More recently the study of ancient medicine has gained attention, not from merely antiquarian curiosity about the developmental history of the healing arts, but from its illumination on kindred concepts arising in and influenced especially by philosophy and science, yet also inclusive of the wider Mediterranean culture. Of particular interest to me today is the Hippocratic Oath, which many believe to apply to a small group of practicing medics due to the parochial constraints it imposes on its adherents, thus necessarily limiting the scope of its practice. However, let’s take a look at this document in full:
I swear by Apollo the healer, by Asclepius, by Health (Hygeia), and Panacea and by all the gods and goddesses, making them witnesses, to bring to completion this oath and written contract in accordance with my ability and judgment:
To revere the man who taught me this art as equally as my ancestors, and to share my living with him, and to share with him when he lacks money, and to esteem his progeny equally as my brothers, and to teach this art, if they wish to learn it, without a wage or written contract, and to share the precepts and lectures and all other instructions both with my own sons and those of the one who taught me, and to no one else.
And I shall make use of a regimen for the help of patients in accordance with my ability and judgment, but not to act for injury or a wrongful act. And I shall not give a deadly drug to anyone, though he ask for it, nor will I offer up such counsel. In a like manner, I shall not give any abortifacent (lit. destructive pessary) to a woman. But I shall observe my life and my art in a holy and reverent manner. I shall not cut even one suffering from the stone, but I shall give way to the practitioners of this deed (i.e. surgeons). As many houses as I enter into I shall proceed for the benefit of the patients, standing afar from every willing and destructive harm, and especially from sexual acts with both female bodies and male, free and slave alike. Whichever things I hear or see in my practice or outside my practice in the course of daily life, things which are unnecessary to ever blurt out, I shall consider such things unspeakable. If I complete this oath, and do not violate it, may there be a gain of reputation because of my life and art from all men forever. But if I transgress and forswear, may there be the opposite (Translation mine, Hippocratic Oath). [1]
I want to draw out a plausible interpretation as to the theoretical guidance of this oath, sworn to not only the four physician gods, but of such gravity that all the gods and goddesses are invoked as witness. My idea is that a reverence for the body guided this guild (for this seems an apt description for this dedicated association) in all its interactions with patients. There may have been some religious motivation for this precept or more likely, it was merely a central, refining filter through which medical practices could be easily guided instead of the alternative of detailed and cumbersome rules, such as the nitpicking “best practices” I imagine hinders modern day medical ethics.
Here are some examples that make me suspect a cult of the body. Now of course, just as today, the physician is sworn not to give any poison to a man, and “in a like manner” (ὁμοίως) he is also not to give an abortifacent to any woman. The “in a like manner” is intriguing because, if we are to draw an analogy, in the first instance it is the man’s body that is injured by being drugged. Thus, in the second instance, we may infer that the woman’s body is injured by being drugged by the abortifacent. [2] Also of note then, is that the preservation of the child is not primarily in view. More intriguing is the proscription on surgery, telling physicians that they cannot “cut” even if the patient is suffering from stones, one of the most painful maladies. [3] The patient must be given a referral instead. It is tempting to think that a ban on cutting is due to an overzealous adherence to preserve or improve not the state of the patient’s health, but rather to have the physician impose even a temporary harm for a greater long-term good. Alternatively, though, given the last line of the oath, perhaps we can consider that the physician has his good reputation in mind, and that if word gets around that he “cuts” people, even for the better, patients will be hesitant to visit him. One need only reflect on how skittish moderns are towards doctor visits, even with drugs, anesthesia and centuries of knowledge. Lastly consider the strange wording of the prohibition on sleeping with patients: abstain “especially from sexual acts with both female bodies and male, free and slave alike.” This is the literal translation, it is does not say abstain from females and males, but female and male bodies (γυναικείων σωμάτων καὶ ἀνδρῴων). The relationship of patient and doctor requires and must respect the solemn vulnerability of the nude body, and what better way to further this than with a principled, philosophical reverence for the body?
REFERENCES:
[1] Ὄμνυμι Ἀπόλλωνα ἰητρὸν καὶ Ἀσκληπιὸν καὶ Ὑγείαν καὶ Πανάκειαν καὶ θεοὺς πάντας τε καὶ πάσας, ἵστορας ποιεύμενος, ἐπιτελέα ποιήσειν κατὰ δύναμιν καὶ κρίσιν ἐμὴν ὅρκον τόνδε καὶ συγγραφὴν τήνδε· ἡγήσεσθαι μὲν τὸν διδάξαντά με τὴν τέχνην ταύτην ἴσα γενέτῃσιν ἐμοῖς, καὶ βίου κοινώσεσθαι, καὶ χρεῶν χρηΐζοντι μετάδοσιν ποιήσεσθαι, καὶ γένος τὸ ἐξ αὐτοῦ ἀδελφοῖς ἴσον ἐπικρινεῖν ἄρρεσι, καὶ διδάξειν
10 τὴν τέχνην ταύτην, ἢν χρηΐζωσι μανθάνειν, ἄνευ μισθοῦ καὶ συγγραφῆς, παραγγελίης τε καὶ ἀκροήσιος καὶ τῆς λοίπης ἁπάσης μαθήσιος μετάδοσιν ποιήσεσθαι υἱοῖς τε ἐμοῖς καὶ τοῖς τοῦ ἐμὲ διδάξαντος, καὶ μαθητῇσι συγγεγραμμένοις τε καὶ ὡρκισμένοις νόμῳ ἰητρικῷ, ἄλλῳ δὲ οὐδενί. διαιτήμασί τε χρήσομαι ἐπ᾿ ὠφελείῃ καμνόντων κατὰ δύναμιν καὶ κρίσιν ἐμήν, ἐπὶ δηλήσει δὲ καὶ ἀδικίῃ εἴρξειν. οὐ δώσω δὲ οὐδὲ φάρμακον οὐδενὶ αἰτηθεὶς θανάσιμον, οὐδὲ ὑφηγήσομαι συμβουλίην
20 τοιήνδε· ὁμοίως δὲ οὐδὲ γυναικὶ πεσσὸν φθόριον δώσω. ἁγνῶς δὲ καὶ ὁσίως διατηρήσω βίον τὸν ἐμὸν καὶ τέχνην τὴν ἐμήν. οὐ τεμέω δὲ οὐδὲ μὴν λιθιῶντας, ἐκχωρήσω δὲ ἐργάτῃσιν ἀνδράσι πρήξιος τῆσδε. ἐς οἰκίας δὲ ὁκόσας ἂν ἐσίω, ἐσελεύσομαι ἐπ᾿ ὠφελείῃ καμνόντων, ἐκτὸς ἐὼν πάσης ἀδικίης ἑκουσίης καὶ φθορίης, τῆς τε ἄλλης καὶ ἀφροδισίων ἔργων ἐπί τε γυναικείων σωμάτων καὶ ἀνδρῴων, ἐλευθέρων τε καὶ δούλων. ἃ δ᾿ ἂν ἐν θεραπείῃ ἢ ἴδω ἢ ἀκούσω, ἢ καὶ ἄνευ
30 θεραπείης κατὰ βίον ἀνθρώπων, ἃ μὴ χρή ποτε ἐκλαλεῖσθαι ἔξω, σιγήσομαι, ἄρρητα ἡγεύμενος εἶναι τὰ τοιαῦτα. ὅρκον μὲν οὖν μοι τόνδε ἐπιτελέα ποιέοντι, καὶ μὴ συγχέοντι, εἴη ἐπαύρασθαι καὶ βίου καὶ τέχνης δοξαζομένῳ παρὰ πᾶσιν ἀνθρώποις ἐς τὸν αἰεὶ χρόνον· παραβαίνοντι δὲ
36 καὶ ἐπιορκέοντι, τἀναντία τούτων.
[2] One source (definitely Oxford University Press) I read, though I can not find it now, claimed that only 1 in 10 women survived an abortion.
[3] Aulus Cornelius Celsus (c. 25 BC – c. 50 AD) divided medicine into precisely three areas: dietetic, pharmacology and surgery. This division is believed to extend much further back into antiquity however.
Interesting! I admit with some shame that I’d never actually read the whole thing carefully before. I’m intrigued by your suggestions, and especially unsure what to say about the use of σωμάτων in the sexual prohibition. I’m not so convinced, though, by your reading of the prohibition on poisons and abortifacients. Describing the φάρμακον as θανάσιμον strikes me as pretty clearly pointing to killing as the thing to be avoided, not simply injuring a person’s body (“man’s body” in your description is too narrow if you mean “male”; the gender of οὐδενὶ is masculine simply because it is unmarked). Granted that injury to the body comes into view because certain sorts of injuries to the body will kill a person, it seems unduly restrictive to see the prohibition as focused on the body as such rather than the whole person. Similarly, if the prohibition on abortifacients is grounded “in a similar way,” it would be the killing that is to be avoided, not simply injury to the woman’s body. What’s more, since the prohibition on giving a “lethal drug” to anyone — and not just males — is covered by the previous prohibition, if the only concern about abortifacients were that they kill pregnant women more often than not, there would be little reason to single it out. It seems simpler to prefer the more natural reading, viz. that the prohibition on abortifacients is motivated by reluctance to kill the unborn child. That wouldn’t be an unusual view, so far as I know; Aristotle urges prohibition on abortions after the period in which the fetus has the capacity for perception (Politics VII 1335b20). But there may be considerably more evidence for Hippocratic attitudes; I just don’t know the material. I’ll see what my ancient medicine friends think.
“Describing the φάρμακον as θανάσιμον strikes me as pretty clearly pointing to killing as the thing to be avoided, not simply injuring a person’s body…” I take the prohibition on the deadly pharmakon to include injury of any kind, so that a fortiori, the greatest injury, death, is also prohibited. But also I intend to draw attention to the body because it is the center of attention of the physician’s craft, not the patient’s mind, which might desire, as the case may be (so I read the oath) either for a poison or for some sexual indulgence from the doctor, for example.
This is why I think abortifacents are singled out,) although I think that the child might also be in view, just as a secondary concern): were this qualification not added, an oath-sworn Hippocratic might plausibly think that in the case of an abortifacent, the poison is not being truly administered to the mother, but rather to the fetus, and so there is no real poisoning being done, especially on the expectation that the pessary is a somewhat local medicine, affecting the unborn alone. I do see equal merit on your interpretation, but do not see why it would be a more natural reading.
A friend of mine who is an expert in ancient medicine but prefers not to post on blogs sends the following along:
This is the only reference in the entirety of the Hippocratic Corpus to male-male sexual relations. The term somata is used generically of slaves in legalistic language, so the final clause makes it clear that the prohibition against contact goes beyond slaves to “free and slave”. I do not know if this is the only passage in the Corpus that directly speaks of sexual contact between doctor and patient, but the gynecological treatises suggest that women were ashamed to speak of their diseases before male doctors. (Later tradition and quacks, of course, could make hay of the idea of a physician ‘curing’ female infertility.)
The refusal to cut, not even in cases of the stone, is generally seen as a proclamation of the swearer’s avowed lack of expertise in the delicate operation of a bladder stone, a condition that will ultimately be fatal if not treated. The lithotomy operation was widespread in antiquity (Celsus Medicine 7.26 is a lengthy account), although it may not have become more common until the Hellenistic period; many medical lithotomy tools (scoops, knives, tongs) survive in archaeological contexts.
The phrase ‘do no harm’ or primum non nocere occurs not in this Oath but in the Hippocratic Epidemics 1.11 (“to help, or at least do not harm”). The giving of a poison in the Oath is treated as murder on another’s instigation, not suicide assisted by the physician. The Oath’s formulation “I will use my power to help the sick to the best of my ability and judgement; I will abstain from harming or wronging anyone by it” is sufficient for allowing the removal of a gangrenous limb, a preventative and drastic surgical intervention that might not be allowed on a strict understanding of ‘do no harm’.
As for the abortion of the fetus, many Hippocratic texts give evidence and recommendations for how to abort it. The later physician Soranus discusses it at length in his Gynecology; Tertullian says that certain physicians invented a device he calls a embryosphaktes “fetus-slaughterer”, for cutting up the child in utero in order to remove it. Difficult births must have presented a special challenge for midwives and physicians and Soranus has much advice about which births can be attempted successfully, depending on the position of the child. Here is a passage I read aloud for my class from Hippocrates Nature of the Child 13 about aborting a pregnancy at an early stage (obviously not the 6 days its author claims):
As a matter of fact I myself have seen an embryo which was aborted after remaining in the womb for six days. It is upon its nature, as I observed it then, that I base the rest of my inferences … A kinswoman of mine owned a very valuable dancing-girl, whom she employed as a prostitute. It was important that this girl should not become pregnant and thereby lose her value. Now this girl had heard the sort of thing women say to each other — that when a woman is going to conceive, the seed remains insider he and does not fall out. She digested this information, and kept a watch. One day she noticed that the seed had not come out again. She told her mistress, and the story came to me. When I heard it, I told her to jump up and down, touching her buttocks with her heels at each leap. After she had done this no more than seven times, there was a noise, the seed fell out on the ground, and the girl looked it in great surprise. It looked like this: it was as though someone had removed the shell from a raw egg, so that the fluid inside showed through the inner membrane — a reasonably good description of its appearance. It was round, and red; and within the membrane could be seen thick white fibres, surrounded by a thick red serum; while on the outer surface of the membrane were clots of blood. In the middle of the membrane was a small projection: it looked to me like an umbilicus, and I considered that it was through this that the embryo first breathed in and out.
Ancient attitudes and recommendations toward abortion can be found in Riddle, J. 1992. Contraception and Abortion from the Ancient World to the Renaissance. HUP.
He adds:
So is there a reverence for the body in the Hippocratic Oath? Perhaps. Moral wrong-doing is prohibited more than physical harm to the patient’s body, if you accept that the admonition against lithotomy is a generalist’ refusal to do specialist interventions. It is striking to all ancient medical historians that, whatever the origins of the Oath, its prescriptions against surgical intervention, abortions, and poisonings were not followed in antiquity. Apart from Cato the Elder’s confused allusion to some doctor’s oath in Pliny NH 29.14 (is this the Hippocratic Oath?), the first extant source to mention the Oath is Scribonius Largus’ introduction on the professio medicinae, written several hundred years later under the emperor Claudius. I teach the simple conclusion that the Oath is intended to set the patient-doctor relationship on a moral and religious footing.