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HIPPOCRATES.

Born: C. 460 B.C., on Cos, an island in the Aegean Sea

Died: C. 370 B.C., Larissa, in northern Greece

Major Works: Nature of Man, Prognostic, Regimen in Acute Diseases; Airs, Waters, Places; Epidemics I and III

Major Ideas

Diseases have natural origins: They do not arise from divine action; the course of diseases and their critical days can be found from observation and experience.

Good health results from a balance of fluids (humors) in the body; disease results from an imbalance.

The balance of fluids--hence the occurrence of disease-is governed by environmental factors: heat, cold, water, winds; close observation of these factors enables the physician to predict the frequency of disease in any given locality.

Nature itself accomplishes all healing by attempting to blend harmoniously the body's humors; a physician's task is to remove any obstacles to nature's healing action and to foresee the course of the disease.

Little is known about the life of Hippocrates of Cos, the most famous physician of antiquity. In his own lifetime, he was known to Plato as a prominent physician who accepted pupils and wrote books. He is said to have been. the son of a doctor, Heraclides; to have studied with his father, and to have traveled widely in Greece, meeting the contemporary philosophers. Legend elaborated on his career: He saved. Athens from the plague; he was invited by King. Artaxerxes of the Persians to heal a plague that had fallen on his army; he averted an Athenian attack on his home island of Cos by an impassioned plea to the Athenian assembly; during his travels he met the philosopher Democritus and rescued him from .being certified insane. This last story, even if fictional, certainly, symbolizes the close ties between fifth-century medicine and contemporary pre-Socratic philosophy.

About seventy medical treatises attributed to Hippocrates have survived. Unfortunately, no criterion allows us to attribute with certainty any individual treatise to the master himself, although several (particularly Epidemics I and III) show a talent for accurate observation and description and seem to be from the same hand. One would like to believe that these works show Hippocrates at his best. Regimen is mentioned in Plato's Phaedrus and may also be from the master's hand. Difficulties in attributing authorship arise for several reasons: The various treatises expound contradictory theories about the nature of health and disease, and among all these theories it is always difficult to distinguish Hippocrates from his contemporaries and from the more developed theories of later physicians like Galen (second century A.D.), who considered that all developments in medicine were in fact implicit in Hippocrates's work. For the sake of convenience in this survey, I will attribute significant theories and methods to "Hippocrates" or "the Hippocratic physician."

To most readers, the major treatises seem divided into two distinct categories: those like the Epidemics, which report in graphic detail episodes of disease and the specific environment in which they occurred, and the theoretical works (Prognostic, Regimen in Acute Diseases, Nature of Man), which attempt to give the causes for disease. An example of the first sort from Epidemics I:

Philiscus lived near the city wall of Thasos. He took to his bed and the first day he bad an acute fever, sweating, a miserable night. Second day: generally worse ... a calm night. Third day: in the morning and until the middle of the day, he seemed without fever; then in the evening, acute fever, sweating, thirst, black urine; a miserable night... Fourth day: worse, black urine, a better night. Fifth day: around midday, a slight nosebleed; irregular urination with floating particles in suspension ... a miserable night, delirium, extremities cold, brief drowsiness towards dawn, no voice, cold sweats ... He died around the middle of the sixth day. Toward the end, deep, infrequent breathing ... The spleen stuck out ...; cold sweats until the end.

(The unfortunate Philiscus was suffering from a particularly malignant form of malaria.)

These clinical observations have served as models for generations of physicians because of their standard terminology, orderly analytic procedures, and attempt to avoid hasty or a priori judgments. No name is given to Philiscus's disease, not because it had none (the physician would have called it a kausos, an ardent fever), but because the observer does not wish to prejudice the observation by a premature labeling. This starkly phenomenological approach is one of the noteworthy traits of the Epidemics.

In addition to these case histories, the Epidemics presents "constitutions," which describe environmental conditions in a given season at a given locality (generally the north Aegean around 400 B.C.) and the syndromes that followed throughout the entire population. The constitutions attempt to give the data from which the environmental causes of epidemics might be deduced. These sketches were apparently written as generalizations derived from individual clinical histories, as detailed study shows. Indeed, Philiscus's case is cited in the third constitution of Thasos (Epidemics I).

The delightful Airs, Waters, Places also combines acute observation with generalization about the influence of the environment, specifically on the physique and character of the inhabitants of various nations. This treatise asks the physician to evaluate the effects of the seasons, the winds, the quality of the water, and the nature of the soil on the inhabitants of the town he is visiting. If he does this, he will not be ignorant of the prevailing diseases: He will be able to forecast their attacks, will know the remedies in advance, and-last but not least--he will "achieve the greatest triumphs in the practice of his art." This last phrase reveals the conditions under which the itinerant physician practiced, ever in competition with his fellow physicians, not to mention local healers and medicine men. Airs, Waters, Places outlines how each environmental factor, for example, north winds vs. south winds, dry seasons vs. wet seasons, affects the health of cities and regions. In a further sweep of generalizati on, Hippocrates then describes the nature of the various nationalities, Egyptians, Libyans, Scythians, Greeks, and so forth, and attempts to show how the environment of each nation has molded the character of the inhabitants: Asiatics (inhabitants of the Near East) are less warlike than Europeans-and therefore feeble and tyrannized by kings-because of the uniformity and mildness of the seasons in Asia; the Scythians (steppe dwellers of the Ukraine) have a moist and cold nature from the fogs and cold wind of their northern home and they are fat, ruddy, relatively infertile, and so on. The ethnography of Airs, Waters, Places can be compared to passages in the history of the contemporary historian Herodotus, particularly in their common interest in the Scythians.

In contrast to the Epidemics and Airs, Waters, Places, the treatises Prognostic, Regimen in Acute Diseases, and Nature of Man present the theoretical structure for medical practice. Earlier Greek literature portrayed disease as originally external to mankind: Disease, or sudden death not from violence, was symbolized by the arrows of Apollo (in Homer) or by the plagues that flew from Pandora's jar (in Hesiod; both authors seventh to eighth centuries B.C.). In either event, they are not part of the natural order, but are autonomous, striking where they will. In contrast, Hippocrates and all of later Greek medicine considered disease to be a disturbance of man's natural equilibrium. In 500 B.C., Alcmaeon of Croton used a political metaphor: "Health results from equal rights of the qualities, wet, dry, cold, hot, bitter, sweet, etc. A dictatorship among the qualities produces disease." The pre-Socratic philosophers systematized this concept: Empedocles (490-430 B.C.). taught that love and strife brought about o pposite effects on the four elements of life: earth, air, fire, and water. Anaxagoras (500-428 B.C.) taught that the original mixture of things consisted of pairs of opposite qualities wet/dry, hot/cold, light/dark. The Hippocratic physicians applied these theories to health and disease attempting to establish a logical foundation for medicine. Thinkers differed widely in the proposals they offered, but all had in common a preference for reason over authority, experience over tradition. Typical is the statement that begins On the Sacred Disease (sacred disease: epilepsy) "The disease which is called sacred is no more sacred than the rest, but has natural causes."

Hippocrates's explanation for disease was based on the theory of humors: An originally undetermined number of these fluids occur in the human body and they combine with air to create an individual s state of health. A balance of humors produces good health; excessive air, water, or an imbalance of a given humor causes disease. When the humors are proportioned correctly with one another, a person enjoys the most perfect health. Illness arises when one humor is in deficit or excess, or is isolated in the body without being compounded with all the others. In time, the number of humors was reduced to four, although which four remained in doubt. The treatise Diseases names water bile blood and phlegm: water from the spleen bile from the gallbladder, phlegm from the head and blood from the heart. Nature of Man, which best describes humor theory, proposes a new humor in place of water: black bile, causing diseases of the kidneys, spleen, liver, quartan fever, headaches, and epilepsy. Black bile is visible in black feces (from ulcers), and black urine (in the malignant form of malaria experienced by Philiscus). The following table shows the relationships among these humors:


Humor       Element Season
Yellow bile Fire    Summer
Black bile  Earth   Autumn
Phlegm      Water   Winter
Blood       Air     Spring



Combinations        Qualities
Yellow bile + blood    Hot
Yellow + black bile    Dry
Blood + phlegm         Wet
Phlegm + black bile   Cold



The relation of the humors to the four elements and to the four human temperaments--the melancholic, sanguine, bilious, and phlegmatic--is not fully developed in the Hippocratic corpus, but was of great scientific and literary importance in later centuries.

An example: phthisis, or "consumption" (which often means tuberculosis), is said to arise from a flow of excess phlegm from the head to the lungs, where it festers and forms abscesses (masses of pus), which may then be evacuated by coughing or may remain and continue to plague the organism. Note that the concept of contagion, the transmission of disease from one person to another, does not occur in Hippocrates. He considered that epidemics occur because of similar environmental factors affecting all inhabitants at the same time. Since the concept of contagion was so close to the magicoreligious concept of pollution, and since all explicitly magical concepts were rejected by the rational physician, the (to us) obvious occurrence of disease transmission was not noticed.

The remedies mentioned in these treatises (drugs, herbs, exercises, plain living) operate by helping the body counteract the excess humor and restore the natural harmony; this state of harmony is called a "blending," or krasis. The process of restoration was viewed as a "cooking out," or pepsis, by the body of the excess humor. Sudden expulsion of the excess brings a crisis, a sudden turn in the disease; a long cooking-out is a lysis, a slower recovery. The expulsion may take the form of vomiting, sweating, and so forth, or the morbid excess may be isolated in an abscess, tumor, or gangrene. The physician's function is to aid this restoration. Some physicians went to extremes: Herodicus, mentioned by Plato, killed patients by prescribing excessive exercise; for others, "plain living" meant a starvation diet. As often happened in Greek theorizing, a common-sense rule was subjected to pathological overelaboration. Other than explaining the theory behind the restoration process, the Hippocratic treatises give little attention to specific remedies for specific diseases. One must rememb er that the Hippocratic writings do not offer recipes for the everyday healer; they offer theories for the thinking physician. The writers could assume that any healer would know the appropriate remedy for a given case.

In addition to the theory of humors, Hippocrates used a system of critical days to structure his observations: Fevers recur on the odd days or the even days, and a crisis on other than the expected day will probably be fatal. This system of critical days may owe something to Pythagorean numerology, but it also satisfied the scientific impulses of the physician. Just as astronomers or engineers used numbers to solve problems, so too could the physician predict the outcome of disease with numbers. Very important was the reality behind the critical days: The fevers of malaria, the single most important disease in the ancient Mediterranean, recur at two-, three-, and four-day intervals, depending on the strain of the disease. Sufferers from pneumonia, also common, suffer a crisis after a week of fever.

Using the theory of humors and critical days, Hippocrates required the physician to attempt a prognosis, a forecast of the outcome, for all cases presented to him. Successful prognosis--in addition to impressing the client and confounding the physician's rivals--served as the equivalent of the modern diagnosis, since the physician, in order to forecast accurately, must recognize the syndrome in question and classify it by outcome. The correct prognosis, as the touchstone of the skilled physician, was valued for its own sake, even if the prognosis was inevitable death.

The theoretical underpinnings of Hippocratic medicine bave been described. Many treatises in the corpus fall neither in the clinical nor the theoretical categories but instead can be called practical handbooks. These include Anatomy, Nature of Bones, Surgery, and a dozen treatises on childbirth, premature infants, and gynecology. Miscellaneous works include the Oath, today perhaps the best-known work of Hippocrates. It has two parts; the first of which commands the candidate to show gratitude toward the person who taught him the art. The second lists the obligations resting on the physician: (1) do no harm, (2) assist in no suicide, (3) cause no abortion, (4) perform no surgery, (5) maintain professional confidentiality. Several of the provisions are strange, particularly (3) and (4), since abortions and surgery were in fact frequent in antiquity; surgery is mentioned without prejudice in many Hippocratic treatises. Consequently, the Oath has been considered to be of Pythagorean origin, since that sect did p rohibit these actions. In late antiquity the Oath became the standard of medical conduct: Surgery was separated from general medicine, and measures were taken against suicide and abortion. It remained the standard until modern times.

The Hippocratic writings display two characteristics of early scientific texts: The theories are wrong, but the attitude toward research is correct. The theory of humors and the system of critical days were both derived from observations of the medical realities of ancient Greece, then wrongly applied as universal principles. On the other hand, Hippocrates's insistence that (1) there is a natural origin for disease, discoverable by rational investigation, (2) close observation, unprejudiced by a priori theorizing, is necessary for an accurate appreciation of the facts, and (3) environment and health are correlated, made future progress in medicine and the other sciences possible.

Further Reading

Edelstein, Ludwig. Ancient Medicine. Baltimore: John's Hopkins, 1967. A collection of papers by one of the foremost researchers in ancient philosophy and medicine; topics include the role of the physician in ancient society, the origin of the Hippocratic oath and later Greek medicine.

Grmec, Mirko D. Diseases in the Ancient World. Translated by M. and L. Muellner. Baltimore: Johns Hopkins, 1989. Originally published in France as Les maladies a l' aube de la civilisation occidentale (Paris: Payot, 1983), this landmark text studies the medical reality behind the Hippocratic treatises.

Lloyd, G. E. R. The Revolutions of Wisdom. Berkeley: University of California Press, 1987. The first chapter of this text, a study of the transition from myth to quasi-science, discusses Hippocrates and puts him in the pre-Socratic context. Other chapters discuss the position of science, including medicine, in ancient Greece.

Potter, Paul. Short Handbook of Hippocratic Medicine. Quebec: Editions du Sphinx, 1988. An excellent overview of the subject, this text contains short synopses of sixty-eight important Hippocratic treatises, with a list of available translations.

Smith, Wesley D. The Hippocratic Tradition. Ithaca, N.Y.: Cornell University Press, 1979. This study investigates the origin of the Hippocratic corpus and the attitude of later physicians toward Hippocrates, with particular attention to Galen, the chief medical theorist of Roman times.
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Author:RILEY, MARK T.
Publication:Great Thinkers of the Western World
Article Type:Biography
Geographic Code:4EUGR
Date:Jan 1, 1999
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