JOHN YOUNG M.D.
KEEPER OF HUNTERIAN MUSEUM
JAMES MACLEHOSE AND SONS
Publishers to the University
TO THE GLASGOW UNIVERSITY
When your President courteously procured for me the opportunity of commenting on the Oath (now a Declaration) which Graduands have to subscribe, I fear that I evilly repaid you by taking up too much of your time. When asked to allow the translation of the Oath to appear in the "University Magazine," I had pleasure in complying with the request, and in forwarding the MS. to the printer.
To-day, 11th January, the "Magazine" appears without my contribution, or rather with that contribution blacked out—an act of grave insolence or gross stupidity. I print, sooner than I had intended, the substance of my remarks, and ask your acceptance thereof. I would record my deep regret that I have been made the involuntary cause of trouble and anxiety to my good friend, Mr. John Muir, and those who conduct the "Magazine" on behalf of their fellow-students. My regret is enhanced by the discovery that their actions are liable to the control of foolish persons, whose censorship might have been advantageously exercised on other occasions.
The Oath of Hippocrates is a document of high antiquity, probably of pre-Hippocratic age. It contains reference to some similar formula pre-existent which exercised restraint on intrants to the profession, to the Art, τέχνη, which we have no equivalent, since the Greeks did not then cut the profession into two—theoretical and practical. The phrase from Aristophanes cited by Littré, Adams, and others indicates that the formula was even popularly familiar. Among the Hippocratic writings is a treatise De Prisca Medicina attributed by Plato to Hippocrates, and justly regarded by Littré as of high value. Textual criticism leads others to look on it as the work of a later sophist; but by whomsoever written, it is a narrative animated by somewhat of the same spirit—the strong desire to maintain the credit and dignity of the profession. The Oath is of great archæological interest. I give a translation of a Latin version, of which there are several, not the least elegant being that formerly administered to graduates before modern ways replaced it by a law declaration in English ; the elegant Latin prayer is not yet, I am happy to say, disused on public occasions:
'I swear by Apollo, the physician, and Aesculapius and Hygeia and Panacea, and I call to witness all the gods and goddesses, that I will, to the best of my power and judgment, keep this oath and this written declaration in its integrity. I shall hold him, who has taught me this art, as a parent. I shall devote my life to him, and shall supply him with all of which he has need. I shall regard his sons as my brothers, and, if they wish to be taught, shall teach them this art without fee or indenture. I shall make sharers in the teaching by precepts, and listeners to the oral instruction, and participators of the other modes of instruction, both the sons of my own teacher and those who have bound themselves by indenture and dedicated themselves by the medical oath: but none others. Further, so far as concerns the healing of patients, I shall prescribe to them, as my powers and judgment direct, suitable diet, and shall forbid what is detrimental and injurious. No entreaties shall induce me to give to any one noxious drugs, nor shall I take part in any such counsels. Likewise I shall exhibit to no woman any pessary which shall destroy her fruit at an early or late stage of pregnancy. I shall conduct my life and practise my art in holiness. Nor shall I cut even those who entreat me, but shall leave them to those who practise such surgical operations. Whatever house I enter, I shall do so for the good of the sick, and shall abstain from every hurt or injury, as well as from sensuality with man or woman, bond or free, whose body I have to cure. Whatever I shall hear or see, even when not called in for medical attendance, whatever I shall come to know in the ordinary intercourse of life, which it would be improper to repeat, I shall keep silence regarding it. I shall hold it secret. May I, keeping this oath in its entirety, enjoy my life and art in happiness, and have credit among all men for all time. May the opposite befall me if I break it.'
Hippocrates was an Asclepiad, seventeenth or nineteenth in descent from Aesculapius, the son of Apollo and Coronis, but the term Asclepiad came latterly to mean a member of the medical fraternity. The appeal is strengthened by the invocation of the divine progenitor, of the human ancestor and his daughters, Health and All-heal, as well as of all the powers of Olympus. The Asclepiad key-note is struck when the teacher is acknowledged as in a quasi-parental relation, in Hippocrates' case it was one of real paternity—when responsibility for his maintenance is accepted, and his children, at least his sons, are adopted as brothers. They are to receive gratuitous uncovenanted instruction, and no one beyond the circle of brotherhood by the flesh or by adoption is to be initiated in the art unless he covenants and swears himself into the confraternity. It was indeed a close guild, and so remained until a recent time, apprenticeship being the chief avenue to the profession, in which none could enrol unless as a pupil of some master. The check on the admission of outsiders, at least in undue numbers, was as rigidly enforced as in a trades union, or in that elder brother of the union, the guildry of our large towns. To these latter admission was restricted to descendants, or it any were assumed from the outside, they came in "at the far hand" and paid at a higher rate. Of the professional bulwark the last trace was removed when the University Commissioners practically ended the gratuitous instruction of professors' sons.
The kinds of instruction are not certainly defined. In later times the reader in medicine prelected from prescribed books of Hippocrates or Avicenna, and in the seventeenth century the student at Padua listened for three years to certain books as the main source of his instruction. In the Hippocratic period oral instruction was paramount, the future Aphorisms and Prognostications holding the chief place, while clinical instruction, though not neglected, was incompletely provided for by the private practice of the teacher. There were dispensaries or private nursing homes, such as Aelian speaks of as gossiping centres, and as the means whereby charlatanry was cultivated.
The medical obligations imposed were various, positive and negative. The good of the patient is the first object, and for that purpose dietary of a right sort was to be ordained. Later times read in this mere diet, but the Hippocratic dietary included everything—food, baths, exercises. Cervantes admirably caricatures the absurdity of medical practice in his time when he shows the Governor of Barataria in risk of starvation, his physician ordering everything away as it was presented at his table. The fanciful physiology of an unscientific age did what is now effected by food-chemistry run to seed. Having some acquaintance with gout, I know that a diet dictated by the books would be nearly as unsatisfying as that of Barataria. But the need of care in regulating diet in the Hippocratic wide sense was justly insisted on. We know that a convalescent from typhoid may be killed by so innocent an article as a custard: ancient cooking offered a good many even more noxious substances, fraught with equal danger to a delicate stomach, while unwise bathing or inopportune exercise might upset the balance of not too stable health. The treatises De Balneis abounded, and their perusal makes one wonder how, dietary holding so many traps and atmospheric germs so many more, the human race has survived. Gabriel Bachtischua was imprisoned by Harun Al-Rashīd because he plainly told the monarch that his evil plight was the inevitable consequence of his disobedience to Gabriel’s regulations. The physician of Antigonus was sent to prison for declaring the case of a courtier incurable, while a more supple adviser held the opposite, and even relieved the sufferer. But death followed soon after on a surfeit of unsuitable food, and the physician then explained that he knew the man's want of moderation to be beyond control: that was the incurable disease, not the immediate symptoms which might be alleviated.
The obligation not to administer poison belongs to a curious chapter of medical and social history. Christianity which did not exclude poisons from the Vatican cannot afford to say much regarding a not uncommon Eastern solution of difficulties: the counsel, συμβουλίη, as a preliminary, suggests the existence of men against whom the lofty principles of the Oath were a needful protest and protection.
At that time the physician gave out the drugs from his private stores, and thus might, without detection, do evil. Next came the stage when each physician had his own formulæ, and so restricted his patients to those acquainted with these formulæ, to whom indeed he had assigned the monopoly. The practice still survives: "Prescription No. 1" is not an utterly unknown formula whereby practitioner and drug-seller are partners, a custom against which prohibitive regulations are ineffectual. I have before me examples from an English provincial town where such co-partnery is all but avowed. It might be defended on the ground that in Hippocrates' day the drugs were included in the fee for attendance: this we know still as the way of "shilling a visit and bring your own bottle" practitioners, whose interests are inimical to those dispensaries which, with senior students as visitors, gave the most valuable training when I was a student. I do not know if such institutions still exist on the same lines, but I do know that the attempt to introduce the plan into Glasgow some years ago was brilliantly unsuccessful. The Faculty of Physicians and Surgeons still appoint Inspectors of Drugs, who, even in the days when their power was more absolute, could not altogether prevent curious pharmacy. An old practitioner in the West recently told of a candidate who "knew how ipecacuan was made": "half an ounce of tartar emetic to a pound of pease meal." This represented the practical mode of pharmacy in the eastern part of a large town. But it is not a dozen of years since a practitioner on the other side of the Border dismissed an assistant who insisted on the use of a certain drug which the young woman who dispensed Bottle No. 1, Bottle No. 2, etc., knew nothing about, could not well know since she combined pharmacy with domestic duties. The young lady took the bottles as marked, ignorant of their contents, just as in the sea-port tales of skipper and mate dealing with the B.T. medicine chest.
The pimentarii, or dealers in cosmetics, became drug-sellers: the modern apothecary is certified a proficient in pharmacy, just when the older members of the trade, in view of the multitudinous patent medicines, etc., regretfully anticipate the return of the druggist to his first state—a purveyor for the toilet.
The clause forbidding cutting has excited keen controversy, and the problem is not yet solved. If physicians were known not to have operated, if even it were certain that lithotomy was then in the hands of a select few, whether of good or of mean repute, we might understand the clause. But Hippocrates deals with surgical questions in a way which proves operative familiarity. No one who had not operated could have laid down the precautions he rightly urges. Lithotomy was an old operation; no one is spoken of as its inventor. Ammonianus' invention, as described by Celsus, was for the removal of a calculus too large for the ordinary procedure. Trephining, too, was of great antiquity. Munro has shown that it was freely practised in prehistoric times, and successfully too, if we may safely reason from the fact ingeniously demonstrated by Munro (Prehistoric Problems, c. 5), that the patients survived the operation sufficiently long for the rounding of the cut edges, and for other reparative processes to have advanced a long way. Hippocrates knew all about trephining; why does he forbid lithotomy? There are two ways of meeting the difficulty. Either he did not desire to trench on the province of specialists, for specialism, if not certainly known to have prevailed in Greece, certainly existed at an early period in Egypt, whence many things were borrowed. Cicero doubts whether specialism existed in Hippocrates' time, and certainly paracentesis, even the removal of ribs in empyema, the amputation of a gangrenous limb, the treatment of fistula, the removal of hemorrhoids, all these are spoken of as if the physician knew of them in the ordinary way of his duty. No doubt surgeons at a later time belonged to a less dignified class than physicians, to whom they stood in the relation of ministrants, just as to-day surgeons, even of eminence, put upon the physician the responsibility for an operation which they conduct at his bidding, only seeking to make it safe and effectual. Or, if this does not suffice, it may be said that the passage is corrupt, and Littré's unwillingness to meddle with the text must be set aside if an emendation can be proposed which will make sense of it and not conflict with other knowledge. He suggests that the passage οὐ τεμέω οὐδε μὴν λιθιῶντας should read οὐδὲ μὴν αἰτέοντας—"I will not cut—not even those who ask it of me." The text ΑΙΤΕΟΝΤΑΣ might have been miscopied ΛΙΘΙΩΝΤΑΣ, an alteration such as has frequently been recognised, and of the sort illustrated by Douse in his analysis of examination papers. We at any rate get a meaning for οὐδὲ μὴν, otherwise inexplicable, unless lithotomy was a special exception to Hippocratic practice. The emendation would be still more apposite if castration were meant; at least we know that under the Empire the consent of the victim did not free the operator from penalties, and Littré quotes the case referred to by Justin Martyr in which the governor of Alexandria refused his consent, even on the petition of the young man who desired it. But at best this is only a possible way of evading, not a certain one of meeting, the difficulty. Failing it, the passage must be surrendered as inexplicable, for conjectures about stony tumours and the like are mere idleness. The Hippocratic writings, even the most ornate, are too precise to sanction cryptic interpretations. A good deal might be said in favour of the guild spirit extending to surgeons respect for their speciality. The Arabs certainly placed the surgeon, as a mechanical person, in a low position. Old Burton does not take a high view of this branch of the profession (he called it "fulsome"), which was protected by legislation under Henry VIII. That it was not a popular calling may be inferred from the fact that, under that king, very few followed the speciality. There were only twelve surgeons in London, with, as estimated by Creighton, a population of 123,000 in 1581. The army of Henry VII. numbered 30,000, but it had only one surgeon and fifteen assistants.
Leaving then the prohibition of surgery as a question of propriety rather than of morality, we come to an equally perplexed question, though in a different way—that of abortion. This was commended when necessary, and that, not any abstract question of propriety, was the test for its induction. It was really in the hands of midwives, who, as Plato tells, might bring it on if necessary, and the fœtus young. The removal of the conception was objectionable only after it had acquired life, and Aristotle so distinguishes the innocence or criminality of the act. The Oath seems to contemplate criminal abortion, the destruction of the fœtus when there was no danger to the mother's life. It was easier then than now, for the physician had the drugs, and the pessaries were a bit of cloth over the finger, and dipped in irritating or astringent substances. The prohibition is a wide one, and might perhaps be renewed with advantage. When pregnancy is not dishonourable, abortion is now resorted to reluctantly and after deliberation, the more trustworthy that its induction is in the hands of the practitioner. No doubt there are men willing to gratify patients by ridding them of an inconvenient responsibility, as there are who aid in the concealment of immorality. A practitioner in Glasgow (he came to a violent end) expressed surprise when another of spotless reputation remarked on the number of women patients whom he saw but once, who did not need treatment. This was not the experience he cared for, and he showed on his consulting-table a handy packet of tartar emetic: two or three grains applied to a healthy os necessitated at least one visit to ascertain what was the matter. Such a criminal is, I hope, rare. Yet a hot douche is not unknown, not unused, and family physicians who deem themselves honourable are now and again to be heard of who make use of this fruit of philosophy.
Purity of life and honesty of purpose are the two objects aimed at in the Oath. Customary vices, customary then, now criminal and treated as criminal, are forbidden. I cannot say they are spoken of as intrinsically wrong, but they involve a misuse of professional opportunities, a breach of the promise to visit for the sole good of the sick. In 425 B.C. Apollonides was killed for his intimacy with the widow of Megabyzus the Persian.
The authorship of this Oath is less important than the summary of contemporary opinion it contains. The school of Hippocrates had a lofty standard, and sought to maintain it by the exclusion of unworthy intrants. Lex is an unhappy translation: Nomos would be better rendered as the Standard, wherein it is said that the low status of the profession was due to the ignorance of those who practised it and of those who judged regarding them. There was, it is said, no punishment for incompetence save discredit, and that would not weigh with those who merited it. Extrusion from a town was a small matter to those who had been already "moved on." There were, moreover, itinerant practitioners, among whom the expelled one might count himself and so get lost to sight. "Of all arts (it says) medicine is the noblest, yet on account of the ignorance of those who practise it and of those who judge regarding them, it is held inferior to all arts, of which error the chief cause seems to be that in towns there is no punishment, that medicine alone is exempt from punishment save disgrace, and this little affects those also who in deed seem very like the masks of tragedy, which are not the actors: just as there are many physicians in name, very few in fact." The Nomos may not have been written by Hippocrates, but it expresses his lofty conception of his art.
The vow of secrecy touches the highest level of honour: it is not professional reticence it inculcates—that is the least of its aims. The practitioner pledges himself to forswear gossip: he is not to talk of what he sees or hears in the ordinary intercourse of life, if the matters in question are such as it would be better to leave alone. Of course he is to keep to himself what he learns in the houses of the sick and concerning them—that is only varying the promise to enter such a house for the sole good of the sick. It is a lofty honour which leaves unsaid what might harm any one, be he sick or whole. This aspect of professional secrecy is not sufficiently prominent in the comments on questions affecting the duty of practitioners. The church catechism asks the youth to "keep his tongue from evil speaking, lying, and slandering," and if the author or compilers of the Oath had expanded their views we should probably have had the same suggestive collocation. So there is a chance of the medical man "enjoying his life and art in happiness, and having credit among all men for all time." Many years ago a well-known criminal was removed to a large town, and the jail surgeon, who had visited her in the forenoon of her arrival, was said not to have reached home till evening, telling to everyone in the interval all that he had picked up in his professional interview. Public contempt was entertained, not for the professionally indiscreet man, but for the miserable gossip whose empty head was so engrossed with the novelty of what a journalist would call his "exclusive," that he lost sight of the humanity, the chivalry which the sight of a young woman about to expiate her crime ought to have called into action. Many an able man has failed to win the position to which his talents and skill entitled him because he could not control a loose tongue, and thereby gave the impression of one who could not be trusted in great things because he failed in small. He who ought to be a confidential adviser must, above all things, obey the Oath, and speak of nothing which it would be improper to repeat, whether of his patients or of others. "Death and life are in the power of the tongue, and they that love it shall eat the fruit thereof. Whoso keepeth his mouth and his tongue keepeth his soul from troubles."