basis of medical practice. The healing art, according to Hippocrates, was linked to three conditions: the disease, the patient and the physician; this latter is needed to be moreover a servant of the art (the "techne"). Every patient was a separate case and this individuality precludes a fixed dogma for curative methods.
"For the physician", as it is written in one of his relevant works, "it is undoubtedly an important recommendation to be of good appearance and well-fed, since people take the view that those who do not know how to look after their own bodies are in no position to look after those of others. He must know how and when to be silent, and to live an ordered life, as this greatly enhances his reputation. His bearing must be that of an honest man, he must be towards all people honest, kindly and understanding. He must not act impulsively or hastily; he must look calm, serene and never cross" (40).
The Hippocratic physician was basically both a craftsman and scientist (27, 28), accompanied into his workshop by an audience of pupils and other bystanders, who discussed the diagnosis and treatment of every case. When he went to the patients' home he had the duty to persuade not only him but also the relatives. He followed the more communal character of life in antiquity, which did not permit any special discretion or intimacy in his behaviour. If he made a reputation for himself, then this was publicised in other towns and he probably attracted patients from other regions or he was invited to visit other cities. If he was called upon la undertake the treatment of a serious disease he may have declined or accepted, explaining the slight prospects of a cure. Certain situations, with a predictable fatal outcome, where intervention was prohibited, justified the Hippocratian dogma "to help or at least not to harm".
The Hippocratic physician attended cases of every type, and did not refuse to do his best for a case because the use of an instrument was demanded. He was thus no specialist, but he combined traditional internal medicine with surgery. A number of Hippocrates' surgical methods can still. be considered valid (38, 40). Pus collection around the lungs (empyema pleurae). is an illustrative case. It was treated, and usually cured, by making a small opening .in the chest wall, and inserting a tube for drainage of the pus. In addition, fractures 'in which the bone ends had slipped past each other were restored to the correct position by protracting and stretching. He was reluctant to administer drugs. The Hippocratic drugs were neither numerous nor complex. Some of them, however, were very efficient, and, their judicious if reluctant use at the right juncture saved many a life. The treatment at the Hippocratic School of Kos was comprised of massage, sea baths, diet and exercise (816). Hippocrates had an excellent opportunity of estimating the good and bad effects resulting from the application of gymnastic exercises in the cure of diseases, under the guidance of Herodicus.
In keeping with naturalistic data (34), tending towards the natural course; of disturbances of the whole body and the prognosis rather than the diagnosis of the illness, focusing more on the diseased patient than on the disease, the Hippocratic writings were rooted in the authority of observed facts. Prognosis was considered highly important (12-15, 36). Every phenomenon was carefully recorded. The "Facies Hippocratica", the so-called clinical picture of surgical shock, gave cause for serious alarm: "Nose peaked, eyes sunken, temples hollow, ears cold and contracted with lobes fumed outwards, rough and tense skin, and the whole face greenish or black or grey-blue" (40).
I shall document my review article with ten of the many prophetic concepts from the "Corpus Hippocraticum" (13-15, 38) that are significant and transpire from the study of the Medical school of Kos:
i. "the physician must investigate the entire patient and his environment"
ii. "human health cannot be treated separately from the natural environment"
iii. "the physician must assist nature which is the physician of the diseases"
iv "the physician must co-operate with the patient, the patient's attendants and external ircumstances"
v. "nothing happens without a natural cause"
vi. "the best physician is the one who is able to prevent and predict"
vii. "all excess is hostile to nature"
viii. "for extreme diseases extreme strictness of treatment is most efficacious"
ix. "the brain is the most powerful organ (messenger to consciousness) of the human body";
x. "when more nourishment is taken than the constitution can stand, disease is caused".
To conclude; Hippocrates was the founder of the Medical school of Kos and his name is strongly connected with the first creative period of scientific medicine. His diagnostic system was based on logical reasoning; on careful clinical observation, on a whole humane (psycho-socio-somatic) approach to the patient (holistic v medicine) and on the right way of thinking (rationalism). The greatest figure of the entire history of Medicine was observing diseases with the eye of a naturalist, and established the ethical and moral rules of medical practice. Hippocrates is still a contemporary since modern medicine can draw some useful lessons from his writings.
Acknowledgements
I am indebted to Mary Economidis for her contribution in the preparation of this manuscript.
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Received April 23, I997 Accepted May 28, I997