The Asclepion
Prof. Nancy Demand, Indiana University
- Bloomington
Overview of Hippocratic Epidemics
The treatise Epidemics consists of seven
books which record the observations made by their doctor-authors
during the course of their travels as itinerant physicians in
northern Greece -- Thessaly, Thrace, and the island of Thasos
-- at the end of the fifth and in the first half of the fourth
centuries. The meaning of the title, "Epidemics," is
ambiguous; it could mean either "of the people (demos),"
or "sojourning in a place (deme)"; thus its subject
could be either the illnesses occurring in a given place and
time, or the doctor's visits in an area. The non-Athenian context,
in addition to the fact that these cases are, at least in origin,
non-literary texts, makes them especially valuable as sources
for social history, since much of our other evidence is thoroughly
Athenocentric and literary.
In addition to the case histories, each
book of the Epidemics contains two other types of material: constitutions
and generalizations (aphorisms, prognostic indications, lists
of things to consider, various notes). The constitutions are
summary accounts of the climatic conditions and the illnesses
encountered by the doctor in a particular locality over a specific
period of time, usually a year. These were probably derived by
generalization from the doctor's notes in case histories, but
only in a few instances can a patient named in a constitution
be identified with one in a case history. (One such patient is
Philiscus, who is mentioned by name in the third constitution
of Book I and discussed in detail in the first case history.)
The constitutions are sometimes carefully crafted literary pieces,
which suggests that they were intended for publication, either
to students or to the general public. This impression is reinforced
by their similarity to Thucydides' description of the plague
in his history of the Peloponnesian War, (Thuc. 2.47-54; Thucydides
spent a long exile in the north where he would have had ample
opportunity to come into contact with Hippocratic doctors,) and
by the presence in the Hippocratic collection of other treatises
in which the doctor-author directs his efforts at a lay audience.
The first childbirth case referred to in
the Epidemics occurs in one of the constitutions of Book I in
a passage that gives a good general idea of the style of the
constitutions: (Hipp Epid. I 8, tr. Jones.)
"Though many women fell ill, they
were fewer than the men and less frequently died. But the great
majority had difficult childbirth, and after giving birth they
would fall ill, and these especially died, as did the daughter
of Telebulus on the sixth day after delivery. Now menstruation
appeared during the fevers in most cases, and with many maidens
it occurred then for the first time. Some bled from the nose.
Sometimes both epistaxis (nosebleed) and menstruation appeared
together; for example, the maiden daughter of Daitharses had
her first menstruation during fever and also a violent discharge
from the nose. I know of no woman who died if any of these symptoms
showed themselves properly, but all to my knowledge had abortions
if they chanced to fall ill when with child.
Each book of the Epidemics has its own
idiosyncratic character, and on the basis of these differences
scholars have noted "family resemblances" between books
that have allowed them to define and date three main groups of
books: I and III, dated 410-400; II, IV, and VI, dated 400-375;
and V and VI, dated 375/360-350.
Books I and III of the Epidemics stand
out from the other books in their polished form. They contain
four complete and finished constitutions (three in Book I, and
one in Book III), whose conclusions contain the sole aphoristic
material in these books. The case histories, of which Book I
contains four- teen and Book III two sets of twelve and sixteen,
are organized chronologically according to the days of the illness.
They consist mostly of lists of symptoms; only rarely is allusion
made to treatment, and then only when it elicits symptoms useful
in prognosis. Books I and III have been the most admired books
of the Epidemics from antiquity, and scholars agree that they
form a single work that is the oldest part of the treatise, dating
to ca. 410- 400. They appear as representative of the Epidemics
in most modern selections from the Hippocratic treatises, yet,
from the standpoint of narrative interest, as sources for social
history, and as evidence for the development of medical thinking,
the other books are an equally valuable resource.
Books II, IV, and VI were grouped together
from antiquity and attributed to Thessalus, the son of Hippocrates,
who was said by Galen (7.854) to have edited and published them
from notes made by his father. Thus ancient scholars gave them
the status of Hippocratic at one remove. Book II contains 24
brief cases that give the impression of being rough notes taken
at the bedside; it also contains four fragmentary constitutions,
none as thoroughly worked out as those of I-III. The main interest
of the author seems to have been in medical theory and treatment,
which he presents in the form of general statements that are
not incorporated into either the constitutions or the cases.
The book includes a miscellaneous chapter devoted to gynecological
information as well as several other chapters dealing with gynecological
conditions and the development of the fetus. It has the highest
percentage of female patients (55%) of any of the books of the
Epidemics.
Book VI shares many characteristics with
Book II. It too contains only a few case histories, 19 in all,
and, like Book II, it gives a good deal of attention to didactic
theoretical expositions and to treatment. In contrast to Book
II, however, only 32% of its patients are female, and there is
only one pregnancy-related case. Book VI is probably best known
for the constitution usually called "the Cough of Perinthus,"
which is the product of an accomplished literary writer. The
philosophical allusions that characterize this book suggest that
its author was highly educated: some aphorisms bear a stylistic
resemblance to the work of the philosopher Heraclitus, while
a methodological statement (Epid.VI 3.12) is reminiscent of the
method of Collection and Division propounded by Plato, who was
probably a contemporary of the author (Plato. Sophist. 253bff.;
Politicus 260eff.; Phaedrus 263bff.) A. Nikitas, who has done
a detailed study of II-IV-VI, has suggested that the author of
II and VI had a fundamentally didactic aim; these books might
even have served as lecture notes for a medical course. Wesley
Smith stresses the author's active, invasive approach to treatment:
if nature makes a mistake, the doctor must intervene.
In contrast to Books II and VI, the third
member of this middle group, Book IV, has few aphoristic or theoretical
passages but reports on a large number -- over 90 -- cases, with
many chapters including multiple cases. The book contains two
constitutions that make numerous references to individual patients;
neither is a polished literary piece. When theory appears in
IV, it is modest and often placed within the case histories,
a procedure unique to this book. In general, the book lacks the
attention to therapy and diet, and the didactic tone, which are
characteristic of Books II and VI.
The differences between IV and II-VI suggest
that two authors were responsible for these books. Nikitas, who
characterizes the author of II-VI as a well-educated medical
theorist, probably a professor, assigns IV to a slightly later
author. He describes him as a practical, working physician who
had long been active in the area and had many patients, some
of whom he visited several times; in some families he seems to
have functioned as a sort of "house physician." Nikitas'
study of the names and relationships of the patients involved
in these three books demonstrates that they all belonged to a
single generation, which he placed in the first quarter of the
fourth century.
Books V and VII have also been grouped
together since antiquity and their close interconnection is marked
by considerable overlapping of material. Even in antiquity these
books were considered to be post-Hippocratic: Galen remarked
that everyone agreed that VII was spurious. V.Langholf analyzed
V into three parts: the first part, A, consists of 31 case histories
and appears to be the record of a doctor traveling from the Peloponnesus
through Athens to Thessaly and Thrace. The second part, B, consisting
of chapters 32-50, is clearly different in content and style
from A but similar to the third part, C, which consists of chapters
51-106. All of the chapters in part C, with the single exception
of chapter 86, also appear in Book VII, but in a different order,
sometimes with minor changes in language, and sometimes augmented.
Langholf argued that the two versions of C derived independently
from a common source, which he identified as the archives of
the Hippocratic school on the island of Cos. Modern scholars
agree that V-VII are later than II-IV-VI and date them between
375 and 350. In particular, the fact that three of the patients
were identified as residents of the city of Olynthus requires
a date before 348, when that city was totally destroyed.
Books V and VII both contain relatively
large numbers of cases. Each of the fifty chapters included in
VA-B describes a case. The chapters of VC contain, in addition
to cases, a few general comments on treatment, and two mini-constitutions.
Book VII contains 82 cases not included in Book V. Both V and
VII pay special attention to treatment; prognosis appears to
have fallen into the background, and numbered days have lost
some of their fascination. On the other hand, narrative interest
is higher in these books than in the earlier ones, and the writer
is attracted to unusual cases. For example, V 86 (the only case
in VC without a parallel in VII) recounts the illness of a young
man who overindulged in wine, fell asleep on his back in a tent,
found a snake in his mouth, bit it, and, seized with pain and
convulsions, died. This case (except for its unfortunate conclusion)
bears a striking resemblance to the procedure of dormition cure
used in the temples of Asclepius: patients slept overnight in
the temple and during their dreams they were visited by the god
who either prescribed for them or treated them; sometimes the
companions of the god, a snake or dog, healed the patient by
licking. Was the story of V 86 perhaps intended to suggest that
those who resorted to the god Asclepius and his snake for a cure
might find death instead? Perhaps, but if we consider it in the
context of some of the other cases in V-VII, it seems rather
to be a case of inversion, possibly reflecting further influence
of the philosopher Heraclitus, which we first noted in Book VI,
where it was limited to aphoristic style.
The other cases that exhibit the trait
of inversion follow a pattern in which the same object has opposite
effects, as illustrated by the Heraclitean dictum: The bow is
both life (bios = life) and death (bios = bow) (Heraclitus, DK
22 B48.). For example, in V 9, the case of the man who found
a cure for itching in the baths at Melos, and then died of hydropsy,
the same element, water, was both life/cure and death; and in
V 74/VII 36, the patient was a ship's cargo director for whom
an anchor, an instrument of life/livelihood, became an instrument
of death.
Still another of these odd cases seems
to involve a mocking or inversion of taboos: VII 78, the man
who urinated into the sea as part of a cure. Among the numerous
admonitions in Hesiod's Works and Days are two that involve the
pollution of water by urination: one forbids urinating into a
stream that flows into the sea, and the other forbids urinating
into a spring.
An interesting point is the number of cases
in which baths are indicted as the cause of illness: VII 11,
chill after bath; VII 24, relapse after bath; VII 50, fever after
warming in vapor bath; and V 9, the fatal baths of Melos. (On
the other hand, in VII 102, a patient was saved because she vomited
up a poisonous mushroom in the bath.) The author of Sacred Disease,
in his condemnation of the religious charlatans who interpret
epilepsy as divine possession, says that a prohibition on baths
is part of their treatment. It was also a Heraclitean dictum
that it is death for the soul to become wet (Heraclitus, DK 22
B36, B77, B117, B118). On a more pedestrian level, however, these
cases documenting the deleterious effects of baths may simply
indicate experience with malarial relapses brought on by a chill
suffered during bathing.
Finally, a possible incursion of magic
appears in V 25, in which a woman, barren all her life, at the
age of 60 suffered labor-like pains after eating raw leaks; she
was cured when another woman extracted a stone from the mouth
of her womb. While probably reflecting the results of dietary
indiscretion, this odd story fits the pattern of shamanistic
cure by the removal of a foreign object. (A student has suggested
that perhaps the stone was being used as a IUD.) Whatever the
explanation, the case typifies the womb-centered approach that
is apparent in the later books of the Epidemics.
An especially interesting feature of the
case histories in the later two groups of books is the frequency
with which medical mistakes are acknowledged. This is most noteworthy
in Book V, whose author reports over-strong or ill-timed purgatives,
badly done cauterization, inadequate or late trepanning, and
the application of irritating medicine to a wound. One of these
unfortunate cases involved a pregnant woman who died as a result
of an over- dose of a purgative (V 18). Most of these references
to mistakes appear in VA, although one occurs in VB, and one
in VC, and thus also in Book VII. F.Robert has argued that these
critical comments, some of which appear to refer to the acts
of others, reveal that their author worked as a member of a medical
team. Robert also identified three passages in Book VII that
do not appear in Book V in which the form of expression (but
not explicit criticism of mistakes) suggests a group-practice.
Similarly, the author of Book VI (2.15) criticizes the treatment
of a patient who was given an emetic when a steam bath was called
for, and Smith sees this as evidence that he was working in a
community of doctors. Again, the author of II 1.7 criticizes
the treatment given in IV 26 to the niece of Temenes, who had
an insufficient apostasis to the thumb after suffering fever
and a distended hypochondrium -- the doctor remarks that did
not know if she was also pregnant. The mistake was fatal.
Conclusion
We have seen that the books of the Epidemics
form a series that covers the period between 410 and 350 and
that they have at least three different authors, and probably
more. The earlier books are more rigorously prognostic, with
few indications of treatment and a strict concentration on the
description of symptoms. In the later books the course of the
illness is less often followed in detail and indications of treatment
are more frequent. Interest in theory in the different books
varies probably more in accordance with the interests of the
individual authors than in accordance with any general shift
in direction over time, but there does seem to be an increase
in Heraclitean thinking and possibly even the appearance of shamanistic
practices in the latest books. Given these differences, we can
expect that these variations may reflect changes in the thinking
of the society as a whole over this period of time, as well as
changes in medical thinking and practice.
References referred to:
Langholf, V. "Die parallelen Texte
in Epidemien V und VII, Corpus Hippocraticum. Actes du Colloque
Hippocratique de Mons" (22-26 septembre 1975), Mons,
Universite de Mons, 264-74, 1977.
Nikitas, A. Untersuchungen zu den Epidemienbuchern
II IV VI des Corpus Hippocraticum, dissertation, Hamburg,
1968.
Robert, F. "Medecine d'équipe
dans les Épidemies V," Die hippokratischen Epidemien.
Theorie - Praxis - Tradition. Verhandlungen des V Colloque
international Hippocratique., Stuttgart, 1989.
Smith, Wesley D. "Generic form in
Epidemics I to VII," in Die Hippokratischen Epidemien:
Theorie - Praxis - Tradition. Verhandlungen des V Colloque
International Hippocratique, eds. G.Badder and R.Winau, Stuttgart,
1989: 144-58.
