A Referral Relationship: The Hippocratic Doctors and the
Asklepios Cult in the Ancient Medical Marketplace
A Thesis Submitted to the Faculty of the Classics Department in
Candidacy for the Degree of Bachelor of Arts with Honors in
Classics
Louisa K. Wall
Davidson College
Davidson, NC
April 28, 2011
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Table of Contents
Table of Contents………………………………………………………………………….ii
List of Abbreviations……………………………………………………………………..iv
Acknowledgments…………………………………………………………………………v
Introduction: The Medical Marketplace…………………………………………………..1
1. Hippocrates and the Hippocratic Doctors ……………………………………………12
Hippocrates’ success as a Healer…………………………………………….......12
The Extent of Hippocrates’ Influence: the Hippocratic School………………….15
Pledging loyalty: The Hippocratic Oath…………………………………………16
The Doctors in the Marketplace: The Hippocratic Corpus……………………...19
Compiling the Evidence: The Hippocratic Physicians………………………......22
2. Needs of the Patients and the Doctors’ Response……………………………………23
Evaluating the Physician from the Patient and Community Perspective:………..24
Honorary Decrees from Athens and Cos
An appreciation for Miracles: the Epidaurus Inscriptions……………………….29
Gratitude: Inventories at the Athenian Asklepion……………………………….32
Discrepancies in the Physician-Patient Relationship: Plato’s Writings………….33
Frustrations when Dealing with Patients: The Hippocratic Writings……………37
The Disconnect…………………………………………………………………..40
3. Addressing Patients’ Needs: The Hippocratic Therapeutics………………………...42
An Evaluation of Hippocratic Remedies………………………………………...42
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The Philosophy Involved in Hippocratic Practice……………………………….46
Empirically Based Methods: A Means to an End………………………………..50
Prognosis and the Limits of Medicine…………………………………………...52
4. Competition in the Medical Marketplace……………………………………………56
Asklepion Incubation vs. Hippocratic medicine…………………………………56
The Hippocratic Doctors Respond to Faith Healing……………………………..61
Reasons for Competition…………………………………………………………65
5. Competitive Collaboration…………………………………………………………...69
Association by name: The Branding of the “Asklepiads”……………………….69
Showing Respect: The Hippocratic Oath Revisited……………………………..75
Public Appreciation: Inscriptions………………………………………………..78
Public Dedication: Inventories…………………………………………………...82
Solely Public Interactions: A Disconnect in Therapeutics………………………85
A Public Connection Reveals a Referral Relationship…………………………..88
6. Concluding Remarks…………………………………………………………………89
Appendix………………………………………………………………………………....94
References………………………………………………………………………………101
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Abbreviations
CEG I
Carmina Epigraphica Graeca, I
I. Cos
Iscrizioni di Cos
IG I2
Inscriptiones Graecae: Inscriptiones Atticae
Euclidis anno anteriores
IG II-III2
Inscriptiones Graecae: Inscriptione:Atticae
Euclidis anno posteriores
IG IV2
Inscriptiones Graecae: Inscriptiones
Epidauri
LSJ
Liddell, Scott, and Jones Greek-English
Lexicon
SEG
Supplementum Epigraphicum Graecum
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Acknowledgments
This project would not have been possible without the help and support of a
number of individuals. I would like to give special thanks to Dr. Toumazou for his
encouragement, good humor, availability, and careful editing. Were it not for Dr.
Toumazou, this thesis would never have been completed. I would also like to thank Dr.
Stell for our many discussions about ancient and modern medical ethics throughout the
year. It was during those meetings that the topic and ideas presented in this thesis took
shape.
Many thanks also to Dr. Krentz who took me to the Asklepion at Epidaurus on a
bright March morning in 2009, and who helped with my thesis proposal last fall. His
critical thinking skills were invaluable in that process. I would like to thank him, as well
as Sarabeth Peele, Bryce Bancroft, and Kyle Sanders, my fellow Senior thesis writers in
the Classics Department, for our weekly support group meetings. These sessions offered
both ideas and encouragement without which I could never have completed this project.
I would like to thank the Davidson College Classics Department for the wonderful
education I have received during my years here and for supporting and encouraging my
study of Classical medicine. Thanks also to my parents for cheering me along and
providing comments on my introduction and conclusion, and to Matthew Capone for his
technical support in creating my Appendix.
Finally, I would like to thank my friends who patiently listened to my monologues
about the Hippocratic doctors and the Asklepios cult. While they may not have been
following my train of thought, their discussions helped form the content of this piece of
work, and they have my deep gratitude.
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Introduction: A Medical Marketplace
Medicine in fifth-and fourth-century Greece looked vastly different from modern
healthcare. While modern doctors attend accredited institutions, where they learn the
well-known techniques of evidence-based medicine and the morals of the Hippocratic
tradition, ancient physicians practiced in an era when many methods of healing were
accepted and no system of licensure regulated the practice. The physician was not the
healer, but one of many healers, and all types—magicians, temple priests, and other
laymen—must have competed for customers. This freedom in the profession offered
many options for patients, as well as many risks.
The medical marketplace in ancient Greece was rich with opportunity. A patient
was just as likely to visit their local magician or temple priest as their local physician, and
all of these healers could be present in a large community at the same time. In looking at
the socio-cultural context of the ancient doctor, Vivian Nutton believes that, “the medical
market-place was far from empty. Below the tiny number of elite physicians stretched a
vast pyramid of other health-advisors, male and female, some working full-time for a fee
to heal the sick, others combining doctoring with other activities.”1 While few skilled
healers stood out among the crowd, many attempted to cure illness through a variety of
approaches, some possibly travelling from town to town looking for work.2 In order to
make a living in the field, a healer needed to find his or her niche and network for support
and backing. The identity of each sect determined its success in the medical marketplace.
1
2
Nutton 1995, 13.
Cohn-Haft 1956, 21.
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In order to survive, a healing group needed a defined method of therapeutics3 and a good
reputation.4
Like today, however, healing had its limits in ancient Greece. Therapeutics can
only offer so much. Medical professionals needed some method of addressing cases in
which they could not heal. In this study, I look into the way Hippocratic doctors, a
specific healing group in the medical marketplace, dealt with these issues. I will focus
specifically on how these doctors used another healing sect, the Asklepios cult, to bolster
their success in Greek healthcare.
We must first identify the physician (!!"#$%)—his history and philosophy,
therapeutic methods, role in society, and need for support—in order to understand how
the Hippocratics fit into the profession. According to the LSJ, an !!"#$% is “one who
heals” or “physician.”5 The first definition offers a broader context. Technically, anyone
who claims the ability to heal, whether or not he heals as a primary profession, could be
called an !!"#$%. The second definition, however, suggests that the word refers to a
certain kind of person in society. A person labeled !!"#$% would act as a healer in a
community and would most likely see patients for payment. He or she would be
considered a master of the medical art, as opposed to some other healer, like a temple
priest ("&#&'%), the term used to refer to healers at Asklepieia.6
Healers in 5th century Greece charged for their healing skills, and physicians
(!!"#$() provided this care by means of rational medicine, a practice centered on the
3
Wootton 2006, 2.
Miles 2004, 2.
5
LSJ, “!!"#$%,” 816.
6
LSJ, “"&#&'%,” 821.
4
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principle that disease arises from natural causes.7 While doctors were present before
rational medicine developed, they were linked to the belief in the supernatural, or
irrational medical practices, at that time. Both Homer and Hesiod believed in this
irrational medicine, the notion that the gods send disease and death. To them, doctors
were associated with the divine. Theories of rational medicine developed from Ionian
natural philosophy in the pre-Socratic era after these writers. At this time, medical
philosophers began hypothesizing about their surrounding world and applied those
theories to medicine.8 By the fifth century, medicine had become its own practice,
separate from philosophy. The Hippocratic Corpus demonstrates the movement away
from this philosophical approach to a more empirical approach, one based on careful
observation rather than “a-priori methodology.”9
Doctors provided treatment for both external and internal ailments. External
complaints included bone setting, surgery, and wound healing; internal medicine dealt
with disease. Although the Hippocratic doctors’ remedies for external physical problems
were somewhat effective, their theories on the inner workings of the human body were
primitive at best. The doctors believed that what came out of the body was a reflection of
what happened inside it, and so they developed hypotheses about disease by observing
human excretions.10 As a result, doctors disagreed on the various medical techniques used
7
Longrigg 1993, 26.
Ibid., 29 provides an in-depth analysis of the connections between philosophy and
medicine.
9
Ibid., 82 dates the Hippocratic Corpus to the fifth century BC.
10
Wootton 2006, 33.
8
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in attempts to cure illnesses,11 and particular therapeutics must have distinguished groups
of doctors from one another.
Separate classes of doctors focused on different remedies. Paul Carrick believes
that the status of a physician varied depending on his method and craft. He points to
Aristotle’s three classes of physicians and Plato’s account of the slave-doctor and the
free-doctor as evidence. Aristotle explains that, “’the term ‘physician’ means both the
ordinary practitioner, and master of the craft, and thirdly, the man who studied medicine
as part of his general education.’”12 His definition suggests that all doctors should not be
considered in the same light. But what would be the difference between the “ordinary
practitioner” and the “master of the craft”? Plato looks into this difference in Laws. He
implies that while the slave-doctor practices surgically based medicine, the free-doctor
practices philosophy based medicine (Plato, Laws 720). Carrick argues that Plato tries to
distinguish between those “less rigorous healers who acquired their skills mostly by
imitation and rote” and those “who studied nature in such a way that they deduced their
treatments from universal principles.”13 These free-doctors were the ones who would
look into the inner workings of the body.
Temkin calls the two classes of doctors “the physician” and “the leech.”14 While
the physician practiced rational medicine, grounded in philosophical theory, the leech
merely practiced traditional techniques. On the limitations of leechcraft, Temkin
explains that, “the limitations are those of any technique without theory. The leech may
know very much, but his knowledge will always consist of a certain number of skills.
11
Ibid., 35.
Carrick 2001, 12.
13
Carrick 2001, 13.
14
Temkin 1953, 215.
12
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Beyond this number he cannot go, that is to say he cannot deal with what is unfamiliar to
him and he cannot individualize his treatment.”15 Temkin suggests that the leech may
have borrowed certain theories from physicians to impress patients, but that they had no
grounding in philosophy.16
The fifth-century elite may have sought out doctors who used theory-based
medicine. Some scholars believe that doctors would attempt to improve their social
standing by aligning with certain philosophical ideologies that were popular during the
time. Hui-Hua Chang refers to doctors in the ancient world as “hands-on craftsmen…
often viewed with suspicion.”17 When physicians appealed to intellectual inquiry, a pass
time that was appealing to the upper class, they would be more likely to sell their medical
skills. Chang uses the emphasis on regimen in ancient medicine as evidence of this trend.
The fact that the elite were the only ones with time to follow the regimens prescribed
suggests that the doctors were catering to those types of patients.18 As a result, rational,
principle-based medical theories became a more desirable practice for healers.
Groups—guilds or cults of healers that used certain therapies—and associations
with these groups provided a source of credibility. Greek cities, for the most part, did not
regulate their pluralistic medical culture. No system of licensure existed to determine
which healers were allowed to practice.19 With no need of a certificate, any person could
practice medicine regardless of intentions, and healers must have practiced with all sorts
of motives. While presumably most wanted to help, others may have wanted to harm
15
Ibid., 219.
Ibid., 221.
17
Chang 2008, 220.
18
Ibid., 239.
19
Cohn-Haft 1956, 17.
16
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their patients. Although regulation in the medical market would not get rid of all the
quacks, charlatans, and others seeking to do evil, it would have provided some sort of
baseline for practicing. Patients put themselves at risk by going to a doctor, and many
patients may have feared physicians. Some scholars have even connected the line “I will
not use deadly drugs” in the Hippocratic Oath to patients’ anxiety over physicianpoisoners (Hippocrates, Hippocratic Oath 16). Steven Miles argues that physicians in the
ancient world were often accomplices in murder because they had an alibi and easy
access to poison. According to Miles’ theory, the Hippocratic Oath would quell the fears
of the patients.20 Others, however, view this line of the Oath as a reference to
euthanasia.21 Regardless, with patients wary of healing intentions, doctors needed some
source of credibility to be successful.
Some cities hired public physicians or welcomed physicians from well-known
schools of medicine. Cohn-Haft uses honorary decrees to piece together a possible public
system of health in some ancient Greek communities. The evidence highlights the
growing need for healthcare in these societies. The decrees commend treating patients
without charge and in dire circumstances and grant citizenship to certain travelling
physicians.22 While these decrees, which I will examine in greater detail in chapter 3, do
not allude specifically to a public system, they do provide evidence of the demand for
rational medical treatment in Classical Greece. Certain schools of doctors likely held
credibility in the ancient world because of their reputation. Cos, the hometown of
Hippocrates, for example, was a well-known training ground for Hippocratic physicians.
20
Miles 2004, 73.
Edelstein 1943, argues that the Pythagoreans, who condemned euthanasia, wrote the
Oath in reaction to those who practiced it.
22
Cohn-Haft 1956, 35.
21
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Cohn-Haft, as well as other scholars, believes that the Coan School sent physicians to
various areas of the Greek world.23
In this environment, reputation was based on past successes in the healing market.
While they did not pay penalties if their patients died, as businessmen, physicians needed
to gain the trust of their patients. Ultimately, their patients determined their status as a
healer. Carrick explains that, “if he [a physician] was known to be effective, he was
indeed much sought after. This is why it must be underscored that, in the final analysis,
the social status of a particular doctor varied with the esteem in which his public regarded
him. His performance and resulting reputation were decisive to his financial success and
his ability to make a living.”24 Physicians needed to be wise in their treatment of disease
and in their career moves to succeed in the field of medicine.
In light of the physician’s position in the ancient medical marketplace, certain
features determined the success of physicians, namely an association for support, an
effective set of therapeutics, and a credible reputation. Some physicians were more
successful than others. The Hippocratic doctors, who are frequently mentioned in ancient
and modern sources, serve as an example of one of these thriving guilds. Their success
suggests that they used other methods to boost their credibility, aside from just their set of
rational medical techniques. We know that the Hippocratic doctors were in some way
associated with a religious healing cult, the cult of Asklepios.25 Ancient texts often refer
to the Hippocratic doctors as Asklepiads, and some even claim that Hippocrates was a
23
Ibid., 61.
Carrick 2001, 20.
25
Miles 2004, 20.
24
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direct descendent of Asklepios, the demigod of medicine.26 It is possible that the doctors
used this relationship with the cult to improve their standing as healers.
The cult of Asklepios was very active in many Greek communities from the early
fourth century BC to the fifth century after Christ.27 Asklepios, the patron of medicine,
was born to a mortal mother and Apollo. Cheiron, a centaur learned in the medical art,
trained Asklepios. Asklepios appears as a skilled healer in Homer’s Iliad, and later
sources recount that Zeus threw Asklepios into Hades because he attempted to raise a
man from the dead, but, eventually, he was deified. The cult’s therapies, which centered
on Asklepios’ healing power, included bathing, sacrifices, dream therapy, and possible
medical procedures as well.28 Evidence of this religious-medicine comes from the
archaeological remains of various Asklepieia, the cult’s healing centers, dispersed
throughout ancient Greece. Notable sanctuaries are the ones at Epidaurus, Athens, and
Cos. Inscriptions and surgical tools found attest to a combination of mystical and
medical techniques. Writings about the god, pictures of the god on coins, cups and other
artwork throughout the ancient world reveal the breadth and success of the cult’s
practices. This evidence indicates that the Asklepios cult was widely accepted and
respected.29
Scholars debate the relationship between the Hippocratic doctors and the cult of
Asklepios. Some believe that the two healing groups were intertwined, developing sideby-side and sharing ideas about methods of cure. Nutton believes that the two groups
26
Jouanna 1999, 4.
Aleshire 1989, 6.
28
Wickkiser 2008, 1.
29
Ibid., 37.
27
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were not in opposition.30 Some older scholars even suggest that Hippocratic medicine
started in the temples.31 Others, however, argue that the sects competed against each
other, and claim that the development of the Asklepios cult reflects the reassertion of
traditional values when rational medicine was becoming increasingly popular.32 CohnHaft and Edelstein believe that the popularity of the Asklepieia reveal the failings of
rational medicine. When a doctor could not heal a patient, the patient would likely travel
to an Asklepieion.33 Carrick argues that the two groups developed separately and that the
term Asklepiad merely refers to the guild of physicians to which Hippocrates belonged.34
Gorrini, Wickkiser, and Jouanna provide more recent, in-depth discussions on the
issue. Gorrini points to the two sects’ convergence in inscriptions to argue that, at the
very least, the two groups met and likely interacted.35 Wickkiser sees the relationship
between rational medicine and the Asklepios cult as complementary. The cult did not
steal patients, but took over when the doctors were unable to cure. As a result, “medical
bonds” formed between the two groups.36 Finally, Jouanna proposes that, while the
healers offered opposed medical treatments, and a rivalry likely existed, they were not
hostile toward each other because of both the lineage and social prestige that the
Hippocratic doctors gained from the connection.37
I focus on the Hippocratic perspective of this relationship in question and tie
together the arguments of the three authors. Although the Hippocratics were competing
30
Nutton 2004, 52.
For more information on this debate see Withington 1921, 193.
32
Nutton provides a history for this argument 2004, 53.
33
Cohn-Haft 1956, 29-31.
34
Carrick 2001, 12.
35
Gorrini 2005, 143.
36
Wickkiser 2008, 61.
37
Jouanna 1999, 202.
31
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with the Asklepios’ religious healing for patients, the doctors still associated with the
cult. This competitive collaboration demonstrates that the physicians gained a
competitive advantage by interacting the cult practice. I argue that the Hippocratic
doctors showed public respect for the Asklepios cult in order to address the needs of their
customers more fully. In circumstances when the doctors themselves could not provide
adequate care for their patients, the Asklepios cult served as their reliable pattern of
referral.
Referral relationships, the process of handing over a patient from one medical
practitioner to another, aid in physicians’ success. Scholars often view referral within the
lens of an exchange theory model. This model ultimately predicts that, “an individual is
motivated to interact with another in an activity if he expects associating with him will
result in a positive outcome. The outcomes that two individuals or groups receive will be
better the more rewarding to the other is the behavior each can produce, and the lower
the cost at which each can be produced.”38 A doctor loses income by referring a patient
to another healthcare professional, but will benefit from a good referral. In making
reliable referrals, a doctor ensures the highest quality treatment for patients, leading to
future recommendations from those patients, gains social status by associating with other
respected professionals, and expects return referrals.39 Referral networks may even
“enhance physicians’ ability to garner monopoly profits.”40
Referral patterns have been researched extensively in the modern healthcare
system, both in the US and abroad. The overarching concept and application to healing is
38
Shortell 1974, 14.
Ibid.,15.
40
Gonzalez 1991, 1018.
39
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timeless. Just as there are medical specialists today, there were different types of healers
in the ancient world. If one therapeutic method did not work on a patient, why not try
another?
This thesis consists of five body chapters. The first establishes the success and
identity of the Hippocratic doctors. The discussion reveals that the Hippocratics must
have catered to needs of the patients, the physicians’ customers, most effectively in the
medical marketplace. The second chapter outlines what those needs would be. Ancient
sources shed light on what patients desired as well as the complications that arise when
the doctors cannot meet those desires. The third chapter outlines the ways in which the
Hippocratics treated their customers. Their limits hint at some sort of referral method to
fill in the gaps of their practice. The fourth chapter analyzes the healing methods of the
Asklepios cult and underscores the fundamental differences and the inevitable
competition that would crop up between the two groups. The fifth chapter reveals their
interactions and the ways in which the doctors benefited from them. This analysis shows
that the Hippocratic doctors likely entered into a referral relationship to boost their
reputation and to offer patients options when they themselves could not meet their
customers’ needs. The relationship was a reliable pattern of referral, in a marketplace
where reliability was crucial to success.
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Chapter 1: Hippocrates and the Hippocratic Doctors
Hippocrates and the Hippocratic doctors have left a lasting mark on medical
tradition. Originating in ancient Greece, the Hippocratic tradition has governed the
practice of many physicians over the centuries. The legend of Hippocrates and the fame
of the Hippocratic Corpus and Oath speak to the success of the group of doctors. Just as
any other healing practice in the medical marketplace, the group had to make a name for
itself. Their fame hints at a special method—possibly reliable referral—that led to their
success. In this chapter, I analyze the way in which the members of the association
identified themselves. I look briefly into the fame and the facts of Hippocrates, the
Hippocratic School, the Hippocratic Oath, and the Hippocratic Corpus in order to
highlight the breadth of this healing sect’s success.
Hippocrates’ success as a Healer
Hippocrates (ca. 460-380 BC), “the father of medicine,” was well known during
his life and afterwards. Many ancient authors, both contemporaries to Hippocrates and
later ones, mention him. Some refer to his fine attributes in passing; others describe his
lineage and accomplishments in detail. Plato (ca. 428-348 BC), whose life overlapped
with Hippocrates, refers to him as “Hippocrates of Cos, the Asclepiad” and implies that
the physician was the master of medicine (Plato, Protagoras 311b-c), and Aristotle (ca.
384-322 BC), who wrote a little later, calls Hippocrates a great physician (Aristotle,
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Politics 1326a ff.).1 Both authors speak about Hippocrates’ skill as an especially
successful healer, but do not characterize him as a larger-than-life figure.
During the Hellenistic period, Hippocrates’ life turned into a legend. Medical
men, like Apollonius and Herophilus, studied the Hippocratic writings, which were
compiled in the third century BC, and stories about Hippocrates spread. Nutton explains
that, “the idealization of Hippocrates as a medical authority in this period also gave rise
to, and was in turn influenced by, biographical invention.”2 Authors portrayed the
physician as wise, shrewd, and patriotic. In these pseudo-biographies, he cures King
Perdiccas of Macedonia and the great plague of Athens.3 All of the accounts appear in a
collection of letters and speeches that made their way into some versions of the
Hippocratic Corpus.4
Physicians continued to honor Hippocrates in the Roman era. According to
Levine, Soranus, a physician from Ephesus in the first and second centuries AD, explains
that Hippocrates’ ancestry can be traced to Herakles and Asklepios.5 This regal lineage,
connecting the famous physician to both the Greek hero of courage and the demigod of
medicine, sheds light on what doctors thought of Hippocrates more than 500 years after
he practiced. Galen of Pergamon, a doctor from the second century AD, admired
Hippocrates as well. He identified with Hippocrates as a fellow physician and wrote
commentaries for the Corpus.6 Amidst the glory that Hippocrates has gathered over time,
drawing accurate conclusions about his life can be difficult. Hippocrates was most likely
1
For more information about references to Hippocrates see Lloyd 1975, 171.
Nutton 2004, 143.
3
Ibid.
4
Smith 1979, 215.
5
Levine 1971, 15.
6
Nutton 2004, 219.
2
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not a direct descendant of Herakles and Asklepios, nor did he cure the plague of
Athens—let alone Perdiccas of Macedonia. Scholars, however, frequently use the
biographical accounts written in the Hellenistic and Roman periods to piece together the
physician’s life since they can find few references to Hippocrates while he lived.
While unsure about many parts of Hippocrates’ actual life, scholars do agree on a
few facts. Hippocrates was born into a family that was connected to medicine in 460 BC
on the island of Cos,7 and his training may have been associated with the Asklepios
healing cult there. Some ancient sources explain that Hippocrates learned the medical art
by reading the healing inscriptions on their Asklepios shrine. Others claim that famous
doctors and philosophers, such as Herodicus, Gorgias, and Democritus, tutored him. He
was married in Cos, had three children, and trained his two sons—Thessalus and
Dracon—in the art of medicine.8 At some point, Hippocrates moved to Thessaly.
Ancient myths say that he left Cos because he had burned down the medical library at
Cnidus, where a rival medical school existed. Others suggest that he left to understand
illnesses in other lands.9 He may have even travelled outside of Thessaly and taught
disciples along the way,10 for some of the Hippocratic writings allude to places in
Northern Greece as well. Whether or not Hippocrates actually travelled to these regions
mentioned, such as Propontis, Thrace, and Macedonia, his influence surely extended this
7
Jouanna 1999, 10.
Ibid., 18-19.
9
Levine 1971, 16.
10
Jouanna 1999, 46.
8
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distance.11 The famous physician is said to have died at Larissa in Thessaly, and was
buried between this town and Gyrton.12
The Extent of Hippocrates’ Influence: the Hippocratic School
In discussing the Hippocratic School and its doctors, we must remember that this
“school” should not carry the same connotations as the modern word.13 Modern schools
are associated with institutions and set standards of learning, but ancient schools are
associated with groups of thought. Nutton refers to ancient medical schools as “loose
groups of practitioners associated with particular theories, teachers, and places, not well
organized teaching establishments.”14 The Hippocratic School did not have a
schoolhouse or curriculum from which to teach pupils. Likely forming for economic
reasons, it defined the standards of a medical practice in order to survive in the healing
marketplace. While medical schools of thought most likely began in families, the
Hippocratic doctors became more of a collection of professionals, adhering to the
particular theories of their practice.
Jouanna suggests that the school stemmed from the transition from preserving
medical knowledge within families to teaching outsiders the practice. He speaks of two
branches of the Asklepiad family, who were gifted in the art of medicine, in Cos and
Cnidus that transferred knowledge from father to son. Hippocrates practiced the Coan
medical tradition, which was separate from the Cnidian branch.15 Both families had their
11
Ibid., 29-30.
Levine 1971, 17.
13
Van Der Eijk 1999, 13.
14
Nutton 1992, 19.
15
Jouanna 1999, 45.
12
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well-known doctors, and both produced medical texts. Little evidence exists regarding
their interactions during the fifth and fourth centuries BC, but later ancient sources claim
that there were rivalries between the two branches. The story of Hippocrates burning the
Cnidian library serves as an example of this tension.16 The Asklepiad Oath from Delphi,
a similar oath to the Hippocratic, however, suggests that the two families had a special
bond. Only the physicians from the two branches of the Asklepiad family were meant to
take this oath at Delphi.17 At some point, a family member—possibly Hippocrates
himself—began to teach outsiders the art of medicine for money. As a result, doctors all
over ancient Greece may have been trained in the Hippocratic tradition. These trained
doctors are considered the Hippocratic physicians.
Pledging loyalty: The Hippocratic Oath
The Hippocratic Oath seems to fit well in the transition from passing down the art
of medicine within a family to teaching the art to outsiders, although some question
whether the Oath actually existed when the Hippocratic doctors healed. Jouanna
concludes that outsiders, not in the Asklepiad family, took the Oath in order to commit to
the family’s practice and “can really only be understood in a specific social context in a
particular era.”18 While it does touch on a few essential points in medical ethics and
etiquette, such as the phrase “do no harm,” these aspects were not its main purpose.
Instead, the Oath was a contract between a student and a teacher. The Oath states, “I will
pay the same respect for my master in the Science as to my parents and share my life with
16
Jouanna 1999, 49-50.
Ibid., 51.
18
Ibid., 47.
17
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him and pay all my debts to him. I will regard his sons as my brothers and teach them the
Science if they desire to learn it, without fee or contract” (Hippocrates, Hippocratic Oath
6-7). The student would promise to pay his debts to his teacher, and his teacher would
hold on to the privileges that came with possessing medical knowledge.19 According to
Jouanna’s interpretation, this oath targeted those pupils who were not connected by blood
to the Asklepiads. By ensuring that the teachers were respected, the swearing protected
the family, not the newly inducted members of the Hippocratic community.
Miles, on the other hand, does not downplay the importance of the ethical stances
in the Hippocratic Oath. He sees the Oath as an avenue to understanding the ethics of
the group of physicians, sometime after the transition from family practice to
apprenticeship. A doctor trained in the Hippocratic tradition in ancient Greece may have
taken this oath long after the Asklepiad family held the key to medical knowledge and,
therefore, would not direct his swearing to the Asklepiads. This situation calls to
question whether the Hippocratic Oath was directed toward anyone. Miles argues that
the Oath served as a pact between the physician and society in both public and private
spheres. Each line lays out the way in which a physician should conduct himself toward
a community or a patient.20 While he recognizes that the Oath originally represented a
commitment to honor apprenticeship and an entrance into a close family practice, Miles
primarily focuses on the Oath as a statement of moral obligation both to collaborate with
their professional family and to practice the medical art with good intentions.21 In a
society with no medical licensure, the Oath may have served as a distinguishing feature
19
Ibid., 47-48.
Miles 2004, 52.
21
Ibid., 8-14.
20
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for doctors.22 At the same time, an oath does not bind a person to ethical practice. Taking
the Oath does not turn a bad-physician into a good-physician. Second, it is possible that
other healing sects took their own oaths. If this were the case, then the Hippocratic Oath
would not have distinguished the Hippocratics from other healing groups. Thus, we can
draw few definitive conclusions about the use of the Oath outside of the Hippocratic
School.
Other scholars do not think that the Hippocratic Oath held much weight within
the Hippocratic School. Nutton suggests that the Oath may have been less useful to the
Hippocratic doctors than modern scholars assume. While the Hippocratic tradition,
which upheld more complicated medical ethics than a single statement of ethical purpose,
pervaded throughout medical practices over time, the Oath itself did not take hold until
Christianity came onto the medical scene. Nutton explains, “the appeal of the text whose
wording and interpretation are assumed to possess a universal and unchanging validity
may reveal far more about the medical ethics and medical ethicists of the twentieth
century than it does about those of the fifth century BC.”23 Ludwig Edelstein argues that
philosopher-physicians from the Pythagorean sect wrote the Hippocratic Oath in the
fourth century. According to this theory, the Oath, which possibly reflects Pythagorean
values in its ethical code, was not the defining feature of medical ethics in ancient
Greece. Instead, the Oath became popular with the rise of Christianity because the
Pythagorean values reflected Christian thought.24
22
Ibid., 61-62.
Nutton 1993, 28.
24
Edelstein 1943, 55-62.
23
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Whether or not the Oath defined the Hippocratic practice, the swearing of it
speaks to the Hippocratic School’s need to restrict their healing knowledge. The Oath as
a covenant between student and teacher highlights the commitment needed to learn
Hippocratic medicine. The student must prove his loyalty to his teacher; the teacher must
gain the benefits of holding the desired knowledge. Later, the Oath may have served as
proof of legitimacy for a Hippocratic doctor. In this situation, the doctor made a pact
with his community to practice medicine with integrity. At the same time, the Oath may
not have played a large role in the Hippocratic School because the ethics of the doctors’
practice were most likely much more complicated than the standards set out in the simple
statement. Thus, we can conclude that while the Oath may not have served as the mark
of the Hippocratic practice, it was a way to restrict the information that they marketed.
The Doctors in the Marketplace: The Hippocratic Corpus
The Hippocratic Corpus is a collection of writings about medicine and healing
that came from the Hippocratic School. A combination of physicians, Hippocrates and
his students, most likely wrote the sections, but the specific authors are not named. Many
of the chapters were composed during Hippocrates’ lifetime, but a few were written later.
The audience and content of the texts vary. Some address patients or communities;
others advise fellow physicians. Some focus on ethics; others discuss prognosis and
cures.25 The Corpus is in the Ionic dialect, and consists of about 70 treatises, including
the Oath, but scholars concentrate on about 20 of them.26 Levine aptly uses W.H.S
Jone’s description of the Corpus: “‘The Hippocratic collection is a medley, with no inner
25
26
Jouanna 1999, 57.
Levine 1971, 21.
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bond of union except that all the works are written in the Ionic dialect and are connected
more or less closely to medicine or one of its allied sciences. There are the widest
possible divergences of style, and the sharpest possible contradictions in doctrine.’”27
Scribes did not bring the chapters together until the Hellenistic period, and may have
added sections to complete the body of work. The series of chapters on diseases, for
example, was most likely written during the Hellenistic era. Also, though the Corpus is
often considered one text, the works may have existed separately at one point.28
Many of the works do shed light on certain unified therapeutics and principles in
medicine. Levine outlines 19 of them in his book Hippocrates. Some state specific
theories, such as “the human body is composed of four fluid substances: blood, phlegm,
yellow bile, and black bile.” Others are broader, like, “ change is constant and
unending.”29 Although the texts in the Collection express disparate ideas in medicine,
many of these underlying themes govern the Hippocratic practice.30 Jouanna divides the
treatises into three classes: those from Cos, those from Cnidus, and those belonging to
neither group.31 He categorizes the treatises based on their relationships with one
another. Although he recognizes distinct differences among the works, he sees unity
“with respect to both medical practice and to the rational approach to disease and
treatment they advocate.”32 The existence of these themes suggests that, although
Hippocratic doctors may have travelled across ancient Greece and picked up new ways of
27
Ibid., 20.
Jouanna 1999, 58.
29
Levine 1971, 50-51.
30
Ibid.
31
Jouanna 1999, 71.
32
Ibid.
28
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healing, some methods did unite them. We can, therefore, use the term “Hippocratic
physicians” to describe a certain group of doctors that practiced in the ancient world.
We can also infer from the writings that this collection of doctors was not the only
group of medical practitioners in ancient Greece. Many of the Hippocratic writers
attempt to justify their practice, which hints at the competition in the healing
marketplace. Levine explains:
“Self-criticism on the part of doctors is familiar to those acquainted with the
Hippocratic Collection. It is usually coupled with self-defense, not unnaturally.
And both to the observer appear healthful and helpful. The Hippocratic writers
were at considerable pains to make of their art and knowledge a profession and a
practice which would justify itself to man.”33
Many of the Hippocratic works make claims on how a doctor should conduct himself.
The Canon, for example, describes a good medical student. The author states that, “for a
man to be truly suited to the practice of medicine, he must be possessed of a natural
disposition for it, the necessary instruction, favorable circumstances, education, industry,
and time” (Hippocrates, The Canon). The statement offers criteria for which a good
doctor should be judged and implies that practitioners exist that do not exhibit these
admirable traits. The author of Tradition in Medicine34 targets the sophists in his
discussion on bad medical practices. He opens by explaining, “in previous attempts to
speak or to write about medicine, the authors have introduced certain arbitrary postulates
into their arguments…” (Hippocrates, Tradition in Medicine 1). Later, he says that those
who make the “arbitrary postulates” are the Sophists. His words speak out against the
medical philosophers, who use overarching principles to govern their healing. Like the
author of The Canon, the author of Tradition in Medicine draws conclusions about what
33
34
Levine 1971, 52.
This treatise is also called On Ancient Medicine.
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makes a good doctor. These excerpts show that the authors must justify their medical
practice because bad physicians, who were not part of the Hippocratic tradition, were
prevalent.
Compiling the Evidence: The Hippocratic Physicians
Based on the information offered in this chapter, we can draw a number of
conclusions about the Hippocratic physicians. Hippocrates most likely began the
tradition. His teachings were widely known throughout the ancient world, which
suggests that his and his disciples’ medical practices were successful. The Hippocratic
School was not an institution but a school of thought that developed on the island of Cos.
The medical knowledge that was passed down probably originated in a medical family,
but at some point the family began teaching outsiders. The Oath and the Hippocratic
Corpus provide evidence of this medical association that developed. The Oath represents
both the restriction placed on transferring the familial knowledge as well as a rough set of
guidelines for practice. The Corpus sheds light on both the disparate practices of the
Hippocratic doctors and their unity. This information provides context for the term
“Hippocratic physician.”
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Chapter 2: Needs of the Patients and the Doctors’ Response
Ultimately, doctors work for patients. While many motives—moral principles,
the art of medicine, philosophy—seem to drive a physician’s practice, caring for patients
lies at the heart of the profession, for doctors make a living by curing the sick. The sick
are their clients, who will pay them and recommend them to others. When analyzing the
medical profession, it is easy to lose sight of what matters most—the needs of the patient.
In ancient Greece, the Hippocratic doctors were in competition with other healing
groups, all working toward the same end goal—healing. Each guild must have needed to
be patient-centric, and possessive of their customers in order to succeed. Viewing the
ancient medical profession from the market perspective aids us in piecing together the
identity of the Hippocratic doctors, and their relationship with other healers. Looking
into thoughts of outsiders—the potential patients—can offer insight into the criteria that
an ancient community used to distinguish between good and bad doctors, and
understanding the reactions of the insiders toward the outsiders also hint at the demands
of doctors in the ancient world. Finally, analyzing the reflections of bystanders provide
information about the discrepancies of the medical profession. In this chapter, I use
evidence from a selection of honorary decrees dated before 250 BC found in Athens and
Cos, healing inscriptions and inventories from the temples of Asklepios at Epidaurus and
Athens, as well as excerpts from Plato’s writings and the Hippocratic Corpus to assess
the needs of the patient and the complications that arise when these needs cannot be met.
These pieces of evidence indicate that patients evaluate doctors’ successes based on their
ability to heal; they appreciate miracles and divine intervention; they want caring
treatment, whether or not it is the best kind; and they blame doctors, regardless of who is
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at fault. This analysis of patients reveals that sometimes continuing to treat patients can
be detrimental to the Hippocratic practice. A referral system would therefore be
necessary for their success.
Evaluating the Physician from the Patient and Community Perspective: Honorary
Decrees from Athens and Cos
Honorary decrees reveal the ways in which both the broader community and
specific individuals respected doctors. Many decrees regarding physicians have been
found all over the ancient world, most dated to the late third century BC and after. My
study focuses on a selection from Athens and Cos from the fourth and early third century
BC.1 The sampling sheds light on the ancient physician’s relationship with the public
community, his ideal traits, and his rewards. According to the decrees, an ancient
physician should be a public servant, should show good will, care, generosity,
persistence, and openness, and should be honored with praise. A few testimonies from
individuals emphasize not the doctor’s character, but his medical art. These tributes
highlight a feature that underlies all of the decrees: the success of the doctor’s healing
practices.
The first third of many of the decrees lays out the official nature of the document.
This beginning sets the scene and underscores the physician’s standing with the public.
Each decree provides the relevant circumstances—location, date, and context—before
bringing up the doctor’s name. For example, an Athenian tribute to the physician Phidias
of Rhodes dated to 304/303 BC reads, “In the archonship of Pherekles, during the seventh
1
Refer to the Appendix for complete translations of the selected decrees.
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prytany of the Oineis tribe, in which Epikharinos, son of Demokhares of the Gargettos
deme, was secretary, on the 22nd day of the month of Gamelion and the 29th day of the
prytany, was the assembly”2 Similarly, another decree from Athens dated to 270 BC,
which discusses the ritual sacrifices of physicians, states, “In the Archonship of
Diogeiton, during the 12th prytany of the Demetrias tribe, in which Theodotos, son of
Theophilos of the Keirias deme, was secretary; on the 28th day of the month of
Skirophorion, in the principal assembly...”3 This official, systematic structure reveals
two aspects of the honored physicians in the decrees. First, the physician has made
enough of an impact on the community to warrant a public response. In each case, the
Athenian demos votes to honor the doctor and to provide a record of the honor. Thus, he
must have been highly appreciated among the citizens and have become famous as a
healer. Second, the formulaic nature of the inscriptions indicates that these honors were
bestowed frequently. Successful doctors may have expected to receive these tributes, or
at least striven to gain public recognition in the community. Their healing practices were
public just as much as they were private.4 This fact calls to question whether there was
an official system of honoring doctors in the Athenian and Coan communities.
Some scholars, most notably Louis Cohn-Haft, use these formulaic inscriptions to
argue for a system of public doctors in ancient Greece. Although Cohn-Haft’s study
focuses on the Hellenistic period, the practice may have began earlier. He believes that
the epithet !"µ#$%#& or !'µ#$%()#* meaning “public servant,” which appears with !+,-.&
2
Samama 2003, 115. Decree 007 in the Appendix.
Ibid., 118-119. Decree 011 in the Appendix.
4
Doctors would have healed both to help their customer and to gain other customers.
Public gestures would have increased revenue by impressing members of the community.
When the community members became ill, they would have gone to the publicly
recognized physician.
3
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frequently in honorary decrees, implies that the doctor was a public doctor.5 He proposes
that the state did not hire these physicians so that free healthcare would be provided to the
citizens, rather so that healthcare would be accessible to anyone. Cohn-Haft explains
that, “In the general context of a shortage of physicians and the consequent uncertainty of
medical care being available, it is more than plausible that the citizens of a Greek city
should have considered it a matter of public responsibility to see to the securing of
medical service on a dependable and stable basis.”6 This public system, however, would
not have undermined the competition among healers. While there may have been few
qualified practitioners of rational medicine, other healers offered therapeutics as well.7
Instead, the system may have been a way to keep the best physicians in certain cities.8 In
fact, the honorary decrees themselves may have served as a way of holding onto those
physicians. A public honor would strengthen the reputation of a doctor, and, in turn,
increase his revenue. Regardless of whether or not public doctors existed, however, a city
would measure the quality of a physician based on the same criteria.
The second portions of the honorary decrees shed light on a doctor’s admirable
characteristics. According to the inscriptions, a physician must be caring and generous.
Many of the physicians are recognized showing goodwill and care toward their patients.
Decree 006 from late fourth-century Athens, for example, honors a physician—Evenor—
who demonstrated “only kindness.”9 Similarly, Decree 007, also from Athens and dated
to the same time, states that another physician—Phidias—healed with “emulous
5
Cohn-Haft 1956, 6.
Ibid., 46.
7
Nutton 1995, 13.
8
Cohn-Haft 1956, 35.
9
Samama 2003, 113. See Appendix for complete translation.
6
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desire.”10 These words illustrate the kind of physician-patient relationship that citizens
wanted. Naturally, a physician’s demeanor mattered in determining his success.
A doctor must also be persistent and egalitarian. Decree 123 from third-century
Cos honors physician Xenotimos for being especially helpful in an epidemic. When all
of the other doctors became ill, Xenotimos continued to heal. Moreover, he treated those
who needed help, not those who would pay the most.11 The decree, which recognizes
Xenotimos for continuing to treat throughout an epidemic, shows that the citizens of Cos
value persistence in a doctor. Even in dire circumstances, a physician should not give up.
Also, the account suggests that many doctors did not treat patients equally. Xenotimos
stood out among physicians because he took care of citizens based on need, not wealth.
Finally, the story of Xenotimos calls to question whether he was successful in healing
this epidemic. While the decree may commend his intention, rather than the end result,
Xenotimos likely healed the majority of his patients during the epidemic to be praised.
Lastly, according to the decrees, a doctor must use his medical art effectively.
The honored physicians always treat /+,+ ,"* ,01*'* or ,2* ,01*+* ,2* !+,-%/2*12
(by/according to his medical art), a phrase that appears in many of the honorary decrees.
Decrees 006 and 123, for example, both describe the !+,-.& honored for healing people
“with respect to his medical art.”13 Calling the healer an !+,-.& implies that he practices
rational medicine,14 and, assuming that the “art” refers to the science of rational
medicine, the phrase shows that the public in the fourth century BC has come to
10
Ibid., 237.
Ibid., 225.
12
The Athenian inscriptions use the first, and the Coan inscriptions, which are in the
Doric dialect use the second.
13
Samama 2003, 113, 225. Decrees 006 and 123 are in the Appendix.
14
See definition of !+,-.& in Introduction.
11
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appreciate this form of healing. While the citizens respect the doctor because he heals,
medical art aside, they must believe that his technique has power.15 Referring to his
“medical art,” therefore, means that the doctor was especially skilled in the area of
rational medicine.
The final portions of the honorary decrees, which elaborate on the rewards a
physician should receive, speak to the role of a doctor in a community. The sections
begin by calling in Good Fortune (+3+4"% ,)1(%) to request that people recognize the
doctor. They honor the doctor in three ways: by praising him, crowning him with an
olive-wreath, and documenting the event on a stele. These actions, occurring in decrees
006, 007, and 123,16 highlight the public response to an admirable physician. First,
asking for praise from the people draws attention to the differences between public and
private recognition in an ancient community. The public recognition reflects the thoughts
of individual patients in that it shows that the doctor’s work for individuals warranted a
community response. Second, the crowning reward serves as a token of appreciation.
The duplicate accounts of crowning ceremonies suggest that similar gifts were given to
physicians, and no doubt to other noble citizens, for good works. Third, the act of
creating a stele for the doctor demonstrates the importance of remembering the healer.
The secretary would have displayed the stele in a prominent location—the Acropolis or
the Asklepieion, in the case of Athens—so that citizens may read it.17 A doctor’s overall
practice would benefit from this presentation. In some situations, physicians were
15
On the other hand, saying this phrase at all may show that the public wanted the
doctor’s method of healing to be transparent, and that community is suspicious of the
doctor because he uses the medical art.
16
Samama 2003, 113-114, 115, 225.
17
Sherwin-White 1978, 275.
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granted citizenship for their work. Evenor, the physician in decree 006, for example,
became a citizen of Athens.18 Thus, offering citizenship to select doctors must have
served as a way to keep good healthcare in the city.19
Finally, individuals that honor physicians focus on the wisdom that a good
physician must possess. Decree 008 from Athens, dated to 303/2 BC, holds a tribute
from Batakes of Piraeus to his doctor Argaios.20 Having been healed, Batakes honors his
physician whose wisdom in medicine surpasses all “venerable minds” in the profession
by dedicating a statue.21 The dedication underscores the most important element of a
patient’s desires: to be healed. Batakes lived to write this loving tribute to his doctor. A
doctor would covet this situation in fifth-and fourth-century Greece. His own, living
patient ensured his success by recommending him publicly, and the inscription would
stand as a lasting commendation for the physician.
II. An appreciation for Miracles: the Epidaurus Inscriptions
The iamata are accounts of Asklepios’ healing on stelae found in abata, or
sleeping stoas, at Asklepios sanctuaries, dated as far back as the fourth century BC. The
Edelsteins have compiled and translated Asklepios inscriptions, iamata included, into one
collection.22 Well-preserved iamata from Epidaurus document miracle cures. Most of
the stories end with the patient walking away from the temple healthy after some dire
illness; a few recount the gratitude of the patient having been cured. These patients
18
Samama 2003, 113-114.
Cohn-Haft 1956, 35.
20
Samama 2003, 115.
21
Full translation is in the Appendix.
22
See Edelstein 1998 for complete compilation of inscriptions regarding Asklepios.
19
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demonstrate their appreciation for miracles. While doctors are not involved in these
inscriptions, the invalids of the temples of Asklepios search for the same outcome from
their healers. In this way, the inscriptions show that doctors and temple priests were
working toward the same ends—to cure illnesses.
In studying these inscriptions, it is important to remember that some scholars are
skeptical about the authenticity of the stories. Many Asklepios inscriptions provide no
author or reference to a dedication from the patient, so we cannot rule out the possibility
that the temple priests wrote these inscriptions to bolster their fame.23 I shall not discount
the inscriptions because of the lack of evidence to verify their claims; however, it is
important to analyze them with caution. We cannot use these the inscriptions alone as
proof of the healing cult’s success.
Two inscriptions from Epidaurus serve as examples of the ways patients showed
their appreciation for Asklepios’ healing. One account of an iama found at Epidaurus
and dated to the second half of the fourth century explains one way in which the cult
spread. Thersandrus of Halieis, who was ill with consumption, went to the Asklepieion
at Epidaurus. He was not cured in the sanctuary, but a snake travelled back to Halieis
with him and healed him on his first night home. After consulting with the oracle at
Delphi about this miracle, the community built a sanctuary of Asklepios as a tribute to his
healing power (IG IV2, 121-122 XXXIII).24 The fact that the inscription does not unveil
how Thersandrus got better elevates the power of Asklepios. The unexplained snake
healing suggests that Asklepios can cure the incurable. The god was still able to heal
Thersandrus, who, having travelled to Epidaurus and leaving ill, must have felt
23
24
Jouanna 1999, 199-200.
Edelstein 1998, 235-236.
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discouraged. By recounting that the healing occurred once Thersandrus returned home,
the inscription reminds visitors that the god uses his skills in many ways and his power
extends all distances. Also, the community repays Asklepios well. The sanctuary that
they build illustrates the appreciation of Halieis toward Asklepios’ success. Like the
doctors who received wreathes and citizenship for using their medical art, Asklepios
receives honors from ancient communities for performing miracles. He proves that, even
in dire circumstances, people can still hope.
Other evidence suggests that patients felt indebted to Asklepios’ healing powers.
Another inscription from Epidaurus, dated to the third century BC documents
Hermodicus of Lampsacus, from the third century BC, who dedicates a rock to Asklepios
at the temple. Hermodicus says, “before coming under your hands and those of your
children I was stricken by a wretched illness, having an abscess in my chest and being
paralyzed in my hands. But you, Paean, by ordering me to lift up this rock made me live
free from disease” (IG IV2, 125).25 The actual healing method that took place in this
event is clearer than the previous inscription. Asklepios apparently ordered Hermodicus
to lift a rock. While this technique may raise questions about how lifting a rock cured
Hermodicus, it must have worked because Hermodicus lived to offer a gift for the god’s
service. Like Batakes, who set up a statue for his doctor Argaios (decree 008),
Hermodicus pays tribute to his healer Asklepios. Aside from the fact that Batakes praises
his doctor’s immeasurable wisdom, while Hermodicus simply glorifies Asklepios’ divine
power,26 these two patients are similarly indebted to their healers. And, just as the
25
Ibid., 247.
This difference sheds light on the fundamental distinctions between the two healing
methods, discussed in chapters 4 and 5.
26
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inscription from Batakes would have helped his physician’s practice, Hermodicus’
inscription would have benefited the Asklepius’ practice.
III. Gratitude: Inventories at the Athenian Asklepieion
Archaeological remains from Asklepieia provide further evidence that patients of
Asklepios appreciated his work. The lists of inventories from the Athenian Asklepieion
serve as good examples of the kinds of gifts patients gave to the god. While these
inventories did not begin until around 360 BC, we can deduce some ways the sick treated
their healers in earlier times as well.27
Sarah B. Aleshire analyzes the dedications using five characteristics: class, type,
sex of the person dedicating, material, and weight of money.28 She divides the “class”
category into three groups. First, she analyzes the replicas of body parts given either in
hope of maintaining health or as thanksgiving. The many votives offerings of eyes, legs,
feet, and abdomens reflect targeted ailments. The abdomens, for example, suggest that
the patients were having trouble with their innards.29 Second, she examines the coin
dedications, which make up about one-sixth of the inventories.30 Third, she discusses the
typoi, or small plaques with pictures of dedicators, the god, small horns, or cornucopias,
that make up about one-fifth of the dedications. Finally, she lists miscellaneous
offerings that do not fit in one of these groups, such as jewelry, medical equipment, and
house ware.31
27
Aleshire 1989, 15.
Ibid., 40.
29
Ibid., 41.
30
Ibid., 43.
31
Ibid., 44-45.
28
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In analyzing the sex of the dedicators, Aleshire notes that the majority of the
givers are female, although some discrepancies are due to chance or lack of preservation.
While women gave more “anatomical ex votos,” men gave more coins.32 Aleshire also
concludes that the weight of silver varies from year to year, depending on the priests,
because some of the metal was melted for various reasons.33
Dedicators showed their respect for the cult in a variety of ways. While many of
patients’ gifts are similar depending on sex and ailment, the spectrum reveals that there
was no set standard for giving. Patients, or possibly family members after their loved
ones had died, may have dedicated items that they felt were appropriate for the services
they received. Overall, the offerings reveal a combination of gratitude and fear. Some,
not having expected to live after falling ill, would praise Asklepios for their recoveries;
others, hoping to ward off disease, would offer gifts to ensure good health. A dedication
would repay Asklepios as well as prevent future illness.
IV. Discrepancies in the Physician-Patient Relationship: Plato’s Writings
From inscriptions and inventories, it seems that the patient’s need—to be
healed—is simple. When the healer cured an individual, he succeeded in his profession;
when he did not, he failed. Plato, however, addresses complexities to this seemingly
straightforward cause and effect relationship. A selection of his works, namely the
Republic, Gorgias, and Charmides, discuss the role of the doctor and patient during the
early fourth century BC.
In his writings, Plato exposes problems in the medical
profession and paints a picture of what a solution to the problems would be. His views
32
33
Ibid., 46.
Ibid., 46-48.
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on healthcare in the excerpts hint at patients’ tendencies toward doctors. Plato highlights
patients’ lack of respect for the meaning of life, and their ignorance regarding quality of
treatment and credibility in medicine. These characteristics lead to tension between a
doctor and a patient because physicians cannot always satisfy their patients.
In Book III of the Republic, Plato reveals that many individuals do not understand
the importance of ending life. They fear death and desire to prolong their time on earth
for as long as possible. The rich are able to extend their lives by ordering treatments
from doctors. Doctors—even the Asklepiads—cater to their desires because these
patients pay them (Plato, Republic 405d). According to Plato, for patients, attempting to
prolong life is wrong, and, for doctors, providing treatment for them is wrong. Plato uses
two examples for both groups to warn against these tendencies. First, he discusses the
base physician Herodicus. Herodicus, a gymnastics teacher, got sick, and so he created a
regimen for himself that combined gymnastics and medicine. By abiding strictly to this
regimen, Herodicus allowed his disease to take over his life. Plato explains, “He drew
out his death… attending the mortal disease, he wasn’t able to cure it, I suppose, and
spent his whole life treating it with no leisure for anything else, mightily distressed if he
departed a bit from his accustomed regimen” (Plato, Republic 406b). In this account,
Plato shows that a person must perform his duties, not spend his time nursing a lifelong
illness. A person should not be able to afford that sort of leisure.
In order to demonstrate that doctors should not meet the demands of the rich at
the expense of their art’s integrity, Plato draws from the myth of Asklepios. He recounts
a story from Pindar, which says that Zeus threw the demigod Asklepios into Hades for
trying to raise a fatally ill man from the dead because the man was rich. Socrates warns
Wall 35
against this action, but also questions the feasibility of this story. He says, “if he was a
god’s son, we’ll say he wasn’t basely greedy, and if he was basely greedy, he wasn’t a
god’s son” (Plato, Republic 408c). In this statement, Plato sheds light on the fact that all
men are greedy, and, therefore, can be tempted by money, but, even if a physician is
tempted by money, he cannot change fate. By illustrating a situation in which doctors
cannot meet the needs of patients, Plato exposes complications that can arise among
healers. Patients fear death and are willing to use their money to ward it off. Doctors
want to receive patients; yet they cannot cure the incurable.
In Gorgias, Plato analyzes the complications that can arise when patients mistake
comfort for cure. He uses the contrast between cookery and art to shed light on how a
true physician should act toward his patients. In a conversion with Gorgias, Socrates
explains that cookery, which is a form of the art of flattery, “assumes the form of
medicine, and pretends to know what foods are best for the body” (Plato, Gorgias 464e).
And flattery, he says, “aims at the pleasant and ignores the best” (Plato, Gorgias 465a).
In order words, “comfort-care” does not replace true medical care, especially when the
doctor disguises the comfort caring for real caring. Plato hints that many physicians
would provide the patient with a comfortable regimen instead of a painful cure, if it
meant that they would be paid for their services. And he assumes that, since patients are
ignorant of the difference between the true doctor and the quack, they often times pick
the wrong kind of treatment. Although it is natural to want to feel better, the best
medicine is not always pleasant.
Plato’s analysis of the patients’ ignorance speaks to the way doctors made a name
for themselves in Athens, and possibly other Greek cities. According to Plato, in order to
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become publicly recognized in a city, a doctor first needed to undergo a public
examination (Plato, Gorgias 455b). The doctor then needed to further demonstrate his
persuasive skills in public debates with other doctors. These debates served as a sort of
competition.34 Jouanna concludes that the Classical physician “was obliged from time to
time to speak in front of substantial audiences of varying size, whether arguing against a
colleague before the patient’s family and friends, or taking part in verbal sparring
matches in the public square.”35 The physician, therefore, was just as much a public
figure as he was a private figure.
But Plato believes that these persuasive skills hold no weight in the actual art of
medicine. A physician may speak well and flatter with ease but lack wisdom in his own
profession. While Plato commends the physician who treats according to his art and not
his patients’ desires, it seems that the public—those who pay the physicians—would not
commend him as well. For, why else would Plato be speaking so adamantly against these
less-than-admirable healers? Patients want sincere healers, but consistently pick
insincere ones.
Plato calls to question how someone can know whom a true physician is in an
excerpt from Charmides. In the dialogue, Socrates and Critas contrast what a patient
knows and what a physician knows about medicine, and decide who must judge the
physician on his art. On the sciences and health, Socrates explains that, “he who is
ignorant of all this will not know what he knows, but only that he knows” (Plato,
Charmides 170c). Therefore, this ignorant person “will also be unable to examine
another man’s claim to some knowledge, and make out whether he knows or does not
34
35
Cohn-Haft 1956, 57.
Jouanna 1999, 85.
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know what he says he knows” (Plato, Charmides 170d). This description of the man
looking into the science of medicine from the outside illustrates how a patient would treat
any person who says that he is a doctor—sincere or insincere. A patient would not be
able to distinguish between the two. Any medical man could easily trick a patient with
flattery.
Plato’s answer to this problem supports the movement toward associations of
doctors, like the Hippocratics. According to Socrates, the only person who can critique
doctor is one who knows the art himself. He answers his own question, “could anyone
follow up either of these points with the medical art?” with the response, “nobody at all,
it would seem, but a doctor” (Plato, Charmides 171c). Doctors, therefore, are more
credible when others in their profession can vouch for them. Patients would most likely
want a credible doctor—someone who could heal and would not overcharge them. An
association would provide a built in recommendation network. These doctors would be
the ones hired to treat patients.
V. Frustrations when Dealing with Patients: The Hippocratic Writings
Finally, we can gather hints about patients’ needs from the doctors’ writings about
patients. In the Corpus, a few Hippocratic doctors discuss the problems in the attitudes
of those they treat and express frustrations about patients’ reactions toward their failings.
The selections reveal what patients demanded from the Hippocratics, and how the doctors
responded to those demands. The Science of Medicine,36 one treatise of the Hippocratic
Corpus that focuses on separating Hippocratic doctors from quacks and charlatans,
36
This treatise of the Corpus is often referred to as The Art.
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addresses the blame, guilt and expectations in physician-patient relationships. The
discussion highlights the disconnect between the needs of patients and the treatment that
doctors were able to give them.
In defending his science, the author of The Science of Medicine blames patients
for denouncing the art of medicine. He exposes both the criticism that doctors received
and the deficiencies of the science. In one passage, which addresses the argument that
people get well without going to a doctor, the author warns against judging against
medical treatment too quickly. He uses a sick man with remedies as an example of the
success that can come from the art of medicine. The author explains:
“if a sick man comes to praise or to blame the remedies by which he is cured, he
is employing the science of medicine. The failure of remedies too is no less a
proof of the reality of science. Remedies are beneficial only through correct
applications, but are harmful when applied wrongly.” (Hippocrates, The Science
of Medicine 5)
By emphasizing both the ignorance of patients and the necessity in employing a doctor,
the physician suggests that a sick man would not treat himself correctly. He brings up the
same point that Plato makes in the Charmides: a patient cannot fully know the art of
medicine. According to the author, since physicians are knowledgeable in the field, they
should determine appropriate remedies for sick men. His argument indicates that
individuals were often too quick to turn away from the art of medicine. If a treatment did
not work, the patient would denounce the entire practice.
Next, he blames patients for the ineffectiveness of many medical treatments. This
section reveals that individuals blamed doctors for causing death. The author retorts,
“but those who use the example of patients who die from their illnesses wonder what
trustworthy reason leads them to absolve a patient’s weakness of character, and impute
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instead a lack of intelligence on the part of his physician. As if doctors can prescribe the
wrong remedies but patients can never disobey their orders!” (Hippocrates, The Science
of Medicine 7). While what the doctor says holds truth, for patients do not always follow
the prescribed remedies, the sarcastic comment exposes more about the expectations his
patients held. Many died, with or without a doctor by their bedside. And, though the
patient would easily blame the physician involved, he or she would most likely have died
anyway. By hiring a physician, a patient expected a good outcome. The doctor reacts
toward this expectation with frustration because, quite possibly, the blame from patients
affected his livelihood. Jouanna points to the “trial metaphor” in this passage, explaining,
“the physician finds himself in the dock, accused of having killed his patient—unjustly,
since it is the patient who, by disobeying the physician’s orders, brought about his own
death.”37 A doctor’s reputation would have taken a heavy blow in this situation.
Finally, the author claims that the science of medicine is infallible. He argues
against taking on incurable cases, despite his patients’ wishes. He admits that, “his
practice is limited by the instruments many available by Nature or by Art. When man is
attacked by a disease more powerful than the instruments of medicine, it must not be
expected that medicine should prove victorious” (Hippocrates, The Science of Medicine
8). In this statement, he reveals that his clients want medicine to be victorious and that
they are dissatisfied with its limits. They want physicians to push boundaries. But this
doctor understands that catering to these patients’ desires can only lead to failure.38 He
will not blame the treatments of physicians. Instead, “when the physicians fail, it is the
power of the disease which is responsible and not deficiencies in the science of medicine”
37
38
Jouanna 1999, 139-140.
Couch 1934, 141.
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(Hippocrates, The Science of Medicine 8). Fruitless attempts to treat those deemed as
good as dead would hurt the doctor’s reputation because he would be considered
unsuccessful as a healer. Thus, taking on these cases would neither honor the art of
medicine nor bolster the doctors’ credibility. For, although patients say that physicians
should care for the dying, they actually hope that their healing powers will bring
miracles. In these situations, it would be best to turn patients away, or turn them over to
another healer.
VI. The Disconnect
Ultimately, patients want to be healed. Honorary decrees, while they highlight
the admirable characteristics that a doctor should hold, honor one skill above all other
qualities, the ability to heal. The Asklepios inscriptions and inventories speak to this
same need. The healing accounts and endless lists of votive offerings show that patients
appreciate miracle cases and feel indebted to those who cure them. As service providers,
healers must cater to patients’ needs. But, while this relationship may seem simple,
subtle elements create tension. First, no one lives forever and not all cases lead to good
outcomes. The inability of healers to cure complicates the healer-patient relationship.
Plato suggests that those physicians who understand the limits of their profession are the
admirable ones. The author of The Science of Medicine agrees with Plato and hints that
one must draw boundaries in order to be successful as a healer. Second, although
patients want to be healed, they are ignorant of actual healing techniques. Healers can,
therefore, exploit the ignorance of many patients by pretending to be legitimate. Plato
calls this fraudulent behavior “cookery” and believes that the only way to distinguish a
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true physician is through recommendations from fellow physicians. The author of The
Science of Medicine advises against these pretend healers with destructive remedies. His
warnings reveal his appreciation for his art and the competition for patients. This
evidence—from patients, onlookers, and doctors—paint a picture of the relationship
between patient and physician in the Classical world. Physicians needed some sort of
way to satisfy dying patients without hurting their reputations.
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Chapter 3: Addressing Patients’ Needs: The Hippocratic Therapeutics
In light of our understanding of patients’ needs, we can now look into the
methods that Hippocratic physicians—within their limits—used to respond to those
needs. How did the Hippocratic physicians heal their patients? Hippocratic therapeutics
was distinct from other healing practices of the time. The unique combination of
philosophy and scientific observation separated them from other healing groups, and
possibly even from other physicians. The doctors marketed this set of therapeutics,
which defined their niche in the medical marketplace. Their writings speak of methods
for both externally and internally based medicine and discuss remedies, theories, and
approaches. Amidst their various techniques to cure illness, however, a distinct feature
stands out—their emphasis on prognosis. The Hippocratic doctors frequently allude to
the boundaries of their art. While this distinction in their practice protected their
reputation, it led to complications in treating terminally ill patients. This chapter
discusses the Hippocratic methods of healing inside and outside the bounds of their art.
An Evaluation of Hippocratic Remedies
The Hippocratic doctors lay out a set of techniques that deal with external
ailments. These techniques have proven to be somewhat effective according to modern
standards of medicine. Guido Majno offers accounts of reenactments, often cases in
which Hippocratic methods were used, with mixed outcomes. In the reenactments, he
used methods and advice from a compilation of the Hippocratic medical texts, not
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favoring any one over another.1 The cases include: a severe hemorrhage, a round ulcer,
pus in the chest, a fallen lung, a cut in the face, recurrent dislocation of the shoulder,
carpentry on the skull, a chest like boiling vinegar, punches in the head, and stripes. I
will discuss a few of these techniques as examples. According to Majno, a Hippocratic
doctor used sap from a fig tree and elaborate dressing for a severe hemorrhage. The fig
tree juice clotted the blood, the wool plugged the wound, and the white-bandage soaked
in red wine protected the sore area. All these methods would have all helped, except that
the doctor would have then bled the patient from the ankle.2 For a cut on the face, a
Hippocratic doctor would have sutured the wound and then applied copper oxide with
honey and a cloth soaked in wine as dressing. Again, the doctor would then prescribe
harmful post-operation treatment by giving his patient a purgative, a drug that was
supposedly meant to prevent pus. He would have also told the patient to eat very little,
which would also have slowed the healing process.3 For stripes, a Hippocratic doctor
would have cooled the wound, since any temperature imbalance was considered harmful,
and applied some zinc oxide ointment. While this remedy did not harm the patient, it
also did little good.4
Majno also explains a number of common methods that the Hippocratic doctors
used, some helpful, others not so helpful. First, the Hippocratic doctors bled their
patients regularly in hopes of “drying up the wound.”5 Second, the doctors had rules
regarding pus: white pus was pure, suppuration helped a bruised wound, swelling was
1
Majno 1975, 150.
Ibid.
3
Ibid., 161.
4
Ibid., 176.
5
Ibid., 182.
2
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good for severe wounds, and good pus released evils from a wound.6 Third, Hippocratics
often treated wounds with vinegar or wine, which could have acted as a mild antiseptic. It
was not as helpful as modern antiseptics, but there were some benefits to using them.
Other methods were actually harmful to patients. While Hippocratic surgeries may have
done some good, post-surgery treatment lead to problems. The doctors frequently
prescribed Hellebore, a purgative that induces nausea and diarrhea, and eventually causes
death if large amounts are taken.7 Also, the doctors recommended a diet of meat, cereals,
and no fruits or vegetables. As a result, patients became vitamin deficient.8 Finally, the
doctors developed large classes of drugs—sarcotics, epispastics, catheretics, mundifiers,
emollients, and others—for certain conditions that have been proven to be ineffective.
Nonetheless, physicians incorporated these medications into their regimens through
World War I.9
Hippocratic doctors used a few therapies for many different types of cases.
Jouanna categorizes Hippocratic remedies into three groups: medicine, incisions, and
cauterization. These techniques were thought to “expel the scourge of disease.”10 Just as
Plato’s Gorgias suggests, the practices of true physicians were not pleasant all the time.
In fact, the methods were rarely pleasant. Medicines prescribed, such as Hellebore,
induced evacuation. According to the doctors, a patient purified himself by emptying the
cavities of his body.11 Alternatively, physicians used incisions to let out impurities.
6
Ibid., 183.
Ibid., 189.
8
Ibid.
9
Ibid.
10
Jouanna 1999, 155.
11
Ibid., 157.
7
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Techniques such as bloodletting were common among Hippocratics.12 As a last resort,
the physicians turned to cauterization, burning the patient’s flesh to stop the spread of an
illness. These techniques could be lethal,13 and natural healing often times would have
been the better option.
Hippocratic doctors continued these techniques despite the fact that they were
harmful and hurtful to patients because their patients seemed to benefit from the
remedies. The placebo effect without the actual pill may have been at play for the
physicians. David Wootton explains that, “the fact that there was no progress—far too
little to have any systematic impact on life expectancy—and the fact that medical
intervention did more harm than good, does not mean that doctors did not cure
patients.”14 The placebo effect works for both effective and ineffective remedies. In both
situations the doctor’s prescriptions help to “mobilize the body’s own resources.”15
Wootton points to one study in which an estimated one third of the good that comes from
effective modern medical techniques has to do with the placebo effect.16 The question
arises, however, as to whether the Hippocratic remedies were harmful enough to
outweigh the benefits of the placebo effect. Treating patients with incisions and
cauterization can compromise their immune systems, and prevent healing.
On the one hand, Hippocratic doctors may have continued their treatments
because they sometimes relieved symptoms. Patients who felt better temporarily may
have attributed this relief to the doctor’s work. Bloodletting, for example, can cause a
12
Ibid., 159.
Ibid., 160.
14
Wootton 2006, 67.
15
Ibid., 68.
16
Ibid.
13
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person to feel light-headed and will relieve pain for a short period of time by inducing
sleep. At the same time, blood-loss is terrible for the overall healing process in most
situations. The temporary relief is misleading.17 By alleviating symptoms for a short
time, a Hippocratic doctor’s remedy would have tricked the patient into thinking that he
or she was healing.
On the other hand, Hippocratic doctors may have wanted their patients to feel
pain because the pain meant that they were releasing disease. According to Jouanna, the
positive image of a physician was one who “acted vigorously by means of knife and fire
on behalf of the patient.”18 While this technique may have worked for some patients by
convincing them to think that their disease was leaving their bodies, others may have
feared physicians. Jouanna explains that some ancient authors, including Plato and
Heraclitus, spoke to the image of the physician as a torturer.19 These negative portrayals
may have deterred patients from visiting their local physicians, opting for more appealing
methods of healing, such as those used at Asklepieia.
The Philosophy Involved in Hippocratic Practice
In understanding why the doctors continued to perform detrimental procedures, it
is also important to remember that rational medicine in ancient Greece developed from
the philosophical thought of the time. While Hippocratic doctors claimed to be separate
from philosophy, some philosophical perspectives played a part in their medical
practices. Hippocratic remedies flowed from the Hippocratic philosophy of medicine.
17
Armitage 1983, 325 discusses the importance of statistics in understanding the negative
effects of bloodletting.
18
Jouanna 1999, 155.
19
Ibid.
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This philosophy—humor theory—stood on the principle of balance. According to the
Hippocratics, the human body must maintain equilibrium among its humors, which were
blood, phlegm, yellow bile, and black bile. Disease sets in when these humors are out of
balance. The number four pervaded throughout all other constituents of life, including
seasons, winds, states of matter, tastes, and temperaments.20
Although Hippocratic doctors would not admit that their theories were linked to
traditional philosophy, their elemental theory stemmed from the ideas of previous
philosophers in ancient Greece. Longrigg argues that the basis of the Hippocratic
practice began with Ionian natural philosophy in the sixth century BC. At this time,
philosophers, such as Thales, Anaximander, and Anaximenes, planted the seed of
rationalism, which made its way into medical thought.21 These philosophers sought for
some order in the universe apart from the divine and developed unifying principles that
applied to all of life.22 Later philosopher-doctors influenced the Hippocratic writers more
directly. Empedocles, for example, applied pluralistic theory, or the idea that a group of
immutable entities combined in different ways to create the components of everyday life,
to medicine. He believed that human flesh and blood was composed of the four worldly
elements.23 Alcmaeon was another highly influential philosopher that contributed to the
Hippocratic view of medicine. Longrigg explains that, according to Aetius, Alcmaeon
saw health as an “equality of powers—moist and dry, cold and hot, bitter and sweet, and
20
Majno 1975, 178.
For more information on the development of medicine from philosophy, see Longrigg,
Greek Rational Medicine: Philosophy and Medicine from Alcmaeon to the Alexandrians,
1993.
22
Longrigg 1993, 27.
23
Ibid., 70.
21
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the rest—and the supremacy of any one of them causes disease; for supremacy of either
is destructive.”24 This theory of opposites appears frequently in the Hippocratic works.
Thus, ancient philosophy pervades the Hippocratic writings, although the writers
attempt to separate themselves from these lines of thought. A few physicians make
statements against rational thinkers, but their descriptions of treatment allude to certain
philosophical views. These contradictions suggest that, while this group of physicians
wanted to provide unique medical treatment, modern conceptions of the world may have
permeated their medical beliefs. Examples of this tendency come from Tradition in
Medicine and Epidemics I. The former proposes:
“There are some doctors and sophists who maintain that no one can understand
the science of medicine unless he knows what man is; that anyone who proposed
to treat men for their illnesses must first learn of such things. Their discourse then
tends to philosophy, as may be seen in the writing of Empedocles and all the
others who have ever written about Nature; they discuss the origins of man and of
what he was created. It is in my opinion that all which has been written by
doctors or sophists on Nature has more to do with painting than medicine”
(Hippocrates, Tradition in Medicine 20)
In this statement, the author attacks philosophical medicine with force. He does not
believe that the theories of doctors and sophists constitute correct medical practice. By
denouncing these belief systems, the physician sets himself apart for those who practice
philosophical medicine. Instead, he practices the correct art of medicine, an art not
defined by the Nature of man—the theories of hot, cold, wet, and dry, and opposites.25
His vehemence suggests that many people—maybe even his patients—were convinced
that philosophy and medicine were connected. Or else, his credibility gives him power to
condemn others in his field.
24
25
Ibid., 52.
Lloyd 1963, 113.
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Yet, the author of Epidemics I recommends what the previous physician
condemns. He thinks that we must take the nature of man into account when diagnosing
a patient. The physician explains, “the factors which enable us to distinguish between
diseases are as follows: First we must consider the nature of man in general and of each
individual and the characteristics of each disease…” (Hippocrates, Epidemics I 23). This
explanation is in passing; he neither defines “the nature of man” nor attributes the phrase
to a particular sect of philosophers. We can take this silence on the “nature of man” in
two ways. On the one hand, it is possible that this physician considers the nature of man
to be different from the beliefs of the past philosophers. He may use the phrase in the
context of a case study. In this case, man “in general” refers to his knowledge of the way
man responds to disease based on his past experiences as a doctor. On the other hand, he
could be referencing philosophical thought, assuming that the reader would understand.
In this case, the comment sheds light on his relationship to medical philosophy. It shapes
his outlook on the workings of man.
The role of rational philosophy in Hippocratic thought becomes clearer in
analyzing The Nature of Man. The author on this treatise condemns philosophical
musings on man, but applies the theory of opposites to his medical practice. The
physician begins by stating:
“This lecture is not intended for those who are accustomed to hear discourses
which inquire more deeply into the human constitution than is profitable for
medical study. I am not going to assert that man is all air, or fire, or water, or
earth, or in fact anything but what manifestly composes his body; let those who
like discuss such matters. Nevertheless, when these things are discussed I
perceive a certain discrepancy in the analyses for, although the same theory is
employed, the conclusions do not agree.” (Hippocrates, The Nature of Man 1)
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Like the author of Tradition in Medicine, this physician finds fault in applying
overarching philosophical theories to medicine. Again, this author implies that thinking
about medicine in this way is commonplace, and he separates himself from those who
discuss the theories. Yet, later in this same treatise, the author recommends that,
“Treatment then should aim at opposing the cause of the disease… that is,
treatment should involve a change in regimen. For, in each case, it is obvious that
all, most, or at least one of the factors in the regimen does not agree with the
patient; such must be sought out and changed having regard to the constitution of
the patient, his age and appearance, the season of the year and the nature of the
disease.” (Hippocrates, The Nature of Man 9)
While he denounces postulates connected to Empedoclean philosophy, he applies the
theory of opposition to his practice. He discusses balancing the four humors and
connects the humors to the four seasons, but does not think that hypotheses about the
workings of the world apply to medicine. This contradiction shows that, while he may
disagree with his contemporary philosophers who abide by Empedoclean principles, past
philosophical thought is embedded in his present outlook.
Empirically Based Methods: A Means to an End
Hippocratic doctors did not sell their philosophical beliefs, for patients would not
have hired them for their theories alone. They would only respect Hippocratic theories if
their applications in medicine worked. In other words, the physicians needed to succeed
in healing. The Hippocratic doctors, therefore, may have used the humoral theory to
develop their techniques, but the theory would have had little bearing on their success.
Their success came from other aspects of their practice.
Analyzing the Hippocratic writings provides some answers to this question.
Many of the Hippocratic writers observe carefully and rarely apply theories before
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observation. Ancient versions of case studies litter the pages of the Hippocratic works.
Examples come from Epidemics, Airs, Waters, and Places, Prognosis, Regimen, and The
Science of Medicine. Their observations shed light on how Hippocratic doctors treated
patients and how patients responded to Hippocratic doctors in everyday situations. By
examining each patient thoroughly, the physicians would have gained trust. Their
examinations would have led their patients to believe that they would heal them.
The author of Epidemics I demonstrates his careful examination process through
detailed descriptions of his patients. At the beginning of his treatise, the author
recommends that a doctor should, “consider what has gone before, recognize signs before
your eyes and then make your prognosis” (Hippocrates, Epidemics I 11). He applies this
system of identifying illness in his case studies later in the chapter. The cases trace the
progression of diseases: Philicus has a fever for six days, Silenus has bowel problems for
eleven days, the wife of Epicrates has trouble in childbirth (Hippocrates, Epidemics I ixiv). In each situation, the doctor maps the patient’s progression, noting changes in the
color of the blood, urine, and feces. He records both deaths and recoveries, but rarely
indicates his treatment for these patients. This silence calls to question whether the
doctor of Epidemics I did anything for his patients. He may have determined that they
were untreatable, but continued to check on them occasionally. Or, he may have taken a
long time to make a prognosis. Alternatively, he may have been treating the patient
throughout the illness and did not take note of it.
The author also attempts to draw patterns in the progression of diseases, but some
of them are off base. He frequently mentions whether the date of a patient’s death was on
an odd or even day, as if it had some bearing on the disease’s outcome, yet the days do
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not seem to affect his visits with the patient (Hippocrates, Epidemics I i-xiv). We can
conclude, therefore, that the author’s attempt to draw patterns, though inconsequential,
reveals his reasoning based on observation. Regardless of the superstitious patterns he
develops, the physician was spending a lot of time with his patients.
While the author of The Science of Medicine does not provide case studies, he
does list important qualities that a doctor must have. In one passage, he lists the ways of
determining needs: watching the patient, listening to the voice, touching the skin, and
checking fluids. He explains that, “by weighing up the significance of these various signs
it is possible to deduce of what disease they are the result, what has happened in the past
and to prognosticate the future course of the malady” (Hippocrates, The Science of
Medicine 13). This method of examining matches the way in which the physician of
Epidemics treats his patients. The recommendation provides an explanation as to why the
Epidemics author focuses on the symptoms rather than the treatment. The goal in
studying patients is to determine the course of the illness so that the doctor can decide
how to help the patient most. While the doctor pays attention to the patient, he examines
carefully to judge whether his services would be of help in a given situation.
Prognosis and the Limits of Medicine
The Hippocratic doctors used prognosis, or prediction of the outcome of an
illness, to determine whether they would attempt to heal a patient. Their careful
observations, which also allowed them to develop relationships with patients, ultimately
led to a verdict. The author of The Science of Medicine discusses the course a doctor
must take in diagnosing internal maladies. He explains that, “if the nature of the disease
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cannot be perceived by the eye, its diagnosis will involve more trouble and certainly
more time than if it can” (Hippocrates, The Science of Medicine 11), and later advises
that in these situations the doctor must “have recourse to reasoning from the symptoms
with which he is presented” (Hippocrates, The Science of Medicine 11). According to the
author, understanding internal illnesses can take time, and careful observation is needed
to decipher it. The physician’s goal in the examination is to predict the patient’s
outcome.
This method protected doctors’ reputations by avoiding cases with futile ends and
the frustrations that arose when the needs of patients were not met. An entire chapter of
the Corpus devoted to prognosis speaks to this desire to maintain reputation. The author
of this section lists the many signs of an acute disease, including headache with fever,
sneezing, gestures of hands, and abnormal eyes. He asserts that a physician should focus
on prognosis because,
“if he is able to tell his patients when he visits them not only about their past and
present symptoms, but also to tell them what is going to happen, as well as fill in
the details that they have omitted, he will increase his reputation as a medical
practitioner and people will have no qualms in putting themselves under his care.”
(Hippocrates, Prognosis 1)
The statement sheds light on why these doctors would care so much about prognosis. In
order to maintain credibility among their patients, the doctors needed to be successful in
healing. The doctors first had to decide whether they could help a patient at all so that the
patients that they did attempt to heal would recover. In this way, they would keep a good
track record.
The physicians, therefore, proudly admit that their therapeutics have limits. As
discussed in chapter 2, the author of The Science of Medicine addresses the boundaries of
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his practice.26 While patients may be frustrated with him because they want treatment for
an incurable illness, by recognizing his boundaries and stepping aside when powerful
disease spreads, the doctor is better off. His practice benefits from openly discussing his
limits because patients do not hold unrealistic expectations in his abilities. In a field
where many pseudo-doctors had the opportunity to trick people into believing that they
knew how to cure an incurable disease and thereby charging them for ineffective
treatment, patients would have appreciated the Hippocratic transparency.27
Thus Wickkiser believes that by turning patients away, the Hippocratic doctors became
more credible. She sees the limits of medicine and the refusal to treat as central to their
practice. Though some of the physicians alleviate patients’ symptoms, they made clear
that they could not master the disease.28
After caring for a patient for an extended period of time to determine a prognosis,
however, a doctor would not easily give up on a patient. Although most of the Corpus
authors advise refusing to care for terminal illnesses, actually refusing a sick individual
would be much more difficult. The fact that so many of the authors address their limits,
yet some of them admit to treating symptoms of the incurable suggests that these patients
were hard to refuse.29 Current palliative care studies arrive at the same conclusions.
Merely revealing prognosis to terminally ill patients appears to be an insurmountable
challenge for many modern oncologists.30 Also, by turning patients away, a doctor may
anger families desiring care for their loved ones. These disputes could potentially hurt
26
See chapter 2 for further explanation on the passage.
Wickkiser 2008, 27.
28
Ibid., 25-29.
29
Ibid.
30
Hancock 2007, 507.
27
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the doctor’s business. The Hippocratic physicians needed some way to ease the suffering
of their terminally ill patients while maintaining their reputation.
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Chapter 4: Competition in the Medical Marketplace
At this point, we must turn to the Hippocratic competition: the Asklepios cult.
The Hippocratic doctors offered a set therapeutics that was separate from the techniques
of the priest healers at the various sanctuaries of Asklepios. While the Hippocratic
doctors observed patients carefully and provided rational treatments, Asklepieion healers
practiced religiously oriented dream therapy. The two healing methods stood at odds
with each other, yet their points of contention may reveal reasons for the two groups to
connect. In this chapter, I will first discuss the Asklepieion incubation, the dream therapy
technique used in the sanctuaries, the Hippocratic reactions toward this technique, and the
reasons for going to temples rather than doctors. These points shed light on the inherent
differences and the potential competition between the healing sects. In the next chapter, I
will analyze the way this competition actually looked.
Asklepieion Incubation vs. Hippocratic medicine
The Asklepios temple healers practiced incubation, or dream healing. A patient
who traveled to an Asklepieion healing center, must sleep in the abaton there, dream of
being healed—either through medication, surgery, or some other mysterious cure—by
Asklepios, and walk away healthy the next day. The iamata from Epidaurus and an
excerpt from Aristophanes’ Plutus1 provide evidence of the healing centers’ early years
during the late fifth century BC. The writings show that the Asklepios’ sole healing
technique was curing through dreams. While some believe that the occasional accounts
1
This excerpt will be discussed later in the chapter.
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of surgery and remedies suggest that there were some connections to rational medicine,
all of these procedures occur within dreams.2 The lack of observation, the emphasis on
faith, and the success of Asklepios’ mystical practices heighten the contrast between
Hippocratic and temple healing.
While some inscriptions recount rational medical techniques in dreams, they do
not offer convincing evidence that rational medicine was actually practiced at Asklepieia.
In analyzing the reasons behind the inscriptions, we see that rational medicine did not
hold any weight at Asklepieia. Two Epidaurus inscriptions illustrate the kind of rational
medicine that temple healers may have practiced. The first describes a woman from
Pherae who was pregnant with worms. Asklepios did not heal her when she travelled to
his temple, but on her way home a man found her, cut open her belly, and removed the
worms. According to the inscription, “after having stitched her belly up again and made
the woman well, Asklepios revealed to her his presence and enjoined her to send thankofferings for her treatment to Epidaurus” (IG IV2, 121-122 XXV).3 The cryptic story does
describe a surgical procedure, but it explains little about the exact ailment of the
woman—how she acquired it, how she recovered, or how she was healed. The simplicity
of the account suggests that the surgery is not the central point of the story. Instead, the
account highlights the many manifestations of Asklepios’ healing powers. The
inscription would reinforce Asklepios’ healing nature to visitors, not the rational
technique used.
A second inscription about another woman, Erasippe of Caphyiae, with worms
sheds light on the variability of Asklepios’ healing practice. Like the previous inscription,
2
3
For more information on these arguments, see Edelstein 1998, 239-245 (commentary).
Edelstein 1998, 234.
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this woman from Caphyiae came to the temple with worms, but the god healed her in a
different way. While in the last inscription Asklepios came in the form of another
human, in this story:
“the god massaged her stomach and kissed her and then gave her a vessel which
contained a drug and ordered her to drink it and then ordered her to vomit; when
she vomited, her dress was full with it. When day came she saw that her whole
dress was full with the evil matter which she had vomited, and thereupon became
well. ” (IG IV2, 121-122 XLI)4
The differences between the two accounts show that the ways the women are healed are
not what the inscriptions are meant to emphasize. The last story reveals Asklepios’
manifestations; this story reveals the mystical power of incubation. Although the
purgative remedy that the god gives her does hint at a similar technique that a
Hippocratic doctor would use, the fact that the whole story occurs in a dream adds a new
element to healing through remedies. Since the healing happened in a dream, whether or
not the woman actually drank a potion becomes uncertain. The only conclusions we can
draw from the inscription is that Erasippe came to the temple sick, and left healthy after
seeing Asklepios in a dream.
Some scholars propose that the visions shed light on the patients’ experiences
with medicine. Rather than hinting at rational medical techniques, the testimonies merely
show that the sick had seen rational practices in the past and, therefore, saw them in their
dreams. Edelstein explains:
“Not only did people see the god operating upon themselves, as they had seen the
human doctor operating upon their friends, not only did they hear him give
advice, as they had received prescriptions from their physicians, they argued with
the god when they were displeased with his procedure (T. 427), as they were wont
to argue with their doctors.”5
4
5
Ibid., 237.
Ibid.,165 (commentary).
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Nonetheless, although these patients only saw Asklepios in their dreams, they were
healed in reality. Edelstein points out that the visitors were grateful for any kind of help
they received from the god. Due to a combination of the placebo effect and a little advice
from the temple attendants, Asklepieion healing must have been successful.6 The
Asklepieion methods, therefore, were wholly separate from rational medicine.
The lack of observation, the emphasis on faith, and the unparalleled healing
power of Asklepios in the accounts reveal stark contrasts between the Asklepieion and
Hippocratic healing. Many of the Asklepios testimonies are short. Unlike the case
studies of some of the Hippocratic doctors, they do not describe the symptoms of visitors
in detail. A boy has no voice; a man has leeches; a woman has a prolonged pregnancy
(IG IV2, 121-122 V; XIII; II).7 The testimony takes no more than a phrase to address each
ailment. These short descriptions call to question whether the kind of illness that each
visitor suffers actually matters. While the diseases mentioned are different, the power of
the god is universal. He heals both small ailments and large disabilities. The record of
the disease, complete with all its distinguishing features is inconsequential—prognosis is
not the goal.
Instead, the inscriptions underscore each sick individual’s faith, a kind of faith
that stands at odds with Hippocratic medicine. While Hippocratics trust in the art of
medicine and encourage patients to appreciate its power and limits, Asklepios trusts in
faith. Rather than systematically taking apart the causes of illnesses, Asklepieion healing
merely requires a patient to believe in religious power. One testimony emphasizes the
importance of faith in Asklepios’ healing. A man with paralyzed fingers who was
6
7
Ibid., 172 (commentary).
Ibid., inscriptions 229-233.
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“incredulous” of Asklepios’ healing power and “scoffed at the inscriptions” travelled to a
temple (IG IV2, 121-122 III).8 After an encounter with Asklepios in a dream, the man
had a change of heart, and he left the Asklepieion cured. This story shows that even
those visiting Asklepios who are wary of his powers can be healed. The people only
need to realize the god’s skill. Asklepios discriminates against no one.9 The Hippocratic
doctors, on the other hand, give orders to their patients. They use their knowledge and
skill to help, but ultimately it is up to the patient to get better. It is not the doctor’s fault
if the ill worsen from their prescribed remedies as noted in The Science of Medicine
(Hippocrates, The Science of Medicine 5). The Hippocratic patient must take an active
role in the healing process, but Asklepios’ patients merely have to dream.
Finally, the unfailing strength of Asklepios’ healing techniques is opposite to that
of the Hippocratic physicians. Asklepios reveals his force through the speedy recovery of
his patients. Each sick person that Asklepios heals walks away from the temple healthy.
A woman with tapeworm is “made well”; a blind man “walked out sound”; a man with
lice “left the Temple well” (IG IV2, 121-122 II; XVIII; XXVIII).10 The inscriptions say
nothing more about the future of each patient. Meanwhile, Hippocratic doctors describe
lengthy illnesses that they treat as in Epidemics I.11 The universal, faith-based nature of
Asklepios healing suggests that the temples took on cases that Hippocratic doctors would
not touch. The therapy, which, for the most part, clashes with rational medical
techniques, may even reflect the deficiencies in other types of medicine and the need to
8
Ibid., 230.
Ibid., 174-175 (commentary).
10
Ibid., 229-235.
11
See chapter 3 for discussion on Epidemics I.
9
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find some sort of comfort in treatment.12 When the Hippocratics are unable to help,
Asklepios steps in.13
The Hippocratic Doctors Respond to Faith Healing
One chapter of the Hippocratic writings, The Sacred Disease, sheds light on how
the doctors viewed temple healing. While the author never explicitly discusses
Asklepieia in the chapter, the kinds of practices that he addresses relate to temple
medicine. Therefore, we cannot draw definitive conclusions, but we can make inferences
about the doctors’ thoughts. According to the chapter, the Hippocratic doctors did not
respect divine intervention in medicine.
The Sacred Disease provides information on how the Hippocratic doctors viewed
the role of the divine in healing. The topic deals with what ancient healers called the
“sacred disease,” and what modern doctors call epilepsy. The author suggests that, while
many healers believe that the disease has a divine origin, it actually comes from natural
causes.14 He says:
“I do not believe that the ‘sacred disease’ is any more divine or sacred than any
other disease but, on the contrary, has specific characteristics and a definite cause.
Nevertheless, because it is completely different from other diseases, it has been
regarded as a divine visitation by those who, being only human, view it with
ignorance and astonishment.” (Hippocrates, The Sacred Disease 1)
In this statement, the author defines the difference between rational and divine medicine
and describes how most people see the two types. Many, since they are “only human,”
view the disease as coming from divine origin and thus treat it with ritual purification.
12
Nutton 2004, 104-105.
Wickkiser 2008, 33.
14
Laskaris 2002, 69.
13
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Religious-medical treatment is the norm. Arguing for rational medicine, this physician
goes against common beliefs.
But the author does not only rebuke specific healing practices, he also criticizes
specific healers. Later in the passage, the author points to medical men, presumably ones
that he competes with in the medical marketplace, that have misinterpreted the disease.
He explains:
“Those who first called this disease ‘sacred’ were the sort of people we now call
witch-doctors, faith-healers, quacks, and charlatans. These are exactly the people
who pretend to be very pious and to be particularly wise. By invoking a divine
element they were able to screen their own failure to give suitable treatment and
so called this a ‘sacred’ malady to conceal the ignorance of its nature.”
(Hippocrates, The Sacred Disease 2)
This Hippocratic physician attempts to expose the deceptive nature of these faith healers
and quacks. He points out that, rather than admitting ignorance of the disease, these
practitioners prescribe ineffective remedies for which they charge their patients.15 The
author concludes that a healer should either treat the disease rationally, or admit failure.
He seems to view those who conceal their ignorance as worse than those who genuinely
believe in divinely oriented treatments, for he claims that the healers who propagated the
sacred element of this malady were those who only pretended to be pious. Those who
feign piety, however, are different from those who are truly pious.
The Hipporatics’ hostile response to the irrational treatment of disease questions
where the Asklepios cult would fall. According to the inscriptions at Epidaurus,
Asklepios healed through faith and religious-magic without any sort of rational medical
treatments. Their healing practices easily fit into the category of “faith-healers,” which
the Hippocratic author condemns. But would the Hippocratic physicians consider temple
15
Couch 1934, 142.
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healing to be fraud—“pretending to be pious” in order to conceal ignorance? While they
do invoke divine elements, no evidence suggests that the incubation methods were
ineffective, or that the priests promised miracles. The temples merely offer assistance to
individuals—never insuring success.16 At the same time, visitors and temple priests
would not have addressed the rational cause or treatment of a disease. Healing at
Asklepieia was based on faith.
Yet Hippocratic doctors did not believe that medicine and disease were
completely separate from religion. The physicians do discuss the gods’ relationship to
disease. In The Sacred Disease, the author does not claim that the gods do not take any
part in curing, but that they do not infect a person. Gods are pure, while humans are base.
Purification, therefore, does not rid an individual of some evil deity. Rather, “it is the
deity who purifies, sanctifies, and cleanses us from the greatest and most unholy of our
sins” (Hippocrates The Sacred Disease 4). While the statement only mentions the gods
helping individuals repent, the broader context suggests that the gods are available for
healing illness as well. According to Wickkiser, “although the gods do not pollute, they
can help in eliminating pollution; hence the need for prayer, sacrifices, and visits to the
gods’ sanctuaries.”17 Wickkiser believes that the author’s comments demonstrate the
Hippocratic connection to Asklepios healing. She is right in that the statement does hint
that a patient is free to appease the gods to hasten his recovery, but the physician makes
clear that in order to directly cure an illness, a man with knowledge of medicine must
combat a disease by “applying the remedies most hostile to the disease and those things
16
17
Jouanna 1999, 200.
Wickkiser 2008, 32.
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to which it is accustomed” (Hippocrates, The Sacred Disease 21). The gods can help, but
physicians must lend a hand in the healing process as well.
To the Hippocratic physicians the gods were not detrimental to recovery, but the
methods the Asklepieia employed—incubation—may have been. Some of the therapies
described in the mystical accounts go against Hippocratic practice. Jouanna points to the
account of an epileptic at Epidaurus to highlight the contrast between the two types of
medicines. This epileptic from Argos dreamt that Asklepios pressed his ring to his mouth,
nose, and ears. The treatment cured the patient, and he walked away healthy.18
According to Jouanna, this ring was used as a magical device for healing. While the
method was popular at the time, a Hippocratic physician would not have promoted it,
“nor could he endorse the whole series of cures, each more stunning than the last, that the
staff of the sanctuary of Epidaurus had selected to promote the god’s image as a
healer.”19 The two practices were at odds.
The author of The Sacred Disease may have been attempting to distinguish
himself from other healers because he was competing against them in the medical
marketplace. Laskaris proposes that the differentiation between the medical sects is
largely due to financial reasons. She explains:
“it is precisely because of the common ground that the author is compelled to
launch his polemic against magico-religious healers, and that the differentiation
he seeks to make was rhetorically based, and probably motivated by financial or
other non-intellectual considerations rather than by fundamental conceptual
differences with his opponents.”20
18
Jouanna 1999, 201.
Ibid.
20
Laskaris 2002, 29.
19
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While there is some truth to Laskaris’s statement, for the author was likely trying to
separate from magico-religious healers, we must consider what comes first—the
therapeutics or the differentiation. The Hippocratic author of The Sacred Disease must
have had some reason to condemn other healing methods that involved divine
intervention. If there were similarities between the two practices, then it would not be in
the doctor’s best interest to stand against the techniques that he also used. Instead, he
would want expose the inherent differences to gain the competitive advantage.
Reasons for Competition
Since the two practices were fundamentally different, a patient needed to make a
choice on how to be healed. In order to understand the Hippocratic doctors’ interactions
with the Asklepios cult, we must first consider why a patient would travel to an
Asklepieion rather than consult a Hippocratic doctor. Scholars have developed a variety
of answers to this question based on socio-economics, therapeutics, and success.
One argument centers on the universal healing of Asklepios. While doctors,
including the Hippocratics, could be expensive, no evidence indicates that there were fees
for attending an Asklepieion. Edelstein points to accounts of Asklepios’ charitable
attitude to demonstrate the possibility that Asklepieia were healing centers for the lower
classes.21 The votive offerings found at the archaeological site in Athens,22 for example,
reveal the ways in which visitors gave thanks to Asklepios. While some patients gave
money, others gave trinkets and tools. The diversity of the offerings suggests that there
was no set value for Asklepios’ services.
21
22
Edelstein 1998, 175 (commentary).
Refer to Chapter 2 for more information on the Athenian Asklepieion inventories.
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An excerpt from Aristophanes’ Plutus also provides evidence for Edelstein’s
theory. The passage describes the decision of Chremylus and Blepsidemus to travel to
the temple of Asklepios to heal a blind man. After the two characters realize that there is
no doctor nearby because “there are no fees, and therefore there’s no skill,” they
determine that they must “let him lie inside Asklepios’ temple/ a whole night long”
(Aristophanes Plutus, 400-414).23 The discourse shows that physicians did not practice in
areas where there was no money to be made, but that Asklepios’ sanctuary was open
regardless.24 According to this excerpt, it is not that the doctors would limit themselves
to certain social classes, but to certain areas with money.
The Honorary decrees to doctors also hint at this issue of fees. A few inscriptions
from Athens (006, 007) commend certain physicians for providing service without pay.25
These honored physicians must have performed tasks outside the norm. While many
doctors required fees for service, these physicians treated free of charge. Their actions
were enough to warrant recognition in their community. In analyzing these inscriptions,
we must ask how frequently a community encountered doctors. It is possible that most
doctors were generous, but came to certain areas only occasionally. The people,
therefore, would have little experience dealing with !!"#$%. These two decrees, however,
came from Athens, an area that was most likely rich with rational medical care. The
citizens there would have come across many kinds of healers, and the honored doctors
stood out among them.
23
Edelstein 1998, 213.
Cohn-Haft 1956, 21 discusses this idea of the “travelling doctor” in his argument in
favor of public physicians. Also, see Chapter 2 for more information regarding his
argument.
25
Samama 2003, 113-116. See Appendix for translations of these decrees, as well as
chapter 2.
24
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Another reason why the sick would travel to an Asklepieion instead of a doctor is
based on therapeutic techniques. While Hippocratic methods could be painful,
unpleasant, and, often times, ineffective, Asklepios’ dream therapy was effortless.
Patients, judging by the testimonies, walked away healthy, unlike those believers in
rational medicine who suffered a long road to recovery. Joaunna points to one of the
Epidaurus accounts: an empyematic man from Troezen who saw Asklepios in his sleep,
telling him not to be cauterized but to come to his temple instead. The patient went to
Epidaurus and was healed. Jouanna explains that, “in this case, where physicians had
recommended an operation that would have been doubly unpleasant for the patient even
in the event it was a success—for cauterization was painful and left unsightly marks—the
god, appearing in a dream, intercedes…”26 As a description of a situation in which one
healing method is preferred over the other, the account reflects the competition between
the two groups.
Many patients must have shied away from Hippocratic healing because it was
unpleasant. This attitude stands in line with Plato’s argument in the Gorgias. Plato
points out that many times the best medicine is not the pleasant medicine (Plato, Gorgias
465a).27 His comments, which challenge what most people would have thought at the
time, shed light on patients’ attitudes toward healers. Speaking about this issue as a way
to encourage others to think differently about medicine, Plato exposes what patients did
not think, rather than what they thought. The sick wanted therapeutics that comforted
them, and dreaming at the temple of Asklepios would have provided them with this
comfort. Hippocratic methods would have troubled many of them.
26
27
Jouanna 1999, 200.
See Chapter 2 for further discussion on Plato’s work.
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Finally, patients travelled to Asklepieia when doctors could not help. Hippocratic
doctors, after spending time on the prognosis of an individual, would determine whether
an illness was incurable. If a disease were labeled “incurable,” the patient would need to
seek other means of healing or resign to death.28 In these situations, the healing powers
of Asklepios were still an option. While the ailments in the Epidaurus inscriptions vary
greatly, a large number of them describe potentially life-limiting illnesses. Jouanna
addresses one that is of special interest to the theme of life-limiting illnesses. The
inscription again tells the story of a woman with intestinal worms. The doctors were
unable to cure her and so she travelled to Epidaurus.29 This inscription sheds light on
those dire situations in which doctors decided to turn patients away.
Thus, the line between the two healing groups must have been a fine one. Some
scholars believe that the relationship between the two healing groups strengthened due to
this business of handing over patients. Wickkiser claims that, although Hippocratics in
principle disagreed with irrational medical techniques, “some doctors, by making certain
concession to deities and prayer while disparaging most other forms of healing suggested
that ailments they themselves could not treat were best left to the gods, prayer, sacrifice,
and healing in sanctuaries.”30 In these situations, however, doctors would merely admit
defeat. In light of the inevitable competition between the two groups paired with the
doctor’s reluctance to give up patients, this business of simply handing over is highly
unlikely. In order for this funneling to occur, a system would need to be put in place.
Their interactions hint at a possible referral system instituted.
28
See Chapter 3 for further discussion of Hippocratic prognosis.
Jouanna 1999, 200.
30
Wickkiser 2008, 33.
29
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Chapter 5: Competitive Collaboration
Up to this point, we have discussed patients’ needs and the ways in which two
separate healing groups—the Hippocratic doctors and the cult of Asklepios—went about
catering to those needs. Their fundamental differences in therapeutics and medical
philosophy reveal the inherent competition that would have existed. In light of the stark
contrasts, we would expect the Hippocratic doctors to abhor or, at least, avoid the cult of
Asklepios all together, but no evidence exists that hints at any sort of animosity. Instead,
literary and epigraphic data reveal that the two groups interacted and respected each
other. This information calls to question why the Hippocratic doctors would have
interacted when they were competing against Asklepios’ faith healers. The
representative, largely public interactions between the two healing groups suggest that the
Hippocratic doctors used their relationship with the Asklepios cult to gain a competitive
advantage in the medical marketplace, despite their competition. Their interactions hint
at a system of referral from the Hippocratics to the temple priests. This pattern would
have allowed the doctors to address patients’ needs, while maintaining credible
reputations.
Association by name: The Branding of the “Asklepiads”
One important potential connection between the two groups is that Hippocrates
and the Hippocratic doctors were called Asklepiads. Notable accounts of their linkage
during the fourth century come from Plato and Aristotle. Both philosophers provide
outsiders’ perspectives on the Hippocratic relationship with Asklepios. They tie the two
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groups together by using the term !!"#$%&'()&, translated as “Asklepiads” or “the sons
of Asklepios.”1 In his Phaedrus, Plato explains, “at least if Hippocrates, the Asklepiad, is
to be trusted…” (Plato, Phaedrus 270c).2 And in the Protagoras, he also calls
Hippocrates from Cos an Asklepiad.3 Clearly, Plato associates Hippocrates with the
term. But, while Plato does consistently refer to Hippocrates as an Asklepiad, he does
not clarify what he means by it. Does he merely mean a “doctor” when he uses the term,
or something more?
Other uses of the words “Asklepiads” and “doctors,” separate from Hippocrates in
Plato’s writings shed light on the potential differences between an Asklepiad and other
rational medicine practitioners. In the excerpt in Book III of the Republic on the art of
medicine, Plato uses both terms.4 In distinguishing the problems in Athenian society,
Plato hints that those who need medicine as a result of “idleness and a way of life such as
we described, full of humors and winds like a marsh” force the “subtle Asklepiads to give
names like ‘flatulence’s’ and ‘catarrhs’ to diseases” do not do justice to rational medicine
(Plato, Republic 405d). Plato implies that the “subtle Asklepiads” should not have to use
their art to treat idle people. Later, he explains, “this current art of medicine which is an
education in disease was not used by the Asklepiads of former times…” (Plato, Republic
406a). By bringing up the former Asklepiads, Plato suggests that the current Asklepiads
do practice medicine appropriately because of the pressure from their patients. By
diagnosing small, inconsequential ailments, current Asklepiads do not honor their
medical art.
1
LSJ, definitions 1 and 2.
Edelstein 1998, 104.
3
Ibid.
4
See Chapter 2 for further discussion on Plato’s Republic.
2
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Plato uses the term “doctor,” or ")*+,-, in discussing the actual medical
profession. Later in the same passage, he outlines the qualities of a clever doctor—
learned in the art, familiar with “bad bodies,” and a veteran of many diseases. These
traits allow the doctor to fully understand the body in order to treat it. Plato does not use
the two terms interchangeably in this excerpt. When discussing history, honor, and the
true art of medicine, Plato uses “Asklepiad.” When referring to the actual medical
profession, he uses “doctor.” This difference is subtle. In his outcry against idle people,
Plato seems to employ the term “Asklepiad” in reference to the present medical
profession, but the context of the passage reveals that Plato sees the Asklepiads as
stooping to the level of the idle patients and not honoring their art. Although Plato may
refer to the same professionals with the two terms, he uses them to express different
aspects of their practice.
While I will not go into Aristotle’s discussion of Hippocrates or the Asklepiads
in detail, I will mention that, in his Metaphysics, Aristotle calls Hippocrates the “leader of
the Asklepiads” (Aristotle, Metaphysics 1027a).5 In this description, Aristotle insinuates
both that there is an organization of Asklepiads and that Hippocrates is the leader of
them. While the passing reference does not provide much information about the
“Asklepiads,” it does show that the group—however large it may be—is defined. We can
draw out new meaning when applying the connotations that Plato established with the
term Asklepiad to this phrase. According to Aristotle’s statement, Hippocrates is the
most honorable and respected practitioner of the art of medicine and leads other
5
Edelstein 1998, 104.
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honorable, respectful physicians. Aristotle’s comment hints at a defined group of
physicians under the master Hippocrates.
The history of the word “Asklepiad” connects the term to the god Asklepios and
his cult. Theognis of Megara from the sixth century BC6 offers the earliest dated use of
the word. In his Elegiae, the poet writes, “if god had granted this to the Asklepiads, to
heal the evils and the hearts of men blinded by reckless impulses, they would reap a great
store of wealth” (Theognis, Elegiae 432-434).7 The account shows that the art of the
Asklepiads was known during Theognis’ time or shortly after. Edelstein brings up the
possibility that this excerpt was inserted into the text later, but concludes that it was most
likely part of the work by the fifth century and thus believes that the word “Asklepiad”
came into existence sometime in the sixth century or earlier.8 By the fourth century BC,
the time of Plato and Aristotle, the Asklepiads were famous enough to warrant employing
them as examples to illustrate points in their philosophical writings.
With this fame in mind, we must decide to whom “Asklepiad” referred. A variety
of proposals have cropped up over the years about the connection between the terms
“Asklepiad” and the more general, “physician.” Some scholars conclude that all
physicians were called Asklepiads. Originally, scholars believed that the words were
synonymous because they thought that rational medicine began in temples. An excerpt
from the Suidas about Democedes, a sixth-century BC physician who was also a temple
6
Edelstein dates Theognis of Megara to this date.
Edelstein 1998, 104.
8
Edelstein 1998, 55 (commentary). Edelstein provides a more thorough timeline of the
term’s use, but for the purpose of this thesis we need only to know the way in which the
word was used in the late fifth century.
7
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priest of Asklepios speaks to this argument (Suidas Lexicon).9 The date of the Suidas,
which is around the tenth century, undermines this proposal. While the author of the
Suidas in late antiquity may have thought that physicians were originally temple priests,
he wrote much later than the time of Hippocrates. His ability to evaluate the
professionalization of the physician is, in some ways, equal to modern historians.10
Edelstein believes that the medical knowledge of the Asklepiads started within one
family, but by Roman times the term spread to all physicians.11 Jouanna concurs that the
Asklepiads began as a family with knowledge in the art of medicine.12 Jouanna proposes
that outsiders, who practiced Asklepiad medicine, had to take the Hippocratic Oath. By
pledging, they promised to honor the Asklepiad family and their medical knowledge.13
These physicians were more or less always connected to Asklepios. In
distinguishing between the different forms of Asklepios, some scholars question whether
the Asklepiads were connected to the god-Asklepios or the hero-Asklepios. Jouanna,
along with many others, argues that Hippocrates and his family of Asklepiads were
actually direct descendents of Asklepios the mortal physician. He quotes Johannes
Tzetzes, explaining:
“Those whose line descends from this origin [that is, from Asklepios] are called
Asklepiads in the proper sense of the term, whether they are physicians or
whether they practice another activity, as Hippocrates and many others. But all
physicians are called, by an improper extension [of the term], Asklepiads from the
fact of such an art.”14
9
Edelstein 1998, 107.
For more information on this argument, see Withington 1921, 192-194.
11
Edelstein 1998, 55 (commentary).
12
Jouanna 1992, 45.
13
Ibid., 47. Refer to Chapter 1 for further discussion on this argument.
14
Jouanna 1999, 10.
10
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According to this theory, Hippocrates’ family descended from Podalirius, mentioned as
the son of Asklepios in Homer’s Iliad.15 Edelstein explains that this lineage came from
the hero-Asklepios, their patron saint of sorts. He asserts that, for the most part,
Asklepios was not elevated to the status of a deity until after the fifth century. In fact, the
first account of Asklepios’ divine birth does not appear until 420 BC in the Homeric
Hymn to Asclepius.16 The physicians, therefore, were not directly connected to the
temple god, who became famous later.17 But how likely was it that Hippocrates actually
descended from Asklepios? He would have been associated with whatever form of
Asklepios his contemporaries recognized. In practice, distinguishing between the two
would have been irrelevant. Thus, it is more likely that the connection between the
alleged hero of medicine and the leader of the medical art was drawn for economic gains.
Undoubtedly, the link would have made the Asklepiad family more credible in their early
years of practice.
Although the family may have originally been attached to the hero-Asklepios, the
alternate forms of the demigod must have blended by the time of or shortly after
Hippocrates.18 In the Republic’s passage dealing with the Asklepiads, Plato questions
whether Asklepios was a god.19 In the excerpt, Socrates portrays Asklepios, son of
Apollo, as the first teacher of medicine, who revealed to his sons the limits of the art, but
then recounts his downfall. According to Pindar, after raising a man from the dead, Zeus
struck Asklepios with a thunderbolt (Plato, The Republic 408b). Socrates concludes that,
15
Ibid.
Edelstein traces his Asklepios’ development as a god 1998, 68-70 (commentary).
17
Ibid., 55-56.
18
Hippocrates lived between 420- 370 BC, and Plato’s Republic is dated to 380 BC.
19
See Chapter 2 for further discussion on this passage.
16
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“if he was a god’s son, we’ll say he wasn’t basely greedy, and if he was basely greedy, he
wasn’t a god’s son” (Plato, The Republic 408c). The story hints that Asklepios’
background during Plato’s time was undefined, yet Plato seems to accept his mysterious
nature and move on. His brief description suggests that Plato and his contemporaries saw
Asklepios as some sort of god-like figure associated with medicine, and did not focus on
the details of his status.
To patients and other worshippers, the distinction between the god and the hero
may have been fluid. While it may have made a difference to those within the guild,
outsiders would have linked the healers to the god just by associating the two names.
The fact that the Asklepiads kept their name, perpetuating it as they spread their medical
knowledge, shows that they wanted to remain attached to Asklepios, god and hero. It is
even possible that the family branded their own name. Wanting to restrict their medical
knowledge to those who would honor their art, the title would have been a stamp of
approval. Therefore, although some scholars believe that the Asklepiads were distinct
from the growing cult of Asklepios, the Asklepiads—even if they were originally
connected to the hero-Asklepios—must have associated with the name Asklepios for
practical purposes.
Showing Respect: The Hippocratic Oath Revisited
The Hippocratic Oath sheds light on how the Hippocratic doctors viewed their
relationship with Asklepios and how they wanted others to view this relationship. While
scholars argue about the extent to which the Oath played in an ancient physician’s
practice, the fact that it exists today connected to Hippocrates and his pupils shows that,
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at some point, the physicians deemed it necessary to document their allegiances.20 With
this knowledge, we will assume that the Hippocratic Oath represents the Hippocratic
practice. The first lines of the Oath state:
“I swear by Apollo the physician and by Asklepios and by health [Hygeia] and
Panacea and by all the gods as well as goddesses, making them judges
[witnesses], to bring the following oath and written covenant to fulfillment, in
accordance with my power and my judgment.” (Hippocrates, Hippocratic Oath 14)
This opening reveals the Hippocratic doctors’ official stance on faith. According to the
Oath, these physicians greatly respect the gods—Asklepios included. While they do not
believe that the gods alone could heal, they do view them as authorities, ensuring that the
Hippocratic doctors abide by the oath they take. Naming the gods and heroes of
medicine specifically, like Asklepios, shows that the doctors felt some affinity to these
deities: they appreciated their patrons as masters in their field of work. At the same time,
these Hippocratic physicians do not ask for a helping hand. They merely request that the
gods make sure they keep their word.
The way in which the Hippocratic doctors used the Oath calls to question the
extent of their relationship with divine healing. In order to understand why the doctors
first formulated an Oath, we must look into the purpose of taking oaths. While oaths can
actually mean little to those who swear, they hold weight among those who watch the
swearing. In the 1600s, Samuel Pufendorf sheds light on the significance of oaths in
society. He argues:
“An oath is held to lend conspicuous support to our speech and to all acts which
involve speech. For it is a religious affirmation, by which we give up our claim to
God’s mercy or call down divine punishment if we shall not speak truth. An oath
raises a presumption of truth by invoking an omniscient and omnipotent witness
20
See Chapter 1 for arguments regarding the Hippocratic Oath.
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and avenger, because we find it hard to believe that anyone would be so impious
as boldly to call down upon himself God’s most heavy wrath. This is the reason
why the duty of those who swear is to take the oath with reverence and to observe
scrupulously what they have sworn.” (Pufendorf, On the Duties Involved in taking
an Oath 1)21
Oath takers take on no new obligations. Instead, they solidify ones that are already
expected of them. Rather than using oaths as a positive reinforcement to honor and treat
their peers with respect, societies instate them to instill fear in those who swear. By
swearing to an “omniscient and omnipotent” being, sly individuals cannot escape
punishment. But if someone were not likely to tell the truth with an oath, would they tell
the truth after taking one? And, for those who are already truthful, would an oath change
the way they act? Pufendorf illustrates that oaths are actually ineffective for those who
swear them but provide comfort to the surrounding individuals. They trust the oath taker
because they believe that the one who swears will be less likely to wrong them.
By pledging, the oath takers invoked respect from their audience. In swearing to
fellow Asklepiads, a doctor promised to honor the art of medicine passed down through
the generations.22 The Oath served as a way of officially restricting knowledge for the
originators of the practice. Whether or not restricting knowledge in this way was
effective, the pledge gave comfort to the fathers of the medical practice. By swearing to
the public, a doctor promised to treat his patients with respect. It was a way of ensuring
moral obligation to members of society.23 In a society where no medical licensure
existed, an oath would have held weight in the community.
21
Silverthorne 1991, 1.
Jouanna 1999, 47-48.
23
Miles 2004, 52. See Chapter 1 for Jouanna and Miles’ arguments on the Hippocratic
Oath
22
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The Hippocratic doctors, therefore, swore to the gods—the “omniscient and
omnipotent” beings—to comfort their fellow doctors and patients. Those individuals
respected Apollo, Asklepios, Hygeia, and Panacea as healing deities, and so it would
have been in the physicians’ best interest to commit to these gods as well. But pledging
to Asklepios through an oath is very different from interacting with Asklepios’ healing
practice. At the same time, the Asklepios’ healing practice was not separate from
worshipping the god. The Asklepieions encompassed both shrines and healing centers.24
By showing respect for Asklepios the healing god, the Hippocratic doctors would
inevitably have attached themselves to Asklepios’ healing cult.25
Pledging allegiance to Asklepios shows that the Hippocratic doctors respected the
Asklepios temple healers. The two groups’—temple healers and Hippocratic doctors
alike—devotion to the healing god hints that they had some sort of middle ground aside
from just associating with the same deity. The doctors must have had some reason to
publicly link themselves with the god because, through their Oath, patients would have
associated the two kinds of healers.
Public Appreciation: Inscriptions
An inscription that illustrates the physicians’ devotion to the temple of Asklepios
provides further evidence of the interaction between rational medicine and cultic healing.
The decree, dated to 270 BC, comes from Athens and describes an assembly decision to
appoint a priest for life. One line of the record points to the physicians’ sacrificial ritual.
24
Sherwin-White 1978, 277.
Ibid. Sherwin-White argues that although the “Asclepiadai” (the physicians claiming
decent from Asklepios) were different from “Asclepiastiai” (the name of the religious
organization), the groups could have still associated because they tied to the same god.
25
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It states: “Since it is the tradition among doctors who are on public service to sacrifice to
Asklepios and Hygieia twice a year on behalf of both themselves and the persons that
each one of them healed.”26 The rest of the sentence is unreadable. Although the
statement is incomplete, it does shed light on the doctors’ semi-annual sacrifice to
Asklepios.
By making a point of sacrificing publicly, these doctors demonstrate respect for
the cult and their own profession, as well as their concern for patients. The fact that this
ritual is semi-annual hints that the doctors have developed some sort of system to display
their relationship with the Asklepios cult. Others know when the sacrifice will take
place; they anticipate the appreciation that the physicians will show to the cult. Just as
the swearing of the Hippocratic Oath, the physicians’ ritual performance, which was
intentionally public, promoted their medical practice. Also, the inscription implies that
the doctors, who sacrifice on behalf of the people they have healed at the Asklepieion—
where other patients are treated—show concern for all patients. While inconclusive, the
decree does suggest that there was no clear distinction between the patients of the doctors
and of the Asklepieion. The system of handing over patients was likely fluid. While the
Asklepieion may have treated patients that the physicians could not help, the doctors
must have still cared about their well-beings. They must not have turned patients away,
but referred them to Asklepieia. This referral would have allowed the doctors to keep
tabs on their customers, while deferring the burdens of healing, and the expectations that
come along with it, to the sanctuaries.
26
Samama 2003, 119. See Appendix, 011 for complete translation.
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Two problems arise when analyzing this inscription of the semi-annual ritual in
our study of the Hippocratic doctors. First, the record does not say whether these doctors
were Hippocratic, but based on the previous connections made between the Hippocratics
and Asklepios, we will assume that the Hippocratic doctors took part in this kind of
ritual.27 Also, the date of this inscription (270 BC) is slightly later than our time period in
question, which is the late fifth century and early fourth century. The two healing
groups’ relationship may have differed between the two times.
The inscription, however, should not be discounted in our study because it likely
reflects earlier interactions. The official nature of the decree suggests that the doctors
performed informal sacrifices to Asklepios much earlier. The fact that the assembly
considers the doctor’s semi-annual sacrifice “tradition” shows that the relationship has
roots. Also, an earlier decree, dated to 329 BC, from Athens honors Phidias of Rhodes
for his outstanding service to the city, and determines to engrave a stele for him and place
it at the Asklepieion, an appropriate place for a tribute to a doctor.28 The placement of
the stele hints at a connection between the two healing groups. In light of this older
decree, the 270 BC inscription exposes previous interactions between the Hippocratic
doctors and Asklepios. By shedding light on the development of the relationship, the
inscription speaks to the mutual respect between the healing sects that began in the fifth
century.
Many scholars use the 270 BC inscription as evidence that the two healing groups
were intertwined. Maria Elena Gorrini analyzes the inscription as well as the series of
inventories from Aleshire. From her analysis, Gorrini rightly concludes that, at the very
27
28
The inscription uses only the word ")*+,-. See appendix, 011 for complete translation.
Appendix, 007. See Chapter 3 for further discussion of this decree.
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least, the two healing groups met at sanctuaries of Asklepios. She explains that these
meetings reveal two elements of their relationship, “that medical doctors respected
Asklepios among the healing deities; and that, on the other hand, rational medical
practices may have been echoed in the temple healing practices, as a consequence of the
intercourse of priests and medical doctors.”29 While her evidence shows that the doctors
respected the institution of Asklepios’ temple, it does not hint at any melding of practices.
Over the centauries, the two groups may have lost some of their identity, but in the late
fifth century they likely remained faithful to their separate traditions. It would not have
been in the doctors’ best interest to use semi-faith healing treatment. The physicians
would have needed to offer distinct therapeutics in order for patients to choose them
instead of going to an Asklepieion at the start of an illness. The Hippocratic statements
against faith healers and charlatans, as demonstrated in The Sacred Disease30 represent
their distinct divide with other healing practices.
Other scholars use the inscription on the physicians’ traditional offerings to
highlight the distinct identity of secular physicians. Cohn-Haft argues that the inscription
merely reveals the public practice of physicians. The ritual, which the community
witnessed, demonstrates the doctors’ ability to give medical service, rather than their
relationship with the Asklepios cult.31 He concludes that the two groups were not in
competition, nor did they have any sort of professional connection. Instead, physicians
were only connected to the patron god of their profession.32 In comparing the Hellenistic
Epidaurus inscriptions to other Asklepios accounts, specifically from Aelius Aristides,
29
Gorrini 2002, 145.
See Chapter 4 for more information on their competition.
31
Cohn-Haft 1956, 60.
32
Ibid., 29.
30
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from the Roman period, Cohn-Haft unveils the absence of rational practices at the temple
during the Hellenistic era.33 He explains that no evidence exists “connecting any known
physician officially with a temple of the god, nor identifying a priest or other templeattendant of Asklepios as a doctor.”34 According to Cohn-Haft, the evidence of the
connections between the two healing sects, reflect no underlying collaboration.
The crux of this argument lies in the fact that by sacrificing at the temple of
Asklepios the physicians inevitably associate with the Asklepieion and its healing cult.
Arguing for distinctions between the two manifestations of the god is difficult when the
doctors perform semi-annual rituals at the location of the god associated with the cult.35
Just as the name “Asklepiad,” this semi-annual sacrifice inevitably connects the
Hippocratic doctors to the cult. The relationship between the Hippocratic doctors and the
Asklepios cult, therefore, most likely fell between the arguments of Gorrini and CohnHaft. While the group of doctors retained a distinct identity in the fourth and fifth
centuries BC, they did publicly respect and refer to Asklepios and his cult.
Public Dedication: Inventories
The medical elements from the inventories at the Athenian Asklepieion, also
suggest that the Hippocratic doctors and the cult of Asklepios intertwined. Two types of
inventories shed light on the relationship in question: those that describe medical tools as
objects of dedication and those that refer to the doctor as the dedicator. The two types
33
Ibid., 28.
Ibid., 29.
35
Aleshire 1989, 94.
34
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show that both doctors and the public recognized the collaboration between the healing
sects.
Two inscriptions from fourth-century BC Athens mention the dedication of
physicians’ instruments, but not the name of the dedicator. The first describes a series of
iron objects, which includes accounts of seven medical forceps, six scalpels, and four
writing tablets.36 The second mentions a physician’s writing tablet (IG II2, 1533 116).37
Since we do not know who dedicated these objects, we can assume either that a physician
dedicated them to honor Asklepios, or that a patient somehow got hold of these objects
and gave them to the temple. Aleshire believes that physicians offered medical
instruments as dedications, although often times their names are not inscribed.38 Like
other evidence of their interactions, the dedications would show that physicians respected
the cult. The public would have recognized this respect by witnessing their dedication
ceremonies and by reading the records.
Alternatively, these medical tools could have come from patients, which would
show that the patients linked the two healing groups. Dedicating objects associated with
rational medicine to the cult of Asklepios implies that the patients believed either that the
cult practiced rational elements, or that the doctors were connected to such an extent that
medical tools represented both practices—the two sects were essentially one. If they had
seen the physicians’ rituals or heard of friends and acquaintances visiting both healers,
community dedicators would likely link the two groups. Although the doctors competed
with Asklepieion healers, this mixing would inevitably occur. The dedication, however,
36
Samama 2003, 112.
Aleshire 1989, 141.
38
Ibid. 65.
37
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still begs the question how the dedicators got hold of physicians’ tools. A patient may
have obtained the instruments from a doctor, through the market, or by making them
themselves.
The second group of inscriptions from third-century Athens attributes dedications
to certain doctors. Two inscriptions come from what Aleshire refers to as Inventory IV.
The first records a doctor giving a “finger-ring with a cornelian set in gold,”(IG II2,
1534A 67) 39 rather than a medical instrument. The fact that this dedication is not
medically related introduces the possibility that the medical instruments described earlier
were not from doctors. Doctors likely gave medical instruments, valuables, or both,
depending on what they could afford. Addressing the unnamed doctor on this inscription,
Koehler and Kirshner restore his name to Onetor and link him to a priest named Onetor
from other portions of inventory IV. Having drawn these parallels, they conclude that
Onetor was both a physician and a priest. If this were true, then the inscription would
allude to a deep connection, not evident in other primary sources between the two healing
sects. While a few scholars have latched on to this theory, many have discounted it.
Aleshire concludes, “there seems to be no good reason for either the restoration or the
identification, since there is no other evidence of doctors as annual priests.”40 The record
does, however, suggest that he desires to demonstrate his wealth and success.
The next dedication verifies that some doctors did dedicate their tools. The
inscription states that Kallimachos Thymaitades dedicated a “hollow cauterizing
instrument” (IG II2, 1534A 84).41 While the account does not specifically state whether
39
Ibid., 198.
Ibid., 231.
41
Ibid., 200.
40
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Kallimachos is a doctor, Aleshire believes that he was.42 This situation seems typical: a
doctor dedicates a tool of his profession to the patron god of his art. A third inscription,
however, from Inventory V dated to the third century describes a physician, Nikomakhos,
who gives a monetary amount in drachmas to the Athenian Asklepieion.43 Like the
unnamed doctor, Nikomakhos demonstrates his wealth by offering money. While this
evidence draws no definitive conclusions about the common dedications of physicians, it
hints that doctors desired to show off their offerings through public dedications.
Clearly, these physicians cared about the way the public viewed them. Both the
inscriptions of the semi-annual sacrifice and the records of the dedications demonstrate
that doctors desired to be publicly connected to the Asklepios cult. By sacrificing semiannually and offering gifts to the temples, the doctors would have proven to be pious.
Yet, while patients may have confused the two groups, the doctors’ respect for the cult
appears to be primarily public in nature, rather than embedded in their therapeutics.
Solely Public Interactions: A Disconnect in Therapeutics
A final piece of evidence of the interactions between the Hippocratic doctors and
the cult of Asklepios comes from the Hippocratic writings. Some interpret the
Hippocratic treatise Dreams as evidence of the connection between the two healing
groups. Dreams outlines the way in which doctors should use dreams as diagnostic signs.
The author explains that dreams are especially useful as signs of sickness and health
because “when the body is at rest, the soul is stirred and roused and becomes its own
master, and itself performs all the function of the body” (Hippocrates, Dreams 86). This
42
43
Ibid., 65.
Ibid., 282. See Appendix, 009 for inscription translation.
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physician believes that dreams reflect bodily maladies. For example, if the moon is
present during sleep, then the dreamer most likely needs to purge himself of something
harmful inside. Or, when the heavenly bodies wander during sleep, then the dreamer
must be anxious. After a long list of dream interpretations, the author concludes that the
gods help mortal lives by offering signs through dreams. Thus, interpreting dreams is the
“best regimen” (Hippocrates, Dreams 93).
The parallels between this theory of dream interpretation and the incubation
practiced at Asklepieia seem to be significant. In other words, the fact that Hippocratic
physicians incorporate dreams into their diagnostic techniques demonstrates a connection
in therapeutics that would tie together the very heart of their practice to the cult. Analysis
of Dreams, however, reveals that the two methods of dream therapy are decidedly
different. This Hippocratic doctor uses dreams as a diagnostic tool. He does not speak
about divine interventions in dreams. He does draw attention to prophetic dream
interpreters, but explains that they are rarely useful when reading diagnostic dreams and
usually just recommend that the dreamer pray to the gods.44 The physician counters,
“prayer is a good thing, but one should take on part of the burden oneself and call on the
gods only to help” (Hippocrates, Dreams 87). The author concludes that it takes a trained
doctor to interpret medical dreams correctly.45 Meanwhile, Asklepios appears in dreams,
taking drastic measures to save patients.46 Rather than using the dream to treat a malady,
the dream itself cures the malady.
44
Holowchak 2001, 389.
Ibid.
46
See Chapter Four Section I on Asklepios’ therapeutics.
45
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Mark Holowchak looks into the dream therapy techniques of the Hippocratic
doctors in Dreams in detail. By taking apart what the author of Dreams has to say about
prophetic and medical dreams, he highlights the contrast between the two methods of
interpreting dreams. He questions whether there were differences in the dreams
themselves that led to the disparate practices, or whether the two sets of dream
interpreters—the oneirocritics and the physicians—came to different conclusions after
analyzing the same dreams.47 In comparing the Hippocratic approach to interpreting
dreams to Artemidorus’ Oneirocriticon from the second century AD, Holowchak draws
conclusions about the way in which the Hippocratic doctors used dreams. He determines
that, “because there were no manifest features to distinguish diagnostic from prophetic
dreams, it is likely that physicians who examined their patients’ dreams considered all of
them as possible diagnostic indicators.”48
While Holowchak does not discuss the role of dreams at Asklepieia specifically,
he does shed light on the distinct way Hippocratics interpreted dreams. They saw dreams
as indicators of bodily ailments, and treated patients using dreams accordingly. Their
views on dreams were unique to their practice. Although both healing sects employed
dreams, the inherent differences in the role of dreams reveal that their therapeutic
practices did not intertwine. Rather, the introduction of dreams into Hippocratic regimen
may reflect surface interactions between the two groups. If the Hippocratics were
exposed to incubation methods first hand, their writings would likely hint at their
understanding of the therapy. Instead, they integrate the basic principle of the remedy,
but completely rework it to fit their needs. This analysis of dreams provides further
47
48
Holowchak 2001, 392.
Ibid., 394.
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evidence of an exclusively public relationship between the Hippocratic doctors and the
cult of Asklepios.
A Public Connection Reveals a Referral Relationship
The pieces of evidence that reflect collaborative interactions between the
Hippocratic doctors and the cult of Asklepios speak to a publicly oriented relationship of
mutual respect and hint at a systematic referral relationship. The fact that the Hippocratic
doctors called themselves Asklepiads and pledged allegiance to the god Asklepios
suggest that they connected their guild to this patron god. The god and the cult were
likely linked, and so the connection must have extended to the cult itself. The
inscriptions and inventories found at the Athenian Asklepieion speak to their relationship
with the cult. These public demonstrations of respect show that the doctors wanted the
community to recognize their connection to the Asklepieion. Such connection helped
their reputation to be considered pious individuals, and to remain connected to their
patients even when they could not help them. The Hippocratic chapter On Dreams
highlights this surface relationship. While they did associate with the cult publicly, their
therapeutics, which defined their practice, did not intertwine with the religious healing
group. The Hippocratics were still a separate sect that offered fundamentally different
healing techniques from the cult of Asklepios. Yet, it was in the best interest of their
profession to attach themselves to Asklepios’ temple. By protecting the Hippocratic
reputation and allowing for a reliable referral pattern, the connection gave the doctors a
competitive advantage over other healers.
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Concluding Remarks
Through the evidence of the Hippocratic doctors’ interactions with the Asklepios
cult, we can gather how the doctors used their relationship with the cult to enhance their
standing in the medical profession resulting in a competitive, yet complementary,
connection. During the late fifth century and early fourth century, the well-known healer
Hippocrates and his followers began promoting their medical techniques. Sources in
various generations, from Plato to Plutarch, attest to Hippocrates’ healing ability. As
time passed, his fame increased. His life became a legend to physicians in the Roman era
and beyond. His school, formed in Cos, trained students outside the medical familial
bonds of the “Asklepiads.” The Oath and the Corpus provide evidence of the
Hippocratic method of training. Thus, the Hippocratic doctors came to be.
Now branded by the sacred knowledge of the Asklepiads that claimed lineage to
the medical demigod Asklepios, the doctors practiced in many areas of ancient Greece,
including Athens and Cos. Faced with the growing medical marketplace that
encompassed all types of healers—magicians, medical philosophers, charlatans, quacks
and more—and without licensure to determine the quality or intentions of any practice,
the doctors needed a way to separate themselves from the medical masses. They needed
a competitive advantage.
This competitive advantage would allow the physicians to tailor their practice to
the needs of their patients, for ultimately their patient base controlled their success.
According to the selection of honorary decrees, ancient Athenians and Coans desired
results from the medical practitioners they employed. They appreciated reputable,
trustworthy, and egalitarian healers and respected the art of medicine. At the same time,
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the customers recognized the importance of miracles. Journeying to sanctuaries of
Asklepios, they placed faith in the god’s ability to heal through dreams.
Yet, complications arose when doctors could not meet patients’ needs. According
to Plato’s Gorgias and Republic, patients hardly knew what was best for them. They
preferred comfortable therapies to painful medical treatments. Ignorant of a frauddoctor’s telltale signs—for who, other than medical professionals, can distinguish
between a quack and a true physician?—the sick easily succumbed to low quality care.
And the physicians, trained by the honorable Asklepiads, deigned to treat idle patients
with minor maladies. These frustrations evident in Plato’s writings are echoed in the
Hippocratic Corpus. The author of The Science of Medicine blames patients for turning
away from the medical art too quickly, for refusing to carry out their prescribed regimens
appropriately, and for expressing dissatisfaction with medicine’s limits. His polemic
words shed light on both his patients’ expectations of rational medicine and his inability
to treat them satisfactorily. Thus, succeeding in the medical marketplace was more
difficult than one might expect. The Hippocratic doctors battled to uphold their dignified
medical art, while dealing with patients easily led astray.
To make matters worse, Hippocratic therapeutics—the set of medical techniques
that they used to heal patients—were not always effective. Doctors had much to learn
about human anatomy and physiology before they would be able to cure patients reliably.
Reenactments of certain Hippocratic remedies reveal its inconsistent results. Many of the
treatments were extremely painful. Relying on purgatives, incisions, and cauterization,
the physicians often did more harm than good.
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Despite these injurious practices, the Hippocratic doctors still managed to heal
and to maintain a patient base. Part of their success may have been due to the placebo
effect. The simple act of visiting a doctor and receiving a diagnosis and prescription
often comforts sick individuals. The doctors were not giving their patients sugar pills per
se, but they did provide them with the mental mindset needed for recovery. As well, the
physicians gave their patients the attention needed for recovery. Developed from sixth
century medical philosophy, Hippocratic therapeutics had not yet separated itself entirely
from the all-encompassing principles that philosophers applied to the human body. From
these philosophical remnants, however, the Hippocratics introduced new therapies based
on observation. By examining their patients carefully, the doctors were able not only to
form relationships with those who visited them and give them the attention they desired,
but also to predict the outcomes of illnesses.
This prognosis determined whether or not they could treat a patient. In order to
keep a good track record for their healing practice, the physicians had to understand when
ailments were beyond their means of healing. At the same time, they could not merely
give up on patients who came to them for help. They needed a way to continue to look
out for their coveted customers, while protecting their reputation in the medical
marketplace.
At this point, the Asklepios cult came into play. As a healing group that offered
fundamentally different therapeutics from rational medical doctors, the cult filled in the
gaps of the Hippocratic physicians’ practice. Their faith-based dream therapy gave hope
to patients in dire circumstances. Cured by merely believing in Asklepios and sleeping in
his sanctuary, visitors valued this passive method of healing. The many successful
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treatments and lengthy lists of votive offerings documented on the Epidaurus inscriptions
and the Athenian Asklepieion inventories attest to the power and popularity of Asklepios’
healing practice. The god cured all kinds of ailments, from worms to paralysis, of those
that travelled to his shrines littered throughout the ancient world.
In principle, this type of therapeutics repulsed the Hippocratics, who abhorred
faith healers, charlatans, and quacks. It would seem that the doctors, viewing the cult as
competitors, would condemn Asklepios’ religious healing practices, especially since they
condemned so many other types of healers. The author of The Sacred Disease, for
example, expresses hatred toward those healers who treat the “sacred disease” as a divine
malady, while covering up their ignorance of the illness’s actual cause. His heated
remarks against faith healers suggest Hippocratic physicians stood against Asklepios
therapies publicly. Yet, the writings never mention the growing cult. This silence calls
into question how the competition between the two healing sects actually looked.
The physicians interacted respectfully with the cult. They used Asklepios’ name,
swore to his godly healing power, and sacrificed at his sanctuary. And, in order to
demonstrate their connection, the doctors made others aware of their actions. While they
may have begun to promote their “Asklepiad” label before the cult became popular, they
continued to foster their bond through name well into the time of Aristotle. The
continuation shows that the doctors wanted to remain connected to the Asklepios and his
cult, despite their difference in therapeutics. The Hippocratic Oath, which was most
likely taken publicly, also tied their profession to Asklepios. By calling on the god to
ensure that they uphold their art, the physicians made known that they answered to their
patron Asklepios. Finally, inscriptions show that they developed a systematic semi-
Wall 93
annual ritual performance to communicate the relationship. This sacrifice was a constant
reminder of the connection.
At the same time, their relationship was skin-deep. The Corpus reveals that the
doctors did not compromise their own practice of rational medicine by associating with
the temple healers. Their therapeutics remained distinct from Asklepios’ incubation. The
author of Dreams, for example, recommends other doctors to use dreams in practicing
medicine but explains theories about dreams that are fundamentally different from the
Asklepieion dream-therapy. While the Hippocratic doctor interpreted dreams, Asklepios
healed through dreams. The differences in technique show that the actual healing
practices of the two groups did not overlap.
The evidence indicates that the Hippocratic physicians formed an intentional
relationship with the Asklepios cult. The doctors had specific reasons for publicly
associating with the Asklepios faith healers. The popularity of the cult bolstered the fame
of Hippocratics, and the therapeutics of the cult provided the physicians with a way to
better care for their patients’ needs. When a doctor deemed a patient incurable by
Hippocratic standards, he continued his connection to the patient by referring him or her
to the Asklepios cult. This reliable pattern of referral enabled the Hippocratic doctors to
both satisfy patients until death and uphold the dignity and reputation of the medical art.
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Appendix
A selection of decrees from Samama, 2003.1
0012 Epitaph of the physician Aineas, (Athens 4th century BC; IG I2, 1019; CEG I, 62)
This monument is a remembrance of the wisdom of Aineas, an excellent doctor.
003 Metrical Epitaph of the physician Aristokrates (Athens 4th Century BC; CEG II,
500)
For mortals, he was the best doctor of all against disease: here lies the son of
Pnytagoras, Aristorkrates.
004 Inventory of the sanctuary of Asklepios (Athens 4th Century BC; IG II-III2, 47)
Here are the iron objects:
A large ring attached to a chain; a large scraper; medical forceps; six scalpels
and medical forceps; four tablets…; a pair of fire-tongs; three medical forceps etc.
1
Cohn-Haft and Aleshire also reference a number of the selected inscriptions. I have
included references to these authors as well.
2
The decrees are numbered according to Samama’s method.
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006 Decree for the physician Evenor of Argos in Akarnania 3 (Athens 307-303 BC;
IG II-III2, 374)4
… and the joint-presidents; it was resolved by the people… of the Gargettus deme, the
son of …kleus,, said: since Evenor, the doctor, both demonstrated only kindness to the
people and has made himself useful with respect to his art to those citizens and others
living in the city needing him; and only recently he has readily contributed for the
preparation, one talent of silver, in Good Fortune; it has been resolved by the people to
praise Evenor, son of Evepios of Argos, and to crown him with an olive -wreath on
account of his good-will concerning the people of Athens; and to make him and his
offspring Athenian and to have him enrolled in the tribe and the deme and the phratry
3
4
Although this inscription does not mention Akarnania, Samama named it this way.
Cohn-Haft 1956, n°4.
Wall 96
which he chooses according to the law; to give the prytaneis of the Hippothonthis [tribe]
the vote toward him in the first assembly; and to have this resolution inscribed by the
prytany secretary on a stone stele and to set it up on the Acropolis; and to give for the
inscribing of the stele…
007 Decree for the physician Phidias of Rhodes (Athens 304-303 BC; IG II-III2, 483)5
In the archonship of Pherekles, during the seventh prytany of the Oineis tribe, in which
Epikharinos, son of Demokhares of the Gargettos deme, was secretary, on the 22nd day of
the month of Gamelion and the 29th day of the prytany, was the assembly:of the presiding
officers, Phylaxias, son of Phanias, of the Anagyrous deme and the other joint-presidents
put to a vote. It was resolved by the people: Euboulides, son of Euboulos of Eleusis said,
“Since the doctor Phidias continues doing profitable things for the people of Athens and
healing those Athenians in need with emulous desire, and has now offered himself to give
public service for free, showing the good-will that he has toward the city, in Good
Fortune, it was resolved by the people to offer praise to Phidias the Rhodian, son of
Apollonius, on account of his good-will and care, which he continues to give to the
5
Ibid., n°5.
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people of Athens, and to crown him with an olive-wreath; and that the prytany’s
secretary inscribe this resolution on a stone stele and set it up in the Asklepieion.
008 Dedication to the physician Argaios (Athens 303/2 BC; IG II-III2, 3782(a) &
3783(b))
Argaios of Plothea, son of Argaios.
Batakes of Peiraeus, son of Batakes, having been healed, dedicated
Demetrios of Pletea, son of Philon of Pletea made it [the statue]
If ever the venerable mind of mortals has discovered something in the art [of medicine], I
say that you have known with your thoughtful insights, having judged the wise opinions
of doctors and having plucked the extraordinary from books with the eyes of your mind.
You, Argaios, have offered the joy of Bacchic wine, that rescues the weary stiffening of
limbs; For this, the lovely glory of your art will never come to an end, but will be brighter
than the heavenly stars.
009 Catalogue of donors (Athens 3rd Century BC; IG II-III2, 1534 B & 1535)6
from the doctor Nichomakhos, 20 [drachmas]
6
Aleshire 1989, 249.
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011 Regulation of worship for the public physicians to Asklepios and Hygieia
(Athens 27/69 BC; IG II-III2, 772)7
In the Archonship of Diogeiton, during the 12th prytany of the Demetrias tribe, in which
Theodotos, son of Theophilos of the Keirias deme, was secretary; on the 28th day of the
month of Skirophorion, in the principal assembly Diodorus of presiding officers, son of
Epikhares of the deme of Coprus, and the joint-presidents, put to vote. VAC It was
resolved by the people: Akrotimos the Ikarian, son of Aiskhios, said, ‘Since it is the
tradition among doctors who are on public service to sacrifice to Asklepios and Hygieia
twice a year on behalf of both themselves and the persons that each one of them healed.
VAC. In Good Fortune, it seemed to the council VAC that the presiding officers, who
have been drawn by lot to make deliberations in the coming assembly concerning these
matters in the temples, present the decision of the council to the people on what seems
goods to the council VAC that the priest be appointed for life.
7
Cohn-Haft 1956, n°5 and Aleshire 1991, 81.
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123 Honorary decree of Cos for the physician Xenotimos (Cos 3rd Century BC;
I. Cos, n°5, SEG 33(1983), 670)8
Praximenes said: Since Xenotimos son of Timoxenos, took care of citizens in earlier times
with his medical art, proving himself to be dedicated to the salvation of the sick, and even
now, when too many diseases put the sickly to the point of death, and the public service
doctors in the city becoming sickly by the illness themselves because they were taking
care of those weary, Xenotimos, always offering himself to those in need, choosing to
bring (help) to the sick by necessity, healing no one for honor, but hurrying similarly to
all citizens, he has saved many: It seemed good to the people to praise Xenotimos, son of
8
Cohn-Haft 1956, n°13 and Sherwin-White 1978, 178.
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Timoxenos, and to crown him with a wreath of gold on account of his good will and that
he continues to give care to the citizens immediately. Let the sacred herald announce
that the people give Xenotimos, son of Timoxenos a crown of great value, which the
assembly has the power from a great name to put to vote, as great gift on account of his
good-will and providing care with his medical art to those among the citizens who are
sick, so that everyone sees that the people honor those citizens who are useful and show
good-will.
Wall 101
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