HIPPOCRATIC THEORIES

When the Anonymus Londinensis papyrus was first published, in 1893, it created a considerable stir because it contradicted what had for centuries been the traditional understanding of Hippocratic medicine.1 The immediate debate centred largely upon the so-called Hippocratic question, the identification of the source or sources of the ideas attributed in the papyrus to the historical Hippocrates, and upon the authorship, and by implication the reliability, of the doxographical sections that the anonymous author had taken over from Aristotle.2 Less attention was given to the actual theories described in the papyrus, despite the fact that many of the authors named in it were previously unknown. That many of them flourished in the first half of the fourth century was a further reason to omit them from consideration in a study of Hippocratic medicine in the fifth. This excuse for neglect becomes less cogent, however, when one examines the Hippocratic Corpus as a whole (since many of the texts contained therein are likely also to come from the fourth century), and it is certainly out of place in any study of Greek medicine in general. The Aristotelian section of the papyrus opens with the unequivocal statement, probably by the writer himself, that there has been a considerable disagreement (stasis) over just what causes disease. Some believe that diseases result from residues, whether produced pathologically or as natural bodily secretions; others from changes in the body’s elements.3 Although this emphasis on disagreement may simply be an heuristic device to assist in classification and can be found in many similar ancient lists of philosophical and medical doctrines, there can be no doubt that both here and in the Hippocratic Corpus is to be found a variety of competing solutions to the same question: what is disease or illness?4 Yet it is also clear that there are many similarities between all the authors, whatever their theories and wherever and whenever they were active. All provide entirely natural explanations for disease and assume that whatever cause they have identified is a universal cause, applicable to all or most conditions. Some authors thought in terms of more than one cause: Ninyas distinguished congenital from non-congenital conditions, while stressing the effects of harmful residues produced from

nutriment; Philistion held that there were three general causes, an imbalance between the body’s elements, a failure of the body to function properly and external factors such as woundings, excessive heat or cold, and bad food.5 But, whether single or multiple, these causes have a universal application, and can explain all types of disease. Philosophers and doctors can be found on both sides of the Aristotelian division. Although those who attribute disease to residues, where they can be identified, tend to be doctors and those who believe in elements are mostly philosophers, this is not invariably so; nor can one make a sharp division between the two groups in terms of the level of abstraction of their theories. All pay close attention to natural phenomena, even if they interpret the relationship between the same phenomena differently. For Timotheus of Metapontum, as for the author of The Sacred Disease, some diseases arise in the head through the blockage of various passages, and the running nose and streaming eyes of the common cold are the body’s natural way of unblocking them.6 But for Aias it is the purging itself that is the cause of illness; the fewer the outflows, the healthier the patient.7 In a similar reversal of the chain of cause and effect, Petron (or Petronas) of Aegina in the first half of the fourth century held that bile was produced only when the body was diseased, and thus was not, as most people believed, itself the cause of many diseases.8 Other authors seem consciously to have modified the views of their predecessors. Euryphon of Cnidus, perhaps the earliest of those named, living around 450 BC, claimed that diseases were the result of residues left when the belly was unable to rid itself of all the food it had taken.9 His contemporary, Herodicus of Cnidus, while accepting the theory of residues, denied that it had anything to do with the body’s ability to evacuate, and claimed instead that the residues occurred because of a lack of exercise, with the result that food remained undigested until it turned into two forms of harmful liquid. Diseases differed according to the type of liquid involved and the site to which it flowed.10 A similar interest in diseases and their potential variety is ascribed to the even earlier authors of the Cnidian Sentences by the writer of Regimen in Acute Diseases, and by Galen in his commentary on the latter book. Galen suggested that they distinguished seven different sorts of imbalance of bile, twelve kinds of bladder disease, four of kidney disease, four of strangury, three of tetanus, four of jaundice and three of phthisis, a classification that both he and the Hippocratic author felt was too precise, especially when it led the authors to neglect symptoms that would be useful for prognosis.11 Others disagreed, for there are several treatises in the Hippocratic Corpus, notably Diseases 2 and 3 and Internal Affections, that incorporate these or similar subdivisions. The author of Internal Affections, for instance, gives four types of jaundice, four of kidney disease, three of tetanus and three of phthisis.12 Along with the gynaecological treatises, The Nature of Woman, Diseases of Women 1-2, and Diseases of Young Girls, these treatises form a group more interested in the general

description of a disease than in its manifestation in the individual patient. They provide a straightforward listing of the disease, its symptoms, prognosis and therapy, without wider theoretical or professional considerations. Because these treatises follow a similar pattern of arrangement to that criticised by Galen in the Cnidian Sentences and almost certainly drew on them or similar material, they have often been called Cnidian and associated with a medical ‘school’ at Cnidus, although they themselves provide no indication of any origin, author or sources. Whether this attribution can be justified, let alone used as the foundation for constructing a whole series of polarities between so-called Coan and Cnidian medicine (patient centred/disease centred; aetiology/classification; prognosis/diagnosis; organism/organs, etc.), is a matter of vigorous dispute.13 The story of the development of the two groups, or ‘choirs’, of doctors on Cos and Cnidus (see p. 70) is a typical Greek invention to explain the presence of Asclepiads in both places (and their disappearance from Rhodes) and makes no mention of any theoretical differences between them. But the short stretch of water separating Cos from Cnidus was no Berlin Wall. The author of Regimen in Acute Diseases, who, as we have seen, knows and criticises Cnidian material, shows that its usage and influence were not confined to Cnidus itself, or, if he was himself a Cnidian, that there was disagreement among Cnidians themselves. Galen had no difficulty in assuming that Ctesias of Cnidus was familiar with Hippocrates’ work on dislocations, and many texts in the Corpus display both so-called Coan and Cnidian emphases and types of organisation.14 Most modern scholars, therefore, see this neat division between Cos and Cnidus as a creation of earlier historians, ancient as well as modern, projecting back their own conflicts into the past.15 It has some value as a tool for classifying and analysing certain of the texts in the Corpus, but it is of only limited historical worth and may obscure as much as it clarifies the theoretical debates taking place in fifth-and fourth-century Greece. The Hippocratic Corpus contains a multiplicity of theories that resemble in many ways those sketched by Anonymus Londinensis. Breaths endeavours to show that all diseases are the result of air, which has enormous effects within both the individual and the universe as a whole, even when it might not appear at first sight to be the obvious cause, as in haemorrhages and dropsy.16 Places in Man, by contrast, comes close to the theory of Herodicus of Cnidus in its stress on the importance of seven types of flux originating in the head and causing illness at the point where they happen to settle.17 In The Nature of Man, as we have already seen, can be found the theory of the four humours ascribed in the papyrus to Polybus, whose insistence on health as a form of balance is shared with many of the authors of other treatises. Explicitly or implicitly, all the writers within the Corpus acknowledge that their topics can be explained on the same principles as the rest of natural creation, of which mankind is but one part.18 When dealing with a dislocated forearm, one should endeavour to set it in a straight line, for this is its

‘most just nature’; stretching out one’s arm straight is something that one is ‘compelled by the justice of nature’ to do.19 The author of Ancient Medicine insists that one can best learn about nature from the human body, while that of Regimen devotes its first book almost entirely to a discussion of the way in which mankind, like the rest of nature, is the product of the interaction of the two primordial substances, fire and water. Without this understanding of the body, it is claimed, any attempt at providing a suitable regimen is bound to fail.20 Fleshes, similarly, begins with the need to relate the genesis of mankind to the genesis of the whole cosmos, but chooses a different pair of basic substances, the fatty and the glutinous.21 That this correspondence between microcosm and macrocosm, to use later terminology, should not invariably be seen in narrowly physiological terms is also made clear at the end of this treatise, where the author explains the importance of the number 7 in the creation and development of the human body.22 Similar cosmological and numerological speculations appear in Sevens, a tract with parallels in Ancient Near-Eastern literature, which has been variously dated between the late sixth/early fifth century BC and the first century of the Christian era.23 The specific phenomena of the natural world are regarded as strongly influencing the health and disease of the human body.24 The author of Regimen declares it necessary for the doctor to become familiar not only with the constitution of his patient but also with the seasons of the year, the winds, the weather, the geographical region, the rising and setting of the sun and, indeed, the whole cosmos, ‘from which arise diseases for men’.25 Airs, Waters and Places is the most celebrated example of this geographical or meteorological medicine, although its author has a vastly different understanding of the make-up of the human body from that of Regimen.26 In this treatise the travelling doctor is instructed on how to predict the sort of diseases he will find in any locality from its geographical and climatological situation. The inhabitants of a north-facing city, with cold winds and generally hard water, will be vigorous and lean, and any constriction affect the lower abdomen more than the chest. They will suffer, among other things, from pleurisy, eye inflammations and acute diseases: younger men will experience violent nosebleeds in summer; women may become barren because of the water and find both menstruation and childbirth difficult. After giving birth they will often suffer from phthisis, and their young boys from dropsy of the testicles.27 This geographical determinism explains both physical conditions, for example the flabby white bodies of the inhabitants of S. Russia, and mental states. According to the author of The Sacred Disease, purely physical causes produce not only such pathological conditions as mania and epilepsy, the result of an excess of bile and phlegm, respectively, but also general psychological traits.28 The pleasant situation of the inhabitants of Asia, living in an equable, well-tempered climate, neither too hot nor too cold, in a land where crops and animals flourish abundantly, means they lack courage and energy. Their life is just too easy, and this, in turn, accounts for their subjection to kings.