Medical Ethics and Popular Ethics in Greece and Rome

Clio Medica Acta Academiae Internationalis Historiae Medicinae Wie dre nl Mier MA popular pari BN Kupimn fs, Medical and popular ethics in Greveo and I ane |iapports avec “ l'éthique pythagorieienne) : ef. Sciences : Médecine. — Medical and popular ethics in Greece and Rame : CM ON 1970 91-121. | Greco-Roman medical etlues was influenced by non-medical and nonphilosophical morality. The [Hippocratic maxim. to help or at least to do no harm, was common in fields other than medicine. The physician was sometimes regarded as a killer with impunity. Same of the ethical rules of the Hippocratic oath were influenced by popular, rather than Pythagorean morality. PERGAMON PRESS Oxford + New York + London * Paris nt I. Vey Xo KAD LEN FF. VOLUME 5

Clio Medica, Vol. 5, pp. 91-121, 1970. Pergamon Press. Printed in Great Britain. Medical Ethics and Popular Ethics in Greece and Rome FRIDOLF KUDLIEN Nosopy can deny, I think, that there is no really satisfactory monograph that deals with Gracco-Roman medical ethics in all its aspects, professional as well as sociocultural. Paradoxically, this is the case although ethics is, otherwise, one of the most beloved and discussed themes within the vast literature on ancient medicine (whether written by regular medical historians or by interested physicians). Actually, the abiding interest in this theme appears one-sided in a certain sense: GraecoRoman medical ethics and, above all, the ethics of the Hippocratic physician is much too often regarded primarily as a (more or less) timeless one that is grown up in, and belongs to, the very field of medicine alone. But it is a mere truism to state that physicians have always been part of a society, that is to say of a non-medical environment which varies according to a given time and place. If there are indeed timeless and, so to speak, inner-medical essentials in medical ethics, they are, at any rate, accompanied by more common factors which are hound to a certain historical situation and which are of as much importance in developing specific medical ethics. Is it wise, then, to clevate the one by disregarding the other almost entirely? It is only fair to acknowledge that, among a few scholars, Ludwig Edelstein focused his interest upon these “historical” factors in Graeco-Roman medical ethics with oustanding intensity and success. Nonetheless, even his insight proved to be limited or one-sided, too, since he tried almost violently to prove his thesis that Gracco-Roman medical ethics, when it became very professional ethics, was primarily influenced or even guided by regular philosophy. Such an interpretation seems to overlook that common stock of non-philosophical values and rules which may rightly be called “popular” or “vulgar” ethics and of which all members of any society are indeed participants, be it consciously or not.? In the circumstances, it may be justified to envisage Graeco-Roman medical ethics mainly from the viewpoint of non-medical and non-philosophical morality, and to seek for its influence and reactions against it, in medical ethics. The time scems to be apt for doing so, since there are now some recent books on popular ethics in classical antiquity} which can give useful help and information. The following studies are destined to provoke further research in this field, by discussing a few related problems which I believe to be of some importance. I. “TO HELP OR AT LEAST TO DO NO HARM: THE POLITICAL BACKGROUND OF A HIPPOCRATIC RULE One of the best known aphorisms of Hippocratic provenance has recently found a somewhat superficial but, nonetheless, interesting interpretation.* Although being

of almost trite simplicity, this aphorism can doubtless give rise to earnest questions. As it has been formulated in the Ist book of the Hippocratic “Epidemiae” (I. 11), it is (see Edelstein “Ancient Medicine” l.c., p. 324) merely a sober command for a good physician, to achieve the objective of his art. But for a deeply interested historian, it appears justified to ask with Sandulescu (lc. p. 361) for the actual motivation of this command; to quote from the latter’s words: “ . .. a physician represents actually a man who through his occupation removes the effects of an ill status and finally heals the patient who has delivered his life into the hands of the medicineman. Why must we therefore ask a physician not to damage the sick? Isn’t it a useless requirement, a pure paradox?” After having shown that the famous aphorism has many parallels among the Corpus Hippocraticum and that it is, therefore, in full accordance with common Hippocratic theory and practice, Sandulescu points out that the old physicians by their very therapeutical methods (bleeding, cutting, etc.) as well as by their medical errors stood under the suspicious, and even sometimes ““medicophobe”, eyes of the community, so that a command like that under discussion must have been not only understandable but also necessary, after all. In our next section, we will deal with an extreme cxample of public medicophobia. For the present, however, we wish to call attention to another aspect of our aphorism. In fact, this maxim as formulated by Hippocrates was originally “common not only among physicians’, as Ilberg had already seen. There is a passage in Thucydides that can make evident this wider aspect or, in other words, the common ground from which the maxim sprang up: According to Thucydides (VI. 14), one is a good citizen (polites agathos) if one either “helps the native country as much as possible or (at least) does not harm it deliberately”. When following this rule, one is, metaphorically speaking, “a healer for the city (tes poleos iatros)”. In his ambitious attempt to prove anew, and for this time finally, the old idée fixe that Thucydides had known, or even used, some of the genuine Hippocratic treatises as such, Lichtenthaeler® was glad to find such a “‘concordance particulière majeure” between Thucydides and Hippocrates. For Lichtenthaeler, as for his immediate predecessor Wcidauer,” the maxim serves as an additional proof that “Je grand historien s' est inspiré d’ Hippocrate”. Rather unfortunately, for Lichtenthacler there remains “une seule réserve”: The particular coupling of the words “to help’ and “to harm” as found in Hippocrates and Thucydides “a déjà été faite avant Hippocrate et Thucydide”. As to this last statement, Lichtenthaeler does not go into further detail, nor has any other medical historian, as far as I know. What, then, does exactly lie behind Thucydides’ characterization of an average good citizen’s behaviour? In this regard, the above-quoted books on Greck popular ethics can help us considerably: First, there was among the Greeks a very old rule by which any member of the community was bound “to help a friend and to harm an enemy"; usually, this must have been meant in a political as well as private sense.* But in the course of the fifth century 8.c. this old rule, like so many other traditional rules, proved to be an earnest problem that demanded a much-sided debate. Indeed, it is from Plato's “Politeia” (especially, from the first two books) that we can gain the broadest insight into this actual discussion. As Plato describes it by feigning a discussion between Socrates and Polemarchus, there existed a traditional and deep-rooted

Medical Ethics and Popular Ethics in Greece and Rome 93 communis opinio (as represented by Polemarchus) that justice may consist merely in giving what scems due to anyone, that is to say in helping his friends and harming his enemies. Spoken in terms of friendship alone, one must benefit one's friends, à rule but had to be aware, at the same time, that in this regard their own theoretical n E 3). Traditionalists as well as the progressive Sophists!® were adherents to this w or at least do no harm whatsoever to them (‘Politeia’” 331 Eff, esp. 332 A If. and basis came to be questioned: What exactly is a “friend”? Gould one continue comprehending and defining this keyword simply on the basis of a reciprocal giftgiving ?!! Moreover, since the old (and, as such, small and isolated) communities had gradually expanded into city-states, and since there was, now, a clear conception of “fatherland”’'?-—where lay the border-lines, then, between the private sphere (that had become, proportionally, more and more important) and the public or patriotic interest? Finally: Could it be consistent with a wider and deeper concept of cthics that anyone should be tolerated, or even stimulated, by an ethical rule, to harm another man? It is on this background, | think, that Thucydides and Hippocrates must primarily be seen, since both are apparently witnesses ofa very common discussion. Of course, for the political historian Thucydides the political aspect of the old maxim must be in the foreground: Here, “friends” are naturally to be identified with ‘‘native-country” or “city-state”: at any rate, the old maxim retains its unquestioned validity within this area of citizen-ethics.'? On the other hand, if one began to look upon cthics in its essential character, one could hardly remain satisfied with a number of separate moralities. For a philosopher, above all, it must have seemed self-evident that it is thoroughly unethical to harm at all; consequently, this is exactly Socrates’ first reaction (‘“Politera’ 335 D 11f. and E 5). When he, or anv other like-minded man, had to seck for an exemplary sphere of human life where the command “to do no harm” could possess a total, and not only a specific, pretension— what other sphere could be found if not, first and above all, that of the physician? By the very character of his profession, the latter was obliged to harm nobody. Since it is the simplest matter to make such a statement, I cannot sec why Thucydides should necessarily have been inspired by an explicitly formulated medical aphorism when expressing his own opinion in this regard. By the actual situation itself, many people must have felt urged in the fifth century B.c. to discuss cardinal problems of popular ethics and, eventually, to take up an unmistakable standpoint. Thus, we may better understand why old Greek physicians should indeed have been forced to formulate, perhaps for the first time, a main rule of their professional ethics that appears merely self-evident for us. Apparently it was necessary to state, once and for all, that a physician as such would never harm either friend or enemy. But confronted with a situation as described, we must frankly ask: Was a Greek or Roman doctor, when following the maxims as formulated by Hippocrates, enJoined unequivocally to help (or at least, to do no harm to) all men in every case? Or, could there occur a situation when the doctor’s civic obligations had precedence over professional duties, thus forcing him to do, or to forbear from doing, something that he would not do, or forbear from doing, if he were merely an ‘‘unpolitical” person? In the light of this precise equation, it seems remarkable that the maxim as formulated in Epidem. I. 11 is concerned, according to its wording, solely with the

treatment of diseases but not with the patient’s personality. In other words: It is not said who but, only, what is the object of the rule’s intention. The same holds good for the other parallels from old Hippocratic treatises as collected by Sandulescu,'* with a single exception: the famous “Oath”. Here, the personal and social circumstances of the presumptive patients are explicitly mentioned as such, making it clear that the doctor has to put aside any class distinctions or sexual differences, since he is present for nothing but “the benefit of the sick, remaining {ree of all intentional injustice’ (trsl. Edelstein). It is obvious how closely akin this is to the maxim of the “Epidemiae” (as well as to Thucydides; cf. “intentional injustice”), with the only difference, as it was said, that here the patient’s social and personal circumstances are mentioned. Just thereby, however, it becomes obvious that it was by no means self-evident for the Greeks that a doctor had to care for all men in the world without any distinction whatsoever, and that, therefore, a need was felt for a specific injunction. Now, is this injunction, as given by the “Oath”, fully satisfactory with regard to our problem? We must confess, I think, that it is not, and just in that direction which chiefly interests us: the political aspect —that means the behaviour of a Greek physician, as being at the same time a Greek citizen, towards foreigners and “enemies ’—is not at all spoken of. The Greek attitude towards foreigners was not a clear-cut one in the fifth century 8.G.! There was an old belief according to which anv foreigner was held to be a priori an enemy. Furthermore, there was the likewise old, and ambiguous, concept of “harbaroi” (i.e. non-Greeks in general) with all its much-coloured overtones. On the other hand, there was a considerable knowledge of foreign peoples and countries. Many barbarians had contacts with Greeks or even lived in Greece and, above all, at Athens: here, an old tradition existed for helping forcigners if they were in adversity.!© Thus, the old Hippocratic physicians, when visiting “whatever houses’, did of course meet with foreigners as, for instance, barbarian slaves (see c.g. Epidem. V. 35), and treat them as patients. But those slaves or foreigners were usually a part of the Greek house (“oiketai” or “oikeioi*) and, in so far, were themselves “Greeks”, What, however, of non-Grecks when encountered outside, or at war? We must not think of the famous case of the old Greek physician Democedes as evidence of a spontaneous, and self-evident, cagerness to help a barbarian “enemy”. As Herodotus (who is, in this case, the only independent source) tells us, Democedes was taken prisoner by the Persians. After having had a bad time, he was called for by king Darius to treat the king’s dislocated ankle. Now, it seems remarkable that Democedes obeyed only after having refused to help by feigning to possess no medical knowledge at all; it was only by hard threats that he finally ceased to offer resistance (Herod. III. 130). It must be added that Democedes had been, until then, in the service of many people or cities, and that his medical career had been a rather eventful one; but this career had taken place exclusively in a Greek environment and among Greek people. In the circumstances, Democedes’ Persian episode must be regarded as exceptional. Apparently, it was just this almost abnormal singularity which let the common Greek physician ignore the general problem of helping foreigners outside of Greece, or at war. At any rate, it was apparently not the normal custom to do so. In this regard, we must call attention to some later medical testimonies which nonetheless

may truly reflect some of the ethical attitudes ofa distant past. In the Ps. Hippocratic “letter” No. 5, Hippocrates himself, when invited to join the Persian king Artaxerxes and to accept a high position, refuses to do so, stating that he cannot cure barbarians “who are the enemies of the Greeks”. That this is in full accordance with the old ethical command “help the friends and harm the enemies”, becomes clear by “letter” No. 11: Here, Hippocrates says to the Abderites (who are, as Greeks, his explicit friends) that he did not join the Persian court since Persian barbarians are enemies of the Greeks: “I for my part am likewise engaged in a naval war with them” (which is obviously a rather vague allusion to the PersianGreek war and, perhaps, to the battle of Salamis). Moreover: “Do you not believe it to be a nonsense to help the enemy and, at the same time, to treat friends for money” (which is, in this letter, quite identical with “to harm the friends)? Apart from the fact that, among the very heterogeneous “Hippocratic” correspondence, the “letters” Nos. 5 and I] are certainly of a later date (let us say, of a Hellenistic one, in a wider sense), the ethical attitude that is present in the abovequoted passages is doubtless a fully traditional one’? whether or not it is expressed by Hippocrates himself. At any rate, the “letters” show that such an attitude could have been explicitly formulated by a Greek physician under the symbolic name of Hippocrates. This being so, the above-stated “lack” in the “Oath” (and, likewise, in Æpidem. 1. 11) gains a particular significance; we feel justified, now, in having been suspicious as to the full relevance of the medical rule “to help or at least to do no harm”. Furthermore, when in the (likewise Hellenistic) Ps. Hippocratic treatise “ Parangeliai” (ch. 6) the physician is recommended, for his reputation’s sake, to help a foreigner who has need of it, one must be aware of the relativity of the old concept of “philoxenia "18 as well as of the fact that those foreigners meant here were those who saw the physician on Greek soil and in a peaceful situation, but not abroad or at war. It is, I think, not incorrect if one flatly states that neither “philexenia” nor “philanthropia’, since both were narrowed concepts in classical antiguity,!? were as such able to stimulate a Greck or Roman physician to reinterpret our old rule and to comprehend it as a command for strict help (to do no harm is, in this light, a rather ambivalent command!), given to any man at any time or place. In the circumstances, we may naturally be inclined to think of Christianity as the most decisive factor in altering these attitudes. However, matters did not run in a straightforward way. To make this clear, there is, first, an interesting remark in the preface of Scribonius Largus, a Roman physician who lived at the time of Claudius, that is to say in closest vicinity to early Christianity. In fact, one has supposed him to be influenced, or at least touched, by Christian mentality.2° Now, let us look at the original text of Seribonius’ pronouncement: 4. praecipue medicis, in quibus nist plenus misericordiae et humanitatis animus est secundum ipsius professionis voluntatem, omnibus dits et hominibus invisi esse debent. idcirco ne hostibus quidem malum medicamentum dabit, qui sacramento medicinae legitime est obligatus—sed persequetur eos, cum res postulaverit, ut miles et civis bonus omni modo—-quia medicina non fortuna neque personis homines aestimat, verum aequaliter omnibus implorantibus auxilia sua porrectura succursuram se pollicetur nullique umquam nocituram profiletur” This text appears important in several respects. First, while Scribonius cannot be taken as a real Christian physician (actually. he was a Roman pagan and nothing

beyond that), the quoted words prove unquestionably that the physician as being “plenus misericordiae et humanitatis” is as such not an exclusively Christian type. Second, we are to recognize a significant incongruence in Scribonius’ pronouncement, an incongruence that becomes manifest even by the wording’s anacoluthical shape:?? On the one hand, at first glance it sounds new (with regard to traditional Greek popular ethics), and rather Christian, when the physician is explicitly pictured as giving “no bad drug, not even to enemies”. On the other hand, he is explicitly obliged, “as a soldier and as a good citizen”, to harm the enemy in every possible way, if need be. How can we believe, then, that medicine would indeed help “omnibus implorantibus”? Third: our old rule that as such is clearly detectable in the Latin wording (“succursuram . .. nullique umquam nocituram’’) comes out to be, just by Scribonius’ frankness, a virtually ambivalent one: Its very political background can no longer be doubted. As one is easily aware, it is not a discrepancy between (new) “Humanitasethik” and “römisches Denken” (as Deichgraber puts it /.c., p. 15) but an old, and already Greek, dilemma that had remained unsolved from the old Greeks until Roman times:? At the same time, the physician is also a citizen of a given political community. Thus, I cannot follow Deichgräber's statement (/.c., p. 5) that the ethical attitude of the Ps. Hippocratic “letters” Nos. 5 and Il is a merely antiquarian one that had already heen overcome, long since, in Scribonius’ time.?* At first glance, another medical testimony from Roman times seems to come nearer to the ideal of the physician as being a helper for all men (an ideal that was actually realized as late as with the Red Cross). There is an inscriptional Greek poem “On the eternal duties of the physician”, stemming perhaps from the second century A.D.* Here, the idea of the unity of mankind?* touches the physician’s particular sphere in a remarkable way: The latter is instructed “to help all... like a brother, since we are altogether brothers and sisters”. But when we examine with close scrutiny the word “all” and its proper meaning, the poem itself gives a clear and, for our purpose, disillusioning answer: It is the poor and powerless as well as the wealthy and mighty people who are meant to have an equal right to medical aid. In other words: In the light of his professional ethics, the physician is not allowed to make class distinctions. This, however, is an undisputed claim from the “Oath” onwards until Scribonius (“medicina non fortuna neque personis homines aestimat™’) that, on the other hand, has nothing to do with the political aspect of the matter. However deeply Scribonius and the just mentioned poem may be tinged with Stoic-Christian “Weltanschauung”: the political barrier that was inherent to our old medical rule, was not yet overcome by them; in this regard, both Scribonius and the poem belong to one and the same category.?’ In the circumstances, we must seek for those who first consciously postulated the help for an enemy (or, a “hostile” stranger) even in a foreign country. Posing the question in this strict way, it is obviously the Jews who were intended. As Ferguson rightly emphasizes (l.e., p. 210), “the Israelites had themselves known what it was to be foreigners in a strange land’ —an experience which, as we must add, among the Greeks was at best suffered (if at all), with any deeper intensity, by a single man. Hence, it is not surprising to find in the Old Testament several commands for loving “strangers” (ie. the Egyptians or Edonites), “for you were

strangers in their country”. In the same vein, by the Mosaic ethical code Jews are ordered to help the enemy (and the unbelieving).”® Meanwhile, it should have become clear how (and why) Greeks and Romans in pagan antiquity failed to develop an ethical command like that of “love your enemy” (but we are not entitled, on the other hand, to declare Graeco-Roman morality to be a selfish and particularly calculating one, in comparison with Jewish or Christian morality).?® As to Christian ethical commands, it must be said that in Matth. 5. 43f. the old rule “love your friend (‘the next to you’) and hate your enemy” is quoted for giving the new one a sharper-contrast (“But I am saying to you: love your enemics”). Now, since the sect of Qumran (that has recently found a revived interest, as being an immediate fore-runner to Christianity) did not yet know the new command but followed the traditional ethics,?® the line seems indeed to run more or less directly from Jews to early Christians. On this Jewish-Christian ethical background, and on it alone, a new understanding with regard to the political aspects of the old (and seemingly insufficient) medical rule could eventually be developed. As such, a Christian physician should have had, at least from our modern point of view, a priori a deeper sensitiveness in this regard. But did he in fact possess it, being a Greek or Roman citizen at the di — > time of dying antiquity? We cannot answer this question since there is practically no textual evidence for doing so. On the other hand, there is an carly Christian statement which gives us food for thought. In his “letter” No. III to Nepotianus, St. Hieronymus?! writes of Hippocrates as having given (sc. in the “Oath”’) a moral code for medical students: “quanto magis nos, quibus animarum cura commissa est, omnium Christianorum domus debemus amare quasi proprias”. Now, in the “Oath” the physician had been bound to fulfil the recommended moral obligations when visiting “whatever houses’, and as we have shown (see above), it was primarily Greek houses that were actually meant by those words. Thus, it seems remarkable that Hieronymus, while transferring Hippocratic medical ethics to Christian “soulmedicine’’, speaks in a rather self-evident, and unreflected, easiness solely of Christian houses!*? Should we not be entitled, then, to put the doubtful question whether early Christian physicians might possibly have had an attitude towards strangers (i.e, non-Christians) that was not new but quite kindred to that of pagan Greek or Roman physicians and, at any rate, also based on a (however changed) sort of vulgar group-ethics? Anyway, Hieronymus’ statement may be useful for making it clear why medical aid, as a concept, even on the soil of Christian “Weltanschauung” needed a long time to become, finally, a natural attitude that was opened to all men at any time or place, without respect for social, cultural, national or political circumstances, 2. THE PHYSICIAN. AN UNPUNISHED KILLER? (REFLECTIONS ON A GRAECO-ROMAN PREJUDICE) When about 1530 Agrippa of Nettesheim (who was himself a physician) in a printed book accused medicine of being a legally protected “homicidiorum ars”, such an intriguing statement sprang by no means from his own mind. On the

contrary, there are parallels enough in later (cf. Molière)# as well as in earlier literature. In this connection, one may not forget that Agrippa was a humanist, that is to say a man who was thoroughly familiar with the inheritance of classical literature. Moreover, among physicians and physicists of that time, Pliny and his “Natural History’ was a very much discussed and often quoted classical authority. And it is in book XXIX of Pliny’s vast (and not over serious) literary storehouse that we find a collection of the most forthright attacks on medicine and physicians, including the topic of the physician as an unpunished killer (“medicoque tantum hominem occidisse impunitas summa est”, /.c., § 18). Now, one may fairly object that it seems to be a rather needless enterprise to pick up the story of an obviously literary topic that may at best play its role in satire or comedy, amid a crowd of similar paradoxical exaggerations. Admitting, however, that Agrippa’s book is tinged with a strong satirical flavour, and that Molière is a comedian and satirist by birth, and further admitting that Pliny (for whom the same does not hold good) seems to have inherited his medical attacks partly, or even chiefly, from the common stock of Greek comedy-motifs, there remain some general reflections to be made. For both Agrippa and Molière, the attack on medicine, together with all its single topics, is not a matter of jest but of bitter earnest and actuality. Furthermore, it may rightly be questioned whether the roots of a topic such as that of “the physician—an unpunished killer” lie in poetical imagination or wit alone. As it stands, comedy and satire are always, in whatever degree, a mirror of social and cultural life and can as such be used with success by a historian? Therefore, we feel authorized to deal with our theme without scruples, and with as many of its implications as possible. Since the topic of the physician as an unpunished killer scems to have emerged, for the first time, in the Graeco-Roman environment (where it came from, in its literary form, to the Renaissance), we shall be content to research within this area alone while regarding it, so to speak, as an exemplary field. Let us start once more with book XXIX of Pliny’s “Natural History’. Here, the alleged connection between medicine and murder is emphasized several times. In one of the most famous cases, Pliny is referring to an original quotation from Cato (taken from Cato's “libri ad filium”). While sharply attacking the Greeks and, especially, Greek medicine, this classical representative of old Roman life and thought writes to his son: “juraruñt (sc. the Greeks) inter se barbaros necare omnes medicina” (l.c, § 14). True, this is a striking example of pure prejudice, uttered by a grim old nationalist and lacking any factual basis. Moreover, for our purpose this testimony is relevant only in the second line, since it is not a general judgment on medicine and physicians as such. On the other hand, Cato’s statement well illuminates the political aspect of our theme. In such a disguise, the prejudiced disqualification of physicians as being killers may have helped to make the entrance into Rome difficult for Greek medicine. At any rate, one should not forget here the famous (and seemingly historical) account of Archagathus who practised as one of the first Greek physicians at Rome and who was accused of being a “carnifex”, torturing or murdering patients by a cruel surgical therapy (cf. Pliny Le, § 12). On the whole, this special topic belongs to the field of racial prejudices that existed mutually between Greeks and Romans.*® Moreover, it is a very old belief (inherited at last from primitive cultures) that a “stranger” must a priori

cal his tv. ns, um Medical Ethics and Popular Ethics in Greece and Rome 99 be an “enemy” (sec above). In exactly this vein, the Jews, as being strangers par excellence, had from the Middie Ages onwards (and perhaps as early as in the beginnings of Christianity) to suffer from the accusation that they were murderers of god and, consequently, murderers of Christians—a burden that for a very long time came to bear heavily also upon Jewish physicians.?7 While Cato’s attack implies a particular judgment that explicitly concerns Greek physicians and their (allegedly) hostile attitude to Romans, Pliny's other in statements on physicians as killers claim a more general validity. The physician as such is defined (/.c., § 11) as an “imperator vitae nostrac necisque”.*® He “learns from our life-danger and gains experience from our death”; therefore it must be concluded that “the physician alone receives no punishment when he has killed a rat able to kill, above all, by poisoning (/.c., $ 20). to lor man” (Lc, § 18). Finally, by his special knowledge the physician is most easily Like that of Cato, these statements scem to reveal a (more generalized) attitude that may rightly be called a rather prejudiced one. But before confronting Pliny’s statements with the actual legal situation in Greece and Rome, and before secking for the psychological roots which must have been responsible for such a strong anti-medical attitude, we must present a few other Greek testimonies by which it becomes sufficiently clear that Pliny must be, as to our special topic, the representative of an unbroken tradition. From post-Aristophanic Attic comedy (among which the physician has sometimes served even as a title figure*®) there are preserved at least two fragments where the physician is called a killer, In one of them (stemming from an unknown play by Philemon, jr.), a general judgment is made exactly like that in Pliny (lc, $ 18): “doctors and lawyers can alone commit/ murder and not be killed for doing it.“ In the other fragments stemming likewise from an unknown comedy by Phoenicides (fr. 4, HF, Edmonds L.e., p. 249), a hetaera is enumerating some of her former lovers: “I dropped him (sc. a soldier) and gave a doc a turn/who'd hosts of patients that he'd cut or burn/, a statephysician*! with an empty purse/; made stiffs too, and not stories (sc. like the soldier) —he was worse". These few testimonies, coming from comic as well as from scientific literature (if one is willing to call Pliny a scientist), may suffice to make it clear that in GraecoRoman antiquity the physician could a priori stand under suspicion of being, or of becoming, a killer who eventually enjoyed impunity. But was such a suspicion justified in any sense, or was it bound merely to (literary) imagination? To clear this up, we must look first upon the Greek legal situation in general (for Roman laws, see below). Already in early Greece, it is true, murder was held to be one of the gravest crimes the punishment for which came gradually, from divine jurisdiction and private family right, into the more and more rationalized sphere of state legislation.#? Since the concept of murder had originally been a rather narrowed one (death by external wound), murder by poisoning was explicitly discussed as early as in the so-called Dracontic law. Here is the point where medicine and physicians had inevitably to come on the stage; poisons, of course, were always believed to belong, at least in the first line, to their resort. Thus, it is not surprising that Plato in book XI of his “Laws” (932, ET.) deals with a “nomos peri pharmakeias” in which the physician plays an

important role: When a man who is trained in medicine, gives a pharmakon by which any damage whatsoever is caused, he must be punished by capital punishment. Being confronted with a legal pronouncement of this indisputable character, we cannot but come, for the moment, to the conclusion that the slogan “the physician, an unpunished killer” apparently lacked any real basis. On the other hand, however, written law as such does by no means cover the whole situation. When we scrutinize Plato's text with closer attention, we come to find some disputable points that reveal a truly complicated problem: In the old (Dracontic) law, “pharmaka” had been clearly defined as deadly poisons, a category of drugs that seemed to be simple, and without problems, in their nature as well as in their effects. For Plato, however, the law had to be extended in a sense he himself claims to have given to it for the first time: A man who has knowledge of medicine (that means, here, a man who is a physician) can injure another man not only by deadly poisons but also by other drugs; if so, he must be punished by death, as being generally responsible for drugs and drug therapy. In my opinion, there is no doubt that a law of this kind and intention touched some actual, and grave, problems but was, on the other hand, far from giving a satisfactory legal solution for them. In Plato’s eyes, it seems to be rather self-evident that a physician knows exactly all the possible effects of drugs in all possible cases, simply because he is an ‘‘epistemon”. In consequence, when a person is harmed by a drug given by a certain physician, the latter must have caused this harm of his own free will, and with full intention (“hekon ek pronoias’”’ as it runs in Greek legal terminology**); hence, the rigorous plea for capital punishment, in such a case, It seems to be entirely beyond Plato’s thought that the physician concerned could actually have made a mistake, or that the drug’s effect was an unexpected one. This exactly is what we should like to call an oversimplification in Plato's “nomos peri pharmakeias’. Should we not be justified in supposing that behind it there was, among other factors, a certain prejudice not unlike that of Cato? That the physician becomes suspect just because of his therapeutic knowledge is at any rate a phenomenon that is not bound to Platonic or Greek argumentation alone. For instance, we find it expressed in strikingly similar terms in an Arabian folk-tale that may be summarized as followst5: “The doctor who can cure can also poison; this reflection brings the doctor under the king’s suspicion”. The fact that such a prejudice becomes effective in a philosopher’s legal argumentation as well as in folklore seems to make it sufficiently clear how widespread and deeply rooted it must have been, The king’s suspicion Let us think of at least one of many reported cases in classical antiquity*® where a well-known physician was under suspicion of having poisoned an important person. We have in mind C, Stertinius Xenophon, a Coan physician (descendant of an old and famous family of physicians) at the court of the Roman emperor Claudius. In Tacitus’ “Annales” (XII. 67) we can read the following on Claudius’ death, and Xenophon’s role in it: At the instigation of Agrippina, Claudius had been given a dinner that included (poisoned) mushrooms. The court-physician Xenophon who was party to the plot, put a (poisoned) feather into Claudius’

throat by feigning that he therewith had to provoke the patient’s vomiting. As Tacitus says, Xenophon “creditur” to have done it “haud ignarus summa scelera incipi cum periculo, peragi cum praemio”. Again, we mect here with a very significant example of the prejudice that is under discussion: The physician is the most convenient person to come under suspicion when poisoning (either alleged or real) is on the stage. Even when there was neither a public accusation nor a trial (at any rate, Xenophon remained unharmed by any prosecution that could have been awaited, at least in the light of Tacitus’ report), the suspicion as such lived its own life (be it a particular or a generalized one) and needed by no means to be confined to a king’s court. Just as Xenophon seemed to be, at least in the eyes of some people, an unpunished poisonmurderer, so any other physician could fall under the same general suspicion to become such a one, whether he were induced by money or any other reasons. In just this sense we may understand also a passage in Plautus’ “Mercator” (v. 471f.): Charinus, a young man, feels unhappy to the point of death (“Why do I live? Why am I not dcad?”). It is his intention, then, to go to a physician: “ibi me toxico morti dabo”. This does not mean that the doctor should help in suicide (which Charinus could certainly commit without aid, since he is not ill); on the contrary, the poct seems to indicate therewith the simple meaning that one will ever find, when going to a doctor, a “death by poison”! Having discussed thus far, in some of its legal and psychological aspects, the particular motif of the physician as a potential and actual poison-murderer (see also § 20 of Pliny's catalogue), we must now look for the reactions that eventually arose, in this connection, among Greek and Roman physicians. One of the earliest of such reactions may be found in the Hippocratic “Oath”. In its paragraph concerning poison, there is implied, in my opinion, the case of murder as well as of aid for suicide.*? In the circumstances, we may well understand why some physicians (originally, may be, a rather csoteric circlc**) felt urged to secure their professional and personal situation by swearing an Oath that could actually help, for instance, in a trial concerning death by poison. Indeed, there are some later testimonies (either written by physicians, or speaking in a physician’s name) which refer to this professional obligation to make it clear that a physician cannot be a poisonmurderer. In the first century A.D., the Roman physician Scribonius Largus declares that a physician “ne hostibus quidem malum medicamentum dabit” since he is “sacramento medicinae (i.e. the Hippocratic Oath, see Lc, line 39f.) legitime obligatus”, and since medicine is a “scientia sanandi, non nocendi’.49 In the second century, the Roman writer Apulcius tells in his romance “‘Afetamorphoses”’ (X. 9-11) the case of a physician who for money was demanded to give a deadly drug, as an aid for suicide. When the affair was handled in a trial, the physician confessed to have given nothing but a soporific, ‘‘cum . .. nec meae sectae crederem convenire causas ulli pracbere mortis, nec exitio sed saluti hominum medicinam quaesitam esse didieissem”. Finally, there is, in the fourth century, the Greek rhetor Libanius who among many other so-called progymnasmata (i.e. rhetorical exercises) composed a specch for the prosecution that has the title “Against the physician who is a poison-murderer”.°° Here, again, it is stated that those physicians who “stand to the oaths sworn by themselves” are bound to help but not to harm the patients (/.c., § 9).5!

But Libanius’ speech is interesting in another respect: Although it is, as a progymnasma, obviously feigned (neither names nor places are mentioned), just thereby it reveals a vivid picture of a common prejudice. It begins (§ 1) with the assertion that not a few of the accused doctor’s patients died under his cure. This, of course, can be taken as an ever valid statement; every physician must at any ae Fridolf Kudlien — 102 time have had, and would have, cases of exitus letalis in his practice. For Libanius and his public, however (and for all other testimonies so far quoted) the doctor is a priori responsible for the patient’s death, since he is evidently held to be an undisputed and omniscient master of all drugs (one may note the-close parallel to Plato’s opinion; thereby, the persistence of this idea within Greek and Roman thought becomes clear enough). This being so, the doctor must eventually be an intentional murderer who has killed by means of the drugs he gave. The alleged personal motif is, as it was for Pliny and for all others, love of money that is connected, by Libanius (88 11 and 21), with the imputation that some persons who had an interest in the patient’s death had made an agreement with the accused physician. The latter’s protestation that the patients’ death had been due to their own failures in diet, is declared to be a pure trick ($ 13). In consequence, the reputation of the medical profession is gravely harmed: Nobody in the town will now be courageous enough to call for a physician, as Libanius asserts (§ 24). Once given the mere possibility of such a quite hysterical poisoning-phobia springing up from a very knot of prejudices, and once given, furthermore, a somewhat unsatisfactory legal situation as it is manifested by Plato’s text, physicians themselves may indeed sometimes have felt unhappy. True, any accusation of poison-murder must have suffered from a principal difficulty: There was, in classical antiquity, neither a pathological anatomy nor a legal medicine in the modern sense, that would alone have possessed objective methods for making a conclusive test. On the other hand, physicians themselves were uncertain as to the mechanism of drug action and the peculiar reactions of the patient’s body. This is the point where the physician’s “knowledge”, which Plato refers to as an absolute category, ‘ must clearly turn out to be only relative. Moreover, the patients, that is to say the laymen, could be thoroughly aware of the physician's uncertainty. It appears evident that in the circumstances a mere appeal to a sworn oath : cannot have been very effective for, proving the doubted innocence. Consequently, there was another reaction of physicians that is of the greatest interest for our purpose: As we are told by Scribonius Largus (p. 24, 23fT. ed. Deichgraber), some physicians principally refused drug-therapy, following in this the example of their famous colleague Asclepiades of Prusa (Scrib. Larg. le, p. 25, 55ff.). But as Scribonius declares, Asclepiades himself had only in the case of acute diseases refrained from giving drugs, since in his opinion a drugless (and merely dietetic) therapy would be “tutius”. For Scribonius, physicians who totally refuse drugtherapy are criminal and even murderers (“parricidium . . . eos committere’’, l.e., p. 25, 62; cf. also p. 24, 28). ' Poor physicians, who inevitably were held to be murderers—whether they gave drugs or not! But apart from this: What was the deepest motive of the anti-drugtherapists? They, or at least some of them, were admittedly as cautious and sensible

of responsibility as a good physician should ever be. But in the circumstances discussed so far, this should not be taken as the only possible motive for a total anti-drug attitude. In this regard, the word “tutius” seems to be quite revealing just in its double aspect: It was “tutius” for the patient to be treated without drugs— but it was also “tutius” for a physician also to avoid drug-therapy! Indeed, there were, from ancient times onwards, some very common but especially dangerous (and hence suspicious) drugs as, for instance, hellebore, the extremely strong effects of which seemed hardly controllable.5? In this regard, a progymnasma-like speech ! composed by Lucianus, the contemporary of Galen, deserves our attention. Here, a physician who had been twice disinherited by his father, defends his case in front of a court of law. Although he had given his ill (mad) father drugs (the “poison” which he mentions several times may certainly have been hellebore) with great risk but, finally, with success, he had thereafter refused to do so for his stepmother who likewise suffered from temporary madness; hence, his father had punished him by disinheriting. Apart from the psychological complications of this family case, two passages of Lucianus’ speech scem to be particularly interesting for us; In § 4, the physician tells how he gave his father the poison “though most of the people present were suspicious and prone to accuse me”. In $$ 26ff., he presents a medical justification for having refused to adopt the same treatment in the case of his stepmother. There are numerous differences as to constitutions, diseases, drug-cflects and bodily reactions; even if the stepmother would not have been, in the physician’s opinion, a hopeless case, “I would not have risked giving the poison so boldly, from fear of accident (tyche) and defamation”. To sum up: Concerning drug-therapy and, especially, poisons, the physician’s own reaction against public suspicion and prejudice could eventually result ina refusal, casual or on principle, to give any drug at all. But it was not by drugs alone that the physician’s therapy could incur a public risk. One may recall the fact that the Greek physician Archagathus had in Rome been called a “carnifex” because of his surgical treatment. In general, surgical therapy in popular thought figured as “burning and cutting”, and was as such burdened with heavy prejudice.” The public fear of it might at least have been as widespread as in the case of poisons; as Scribonius Largus (/.c., p. 23, 19-23) has it in rather impressive words: “timidum \ genus mortalium inter initia non facile se ferro ignique committebat. quod etiam nunc plerique faciunt, ne dicam omnes, et nisi magna compulsi necessitate... non patiuntur sibi fieri, quac sane vix sunt toleranda”. Thus, it is not surprising that burning and cutting, both indeed traditional therapeutical methods of Greek and ' Roman medicine, could be brought in a close relation to the slogan “the physician, an unpunished killer”. Once again, we must examine the legal situation and the reaction of physicians. Leaving aside, here, the Roman legal situation which we shall later discuss as a whole (see below), it must be said that premeditated bodily injury was held, together with murder, poisoning and incendiary activity, to be a serious crime already in ancient Greek law.° Demosthenes (or. 54, 18) discusses in some detail the legal standpoint with regard to bodily injury arising from the use of dangerous instrui ments. Should we not be entitled to suppose that the physician’s use of such en er

instruments, that is to say the burning and cutting therapy, might often have run the risk of being confronted with legal, or semi-legal, argumentation? On the whole, it scems that the reserve with which not a few physicians regarded such therapeutical methods must be viewed not only in its medical aspect but also in the light of a “sensitiveness’ of society; thus, this reserve may likewise have been sometimes a mere reaction (as it was the case with poisons, and dangerous drugs). One may recall the famous Hippocratic aphorism VIT. 87, according to which the main therapeutical methods have a certain ranking order: First, there are the drugs; if they are useless, the “iron instrument” comes into play; “fire” (ie. cauterization) can only be the ultima ratio. Another famous Hippocratic passage to be considered in this connection is found in the “Oath”: “I will not use the knife, not even on sufferers from stone”, as Edelstein rightly translates it (as such, cauterization is not mentioned in the “Oath”). Afust this have been exclusively, or at least primarily, inspired by Pythagoreism? True, there are, as Edelstein has pointed out,’® two explicit testimonies according to which the Pythagoreans in their medical treatment have used “least of all” cutting and burning, while preferring compresses and, above all, a strictly dietetic treatment; as to drugtherapy, they are said to have been quite reserved. But it is nof said that such a ranking order of therapeutical methods was a Pythagorean monopoly; on the contrary, the differences between it and the aphorism seem to be at best matters of degree. Again, I feel urged to conclude that Edelstein in this point (as with the paragraph concerning poisons) has overemphasized the “Pythagorean” flavor as such. In my opinion, the “Oath” is on the whole an esoteric document (as Edelstcin has plausibly shown). But as to its single clements, at least the paragraphs concerning poisons and cutting must be interpreted, I think, not primarily as an expression of Pythagorean (or whatever esoteric) attitude but as a reaction to a given socio-cultural situation (see below § 3). A particular case of (as we must say) malevolent imputation against a special medica] operation must be mentioned here, as being a peculiarly conditioned one: We mean the early Christian attitude towards such manipulations as are directed against an unborn child. Without wishing to discuss here the much-handled problem of abortion in classical antiquity, we feel justified in following Edelstein in stating that a general antipathy against focticide arose as early as the beginnings of Christianity.” Some statements in Tertullian’s “De anima” (25, 5) seem remarkable here. Embryotomy, as practised by Hippocrates and Alexandrian physicians, is an “infanticidium’’; the instrument especially destined for such a manipulation bears, according to Tertullian, its name “‘embryosphaktes”’ (foetus-killer) as a very proper one. When practising in this way, physicians must have been considered, by Tertullianus and his like, as unpunished killers.5* Indeed, Tertullian is speaking, in this connection, of “jugulatio” and “caecum latrocinium”. For us, it appears particularly interesting that Tertullian’s imputations can be convicted of falsification: The instrument’s actual name was not ‘‘embryosphaktes” (with the bad overtones of the word’s second part) but “embryothlastes” or “—tomos” (where the second part mcans “dismember”, in a thoroughly neutral, and unbloody, sense). Morcover, embryotomy was by no means applied to a living, but to a mortified embryo. Psychologically regarded, Tertullian’s unique misrepresentation of a medical term seems to belong, as a symptom, to the same category as, for instance, the Greek

word “limoktonia” (killing by starving). Physicians and therapeutical methods could always be regarded with prejudiced eyes; in this respect, early Christianity did not differ from Graeco-Roman paganism. Thus far, we have discussed how a physician could come under suspicion of being an unpunished killer just by his particular knowledge and power. But there was a contrary possibility, too, for a physician to become suspicious, too, as a result of his alleged, or actual, incompetence. First, one must not overlook the fact that there was in old Greek folklore a certain “popular jest” (as Usener has called it5°); the incompetent, or dull, physician had become a typical figure and as such bore the names “Morsimos (death-bringer)” or “Klymenos (i.e. a cognomen of Hades, the god of the dead)”. Conversely, Death, could for the Greeks be a sort of physician, or medical deity, as he is in not a few folk-tales of various peoples. Apart from such folklore-motifs, which reflect a good deal of popular mentality and current opinion, the “mochtheros iatros” plays his part, for our purpose, in a highly interesting law-court speech delivered under the name of Antiphon, His Tetralogy No. IIT, though being perhaps (like the other Tetralogies) a pseudepigraphon, belongs certainly to the end of the fifih century B.c., and to the Attic environment." Altogether, the Tetralogies are representatives of an obviously widespread Attic discussion on the legal and moral problems of homicide. In Tetralogy III, the case is in short the following: A man who had been killed by the blows of another man, did not die immediately but after a few days, and under the treatment of a physician. Now, this physician was a notoriously incompetent one, as the defence points out.5 The other physicians are said to have prophesied that the wounded man, though a cure might be effected, would die if he came under the hands of this colleague. Hence, the incompetent doctor must be regarded the real killer, according to the defence. However, the prosecution replies‘? that this physician is at any rate protected, admitting that the wounded man might possibly have died by the physician’s treatment (in the law-court’s view, this was not the case); for “the law discharges him”. So was the physician an unpunished killer, after all? Can the quoted statement be taken as an explicit legal confirmation of Philemon’s, or Pliny’s, imputation? Of course, the answer cannot be a simple one, and must be well considered, the more so since we have now reached a very sensitive point of the physician’s responsibility. True, Antiphon’s Tetralogies were not actual law-court speeches, but even though they are fictitious, they are still very different from such compositions as the Progymnasmata quoted above. This means that in Antiphon’s Tetralogies there seem to be reflected not primarily emotions and prejudices (effective as these may have been by themselves) but actual legal problems in a generally authentic manner. This is why I doubt that Adkins (l.c., p. 104) is right to assume that in Tetralogy III “the doctor is only introduced so that the defence may make this point (i.e. the argument that either the doctor was the actual killer or the murdered man was responsible for his own death, he having struck the first blow)”. For the author of Tetralogy III, the doctor’s role in such a case, together with its legal implications, may have been of great interest. At any rate, a modern expert like D. M. Mac- Dowell® takes it for granted that in Greek Jaw, in full accordance with Antiphon, “if a patient died while under the care of a doctor, the doctor was not liable to punishment”. Moreover, MacDowell gives a plausible explanation for such a

striking situation. Seen juridically, the doctor’s responsibility is here closely parallel to that of a man who killed at war a fellow-citizen whom he had mistaken for an enemy. Both the doctor and this man remain unpunished because Attic law is primarily concentrated upon the killers intention (MacDowell L.c., p. 147). This gives us a key for elucidating, from our viewpoint, the Greek and Roman legal situation as a whole. As it stands, Greek law in general seems indeed to have been primarily concentrated upon the killer’s motive and intention. In consequence, involuntary killing, or killing by negligence, remained ultimately unpunished even if there was a trial.5 We must conclude, then, that for a Greek law-court a physician as such could have had only exceptionally, if at all, a motive for deliberately killing his patient; on the other hand, the possible incompetence or negligence of the doctor did not matter juridically, whatever the sequel might be. When in Plato’s “Laws” we met with an entirely different point of view, this must now be called a genuine discrepancy when seen in the context of actual Greek law. As we have seen, for Plato the doctor’s legal responsibility as a killer was based on his professional knowledge; or, in other words, the intention was taken for granted because of the physician’s knowledge which for its part had, in Plato’s argument, the character of an a priort assumption. Here, popular thinking did apparently intrude, perhaps unconsciously, into Plato’s reasoning. For, as is clear from the evidence, it was the popular point of view that was inclined to accuse the physician just because of his therapeutical possibilities. An alleged motive for deliberate killing could easily be found by public rumour, if one referred to money (which is ever a matter of suspicion!); in consequence, our testimonies are full of allusions to money. Furthermore, it was likewise popular thinking that (without any question of intention) an incompetent or negligent physician was necessarily guilty of the patient’s eventual death. This is exactly what we must call a characteristic gap between the legal and the popular standpoint; on such a soil, the slogan of the physician being an unpunished killer could in classical antiquity develop one of its main roots. As to Roman law, the situation seems to have been more or less the same, at least during earlier epochs. From the so-called “lex Cornelia de sicariis” onwards, involuntary killing by negligence was not liable to legal punishment but only to a sacral expiation. Again, the reason was that early Roman law had been concentrated primarily upon the “animus occidendi”, i.e. the intentional killing.“ By later Roman law, it is true, the matter was differentiated in some degree, as the testimonies collected by Below“ make clear: Not only intentional murder (mostly by poison; sec Below /.c., pp. 122-126) but also involuntary killing (see Below Le., pp. 126-128) is under legal. discussion, now. In such a case, the person who for instance has given a drug that caused an unforeseen death, is said to have acted “malo exemplo” (not “malo animo”!), and must be punished by relegation. But it seems very unlikely that the quite sophisticated, and vague, formula “malo exemplo” could have helped in creating a satisfactory legal solution, the less so since there were no adequate means of answering the question whether a patient's death was really due to the physician’s treatment. Moreover, it seems remarkable that a unique passage in the late “lex Aquilia de damnis’®’ and its discussion in Ulpianus, by which the physician’s “imperitia’’ is said to be liable for punishment in a case of resulting death is judged by Below (/.c., p. 111f.) to be an interpolation,

stemming from the “compilatorian mind” of the author: according to Below, the “moral indignation” of this passage is in “remarkable contrast” to other legal discussions of the same problem. Here, again, a bit of popular moral thought seems to have influenced a merely legal, and therefore entirely other-minded, text. Even today, the problem of involuntary killing by a physician’s negligence or incompetence (“ärztlicher Kunstfehler”) is a highly intricate one**—how could it have been solved in classical antiquity? In so far, I cannot follow Below’s (L.c., p. 135f.) rather optimistic evaluation of the effectiveness of Roman law concerning the physician’s liability. ne Now, let us end with a summary consideration: When there was, in classical antiquity, a gap between popular and legal thinking, this might have been an important but by no means the only factor in developing such a strong prejudice as the equation “physician = unpunished killer”. In attempting to clear up the psychological origins which one must assume to have been just as important, the following may be taken into account: Whether skilful or incompetent, the physician stands, and must stand, under the suspicious eyes ofa highly sensitive society that has willy-nilly a perpetual need of him. In fact, people are handed over to the physician for better or for worse, without being able on their own to understand, or to control all of the physician’s intentions or actions. As Pliny has it very impressively (see above): The physician is an “imperator vitae nostrae necisque”. This being so, there is reason enough, at least for sufficiently sensitive persons, to develop a sort of inferiority complex and, in consequence, to compensate this complex by exaggerated prejudices and aggressive criticism.°? Another delicate point is given with the (indeed far-reaching) social and governmental privileges the physicians enjoyed both in Greece and Rome. There is certainly no need of proof for the assertion that privileges as such can become very easily a cause of envy and “antifeelings”.7° In this connection, the word “unpunished”, together with its quite ambivalent overtones, scems to be revealing. As it was said in the beginning of this paragraph, Graeco-Roman antiquity may well serve, for our purpose, as an exemplary field. The legal as well as the psychological implications which, here, for the first time came to be involved into a main problem of the physician’s moral and legal responsibility, continued to be essentially the same for many centuries to come. Even today, some of them may be of some relevance; therefore, the historical background as drawn by us may be of some present interest. 3. THE “PYTHAGOREISM” OF THE HIPPOCRATIC OATH: OLD AND NEW OVERSTATEMENTS By the central thesis of L. Edelstein’s interpretation of the “Oath’’,7! this small document (that has been of such lasting and widespread influence) is set in a quite peculiar light. According to Edelstein, this “Oath” was originally of a very esoteric nature. Moreover, its ethical substance is said to stem altogether from Pythagorean doctrine. Nowadays, however, not so much the esoteric character but the alleged Pythagorcism of the “Oath” proves to be more and more disputable, since one becomes in general more and more aware that “Pythagoreism” has much too often served as an inappropriate label for a series of quite common Greek phenomena.

We must therefore consider the possibility of interpreting at least some of the ethical rules of the “Oath” as influenced by popular, rather than Pythagorean, morality. But before doing so, it may be not without interest to call attention to the fact that Edelstein, while interpreting the “Oath” as a Pythagorean document, has had respectable forerunners who should not be forgotten. After having compared, then, the old and the new in the Pythagorean interpretation of the “Oath”, and after having discussed its (eventually) popular ethical flavour, we shall finish by a few words concerning the startling question how the ‘‘Oath’’, although composed, ultimately, from individual popular elements, could at the same timc have an esoteric character. In the year 1740 there was published, under a rather complicated title and together with a bulk of Prolegomena, Commentaria, and Commentationes, an edition of the Ps. Hippocratic treatise “peri euschemosyres” by Georg Matthiae,?3 a former pupil of Lorenz Heister.?* At that time, Matthiae was a scientific librarian at Goettingen (“Bibliothecae Bulovianae custos” as he is called on the title-page). Now, since it is the main tendency of this Ps. Hippocratic treatise (a tendency that is, as we must be well aware, by no means common to Greek medicine as a whole) to mix medicine with philosophy (see especially its ch. 5), Matthiae was, as a commentator, fully justified in writing at great length on Hippocratic medicine in its relations to philosophy. For him (but not alone for him, nor for his time), the so-called Corpus Hippocraticum was a more or less homogenous unity, a collection of treatises which (maybe with a few exceptions) stemmed from one and the same author: Hippocrates. In the circumstances, Matthiae may be excused for having oversimplified the historical development which, in his opinion, had been in short the following: Greek philosophy was the main, or even sole, source from which Greek medicine could and did derive its scientific basis.” But the first Greek philosopher who had any actual influence and from whom, in the circumstances, all branches of Greek philosophy originate, was Pythagoras (see Matthiae L.c., p. 4ff.). Thus, since Pythagoras and his school also had a particular interest in medicine, Hippocrates, as the founder of Greek scientific medicine, must necessarily be called a ““Pythagorista” (Matthiae /.c., p. 32f., with note).7° By such a view (which he claims to share with at least some other scholars), Matthiae goes on to give an abundant mass of Pythagorean (or rather of what later Greek or Roman testimonies suggest were “Pythagorean") parallels not only for “peri euschemosynes” but also for other Hippocratic treatises. Among them, the “Oath” is named (p. 159) in connection with that remarkably close relationship between teacher and pupil which is claimed in the beginning of the “Oath” and which is so often taken as a particularly significant mark of Pythagoreism (for this special point, Matthiae refers to J. H. Meibom's “Commentatio ad jusjurandum Hippocratis”). May this suffice to remind us of a pan-pythagorizing trend within eighteenthcentury medical historiography. For any historian of the human mind, the tenacity of this trend appears remarkable as it becomes manifest even in modern medical historiography, above all, in J. Schumacher.?? We must call attention to this fact for the purpose of distinguishing Edelstein’s brilliant interpretation from such naive overstatements. True, Edelstein could find in the works of his forerunners rich textual material for rendering acceptable, at least concerning this side of the matter,

his thesis of the Pythagorean character of the “Oath”. But for Edelstein, Hippocrates himself (whom he saw with the more sceptical eyes of a trained historian and philologist) was by no means a “Pythagorista”; morcover, the body of“Hippocratic”’ treatises was so far from being homogenous that it could hardly be the work of a single author, be his name Hippocrates or not. On the contrary, for Edelstein the “Oath” reveals itself as a document ofa completely unique, and isolated, character, in comparison with the rest of the Corpus Hippocraticum; manyof its rules obviously do not agree with the ethical attitude and behaviour of most, if not all, other Hippocratic physicians.?* This was a clear and unquestionable insight which had not been hitherto pronounced with a similar directness—an insight that called, it is true, for a new interpretation of the “Oath”. How can the phenomenon of its uniqueness and isolated position be explained? Here, however, Edelstein is proceeding from a correct insight to a conclusion that must evidently be called an overstatement. For Burkert, an important expert in the hopelessly complicated field of Pythagoreism, Edelstein’s interpretation of the “Oath” proves to be “etwas kurzschlüssig’’.’° As it stands, just the “Oath’s” unique character can easily provoke an interpretation that secks, once and for all, for a mysterious and secret area of its origin. Thus, the “Oath” was also held to be influenced by Orphism.8° As Fdelstein has rightly emphasized, this assumption is rather unlikely (see /c., p. 18, n. 38 and p. 20, n. 48). But it must be questioned, then, whether his own conclusion is more stringent. While interpreting the “Oath” as a Pythagorean document (wherein he might have been confirmed by Erich Frank*'), Edelstein begins with a quite apodictic attempt to prove that the author of the “Oath”, with the corresponding passage, gives nothing but a justification for refusing medical aid in favour of suicide; by other scholars, this paragraph of the “Oath” had been understood also as a warning against any criminal attempt by poison on the patient’s life (see “Ancient Medicine”, p. 9f.). Only after having excluded this possibility of a wider interpretation of the “Oath’s” related rule is Edelstein able to introduce Pythagoreism as a dominating factor (/.c., p. 17). But as was said above (p. 101 with n. 47), his argument relies too much on this single claim. In fact, the paragraph of the “Oath” concerning deadly poisons finds a much less constrained interpretation when seen (as it was already by Littré) as a tentative protection against criminal complications and, furthermore, as a reaction against certain prejudices of popular moral thought.*? The same paragraph contains also a rejection of abortive drugs. Must this be taken as a specifically, or even exclusively, Pythagorean rule (Edelstein Z.e., p. 1817.) ? In fact, abortion was, in classical antiquity, neither for the average physician nor for the average philosopher a matter of scandal. Nonetheless, for Greek religious feeling miscarriage could have the odium of a strong “uncleanness.® Consequently, in a private cult-law dating from the later Hellenistic epoch,®* the giving of abortive drugs (and of poisons also) is enumerated, among other (non-medical) actions, as being forbidden for anyone who wishes to enter the house; such a person must be chaste, pure and holy, in every respect. As Weinreich has pointed out, there are many parallels between this cult-law and the “Oath”. On the whole, such ethical rules belong to a “good Greek morality” (or, in other words, they are common to a religiously tinged stock of popular Greek ethics) as Nilsson states.*5 In Nilsson’s opinion, one need not search for Pythagorean influence to explain these

rules in their proper setting. At any rate, it seems unlikely that the author of the cult-law was a Pythagorean, or that he was influenced by the “Oath”. In the Int (“ul first instance, he was a religious-minded man with a particular weakness for cultrules and institutions; in general, this seems to hold good also for the author of the som are tion “Oath” (see below). In the same vein, some other ethical rules of the “Oath” prove, from an unprejudiced critical consideration, to be fully explicable in the light of parallels from either popular or religious morality. For instance, in two paragraphs the author is referring to the rule discussed above (see our § 1) “to help or at least to do no harm”, which has certainly nothing to do with Pythagoreism. Furthermore, the fact that the famous obligation to be silent about patients’ affairs is characterized by the Greek “mysterious” term ‘‘arrheta”, and that the obligation itself is indeed a moral (and not merely a prudential) one,*® does not argue primarily for Pythagorean origin. First, the command to observe the “aporrheta” is very common in other Greek oath-formulas as sworn by citizens and officials.87 Second, it is an old command of Greek popular ethics (or “polis”’-ethics) to avoid the uttering of aporrheta,#® a command that may have been still current in later epochs, at least in professional and political (civic) ethics if this latter were enforced in the rigid, and traditionally solemn, form of an oath. On the other hand, there are in the “Oath” a few clear signs of a genuine exclusivencss, in the sense ofa mystery- or cult-like character. Edelstein has rightly stated (/.c., p. 15) that the Greek words “hagnos kai hosios” indicate a much elevated level of spirit. But why did he fail to say, then, that by this couple of adjectives the general sphere of religious practice (as for instance sacrifices®®) is touched? In the “Oath”, a physician ofa marked religious belief feels bound to view a physician's medical life and practice as a pious celebration, so to speak. While for a Greek physician this appears a strange, and even unique, attitude, it need not be, on the other hand, a specifically Pythagorean one (Edelstein Le., p. 20). The same holds unic time in C guil phe: the to + prof ope: old hist: disc that Inc and the good for the strong obligations on the “initiate” to regard his medical teacher as a regular father. Here we are led back to the general area of mysterious cults. Here we can find indeed a “father” who bears this very title® and by whom the novice ther evel ethi is to be introduced into the secrecies of the cult. Furthermore, it must be remempoll affe. bered that there were, in Greece, professional guilds which as such had, at least originally, a religious, and therefore esoteric, character and form. Within such “synodoi” (as the most usual of the related Greek terms runs), there was a “father” too”! ; Now what is the situation of the “Oath” as it presents itself in the light of these considerations? First, this brief document possesses formal features (in the beginning, mos ther “ou the invocation of gods; at the end, the closing formula) that make it a regular, and soci, completely normal, oath.°? Next, concerning the contents there are some rules which apparently stem from what one nowadays is calling “popular (or, vulgar) ethics” and which are either closely parallel with Hippocratic medicine (cf. the rule “to help or at least to do no harm”) or (cf. the command for reticence) are common in civic oaths. Furthermore, some rules of the “Oath”, though being without parallels in the rest of Greck medicine, can eventually be explained as reactions against popular anti-medical sentiments and prejudices (cf. the command for refraining from deadly drugs and abortive remedies as well as from any cutting). gem arist but “qu as tı class prise

111 In the case of abortive drugs, moreover, we are led back to a very religious sphere (“uncleanness”, taboo) which could intervene, too, in popular ethics. Finally, some genuine religious aspects (cf. “in purity and holiness” or the “father”’-relation) are as such unmistakable in the “Oath’’; here, cults or cult-like professional corporations come into mind as possible parallels. It is an unquestionable fact that the “Oath” is, precisely by its peculiarities, a unique document within the so-called Corpus Hippocraticum. Until early Christian times there is indeed no hint of its having been accepted, or even merely noticed, in Greek or Roman medicine. Maybe the “Oath” is a relic of a certain professional guild of ancient Greek physicians (if so, Such a guild must have been a rare phenomenon, as far as we can judge from the remaining evidence). Maybe, on the other hand, that a single physician ofa peculiarly religious mind felt stimulated to write such an “Oath” as a literary document that he composed from partly profane and partly religious or cult-like elements. In my opinion, this remains an open question. In the circumstances, we should at least be careful not to repeat old or new overstatements when attempting to understand the “Oath” in its proper historical setting. re ly es In is Ic 4, ARISTOCRATIC TINGES IN OLD HIPPOCRATIC PROFESSIONAL ETHICS When in the foregoing paragraphs “popular”, or “vulgar”, ethics came to he discussed in relation to medical ethics, the term should not be understood to mean that there was a morality that belonged to the lower classes and to them alone. In our discussion, the two adjectives are used as identical with “non-philosophical” — and “non-professional”; but on the other hand, they cover all strata of society the “profanum vulgus” as well as the aristocrats. At the moment, however, we are concerned with two precise questions: Are there any values of a specifically aristocratic origin that were taken over, and, eventually, transformed by the old Greek plrysicians, in regard to their professional ethics? And second: What was the old Hippocratic attitude towards the “hoi polloi”? Or in a more precise formulation: How was the old Greek physician affected by, and how did he react against, what “people” said? First, let us make a few remarks about the general background. Since the two most prominent, and exemplary, Homeric physicians Podalirius and Machaon were themselves noblemen, and since for Homeric society the physician at any rate “outvalues many other people’’,9 it may be rightly expected that at least the general ethics of the Homeric physician was in full accordance with that of the social stratum to which he belonged, that is to say with the values of Homeric aristocracy.°* As such, these values are characterized by the “arcte”-standard for which merely success (prowess at war, protection of family and wealth in peace), but not intention, mattered; the competitive values completely overshadowed the “quieter” ones.°5 Now, it must be kept in mind that within this society there was, as to values and their general validity, no gap between aristocracy and the lower classes. People usually expected a nobleman to fulfil the obligations laid upon him by the arete-standard. Noblemen, on the other hand, were by no means prisoners of their own class, as if living in a splendid isolation; in every respect,

they reckoned with “what people will say (demou phatis)”.°% Public opinion (“public” as including virtually the community as a whole) is most important in what E. R. Dodds and others have called a “shame culture”. Herein, the Greek adjectives “kalos” and “aischros” were to serve as keywords for unmistakably denoting success or failure.” It appears rather self-evident that a change must have come when the close unity, composed of aristocracy and “demos” (a unity that was warranted by the “oikos”—or household-structure of early Greek society), came to break down. This had been inaugurated by the political, social and intellectual revolutions by which Greece was troubled from the seventh century B.c. onwards. There were some people now, who were willing to give up traditional noble ideals and values.°? Conversely, some other people gave expression to a sharp contrast between the despised “dull crowd” and the (revered) aristocracy.°° As it stands, it seems only natural that a physician should have been provoked, in the interest of the ethical standard of his professional activity, to take his decision whether he would eventually accept traditional values, or go with the “demos” and the “demotai”. With regard to the physician’s peculiar connection with patients (who usually came from all strata of society), this may certainly have been an intricate problem. Generally speaking, the social position of an average physician in the sixth and fifth centuries B.c. cannot have been simply identical with that of craftsmen as such and, therefore, on a low level, as Edelstein has it in his doctoral thesis.!00 At least, there was a tradition of ‘““Homeric descent” that had to be either kept in mind (consciously or not) or explicitly abandoned by a Greek physician. May this suffice for delineating the general background of what we shall now discuss in more detail, by means of old Hippocratic texts. We have in mind some treatises of an accepted carly date in which the “demotai” (or their verbal equivalents) are spoken of in this or that direction, or which appear otherwise important for our purpose: De officina medici (Of. Med.) ; De fracturis (Fract.); De articulis (Art.)101; De diaeta in acutis (Acut.); De vetere medicina (VM). As G.-H. Knutzen has pointed out,'® the treatises Fract., Art. and Acut. reveal an “ironisch-sarkastische, aristokratisch-laienfeindliche” attitude. Now, what can substantially be said on the aristocratic tinges within the professional ethics of the Hippocratic authors? First, there are the well-known Greek adjectives “kalos” and ‘‘agathos” which, as coupled with each other, are traditional key-words of a nobility standard. A man who is, or acts as, a “kalokagathos” is denoted, thereby, as a “perfect gentleman” (this is a most fitting translation, used e.g. in Liddell and Scott's Greek-English Lexicon). At any rate, this.is the original meaning of this pair of adjectives. We find the term taken over, for instance, by the Hippocratic author of Pract.,'° ch. 8: A certain orthopedic manipulation is “agathe’”’ when carried out “kalòs”. Such a formulation may be called somewhat tautological; but it is remarkable that a physician obviously felt urged to denote the high quality of a medical manipulation just in this tautological but, nonctheless, traditional way. Here, the question remains open whether it is the technical quality alone or, beyond that, the technical and “moral” claims of the manipulator, that should be construed from the physician's words. In Off. Med. 4, the case is a similar one: Here, the physician is ordered, by a general rule, to act and to behave “agathös, kalös.” Some chapters later

(7 and 8), the relevance of these two adverbs is demonstrated by the applying of surgical bandages: ‘‘kalés’ means a simple harmony; by “agathös”, one has to understand the effectiveness. In the same way “aischros”, the traditional opposite value to “kalos”, is used in Art. 11: A certain surgical manipulation is said to run the risk of being, in its effects, not “kakion” but ‘‘aischion” and, therefore, not in accordance with the claims of the techne iatrike (‘‘atechnoteron”). Finally, one may compare, in this connection, a more general statement in Art. 44 and 78: A manipulation that requires much ado and circumstances (“poulyn ochlon’’) without being proportionally effective, is “aischron”; the simplest method (“aochlotatos tropos”) is by far more adequate, regarding the claims of techne (“technikoteron”’). Thus far, the physician’s person as such, and his attitude towards pcople who have different standards, is not primarily touched. True, the old and traditional values are apparently taken over by, or transposed in, the techne iatrike. As had been the casc already in their original area, they continue to be concentrated mainly upon success (effectiveness) and failure or, in other words, upon the external side of the matter. But in the medical passages quoted, when taken by themselves, there is no hint of “caste” or “class” to be detected. As to their “moral” essence, it is the objective, technical quality alone (as determined by form and effectiveness of the manipulation) that seems to matter. However, these passages cannot be looked upon in isolation and alone in the sense just discussed, as will become fully evident by means of another group of old Hippocratic “moral” terms. First, there is in Fract. 15 a word that spans only a narrow, and quite clear-cut, field of meaning—‘“‘soloikos”. When it is said to be ““soloikoteron”' to use particular orthopedic machines without any necessity to do so, this must have meant something more definite than merely “inappropriate”. Doubtless, this Greek word has certain connotations, the more so when used in a relatively old text where it certainly did not yet serve as a mere, and bloodless, metaphor. By “soloikos’’, one becomes clearly marked down as having bad taste; acting “soloikös’’ mcans erring against good manners. That this must be precisely the sense in Fract. 15, we are able to prove by comparing a few other passages. As we had seen in Off. Med. 7, a Hippocratic author of that time and environment did identify “kalos’” with the ideal ofa simple harmony. And in Art. 44 and 78, a complicated but relatively useless manipulation was said to be “aischron”, while its opposite, the simplest method, was praised by the adjective “technikoteron'.!?* Moreover, a physician who prefers the simplest method acts not only ‘‘technikoteron” but also “andragathikoteron” (Art. 78). As it seems, in Michler’s opinion! this last term needs no further comment since it meant “ethical” in a rather timeless, and self-evident, sense. However, “andragathia” as well as ‘‘euandria” referred actually to a traditional value that was bound to the competitive arete-standard of an aristocratic class,'°5 while lacking, in the circumstances, any ‘‘quieter’’ connotations. That it is used in Art, 78 precisely in its unchanged original meaning, becomes evident by the author’s additional remark that acting in such a manner fits well with the ideal standard of a physician “who does not aspire after plebeian baseness (demoeides kibdelie)”. In such harsh and contemptuous words, we find the first unmistakable hint of an attitude towards ‘demos’ and “demotai” which is highly different from that

in Homer. An open break between the physician’s opinions and value standards and those of the “demotai” is to be recognized, then, in Fract. 16: Once again, the “mechanopoieisthai”, i.e. the construction of machines or other mechanical aids, is under discussion; in the eyes of “demotai”, it is said, a physician is more trustworthy when using, as splints, hollow tiles in the case ofa broken leg; but nonetheless, this is “‘atechnoteron’’. In a later part of his discussion (ch. 22), the surgical author is even willing to admit the use of such splints (“solënes’”’), in a limited measure ;!°7 principally, however, he seems to feel somewhat shocked by the matter’s “vulgar” touch. This appears remarkable. One gains the impression that a physician of such a type and attitude would have scorned not only complicated (or “pompous”’) but also new methods and instruments just because they were new. Or, in other words, he might prefer an old-fashioned ‘noble simplicity” while detesting an “ignoble modernity”. Might his standpoint have been influenced by objective, that is to say, purely surgical considerations, too—the very presence of some completely different categories of evaluation, on the other hand, speaks for itself. As to the conflict by which, in the circumstances, an old Hippocratic surgeon might be troubled, Art. 42 is revealing: Physicians who use a certain mechanical method of treating a gibbus, are blamed for their “desiring to soft-soap the mob (ekchaunoun ton polyn ochlon)”. In the author’s opinion, the method as such is old and, therefore, highly praiseworthy, but “I myself would be ashamed to use methods of that kind, since they are in the hands of tricksters”. Before proceeding with our discussion, we must now make a parenthetical remark, to refute a possible objection. It would be incorrect to understand, within the old Hippocratic writings, the word “‘demotes” strictly as “layman”. Its original social meaning (as being evident, for instance, in Tyrtacus fr. 3a and hb ed. Diehl and in Herodotus Il. 172), seems to be preserved and, morcover, to have gained a cutting tone, in old Hippocratic authors; this becomes unmistakably clear by the use of the synonymous phrase “‘polys ochlos” in Art. 42, Thus, in the Hippocratic environment “‘demotes” sounds more piercing than “‘idiotes”. On the other hand, Acut, 2 (see below) seems to use both “demotes” and “‘idiotes” without any difference, as is clear within the context. In the circumstances, we must at all events keep in mind that in the treatises quoted the “laymen” are not spoken of in a neutral sense but with regard to a certain social level, namely that of the “masses’’. In Acut. 2 (or ch. 6, in Kuehlewein’s numbering) it is stated that the “idiotai” as either culogists or critics are looking merely on unusual, or strange, therapeutics (“heteroia iemata”). Actually, they are much too unwise (‘‘asynetotatoi’’) to form a reasonable opinion about related problems. Here, we find expressed the same attitude as in Art. 42 where the “mob” (or “such ones’) are said to eulogize “astonishing” methods as such. Indeed, the physician had apparently to stand amid the cross-fire of “vulgar” (not merely “public”!) criticism. For the old Hippocratitz of our discussion, this appears a fatal and annoying situation because of the “masses” allegedly characteristic foolishness (cf. also Art. 67). Unfortunately, there are some physicians who flatter the mob while asking anxiously what people like, or dislike. But such colleagues are virtually ‘“non-physicians” (Acut. 2), and their mental level can be identified with that of the “idiotai” and “demotai’’ (cf. Art. | and Af 21). I think that the real difference between the Homeric and ur en

the old Hippocratic attitude towards “demotai” could hardly find a more frank expression. What people say is no longer a leading principle but, on the contrary, a completely negative criterion. Physicians who continue to reckon with the Homeric “demou phatis” are to be seen, now, as detestable outsiders of the medical profession. That this can be called aristocratic in a non-Homeric but, nonetheless, well understandable sense appears beyond question. Essentially, it looks quite similar to this proud but melancholy statement of a very famous Hellenistic philosopher :'%* “The things which I know, the multitude disapproves, and of what the multitude approves, I know nothing”. Moreover, the attitude of the physicians quoted is aristocratic while openly preferring the old, traditional and, above all, simple methods, at least in so far as this preference is not solely depending, here, on medical considerations alone. As it is formulated by Fract. 1: There are physicians who believe themselves to be skilful although actually unwise. While desiring to display even a peculiar skilfulness (“sophizomenoi’’), they praise the “strange-looking” (xenoprepes) more than the traditional (xynethes), and they like the extravagant (allokoton) more than the clear and simple (eudelon). As a parallel, we must in this connection remember Plato's general judgment on medicine, and the best kind of it. In his “Politeia”, he declares that there had been, once upon a time, a break in the development of medicine. While Homeric medicine could be defined as a simple, and uncomplicated, matter (cf. L¢., 405 €, 8f. and d, 7ff.; 406 d, MF; 407 d, 1-4), later medicine degenerated under the influence of a general deterioration of the Greek way of life into a lengthy and complicated procedure (ibid. 405 c, 8-d, 4; 406 b, 4-8). In Plato's eyes, this is “aischron” (ibid. 405 d, 4), and the new-fangled dietetic physicians are “affected” ones (“kompsoi’’, ibid. 405 d, 4 and 408 b, 6). Immediately, we think of the role which the value terms “aischros” as well as “‘kompsos’’ (cf. “kompseuesthai’ in Art. 70) and “allokotos” had to play in our old Hippocratic writings. In his utopian “Laws” where the attitude towards medicine and its role within society is somewhat altered,!°9 Plato speaks of those physicians who practise their craft “by experience alone, without reason (logos)” (cf. “Nomor” 857 c, 7). Such physicians arc “slaves”, in contrast to their opposites, the “philosophical” physicians who arc “freemen”. Once again, we can look back immediately to our old Hippocratic treatises where those physicians who like technical tricks are said to have “skilful hands, while lacking reason” (Art. 33 and 35), and to belong to the same mental level as the “demotai”. Plato himself was a notorious aristocrat and, moreover, a contemporary of old Hippocratic medicine. Should we not suppose, in the circumstances, that with his statements about medicine he might have referred to a medical discussion in which the (already quoted) old Hippocratic physicians formed a like-minded partner, so to speak? Once again it must be emphasized, however, that the aristocratic tinges we have discussed, unquestionable as they are in their very existence, by no means characterize the essence and tendencies of Hippocratic professional ethics as a whole. In so far as physicians felt obliged to care for the shaping of their ethics, they found themselves necessarily in open confrontation with an inner-medical as well as a socio-cultural side of the matter. True, they used some primarily medical arguments in discussing ethical problems of bone surgery, for example; as such, those primarily

medical arguments and viewpoints can be considered for themselves, as M. Michler has shown. On the other hand, just those medical arguments and viewpoints are also bound up intimately, in old Hippocratic professional ethics, to traditional moral values of an entirely different nature. It may be somewhat surprising, for a modern inlooker, in what measure this is the case; but the fact as such can at all events not be questioned. We may explain it by assuming that old Greek physicians had a certain enduring socio-cultural tradition of their own, and that the common values of this tradition were, from long past, at hand for their use if need be. But by using them in a situation when generally many changes and breaks of tradition took place, the physician proved in his attitude towards “people”, almost inevitably to be forced and fixed in a certain direction. That this must have been felt to be an earnest problem becomes evident by a quite different reaction of some other old Hippocratic physicians: In VAf 2, the physician is admonished not to abandon the traditional knowledge and the known paths of medicine, while seeking for “strange” (heteros) methods and forms. Thus far, we are on known and usual ground. But now, when the “demotai” come into play, they are no longer pictured in a roughly negative contrast to the physician’s own position. Instead of this, the physician is admonished, in VM 2, not to refrain from saying things “that are known to people”. Thereby, the purpose is evidently a pedagogic one. In a similar vein, the author of “Peri technes” (ch. 13) demands frankly that the physician should take care of the mind of multitude (“plethos”). A “Homeric” come-back, after all? At any rate, these last passages may indeed represent a distinct voice within an inner-medical discussion. And they may also have been a warning not to overlook the risk of an eventual “splendid isolation” of the physicians—a risk already inherent in the “laienfeindliche” attitude discussed above of some old Hippocratic physicians. NOTES l. See the chapter “The Hippocratic physician” from his Ph.D. dissertation (printed 1931), now available in English translation in: Ancient Medicine, Selected papers of L.E., ed. by O. and L. Temkin, Baltimore 1967, pp. 87-110; and his paper “ The professional ethics of the Greek physician’ of 1956 (reprinted Lc., pp. 319-348). 2. To quote a single example: There is no cogent reason for assuming any influence by the school of Aristotle, or any Peripatetic flavor in the Ps.Hippocratic treatise “On the Physician”, as Edelstein does (Lc., p. 329f. with n. 19), Such rules of right behaviour as, for instance, “do not laugh excessively” and the like, are to be found as early as in that old popular stock of polis-ethics of which Diogenes Laertius and others have delivered some remnants (cf. Clio Medica 3, 333 n. 54 and 55 (1968)). Indeed, this ethics is “that of common morality” as Edelstein himself admits (Le, n. 19, end). Why should we not simply assume, then, that both the later Peripatos and the author of “On the Physician” referred to traditional popular rules, without being influenced by each other? 3. L. Pearson, Popular Ethics in Ancient Greece, Stanford 1962; A. Dire, Die Goldene Regel—Fine Einführung in die Geschichte der antiken u. frühchristlichen Vulgärethik, Göttingen 1962; see also J. FERGUSON, Moral Values in the Ancient World, London 1959 and A. W. H. Apkins, Merit and ResponsibilityA Study in Greek Values, Oxford 1960 (in this connection, A. E. Dobbs’ “Philosophy and Popular Morals in Ancient Greece”, Dublin 1907, should not be forgotten).

udlien chler 1925, p. 9. “ Thucydide et Hippocrate vus par un historien-medecin”, Genève 1965, p. 69f. “ Thukydides u. d. hippokratischen Schriften’, Heidelberg 1954, p. 72f (whose main thesis has been critically reviewed by H. Ditter, Gnomon 27, 1955, p. 13). Cf. Due, Le., p. 32. Cf. Pearson, /.c., p. 13ff. Cf, Dinte, Lc, p. 33 n. 2. ; had imon But lition 10. ll, tably 12. by a See his small pamphlet “Die Arzteschule von Knidos’, Abh.Sächs. Akad. Leipzig 29 idern vents C. SANpurEscu, Primum non nacere—Philological Commentaries on a Medical Aphorism, in: Acta Antigua Academiae Scientiarum Hungaricae 13, 359-368 (1965). © Gr s are noral 117 For changing concepts of friendships in Ancient Greece, see FERGUSON /.c., ch. IV; cf. also SopHOCLES ‘Ajax’ vv. 678-682 for enemies turning into friends, and conversely, As to the development of the Greek concept of fatherland, some material is to be found in H. C. Batpry, The Unity of Mankind in Greek Thought, Cambridge 1965, chs. IL and III and in V. EHRENBERG, The People of Aristophanes, A Sociology of old Attic Comedy, New York 1962 (Schocken Books), p.148. i, the nown See, for this, ApKINS l.c., p. 199. ‘Thus come ıhysiot to 14 15. SC is 16. . 13) itude 17. deed also ion’ assed 18. 19. To which you may add p. technes 5. For the time about 400 ».c., see in general V. EHRENBERG Lc. ch. 6 (Citizens and Foreigners). See F. Weurt, Hauptrichtungen d. griech. Denkens, Zürich 1964, p. 102f. (Wehrli does not conceal, however, that the character of related Attic claims might have been somewhat verbal). “eine älteren Vorstellungen entsprechende . . . Auffassung’’, as DEICHGRÄBER has it in ““Professio medici. Zum Vorwort des Ser. L.”, Abhandlungen d. Akad. d. Wissenschaften u. d. Literatur No. 9, Mainz 1950, p. 5. 20. 21. 22. 23. 24. ‘inted papers “The nence eatise 25. right 26. found s and 168)). dmits later 27, 28. 29, 30. 31. 32. rules, Die tlichen Incient Greek See above p. 104 with n. 15 and EHRENBERG l.c. p. 152. For the original meaning of philanthropia, and the protracted development of this concept among the Greeks, see EDELSTEIN /.c., p. 321ff. and FERGUSON /.e., ch. VE. See DEICHGRÄBER, Le, p. 17 (quoting a Danish physician from 17th cent.). I quote from DEICHGRÄBER's edition, /.c., p. 24 lines 29-37. Cf. DEICHGRÄBER, Le, p. 15. In his résumé of Scrisonius text, EpELSTEIN (le, p. 338) does not discuss this aspect. While speaking on the physician's civic duties at war, SCRIBONIUS may have had before his mind the Hippocratic “letter” No. 11 (see above p. 95). If so, this can eventually serve as a terminus ante quem for dating this letter and, moreover, the section of the correspondence to which this letter belongs. The text is published by J.H. OLiver—P. Maas in: Bull. Hist. Med. 7, 321 (1939); seg also EDELSTEIN l.c, p. 344. For the protracted development and incomplete meaning of this idea among Graeco-Roman culture, see in general H. C. BaLpry (see above n. 12). In so far, I do not believe (as EDELSTEIN does /.c., p. 344) that the poem has reached an ethical level that is higher, or more developed, than that of SCRIBONIUS. For references, see FERGUSON /.c., p. 210f. and Dire Lc., p. 44f. and 115. See for this the plausible remarks Pearson has made /.c., p. 136 and 245 n. 2. See DIHLE, Lc. Quoted by DEICHGRÄBER, /.c., p. 18. Here, it must be remembered that the famous Christian command “love thy neighbour like yourself” in its Jewish form (Leviticus XIX. 18) clearly referred only to fellow Jews (cf. Il. BoLKESTEIN, Wohltätigkeit u. Armenpflege im vorchristl. Altertum, repr. Groningen 1967, p. 64 n. 1). opular For references concerning AGRIPPA and MoriÈre, see Gesnerus 23, 87 (1966).

36. 37. 38. 39, Fridolf Kudlien That Acrippa’s ‘De incertitudine et vanitate scientiarum” (where the anti-medical attack is to be found) must principally be taken as a serious expression of opinion, is rightly emphasized by Ch. G. NAUERT jr., Agrippa and the Crisis of Renaissance Thought, Urbana 1965, p. 196f. As to Motrkre's factual seriousness, we need not quote special literature. See e.g. EnRENBERG's above-quoted (n. 12) book “The People of Aristophanes. A Sociology of old Attic Comedy”. See A. N. SHERWIN-WHITE, Racial Prejudice in Imperial Rome, Cambridge 1967 (for anti-Greek prejudice, see ibid. pp. 71ff.). For Jews as (ritual) murderers of Greeks, see JosepHus, Contra Apionem IT. 91 and the Lexicon of Suda s.v. ‘““Damakritos”’. It must be kept in mind that “nex” means, at least in the first line, not natural death, but death by violence (given some exceptions that seem to form a clear minority). This being so, PLiny may have chosen the word “necisque”’ (instead of ‘‘mortisque’’) with full intention. ANTIPHANES, ARISTOPHON, THEOPHILOS and PHILEMON have written an “Iatros” (see J. M. Epmonns, The Fragments of Attic Comedy, Leiden 1961, vol. II, p. 210, 522, 570 and vol. IIIA p. 20); the famous Roman comedian Praurus wrote a (lost) 40, “"Parasitus Medicus” the source of which was, as usual, a Greek comedy. PRILEMON jr. fr. 3 EDM. (/.c., vol. [IIA p. 253: I quote from Epmonps' charming English translation), 41. 42. 43. 44. 45, 1 wonder if Epmonps is right, here. when translating “demas” as “state-physician”’, For the official Greek terminus technicus for a public physician seems to have been exclusively “demosios” or "demosieuon” (see L. Conn-HAFT, The Public Physicians of Ancient Greece, Northampton/Mass. 1956, where ““demios” is not at all mentioned), In the circumstances, “demios” may eventually mean nothing but a “notorious” man. See in general K. Larre’s rich article “Mord™ (now reprinted in his ““Aleine Schriften”, Miinchen 1967, pp. 380-392). Cf DEMOSTHENES or, XXIII. 22, ArisrotLe “Athenaian politeta” ch. 57 8 3 and LATTE /.c., p. 387. The differentiation between intentional and involuntary homicide was made as early as by Dracon (see LATTE /.c., p. 271 n. 35 and pp. 38211). See R. Pack in: Am. 7. Philol. 69, 300 (1948). The prejudice that the physician is in general to be seen as a potential or actual murderer, can likewise be found in folk 46. 47, literature; cf. St. ‘Tuompson, Motif-Index of Folk-Literature, vol. III, Bloomington! London 1966, p. 427 No. 4581, 4 (a Lithuanian folk tale). See for references K. H. Berow, Der Arzt im Römischen Recht, München 1953, p. 123 (under Ib). 1 cannot feel convinced by EDELSTEIN's rather apodictic argumentation that this paragraph of the “Oath” merely deals with suicide (see EpeLstEIN, Ancient Medicine Le, p. IE). Were this so, the author of the “Oath” could casily have been misunderstood in his formulation as if he, and his colleagues. had felt justified in giving a deadly drug when not asked to do so! Since this makes no good sense, we must, I think, understand “I will neither give a deadly drug to anybody, not even if asked for it” (so, for instance, H. DiLLER understands the Passage in his German translation). The author seems to like this kind of formulation (“I will not use the knife, not even on sufferers from stone”, as EDELSTEIN against others rightly translates and interprets another passage of the “Oath”). Moreover, even the phrase “if asked for it (aitetheis)” need not necessarily refer to suicide, and to it 48. 49. 50. alone; in the circumstances, it could also mean, eventually, that a physician came to be asked to participate in a criminal case (cf. STERTINIUS XENOPHON, above). On the “Oath’s” esoteric character and the problems that are involved in it, see below § 3, Scrin. Larc., Preface ed. DEICHGRÄBER Le., lines 321. and 44f. (p. 24). Edited by R. Forrster, Libanii opera vol. VILL, LetpziG 1915, pp. 182-194,

For this progymnasma and, especially, for the oaths’? mentioned by it, see R. Pack Le., pp. 229-304. As to an old and common fear concerning hellebore, cf. PLINY nat. hist. XXV 47T. Luctanus “The Disinherited” (in: Luciani Samosatensis opera ed. C. Jaconrrz, vol. IT, Leipzig 1913, pp. 85-103). The theme here discussed was obviously a not so rare topic in rhetoric schools (see Seneca Controversiae IV. 5). The oldest corresponding Greek testimony known to me is Heraclitus Ir. B 58 Drers-KrANz (see also EDELSTFIN, Ancient Medicine lc, p. 31 n. 96). See K. LATTE, /.c., p. 283 and the passages from DEMOSTHENES and ARISTOTLE, referred to above n.43. See EDELSTEIN, Ancient Medicine Le., p. 21 n. 55 and p. 30. See EDELSTEIN, Ancient Medicine l.c., pp. 9-20 (for an allegedly old Greek law against abortion, see ibid. p. 16 n. 30). For some more generalised hostile exaggerations against medicine and physicians within early Christianity, see my remarks in Clio Medica 3, 17 n. 19 (1968). Cf. H. Usener, Kleine Schriften vol. IV, Leipzig 1913, p. 231f. Cf. A W. H. Apkins, Lc. p. 102. 61 For the argumentation of the defence, sec Antiphontis orationes et fragmenta, ed. F. Brass, Leipzig 1881, p. 47. 62 63. 64. 65. 66. 67. For the prosecution, see ANTIPHON, L.e., p. SIE “Athenian Homicide Law in the Age of the Orators”, Manchester 1963, p. 7-H. See K. LATTE Le., article ““Mord” passim. esp. p. 391f. (for the Hellenistic epoch). See Prarr’s article ‘“Homicidium” in: Pauly-Wissowa Re VIII 2, 1913, p. 2249. K. -H. BELOW, Der Arzt im Römischen Recht, Miinchen 1953, pp. 122f. SANDULESCU’s remarks on this passage of the lex Aquilia (l.e., p. 366f.) are disqualified by some obvious, and gross errors (confusion of lex Aquilia and lex Acilia; datation in pre-Christian times). 68. See e.g. E. Scuaupt in: Lehrbuch d. gerichtl. Medizin, ed. A. Poxsoup, Stuttgart 1957, p. 46. According to the actual German law, for instance, any manipulation of a physician can eventually be interpreted as a “Tatbestand der Körperverletzung” (§ 226a of the Strafgesetzbuch: see also W. HALLERMANN in: Hefte zur Unfallheilkunde 60, 28 (1959) ). For a discussion of the double aspect of "subjektive Gesinnung” and “‘objektiver Wert” of a physician's treatment in the light of modern philosophical ethics, see F. PAULSEN, System di Ethik vol. I (Sth and 10th ed.) Stuttgart! Berlin 1913, p. 228. 69. 70. 71. 72. 73. 74, 75. 76. See for this my remarks in “Die Sklaven in der griech. Medizin der klassischen u. hellenistischen Zeit”, Wiesbaden 1968 (Forschungen z. antiken Sklaverei Bd. II) p. 331. For a discussion of Jewish privileges as an eventual cause of Graeco-Roman antisemitism, see J. HEINEMANN in: Pauly-MWissowa Rr Suppl. V, 1931, p. 39. See "Ancient Medicine,” Le. pp. 3-63. See for this W. Burkert’s important book "Weisheit u. Wissenschaft’, Erlangen; Nürnberg 1962. “Tractatus de philosophia medici sive ... Hippocratis Coi liber de honestate, etc, etc”, Gottingae 1740. “Praeceptor meus summa observantia colendus, Laur. Heisterus’’, ibid. p. 228. Or, as it was seen by ancient bio-doxography: Hippocrates himself was said to have been a pupil of such philosophers as Gorgias and Democritus (see ¢.g. SORANUS in: Corp. Med. Graec. IV. p. 175 ed. ILRERG). For J. ScHUMACHER's quite identical standpoint see his "Antike Medizin". Berlin 1940, pp. 46. and SI ff. 77. Sec also the late J. Scrumacner’s last book “Die Anfänge abendländischer Medizin in der griechischen Antike”, Stuttgart 1965 (with a foreword of his like-minded colleague W. LEIBRRAND).

78. 79. 80. 81. 82. 83. 84, 85. 86. 87. 88. Sec. e.g. Ancient Medicine, l.c., p. 14f. Burkert, l.c., p. 273 n. 104, Cf. S. REINACH in: Archiv für Religionswissenschaft 9, 318(T. (1906). See EDELSTEIN, Ancient Medicine, l.c., p. 21 n.51; for the highly disputable value of FRANK's contributions to Pythagoras and Pythagoreism, sce BURKERT, /.c., p. 7. The most general (and most medical, of course) background of this paragraph is briefly mentioned by Burkert (l.c. p. 273 n. 104): “Der Arzt als Wahrer des Lebens darf den Tod nicht férdern”. See M. Nirsson, Geschichte der griech. Religion, vol. II?, München 1961, p.130 (40 days as a fixed time of strict seclusion, for related women). Presumably, this rule has very old, and primitive, roots (cf. J. G. Frazer, The Golden Bough;abr. ed. London 1963, p. 275). Edited and commented by O. WEINREICH, Stiftungen u. Kultsatzungen eines Privatheiligtums in Philadelphia in Lydien, Sitzungsberichte Akademie Heidelberg 1919. he, p. 291. See EDELSTEIN, /.c., p. 37. See ZIEBARTH in: Pauly-Wissowa Realencyclopddie etc., vol. V 2, 1905. p. 2080. One may compare, for this, the proverbial sayings of some of the so-called ‘7 Wise Men”, e.g. Cheilon (cf. Diogenes Laertius 1 3, 69) or Periander (ibid. I 7, 98). 89, 90. See Hesion’s * Works and Days” v. 337 (where “katharos” is fully identical with “hosios’’). See Burkert, /.c., p. 163 with n. 11) {in BURKERT's opinion, EDELSTEIN, /.c., pp. 42fT. overstates, when reminding exclusively of the Pythagorean ‘‘father’’-relations). 91. 92, See. e.g. PoLAND in: Pauly-Wissowa RE vol. IV A 2, 1932, p. 1434, 31M See e.g. STEINWENTER in: Pauly- Wissowa RE vol. X 1, 1918, p. 1253f. with further references, ILıap, 11, 514, 94. 95. 96. 97, 98. 99, 100, We do not think, here, of the highly different type of “iatromantis” who was doubtless, in any case, in a peculiar social situation. For Homeric values, see Ankıns, Le., chs. I-III. See ApKINS, /.c., p. 48f. See E. R. Dopps. The Greek and the Irrational, Berkeley/Los Angeles 1964, p. 26 n. 109. For Archilochus, as an example, see H. FRANKEL, Dichtung u. Philosophie des frühen Griechentums, New York 1951, pp. 189fT. As, for instance, at the end of the 6th century Theognis (esp. v. 233f. of his poem) who felt himself as an aristocrat (I would be cautious to identify, in this connection, aristocracy with middle class as FRANKEL does, /.c., p. 536). See “Ancient Medicine‘ p. 87. Some 30 years later, EnELSTEIN’s opinion appears essentially unchanged but, on the other hand, revised in some degree (cf. ‘Ancient Medicine” p. 385f. where it is stated that the physician's social status was “extremely varying’’). 101. 102. As to these three writings, M. MICHLER has recently discussed the Medical Ethics in Hippocratic Bone Surgery” (in: Bull. Hist. Med. 42, 297-311 (1968)) without commenting on the problems we are interested in here. Sec his pamphlet “Technologie i.d hippokr. Schriften peri diaites oxeon, peri agmon, peri arthron emboles”, Abhandlungen d. Akademie d. Wissenschaften u. d. Literatur Mainz, geistes- u. sozialwiss. Klasse Jg. 1963 n. 14, p. 70 ibid. p. 8). 103. 104. (for sarcasm, see also + For a selection of passages concerning “kalon® and “agathon” and their opposite “aischron’’, taken from the surgical treatises, see EDELSTEIN, Ancient Medicine, pp. 91ff. CT. Fract. 30 (end) where it is said to be “aischron” and “atechnon”’ if one constructs machines without primarily asking for their appropriate effectiveness.

l.c., p. 308 n. 45. See ADKINs, /.c., p. 177 and 235. In a similar way, Art. 70 concedes with some reservedness the use of a generally good method of setting a limb, although this method smells a bit of ‘‘parading” (agonistikon) and ‘‘ostentation’’ (kompseuomenos). Epicurus; see Seneca epist. 29, 10. For this, and for the metaphorical character of PLATO'sS related statements, see my pamphlet “Die Sklaven in der griech. Wiesbaden 1968, § 3. Medizin der klassischen u. hellenistischen Zeit, un on ee 105. 106. 107.