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 fart, 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)

DEMOCRITUS 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.


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