The authorship and Probale Date of the Hippocratic Oath

Philological Considerations of the "Xyggrapse" [Greek] with a Short History of Greek Fraternal Societies, Bulletin of the History of Medicine, 8 (1940) . Extracted from PCI Full Text, published by ProQuest Information and Learning Company. THE AUTHORSHIP AND PROBABLE DATE OF THE HIPPOCRATIC OATH LINGUISTIC AND PHILOLOGICAL CONSIDERATIONS OF THE =YITPA®H WITH A SHORT History OF GREEK FRATERNAL SOCIETIES * SAVAS NITTIS Aun Arbor Although one of the shortest of the Hippocratic writings, the Oath still remains the most interesting to both laymen and physicians, not only on account of its high moral ideals, but also because of its unique nature. For it is the written constitution with which Medicine, alone of all Sciences, was provided by its founders, from almost the very start, and which still continues to guide its destinies and influence its moral evolution. Unfortunately, the recent, almost cataclysmic, onward rush of the scientific phase of medicine, seems to have placed its moral values Pay 2©x0 zNIsT,\S, tato di into the background, and the Oath scarcely now receives attention from the teacher, or notice from the student of medicine. Or, when physicians have occasion to refer to it. they do so in order to case their conscience when doing violence to moral medical tradition. misquoting one or another paragraph in an attempt to show that strict adherence to the letter or spirit of the Oath is incompatible with modern society. In a previous paper’ I have attempted to remove a blasphemy from the Oath by giving a new interpretation of the lithotomy clause, which harmonizes logic and grammar. In this paper an effort is made to explain another obscure point and at the same time attempt to establish the date and authorship of the Oath. The hope is expressed that in the near future opportunity will permit the reinterpretation and clarification of other seemingly obscure clauses, and finally, to render a complete interpretation of the Oath in its entity, without violence to its letter and with justice to its spirit. *From the Thomas Henry Simpson Memorial Institute for Medical Research. University of Michigan. * Nittis, Savas: The Hippocratic Oath in reference to lithotomy. A new interpretation with historical notes on castration. Bull. Hist. Medicine, 7: 719, July, 1939.

HIPPOCRATIC OATH LINGUISTIC AND PHILOLOGICAL CONSIDERATIONS OF THE =YIrPA®H WITH A SHORT HISTORY OF GREEK FRATERNAL SOCIETIES * SAVAS NITTIS Ann Arbor Although one of the shortest of the Hippocratic writings, the Oath still remains the most interesting to both laymen and physicians, not only on account of its high moral ideals, but also because of its unique nature. For it is the written constitution with which Medicine, alone of all Sciences, was provided by its founders, from almost the very start, and which still continues to guide its destinies and influence its moral evolution. Unfortunately, the recent, almost cataclysmic, onward rush of the scientific phase of medicine, seems to have placed its moral values into the background, and the Oath scarcely now receives attention from the teacher, or notice from the student of medicine. Or, when physicians have occasion to refer to it, they do so in order to ease their conscience when doing violence to moral medical tradition, misquoting one or another paragraph in an attempt to show that strict adherence to the letter or spirit of the Oath is incompatible with modern society. In a previous paper! I have attempted to remove a blasphemy from the Oath by giving a new interpretation of the lithotomy clause, which harmonizes logic and grammar. In this paper an effort is made to explain another obscure point and at the same time attempt to establish the date and authorship of the Oath. The hope is expressed that in the near future opportunity will permit the reinterpretation and clarification of other seemingly obscure clauses, and finally, to render a complete interpretation of the Oath in its entity, without violence to its letter and with justice to its spirit. * From the Thomas Henry Simpson Memorial Institute for Medical Research, University of Michigan. ! Nittis, Savas: The Hippocratic Oath in reference to lithotomy. A new interpretation with historical notes on castration. Bull. Hist. Medicine, 7: 719, July, 1939.

student of the Oath was ever certain what is actually meant by évyypapr, “ stipulation,” “indenture,” as it is usually translated. The word is found twice in the text and once more in participial form, évyyeypaupévois, That in all cases it refers to a written document there can, of course, be no doubt.” In the first paragraph évyypady must refer to some document in front of the person taking the Oath; Evyypadnv rivde. Or perhaps it refers to the Oath itself in its written form, as distinguished from the oral form, which the candidate was at the moment reciting. The £vyyeypaunevos Te kai pkicuévois vou inrpıxö implies that the student must undergo the same or a similar ceremony as the one the present taker of the Oath is undergoing now, before he becomes eligible to begin the study of medicine. He will have to be already évyyeypappévos. Was this évyypap} a known ‘law ” or tradition? Or does it refer to the évyypaby of the first paragraph? Whatever it was, the document could not have been an impersonal one, such as the Athenian constitution, for instance, which was binding upon all citizens, whether each and every one, individually, wanted it or not, and which all the Epheboi swore to defend and preserve. his It was a very personal document to which the student and fellows are already “syngegremmenoi” by their own free choice and desire. “ Together-written-in ” would be the literal translation. Was it an agreement between two parties? A contract? An indenture? Or was it the “ immutable law ” of medicine, or the “ constitution ” or ritual of a brotherhood? Qualifying, before beginning the study of medicine, by joining a fraternity, should not imply that such fraternity or society had to be a closed one. A society, of course, it was; but there is nothing to make us suspect that it was a secret or a mysterious one, or that ? For the convenience of the reader the first part of the Oath, from the Littré text, is given here: "Quvuur ’Arod\dAwva inrpdv kal ’AokdAnmidy Kal ‘Tyelar kal Ilavakeıav kai Beods mavras Te kal mácas loropas moLeuuevos, ÉmiTeNéa moınoeır kara Öbvanır Kal kploiw éur Öpkov rovde Kai Evyypabnv rnvde: hynoacdaı uev Tov Siddtavrd pe thy réxvnv Taurnv ica 'yevérnoiv éuoioir Kai Blov kouwoaoôar Kal xpewv xpnitovri perádociv moınoacdaı Kal ryévos TO é& wurdov adeAdeois loop émixpivéery &ppeor Kal Siddtew Tr réxvynv, hv xpnttwor pavOdverv, dvev puodo Kal Evyypapis, wapayyedins Te Kal dkponotos Kal THs Noris àamaons amas puerddoci moıncacdaı vioiol re Euoicı Kal roto: Tov éuè didatavtos Kal ualnraior ouyyeypauuévois Te Kai wpKiopévas vow inrpix@, dNNw de oùderi.

SAVAS NITTIS admission was exclusive and limited by other than moral standards, as many scholars have suggested. After all, the physician disposed of the life of his patients at will, in a society where there could be recourse, neither to law for malpractice, nor to lawless violence for justified or unjustified revenge. But does the document support the idea of existence of such medical fraternal societies? Before further considerations, let us first review briefly the history of the various trade and religious associations in Greece, their character, social significance and standing. FRATERNAL AND “ SECRET” SOCIETIES The most ancient ritualistic form and expression of Greek religion, or perhaps, any primitive religion, (primitive here used in reference to chronology, not to form), is strangely, but very closely, interwoven with the beginning of medicine. The collective effort of man to comprehend and reproduce the ever-recurring changes in nature, the desire to unite with, or dominate the outside, supernatural powers, and the seeming accomplishment of this aim through a magical and mystic ritual, a mimic death and rebirth, mark not only the beginning of religion, but, likewise, the beginning of medicine. The Kretan Kouretes, the guardians of the Zeus-Kouros, the child deity-supreme, apparently the oldest “‘ mystic ” society, were as much priests as they were medicine men. It was one of them, Epimenides, who was invited to Athens to cleanse the city from, apparently, an epidemic pestilence, to which the name of a political pollution was given. However, their rituals and “ mysteries’? were conducted openly.® From such movements a multitude of religious, or quasi-religious societies sprang up to fill the Hellenic world, among which chief place occupy the “ thiasoi,” the “eranoi,” and the “ orgeones.” Differing not so much in substance as in name. these societies were * The Kretans, in claiming that “they handed on to other peoples the dues of the gods, their sacrifices and their rites appertaining to mysteries bring forth this point as being, according to their thinking, the chief piece of evidence. Among the Athenians, the initiation rites in Eleusis, which is perhaps the most celebrated of all, and the rite of Samothrake, and the one in Thrace among the Kikones, from where its founder Orpheus originated, are conducted secretly. to initiate all in these rites openly. While in Krete it is lawful And whatever among others is imparted in religious secrecy, among them it is hidden from no one, whosoever wishes to know these things.” Diod., V, 77.

at first formed for the worship of some particular god or hero, or, when commercial intercourse between foreign countries increased, for the worship of the home god or hero. The Solonian law, as Caius states in his 4th book on the Twelve Tablets, accorded recognition to these various “ fraternal orders,” (if we may use the modern equivalent), and declared their laws and contracts valid, if not in opposition to public laws.* This and the well known hospitality and tolerance of the Athenians promoted the establishment of foreign religious institutions in Athens.” Resentment to this license, even though not confined to the verses of the comic poets alone, was either mild or amusing at first, since most of the converts were women, slaves, or perverts. But aside from the curiosity and novelty, definite social, commercial or professional advantages motivated merchants, craftsmen, professional men, working men of all trades, to band together, forming societies, at times for common worship, at times for the sole purpose of comradeship and social intercourse.° The members of a society, irrespective of their condition and origin, exercised the same privileges. A stranger could perform priestly duties and be rewarded for his devotion with a crown, or honorable mention, or have his picture hung in the society’s hall. Anyone so wanting could join some society, but it seems that there was always a test, “ öoxinaoia,”” which was given after the candidate paid the admission fee and had his name inscribed on a stele, éyyeypappevor, while their descendants apparently shared in the privileges, without the necessity of having their name so inscribed on the stele.” From another “ Nomos ” we know that the candidate was 4 ’Eav de önnos Y pparopes Y iepwv dpyiwy, Y vavrai, Y ovocito, Y dubragpoi, Y Gtacwrar, y éri Xelav olx6pevor % els Eumopiav, 5, Tt Av Tobrwv Siabwvrar mpös AAAMAovs, KUpLoy elvas, ¿ay pù Amayopevon Ta ónuócia ypdupara. Diagest. XLVII, 22. De collegiis et corporibus. 5° Aßnvaloı O womep mepi Ta AAXa didokevovyTes ÖLarekovcıv, oÙrw Kal rept roùs Geods. TloANG yap Tor Eevırwv iepov wapedéfavro, Gore Kal éxwuwdnbnoar, kal dy Kal rá @pdkia Kal Ta Ppúyia. Strab., X, 3, 18. 6”Eviar dè Tay koivwriwy bv Hdovny dokovor yiyveodai, Oracwrwy Kal Epaviotwv‘ avrat yap Bvolas Evera kal ovvovoias. Aristot., Ethic Nicomach., VIII, 9, 7. 7... 6mdoor Ev Tu OTAN: èyyeypappévor eloiv N Tovs ToUTwv évydvous. Ong... “Orws è dv ws Theioro. wow dpyewves Tov iepov, Ekeivaı TH ¿av Sé Tıs Bov\ouérw eiveveykavrı . . . Ópaxuas pereivar avrwe Tov iepo Kal els Tr oTnAnv éeyypadecbar: Tods è’ éyyeypapuévous eis Tv arm\mv dorıualeıv robs dpyewvas. Foucart, P., Des Associations Religieuses chez les Grecs, p. 189, Paris, 1873, Klincksieck.

SAVAS NITTIS examined first if he were “ pure, pious and good,”* almost the same expression used in the Hippocratic Oath, and possibly by the primitive Kouretes.” Unfortunately, with the exception of the Iobakchoi, we have only fragmentary references to “laws ” of other societies.'” From these fragments we know that this “law” regulated many activities of the society, such as admission and expulsion, convocation of the assembly, the matter of dues and penalties for failure to pay on time, premiums, sacrificial dues paid by members and strangers for sacrificing in the temple, the use of the revenue, guaranties, the nature and value of compensation for benefactors, and the measures taken to assure respect of the law and execution of the decrees. Questions, however, pertaining to the mystic part of the ritual were, apparently, recorded and preserved in the sacred books. Aischines read from such books the formulas which the initiates repeated during the initiation and purification rites of the thiasos of Sabazios. We have one reference to the “immutable law,” ** besides the one to the “ holy law,” ** but we cannot be certain if they refer to the law inscribed on a stele, or the sacred books. The so-called “ mysteries’ and “unmentionables,” (appnra), of all ancient religious rites, are still completely unknown. 8 But were Nôuos Epavıorwv. Mnöevi é&€orw émiévai els THY TEUVOTÁATNL aúvodov Tay Epavıorav, mpiv dv Öokıuaoôn el éore ayvös Kal evceßns Kal drya- 065° durımalerw de è mpoorärns etc. Foucart, P., l.c., p. 202. ‘Ayvov dé Blov reivwy é£ ov Ads ’Iôaiou piorns yevounv Kal vuXrımoAov Zaypéws Bpovras Tas T wuopa”yous arras Teéoas untpi T’ ôpelw Ôdôas avacxwv Kal KOVPNTWV Baxxos ErAnOnv Öcıwdeis. Eurip., Melanippe the Wise. (Nauck, Frg. 484) 1° For a list of references to a vöwos see Ziebarth, E., Das griechische Vereinswesen, p. 144, Leipzig, 1886, where 16 fragments are listed referring to such documents. 11 Demosth., On the Crown, 259-260. 12 "Eyoxos torw vôuw TH Akıyyrw. Corp. Insc. Gr., No. 2525b. (Foucart, P., I. c., insc. No. 46, line 104, p. 227.) 18 Aeööxdaı rois 'Arrhorais Kkupwaaı pèv Tov lepóy vópov. (Teos, 2nd c. B.C.) Corp. Insc. Gr., 3069.

they, in all cases, really mysteries, or only ‘‘ mystic’? Forbidden to be seen by, or be revealed to, the uninitiated, or simply sacreligious and impious to be seen by the uninitiated, and be mentioned by the initiated? Evidently the latter was the view held by the Kretans.* If the god was not “ demoteles,” (publicly established), it was not offensive to mention “ arrheta ” publicly, as we may assume from Demosthenes’ speech.** Probably such “‘ mysteries ” were no more mysterious then, than the Mysteries of the Greek Church, called Sacraments in the West, are today. Aside from societies formed just for social intercourse and mutual benefit, without having to be secret or mysterious or exclusive, certainly there existed fraternities restricted to the members of one family. And in most societies, while members had their names inscribed on a stele, their sons and descendants were not required to have their names so inscribed, in order to be considered members. (“ éyyeypappévor 1) TOUS TOUTOV èvyovovs ”).? Not only membership, but also certain honors bestowed upon a member, were, if so specified, hereditary." Since every imaginable trade and profession is represented on the stone remnants of such fraternal organizations, it would seem unreasonable if the physicians belonged to no union or society of their own, either for the purpose of common worship, or otherwise for pleasure. Unfortunately, the existing fragments are not clear enough on this point, but in many cases there is little doubt that the reference is to a medical society. Such are the “ oi darò roù Movoeiov > # 33 LAT pot, 66 ~ ~ > Tupvaciapxov Tov iaTpev iepopavrns ” from Kula, etc.'* 15 99 etc., from Ephesos, ‘’Apxiarpos Kai The monument to the famous physician, Menekrates was erected by his “ yvopipor ” who called him their “ Heresiarch.” ** In many, or probably in all fraternal societies, in imitation of the pattern of the “demoteles ” religious societies, such as the Eleusinian Mysteries, there were some sort of initiation, or rather 14 The custom was so general that specific references seem superfluous here. 15 See Ziebarth, E., !.c., p. 98, and Poland, F., Geschichte des griechischen Vereinswesen, p. 120, Leipzig, 1909, Teubner. 16 TiBepiw Khauvdiw: Kovpeivaı Mevexpare: larpwı Kaisäpwr kai idias Aoyyırns évapyovs larpuxns Kriorne ev BiBAlois pvor”, dl’ ©v éreunOn brd THv evAoyluwv tróNewv Ynolo aci évTeréat, ol yvwpipor Tat EavTw@y aipertadpxye TO poor. Insc. Gr., 1759,

SAVAS NITTIS purification, rites, or some test for purity of character.** The members were ‘ éyyeypauuévo ” on a stele, and I believe they could be “ ovyyeypappévo,” without any change in meaning or intention. By the Iobakchoi they were “ droyeyypaypévo.”’ and the process was called àroypapy, Oath. a word so curiously similar to the ovyypa¢y of the Ziebarth translates this “ officielle Anmeldung,” erroneously, I believe, for just a little below, the statute states that those that inherited the membership from their father could procure this ároypapy by paying 25 drachmas, one half of the regular initiation fee of 50 drachmas.*” Although in some societies admission was, apparently, open to “anyone willing ” to pay the fees and dues, ro BovAonevo,” it is unreasonable to believe that such an attitude, despite the democratic ideas of the race, would prevail always. We know that before admission a qualifying test was given ®** and an oath was administered.** Even in the Hippocratic Oath the “ and to none others,” should not be construed as making the medical profession, or their association, if it is referring to one, exclusive, any more so than the ‘ dokimasia-test ” concerning “ purity, piety and goodness,” * or “ worthiness and fitness ” *” of other societies. Both the entrance fee and the monthly contribution or dues connected with the membership, could be waived in certain instances. By the Iobakchoi in Athens ** and the Hymnodoi in Pergamon the sons and even the uncles of a member were preferred for admission to membership, and they paid only a fraction of the regular entrance fee. By the Gerousiastai of Asklepios in Hyettos, the son of a member inherited the membership without payment, and in the absence of a son, the next in line of relationship, who paid only half. In Asia Minor this custom was more frequently observed and, apparently, it implied some distinction, for such members were called ‘“ patrogerontes,” by the Gerontes of Ephesos.*® 17 Mnöevi étéorw ’IbBakyov eivai, éay un Tp@Tov droypaynra mapa Tw iepei Tr vevomiouévmr amoypadpnv kai doxkiuacOn: kal émirndecos rut Bakxeiwi. vrò Tor 'Ioßakxwv YNpwi, ef dios Balvorro “Eorw de rò lonkvoiov Tar un amd marpös Apx. v’ Kal omovön duolws, Kal ol amò marpöos amoypabeodwoav émi Apx. ke. Ziebarth, E., I c., p. 141 and 156. 18 ’Evavrlov TW bpxw dv wuocav Kai re apa nv Eikadeds ernpncaro. Ziebarth, p. 142. Kara Troy Spxov dv bpocav rois épariorais. Ziebarth, p. 142. (C.I.A., II, 619, 9) 19 Poland, F., !.c., p. 298 (“ Die Familie”) and p. 301 (“ Die Kinder”).

AUTHORSHIP PROBABLE DATE OF HIPPOCRATIC OATH 1019 GENERAL CONSIDERATIONS In recapitulation, we have observed that there existed, from an early date, trade, professional, religious and medicinal fraternal organizations, not really secret or mysterious or exclusive, with by-laws and laws valid even before the civil authorities. Such organizations imitated, even in phraseology, the structure of the constitution of the city in which they existed. The document binding the members to certain moral and financial responsibilities was apparently called “ nomos-law ” generally. At times, laws provided for the transmission of certain honors to the sons and descendants of members, and in some societies the sons acquired the membership from their father by inheritance, without any payment and without the necessity of inscribing, i. e., signing, their name on the society’s catalogues. With all these in view it seems that the £vyypady, in the first place in the Hippocratic Oath, öpkov révde kai Evyypadyv Tivde, refers to the ‘ written law ” of some medical fraternal organization. In the paragraph avev wodoi kai Evyypadys, it must imply that the sons of the teacher must, not only be released from the payment of tuition, but also be received into the society without test and without payment of dues. Being born to, and brought up by a teacher of medicine was to be considered sufficient evidence of purity of character. The participial form in the paragraph “ évyyeypaumévois te Kal opriopévos von 3) enrpixo ” implies that others had to qualify by a test, enrollment in the society, which naturally meant meeting the financial obligations of the association, taking the Oath, and the payment of tuition. For, although undoubtedly there were individuals who attached themselves as apprentices to a physician from childhood, and learned the art in this manner, there must have been others who received their medical training attending in large groups men ‘ who held themselves out to be teachers of medicine.” *° But was ever the word évyypapn synonymous to “law?” In Athens during the 5th century (450-446 B.C.) the commissioners appointed to draw up laws for submission to the assembly after approval by the council, were called é&yypageis, 2° Plato, Menon, 27. Copyright (c) 2003 ProQuest Information and Learning Company Copyright (c) Johns Hopkins University Press such laws

SAVAS NITTIS ¿vyypagpal. Such apparently was the common connotation of the word even as late as March, 421 B.C. Thucydides states that in March, 421, during the rule of the Four Hundred, évyypapeis were elected to introduce laws according to which the city may be best governed,” while in October of the same year, after the overthrow of the Four Hundred, the commissioners are called for the first time, ? vouoßeraı,? ° Thucydides gives no explanation for this transition in the connotation of the word, and it may not seem illogical to assume that during this sharply defined period between March and October of the year 421 B. C., the terms évyypaby and vôuos might have been used in Athens interchangeably to convey the same meaning. In the Hippocratic Oath there is a reference to “medical law ” while évyypa¢7 undoubtedly, at least in the first paragraph, stands for the collective meaning that “the law ” implied in the known fragments of other fraternal organizations. For this reason it seems very probable that this document was written in Athens during the period between March and October of 421 B. C. and it was “ the law ” or part of it, of a medical society. In 421 B.C., Hippocrates was approximately 40 years old, and was living in Athens, enjoying great reputation, not only as a practicing physician, but also as a teacher of medicine, as attested by Plato in Protagoras and Menon. And if we are to believe Soranos, the Athenians bestowed upon him unusual honors, being “ the second man after Heracles to be initiated by them publicly into the Eleusinian mysteries. And they made him a citizen and offered public maintenance in the Pritaneum to him and his descendants. And he taught the art generously to the adepts with the befitting oath.” A physician of such distinguished reputation must have belonged to a professional fraternal order, since every man of any importance whatsoever belonged, besides some religious, also to some other, 21... Tdde of xovyypageis xovveypadoav. ... Adumov eine: TA puèv &ANa kadamep ai Xovyypapai TES Amapxes TO Kapmo Toi Beoty, Tas dè yxovrypagàs poépioua róde dvaypapodro è ypauuareus, Dittenberger, W., (Athens, 439 B.C.) Kal TO Syll. Insc. Gr., p. 24. 22 Aéxa dvdpas EeXeodaı Evyypapeis avroxpdropas, rovrous Sè EvyypáyavTaSs Eveveykeiv és Tov Önuov és hucpay pnrv KkGO 6,71 Äpıora 7 mods olxnoerar, VIII, 67. 23 Thucyd., VIII, 97. Copyright (c) 2003 ProQuest Information and Learning Company Yrwunv Thucyd.,

trade, fraternal, or professional society. And since the time and the spirit of the Oath agree with our idea of the historical Hippocrates, it seems to me that the Oath was written by Hippocrates himself, for an Athenian medical society, which probably he himself founded. This ‘‘ Oath,” or part of it, or some modification of it, gradually filtered out of the hall or temple of the Athens Medical Society, and became the universal moral law of the medical profession, and it continued to live, long after the societies of ancient Greece, and their symbols and symbolisms, became meaningless and incomprehensible, or changed their forms and names. And although today all of us may not follow the precepts of the Oath in all their particulars any more faithfully than we do those of the Sermon on the Mount, still no one can dispute that, as in the latter document the lay, so in the first the professional, moral ideals of the individual found the expression of their highest aims.