The Asclepion
Prof. Nancy Demand, Indiana University
- Bloomington
Foundations Of Hippocratic Medicine
THE DOCTORS AND THE PRESOCRATIC PHILOSOPHERS
In order to give their
new ideas a firmer foundation, and to be persuasive to their
patients, many of the writers of the Hippocratic treatises turned
to the writings of the Presocratic philosophers, men who sought
to explain the nature of the cosmos and the things in it in terms
of natural entities and non-personal forces (today we would call
these men natural scientists). Other Hippocratic writers
vehemently opposed this trend, holding to what they saw as an
uncompromising empiricism, based solely on experience, not on
theory. Their debate underlies many of the Hippocratic treatises,
influencing not only content but also the form of argumentation,
which makes it important to consider this philosophical background
briefly.
In the following discussion, the fragments of the Presocratics
are translated from the Greek text found in the standard source,
H.Diels and W.Kranz, Die Fragmente der Vorsokratiker, 6th edition,
1954, and identified with their Diels-Kranz number, abbreviated
as DK). A useful source book for further background is G.S.Kirk,
J.E.Raven and M. Schofield, The Presocratic Philosophers, 1983.
Thales of Miletus
According to tradition, Thales, a native of the Ionian east
Greek city of Miletus (in modern Turkey), was the first of the
Presocratic philosophers. Miletus was a large and cosmopolitan
city, with long-standing trading connections with the states
of the ancient Near East. He himself was probably of mixed ancestry
(his family is said to have been originally Phoenician, and,
like many Ionians, he probably also had an admixture of local
Carians in his family tree). He is reported to have assisted
the Lydian king Croesus in his war against the Persians, and
predicted an eclipse that put an end to a great battle in 585.
Thus he was probably active not much before the beginning of
the seventh century.
None of Thales' own writings have survived, but later writers
say that he held that the earth floats on water, which is in
some way the source of all other things. This may reflect
Egyptian and other Near Eastern influences (Kirk, Raven and Schofield, 92). Since
our reports of his work come from a later period, it is possible
that the idea of water as a source of all things was anachronistic,
reflecting directions taken by later philosophers. Nonetheless,
it seems reasonable to suppose that Thales' was, as tradition
holds, the first of these innovative thinkers who sought a new
way of explaining the cosmos in natural terms.
Anaximander of Miletus
Anaxamander of Miletus was said to have
been the pupil of Thales. If Thales in fact predicted the
eclipse of 585, his pupil must have lived in the mid-sixth century
(the presumption of a pupil-teacher series of philosophers was
the basis of the ancient dating of their lives, which thus remains
very uncertain). He is the first of the Presocratics whose
own words we have:
1. "The beginning of all things was
the Apeiron [the unlimited, unbounded, undefined] ...
from which coming-to-be was for all things, and their destruction
was of necessity into the same. For they suffer punishment and
make reparation to each other for injustice according to the
order of time." (B1 DK)
2. "For this (the nature of the Apeiron)
is everlasting and undying." (B2 DK).
3. A sort of evolutionary process was involved:
"living creatures came to be from moisture evaporated by
the sun. Man was like another creature, a fish, in the beginning."
(Frag. 11.6 DK)
Existing things were formed by a separation
off from an undefined, undifferentiated being (the Apeiron),
and over the course of time were balanced out so that no one
form of being came to dominate the others, but all were bound
to take their turns by a sort of natural justice. Anaximander's
conception of a cosmic balance operating over time expressed
an idea that was fundamental in the development of Greek medicine: human
beings are a part of the natural world, and the natural world
tends toward a balance.
Anaximenes of Miletus
The third of the Milesian monists (proponents
of one elementary substance) was Anaximenes, who is traditionally
considered to have been a pupil of Anaximander. He identified
the unlimited substance (the Apeiron of Anaximander) as
Aer/Air. He provided an analogical argument:
1. "Just as our soul, being air, holds
us together, so also breath (pneuma) and air encompass the whole
cosmos." (B2 DK).
Anaximenes' views were described by the
second-century Roman church commentator Hippolytus:
2. "Anaximenes said that limitless
(apeiron ) Aer (air) was the Arche (first
principle), from which arise the things that are, and those that
were, and those that will be, and gods and goddesses, and the
rest arises from these. The form of Aer is the following:
whenever it is most uniform it is invisible to the sight, but
it is revealed by cold, heat, moisture, and movement. It
is always moving, for nothing that changes changes if it is not
moved. Through becoming denser or rarer, it becomes different.
For whenever it is changed into the rarer, it becomes fire; when
condensed, it becomes winds; when condensed further (felted),
it becomes clouds; becoming yet more condensed, it changes into
water; and still more, earth; and, when thickest of all, stone. So
that the most effective elements of generation are opposites,
cold and hot." (B7 DK)
In the fifth century, the theory of Aer
seems to have become rather popular. Another philosopher,
Diogenes of Apollonia, adopted it as his first principle (see
below), and it is attributed to the character representing the
philosopher Socrates in Aristophanes' comedy, the Clouds. The
author of the Hippocratic treatise, On Breaths, also adopted
the Aer theory.
Heraclitus of Ephesus
Another Ionian philosopher whose ideas influenced the Hippocratic
writers was Heraclitus, a native of the city of Ephesus, not
far from Miletus. He is sometimes classified as a monist
whose first principle was fire, but it is not clear whether he
meant this to be taken literally or metaphorically. His
style was intentionally enigmatic and obscure, intriguing his
audience by paradoxes and leading them into fresh ways of
thinking. Heraclitus' obscure style found some imitators among
the Hippocratic authors.
1. "Nature loves to hide." (B123 DK) "The lord
to whom belongs the oracle at Delphi neither speaks out nor hides
his meaning, but gives a sign." (B93 DK)
2. "The way up and the way down are one and the same."
(B60 DK)
3. "Sea water is the purest and foulest. For fish it
is drinkable and life-preserving, for men it is undrinable and
deadly." (B61 DK)
4. "It is not possible to step into the same river
twice." (B91 DK)
5. "And good and evil are the same. For doctors, cutting
and burning and torturing sick men in every way, still complain
that they do not receive as much pay as they deserve from the
sick, producing the same things, goods and sicknesses."
(B58 DK)
Some fragments suggest that Heraclitus saw Fire is the first
principle of all things, in much the same way that Anaximenes
saw Aer::
6. "This cosmos is the same for all, neither any of the
gods nor of men made it, but it ever was and is and shall be
everliving Fire, kindled by measures and extinguished by measures."
(B30 DK)
7. "The forms of Fire are, first sea; half of sea is earth,
and half is thunderbolt." (B31 DK)
8. "All things are exchanged for Fire and Fire for
all things, as goods for gold and gold for goods." (B90
DK)
9. "Fire lives the death of Air, and Air the death
of Fire: Water lives the death of earth, and Earth of Water."
(B76 DK)
10. "A man when he is drunk is led by an ungrown boy, stumbling,
not knowing where he is going, having a wet soul." (B117
DK)
11. "A dry soul is the wisest and best." (B118 DK)
Yet fire also encompasses the nature of strife and opposition,
and may be a metaphor to convey the inexpressible nature of the
changing world:
12. "All things come into being by conflict of opposites,
and the sum of things flows like a stream . . . . Of the opposites
that which tends to birth or creation is called war and strife,
and that which tends to destruction by fire is called concord
and peace." (Diogenes Laertes, On the Lives of Philosophers,
4.9.9-12)
Parmenides of Elea and the Problem of Change
Parmenides of Elea, a Greek colony in Southern Italy,
took Monism to its logical conclusion when he argued that only
being could be:
1. "For this is impossible to maintain,
that not-being is" (Fr.7 DK)
2. "It [being] never ever was nor
will it be, since it is now, all together, one, continuous. For
what birth will you find for it? In what way, and from what,
did it grow?" (Fr.8 DK)
3. "Nor is it divided, since it is
all alike; nor is any part of it greater, which would make
it constrained, nor any part stronger, but it all is filled full
of being, the whole of it is continuous: for being draws near
to being." (B8 DK)
Since only being exists, the world of change and difference that
we perceive through the senses must be an illusion, or so Parmenides
held. Others followed his lead, either accepting his arguments
(Zeno, with his paradoxes; Melissus), or finding some way to
accommodate them while still maintaining the reality of the perceived
world of change. The solutions offered all posited a plurality
of Parmenidean beings, each one unchanging and everlasting, by
whose interchange and intermixture the perceptible world could
arise.
Empedocles
Empedocles of Akragas in Sicily was especially important in the
development of medical thinking, in fact, perhaps, because he
himself practiced medicine (but not exactly of the Hippocratic
type). He described the cosmic processes as the operation of
four eternal and unchangeable elements or Roots: earth, air,
water, and fire:
1. "For hear first the four roots of all things: bright
Zeus, and lifegiving Hera, and Hades, and Nestis, who moistens
with her tears the springs of mortals (fire, air, earth and water)."
(B6 DK)
The four elements were brought together and separated in great
cycles of change by the cosmic forces of Love and Strife, thus
alternatively creating and destroying the world that we perceive:
2. "But I tell you another thing: there is no birth of all
mortal beings, nor any end in baneful death, but only mixture
and separation of what is mixed, but mortals call this birth."
(B8 DK)
We see the influence of Parmenidean reasoning in one of his arguments:
3. "All these things are equal and of the same age, and
each gives heed to the privilege of the other, and each has its
own character, and they rule in turn as time revolves. And
in addition to them, nothing comes into being or passes away.
For if they perished utterly, they would no longer be. Why would
this whole cease to be? and from whence would it come? Into what
would it be destroyed, since nothing is empty of these things? But
these things are all there is, and through exchanging places
they become at once different and (yet) continuously alike."
(B 17 DK, 27-35)
Like Anaximander, Empedocles reasoned that the beings of this
world evolved. He posited a sort of "preservation of
the fittest," since things that were brought into contact
in the eternal coming-together and separating-off sometimes didn't
"work":
4. "But many came into being with double faces and double
chests, human-headed ox-creatures, and others again ox-headed
with human bodies, and creatures with male and female natures
mingled, fashioned with unclear parts." (B 61 DK)
Empedocles composed his works in epic meter, which has survived
only in fragments. Most of what has survived belonged to
two poems, On Nature and Purifications, but there are some fragments
of a lost work on medicine, in which we see empirical interests
similar to those of the Hippocratics:
5. "[The heart] is turned in a sea of surging blood, in
which that which is called thought by men exists, for the blood
about the heart is thought for men." (B105 DK)
6. "Thus all things breath in and out; in all things bloodless
pipes of flesh are stretched to the uttermost body, and upon
their openings at the periphery of skin they are pierced through
with close-packed slits so that the blood is kept concealed and
easy-flowing passages are cut for air. Thence whenever smooth
blood rushes down, air bubbles in in a raging swell, and whenever
blood rebounds, air breaths back out again, just as when a child
plays with a klepsydra of shining metal...." (B100 DK)
7. "Empedocles holds that seed coming into a warm womb becomes
male, that into a cold female, and that the cause of heat and
cold is the flow of the menses, being hotter or colder, older
or more recent." (A81 DK)
In Empedocles, however, we see not only a man interested in the
physical workings of the body, but also the charismatic, magical
healer who is condemned by the Hippocratics:
8. "But you will know all the drugs against evils and the
safeguards against age, since for you alone will I accomplish
all this. And you will stop the might of the restless winds ...
and if you wish you will bring back avenging winds in turn. You
will ordain after dark rain a season of drought for men, and
after the hot drought tree-nourishing floods. And you will lead
back from Hades the strength of a dead man." (B111 DK)
9. "... And I am an immortal god to you, no longer mortal.
I go about honored among all, as it fitting, wreathed with fillets
and blooming crowns. And when I come to the flourishing towns,
I am honored by men and by women. And the crowds inquire
where is the path to profit; and some are in need of prophecies,
and others wish to hear words of healing against all sorts of
sicknesses, pierced through for a long time by grievous pains."
(B112 DK)
Anaxagoras of Clazomenae
Another important post-Parmenidean philosopher was Anaxagoras
of Clazomenae in Ionia, who went to Athens along with the army
of Xerxes in 480. He apparently stayed on for thirty years, until
he fell victim to political feuding aimed at the associates of
Pericles and, condemned to death, fled to Lampsacus in Ionia.
Anaxagoras held that the ultimate elements were seeds that contained
a bit of everything that exists (bread, bone, blood, rock, etc.). Since
each thing thus had within itself bits of everything, there was
the potential for change (bread that we eat can become blood
and flesh). The seeds were originally set in motion by Mind,
but they came together in a mechanical sort of way to create
the things of our world.
According to Aristotle, Anaxagoras held that the sperm came only
from the male, and that it determined the sex of the embryo,
the female providing only a place and nurture for its development
(The "incubator theory," also put forward by Apollo
in the Eumenides of Aeschylus, 658ff.). For Anaxagoras, sex was
determined by the origins of the male seed: males came from the
right testes, females from the left. (Aristotle, Generation of
Animals, 763b30-35)
Democrutus of Abdera
Democritus of Abdera in Thrace posited that only indivisible
elements, or atoms (the Greek word means "uncut"),
and the void exist. Atoms have size, shape (including projections
or "hooks" which can connect with other atoms), and
density; they neither come into being nor pass out of existence,
but are forever in constant motion throughout the void. Individual
things are created and pass out of existence by the random collision
and subsequent attachment or separation of various atoms. This
leads to a position of extreme relativism:
1. By convention sweet, by convention bitter, by convention hot,
by convention cold, by convention color; in reality atoms and
the void. (B9 DK, also B125, quoted from Galen).
Democritus also took part in the popular debate about sex-determination,
maintaining that both male and female contributed seed and that
either may determine the sex of the embryo:
2. "The man of Abdera [Democritus] says the differentiation
of female and male is in the womb, not through heat and cold,
but from whichever parent the small part of the sperm which differentiates
the male from the female comes in most strength." (A141
DK)
Diogenes of Apollonia
One of the last of the Presocratic Philosophers, Diogenes
of Apollonia on the Black Sea coast, returned to monism, but
his writings can best be described as eclectic. For example,
for the basic element of his natural philosophy he combined elements
of Anaximenes and Anaxagoras in order to produce the idea that
the universe was made up of all-knowing air. Two of the most
remarkable fragments of Diogenes, however, contain detailed descriptions
of the blood vessels of the human body (B6 DK) and of how air
effects mentality (A19 DK).
Conclusion
Early Greek physicians shared with the Presocratic philosophers
the belief that man was part of the nature world and was subject
to the same laws as the rest of the cosmos. They joined in the
debates of the Presocratics and made use of their work in a number
of rather specific ways. (For instance, the humoral theory which
became the basis of most Hippocratic medicine, was interpreted
in terms of Empedicles' four elements. Both philosophers
and doctors took part in the debate about reproduction.)
Beyond the actual theories set forth by the Presocratics, however,
the early doctors were also influenced by the philosophers' use
of rational thought. Greek physicians influenced by the Presocratics
began to make careful observations of medical problems and to
apply logic to medical treatments. Ultimately, the influence
of the Presocratics encouraged early physicians to employ reason
in order to progressively develop medical knowledge, rather than
resorting to supernatural explanations.
The Sophists
Originally the term "Sophist" could be applied to any
wise man or expert of some craft. By the fifth century BCE, however,
the term became specially attached to itinerant teachers of rhetoric
who traveled from city to city lecturing and educating pupils
for a fee. While the Sophists specialized in persuasive speech,
they also taught many other subjects and claimed to be able to
teach their students how to have the greatest success in life.
Beyond merely lecturing, many of the Sophists composed essays
either explaining or demonstrating some aspect of their teaching.
some of these lectures illustrated how to argue both sides of
a question. Since the Sophists were the preeminent teachers of
the day, many early Greek physicians used these Sophistic
texts as a model when they began to write about their own craft.
As a result, many of the Hippocratic treatises contain elements
of Sophistic argumentation. This influence generally manifests
itself in the text by the Hippocratic writers making use of various
forms of logical arguments, and by imitating the tricks of rhetorical
style (antithesis, rhythm and rhyme, paired and balanced clauses).
Hippocratic Writings
Although Hippocrates of Cos (c.460-380 BCE) is considered
to be the "Father of Medicine" little is known about
him. It is generally accepted that he was roughly a contemporary
of Socrates and was a practicing physician. It also seems likely
that Hippocrates would have been an Asclepiad. The Asclepiads
were members of a guild of physicians which traced its origins
to Asclepius, the god of healing. Tradition also tells us that
Hippocrates was the most famous physician and teacher of medicine
of his time. Over 60 medical treatises that have traditionally
been attributed to him. These treatises are collectively referred
to as the Hippocratic Corpus. Most of these treatises, however,
were not written by Hippocrates himself. In fact, several of
the existent treatises were written well after the life of Hippocrates.
The treatises themselves were written over about a two hundred
year period and range in date from c.510-c.300 BCE, so clearly
one man could not have authored all of them. Although It is likely
that Hippocrates did compose some of the treatises, none of the
60 treatises can positively be attributed to Hippocrates. Therefor
at times they contain conflicting materials and different ideas.
In the main, however, they are similar in looking for natural
explanations and treatments of illness and rejecting sorcery
and magic.
