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.



Back to the Asclepion