Hippocrates and the Hippocratic Corpus (b. 460 BCE)

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HIPPOCRATES AND THE HIPPOCRATIC CORPUS
(b. 460 BCE)

Hippocrates, who came from the Aegean island of Cos, is said to have been born in 460 BCE. His legendary status as the father of medicine is secure—unfortunately, just about everything else about him is legendary too. Tradition records a number of entertaining stories, but it is plain that later writers in the notoriously unreliable Greek biographical tradition knew very little about him. Plato mentions him a couple of times, respectfully, and in Phaedrus (270b–d) ascribes approvingly to him the view that in order to know the parts of something one must know the whole. But there is no consensus even as to what the whole here refers to: The whole of the universe? Or simply the complete structure of the body? Different scholars, taking different lines, have consequently seen this remark as alluding to a variety of quite different treatises of the Hippocratic Corpus, and constructed accounts of the authentic Hippocrates accordingly. The author of the most comprehensive and learned recent account of Hippocrates and Hippocratic medicine, Jacques Jouanna, while noting the disagreements and the pitfalls, nonetheless tries to distil some spirit of fact from the mash of the biographical tradition and takes note of some relevant recent inscriptional evidence. But the picture is still obscure and speculative. There almost certainly was (though even here scholars contend) a school of medicine on the island of Cos from the fifth century onward, probably in rivalry with an alternative school at Cnidos on the Anatolian mainland. One of the texts of the Hippocratic Corpus refers to a lost treatise named Cnidian Opinions, and scholars have tried to reconstruct the methodological differences between the schools (the usual, although disputed, suggestion is that Cnidian medicine favored very precise disease classification and a reliance on purgative treatments, and certain texts in the surviving Corpus, notably On Diseases and Internal Affections have been classified as Cnidian on doctrinal grounds). Hippocrates himself was associated with the Coan school, and he may well have traveled elsewhere in Greece, perhaps to Thessaly and Macedonia (doctors of the time were often, although not invariably, itinerant). We need not credit the story, even though it is relatively well attested, that he was forced to leave after maliciously burning the archives of the Cnidian school.

So the pursuit of the historical Hippocrates is largely fruitless. However, there survives under his name a collection of some sixty texts (even this number is disputed since scholars cannot agree as to what constitutes separate treatises)—the Hippocratic Corpus. As has been realized since antiquity, they cannot all be ascribed to the same individual, much less to the historical Hippocrates. They exhibit wide divergences not just in subject matter but also in style and doctrine; and some cannot have been written earlier than the third century BCE (others, such as the fictitious correspondence between Hippocrates and Democritus, are later still). Many, however, clearly belong to the fifth century and as such are among the earliest surviving examples of Greek prose. Some (On Art, On Breaths ) bear the unmistakable stamp of the Sophistic movement and, although containing much of methodological interest, are almost certainly not the work of practicing physicians. Others indubitably are: Some are severely practical and observational in tone (the Epidemics, On Diseases, On Affections ), others are more theoretical (Ancient Medicine, Nature of Man, On Prognosis, On Regimen ). Some address issues of medical ethics although in a fairly pedestrian way: Decorum, The Oath, Precepts. There are treatises on surgery (On Joints, On Fractures, Wounds in the Head ), embryology (On Seed, The Nature of the Child ), and several gynecological texts (Diseases of Women, Sterile Women, Nature of Women ). The remainder of this article will consider, necessarily briefly, some of the more philosophically interesting texts and the topics they raise.

Greek medicine did not arise out of nowhere in the fifth century. The earliest surviving literary products of Greek culture, the Homeric poems, mention both surgery and the administration of various treatments by human rather than divine agents; and there was a medical tradition of immense antiquity in Egypt although it is unclear how early it made any impact on the Hellenic world, if indeed it did at all. Various Presocratic thinkers were also renowned for their healing expertise—in particular, Alcmaeon and Empedocles. But the main innovation of the Hippocratic authors (as they shall now compendiously be referred to) seems to have lain in their desire for systematicity (although the Corpus contains several, evidently incompatible, such systems) and the related drives toward diagnostic precision, prognostic knowledge, and nosological explanation. For the Hippocratics (in general—for reasons by now obvious—no generalization across the entire Corpus, no matter how bland, is secure), medicine is about understanding: understanding the nature of health and disease and the measures needed to maintain the former and cure the latter. And they are, fundamentally, physical phenomena, to be approached from a physical point of view.

In a celebrated treatise on epilepsy and related seizure disorders, The Sacred Disease, the author opens with the following characteristic statement, which might serve as a motto for Hippocratic medicine in general: "Concerning the so-called 'sacred disease,' these are the facts. It seems to me to be in no way more divine or sacred than any other disease, but has a nature and a cause from which it arises, although men think it be something divine because of their inexperience and their wonderment at its dissimilarity with other illnesses" (Sacred Disease 1). The author goes on to castigate as charlatans those who propose religious or magical cures for it, declaring that in spite of its peculiar symptomology, it has a determinate physical cause (excess of phlegm in the brain), which may be countered by means both prophylactic and curative. At the end, he writes:

The so-called sacred disease arises from the same type of cause as the others, from things that enter and leave the body, from cold and heat, and from the winds which constantly change and never rest. All these things are divine, so one should not distinguish this disease as being in any way more divine than the others: all are divine and all human. None is hopeless or untreatable; and most are cured by the same things which cause them.
(Sacred Disease 21)

The latter claim is not to be understood as homeopathic: It is the removal (or counteraction) of the pathogenic substances that produces recovery, and such allopathy is a Hippocratic commonplace ("opposites cure opposites" occurs as a frequent slogan—see, for example, Breaths 1—although it was interpreted in widely different ways). It should also be noted that the author does not reject the claims of divinity altogether—all diseases have an aspect of the divine about them. But crucially, that does not mean that they are not amenable to rational understanding and cure.

Thus, the Hippocratic doctor positions himself in the Presocratic tradition of natural science. Moreover, for many of the authors of the Corpus, a thorough theoretical understanding of the nature of the universe is a prerequisite for understanding, and hence nurturing and curing, the human body. But different authors differ in how far they think such general knowledge should go. Perhaps the most extreme position is that of the author of On Regimen. This is, as the title suggests, a treatise about the ways in which lifestyle (diet, exercise, bathing, etc.) affects health. But it is much else besides (it is also perhaps the most traditionally religious text of the Corpus, advocating prayer as well as more typically Hippocratic types of therapy). But he begins by declaring that "someone who is to deal with human regimen correctly, must first understand and ascertain the general nature of man: understanding his primary constituents and understanding the parts from which he is composed" (Regimen 1.2). The primary constituents turn out to be fire and water, and everything in the universe is in some way an elaboration of these.

Moreover, their ratios of composition and degrees of purity account not only for the generation of other stuffs, but also for the phenomena of mental quickness and retentiveness. Fire is fundamentally motive, water fundamentally nutritive; whereas fire is basically hot and dry, water is cold and wet (although each contains some admixture of the other. The natural world consists of a perpetual fluid interaction between the elements and their properties, and there is no such thing as genuine generation or destruction, only rearrangement, mixture, and separation. So far, late Presocratic—and indeed the author's physical views—seem to be a cento of those of Parmenides, Empedocles, Anaxagoras, and (perhaps predominantly) Heraclitus. The ideal condition of the body is one of attunement of the elements whereas disease is disharmony; and the human body is a microcosm of the structure of the universe as a whole.

All this is obviously schematic and, as such, offers no practical clue as to what steps should be taken to combat illness and ill health beyond the bland injunction to cure opposites with opposites or to suppress the pathogenic influences. There is no consensus in the Corpus as to what the basic elements are: Nature of Man (incidentally the one treatise in the Corpus of which authorship is relatively certain: It was composed, at least in part, by Hippocrates' son-in-law, Polybus) rejects the view that the doctors should offer accounts on the human constitution in terms of any of the so-called elements—air, fire, water, or earth—"or anything else that is not clearly a constituent of the human body" (Nature of Man 1). The author has, in fact, two distinct targets: one is monism, the view that a single underlying stuff could account for all that there is (plurality is needed for variation and change, he argues; and no unique stuff could suffer pain); but the other, as the quoted clause suggests, is excessive reductionism. One should describe the state of the body in terms of the balance or imbalance of the four humors (this treatise is the first in which that celebrated and long-lived doctrine appears in full), blood, phlegm, yellow bile, and black bile, which are (allegedly) observable constituents of the body. (Black bile is a problem—no one is really sure what this was supposed to answer to, and this fact in itself compromises the supposed empiricism of the theory).

Even more uncompromising is the attitude of the author of Ancient Medicine. He argues that "medicine has no need of novel hypotheses" (ch. 1), and rejects philosophical physiology in the manner of Empedocles (ch. 20). The hypotheses in question are that health and disease are the result of balance and imbalance among four fundamental qualities: hot, cold, wet, and dry. Such postulates are useless for medicine, he argues, since the terms either have their ordinary phenomenal senses, in which case changes and imbalances in them do not correlate with health and sickness, or they are arbitrarily specified technical terms, in which case they have no useful empirical content and are simply introduced after the fact to label what are—in the author's view, empirically observable correlations. Thus, it makes sense to categorize foodstuffs in terms of their phenomenal qualities (sweet, sour, salty, etc.) and to relate these to determinable physiological changes; such relations are to be discovered on the basis of long experience (hence the ancient of the title). But anything else is superfluous.

Needless to say, not all Hippocratics agreed. The author of Breaths is quite happy to describe his basic theoretical postulate (that different types of air are fundamentally responsible, along with food and drink, for health and disease) as a hypothesis and, moreover, one that his discourse has vindicated. But that vindication takes the form simply of supplying explanations, of a fairly far-fetched variety, for the incidence of particular illnesses (including apoplexy, epilepsy, and fever) in terms of his favored postulates.

Elsewhere, Hippocratic authors do show themselves to be aware, albeit dimly, of the need to support their explanations with empirical observation and sometimes even experiments of sorts. But these appeals to evidence are of widely varying quality and plausibility. Thus, the author of Airs, Waters, Places, a study of the generalized effects of climate and ambient environment on human health and character, holds that "water from snow and ice is always harmful, because once frozen it never recovers its previous quality" (ch. 8). The author thinks that "light, sweet" water is the most healthful, and that freezing drives off this part of it; in support of this claim, he says that if you measure water into a jar and leave it outside overnight to freeze, then melt the water in the morning, "you will find it considerably reduced in quantity." Here the hypothesis is plainly not entailed or, indeed, even supported, by the evidence.

Another strand of the Corpus is more observational and practical. The Epidemics, a disparate collection of general and particular observations of disease, illustrates this well. Epidemics I and III, which are almost certainly from the same pen, consist in general accounts (Constitutions ) of prevailing epidemic diseases classified by season, place, and other general environmental features. Although apparently the products of disinterested observation, the types of general factors noted point to a particular theoretical account of the origin of disease, again involving the imbalance of climatological and environmental factors. Particular incidences of disease are to be explained in terms of the patients' specific conditions and of particular events that occur to them (excessive eating, drinking, sex, exercise, bathing, for example). The implicit idea, once again, is that the occurrence of disease (as well as the maintenance of health) can be given general, naturalistic explanations in terms of the patient's underlying physiological condition and external occasioning events. It is in this two-fold analysis of the structure of physical explanation, in terms of the interrelation between more or less permanent standing conditions and triggering events, that the Hippocratics made their greatest contribution to the development of the concept of physical explanation.

Much else of importance has been passed over—space permits only a passing mention of the development, in such texts as On the Art and Regimen in Acute Diseases, of concern with defending the scientific status of medicine against its detractors: Doctors often fail to cure patients, and patients sometimes recover independently of treatment. These facts do not detract from the art itself: It is no condition of something being a genuine technical skill that it must yield 100 percent success; there are always other factors that can interfere, such as the failure of the patient to follow the prescription; the disease is already too deeply entrenched to be eradicated. Indeed, the author of the influential On Prognosis notes that one of the advantages conferred by prognostic ability is that of knowing which diseases are incurable and being able to leave well alone. Moreover, the fact that some practitioners are charlatans does not mean that they all are. The existence of such defenses as early as the fifth century BCE shows that the practitioners of the infant science of medicine were well aware of the seriousness of the challenge to their claims to expertise and that they were capable of considerable sophistication in rebutting them.

Finally, a number of texts, usually labeled deontological, deal with matters of professional conduct and ethics. The most famous of these, the Oath, still serves as a template for medical codes of conduct. Among its clauses are injunctions to protect the secrecy of medical knowledge, not to infringe on the turf of other professionals (in particular, surgeons), never knowingly to cause harm, and to resist the temptation to abuse one's professional position for sexual purposes. In spite of their pretensions to comprehensive theoretical and practical knowledge, the Hippocratics were aware of their own limitations, knowing that nature was the best hope for a cure in most cases—the job of the physician being to help nature in its healing course.

Bibliography

Hippocrates. Vol. 1, Ancient Medicine, Airs, Waters, Places, Epidemics 1 & 3, The Oath, Precepts, Nutriment. Vol. 2, Prognostic Regimen in Acute Diseases, Sacred Disease, Art, Breaths, Law, Decorum, Physician (Ch. 1), Dentition. Vol. 3, On Wounds in the Head, In the Surgery, On Fractures, On Joints, Mochlicon. Translated by E. T. Withington (1923). Vol. 4, Nature of Man, Regimen in Health, Humours, Aphorisms, Regimen 1—3, Dreams; Heracleitus: On the Universe. Translated by W. H. S. Jones (1923—1931). Vol. 5, Affections. Diseases 1, Diseases 2. Vol. 6, Diseases 3, Internal Affections, Regimen in Acute Diseases. Vol. 7, Epidemics 2, 4—7. Translated by Wesley D. Smith (1994). Vol. 8, Places in Man, General Nature of Glands, Fleshes, Prorrhetic 1—2, Physician. Translated by Paul Potter (1988—1995). Loeb Classical Library. Cambridge MA: Harvard University Press, 1923—1995.