§2. The Hippocratics
The art of medicine in Greece was originally a traditional skill, especially in surgery and drugs, unwritten and unburdened by theory. However, from the fifth century bce a new medicine appears in the work of the so-called Hippocratics.
Hippocrates is a historical figure, a physician with a school on the island of Cos. He was not, however, the author of the treatises under his name. There are about seventy of these, which probably represent the remains of a library, possibly that of his school at Cos. Many of the treatises are compendia of medical treatments (surgical, pharmaceutical, or dietetic). Medical scholars regard the works on surgery as the best, and in fact the daily practice of a Greek physician (intros') was mostly surgical. Therapeutics were a weak point. For internal disease usually nothing could be done but wait and watch, for which there is at least a dignified name—“expectant medicine.”2Some of the treatises explain the ethics and methods of physicians and their knowledge; others explain the causes of disease. On the Nature of the Child records developmental observations on chicken eggs. Airs, Waters, Places describes an experiment to prove that meltwater loses its lightest part, rendering it insalubrious. Measure an amount of water, let it freeze, then thaw and remeasure. The author says it will be found to be less. The Hippocratic approach to medicine emphasizes prognosis, detecting symptoms and foreseeing their development. Case histories detail the typical course of many diseases, and proffer instructions on examination procedures and the interpretation of symptoms. These authors make no allowance for magic or supernatural causes. Nature acts uniformly, excluding intervention by the gods as a cause of either health or illness. They extol skillful prognosis both as a way to avoid blame for failure, since a physician is not responsible if he foretold the unfavorable outcome, and to bolster the reputation of the art.
The physician who knows and can relate both the past and future of disease will “justly be an object of wonder.”3Hippocratic physicians, meaning doctors who studied at least some of these works, trained in a school of medicine, and whose practice the treatises describe, were a movement that swept through Greece from the latter fifth century. They strove for professional regularity in medicine, establishing standards, and driving out charlatans. They cultivate a professional selfpresentation. A physician has to be accomplished, with a reputation for restoring and repairing the sick and wounded. He has to be competent, and the competence cannot be rhetorical. “It is disgraceful in any art and especially in medicine to make a parade of much trouble, display, and talk, and then do no good.” The physician must be clear in expression and not use jargon. It is “of the greatest importance that anyone speaking about this art should be intelligible to laymen.” Here is the beginning of the demand for verbal clarity usually associated with Francis Bacon and English empiricism two thousand years in the future.4
Hippocratic doctors had a keen sense of their art's difficulty. They had to have faith in the healing power of nature because in many cases they had little else to offer. Their duty was to assist the body to heal itself. They knew theirs to be what Aristotle will call a stochastic art. Good carpenters build good tables, and the work is certain, but a good doctor can still lose a patient. If you crave certainty do not become a doctor. The famous Hippocratic aphorism reads, “Life is short, art long, opportunity elusive, experience (peira) treacherous, judgment difficult.” The sentiment is restated in their texts, where it merges with ideas from pre-Socratic philosophy: for instance in Ancient Medicine, which argues that medical knowledge is not easily won. Necessity compelled medicine into existence (probably a thesis from Democritus); gradually much has been learned, and with continued effort the knowledge can be expected to advance (Xenophanes and again Democritus).5
The dedication to progress in medical knowledge was contrary to the rationalism prevailing in philosophy, and again foreshadows modern empiricism.
The distinguishing mark of technical medicine and what justifies its description as a techne is methodological accountability, which one does not find in the cult of Asclepius. Hippocratic authors and practitioners argue among themselves about why a therapy should or should not be adopted, and expect a doctor's dedication to inquiry and the advance of the art. No less than healing, this medicine is an art of searching and discovery. The same Ancient Medicine extolls research to enhance knowledge of human nature (phusis) by the observation of medical phenomena and the investigation of causes. That is medicine’s “ancient method,” to which the treatise attributes all the medical discoveries of the past and confidently expects more, adhering to the ancient way and not heeding the reckless rationalism of innovators, who are peremptorily dismissed. “I am not going to claim that man is all air, or fire, or water, or earth, or in fact anything, except what his body is obviously composed of: Let those discuss such matters who want to.”6Empirical research was part of any Hippocratic physician’s work, which went beyond healing. Most of these physicians were itinerant. On arrival in a new city, investigations had to begin right away, and some of the treatises were designed to assist physicians in this research. Epidemics is not about epidemics in the modern sense, but about travel and differences of region (epi-demos, among the people). Physicians were expected to observe and investigate their patients. “Try to be an enquirer into nature, attending to the patient’s physical appearance and strength, for there is no fixed standard of these things, but try to gather evidence from these things, using purgations and evacuations of the whole body and the head, and fumigations and pessaries of the uterus. These are your elements.”7
They were also directed to research the environment where they practice. For instance, Airs, Waters, Places directs physicians to investigate the seasons, winds, waters, terrains, and customary diet.
Only then can they make accurate prognoses and prescribe effective treatments. Local sources of water require special investigation. Are they stagnant, marsh, lake, or spring? A physician should take note of rainwater and snow water, and investigate the conduits. Is water carried through pipes, or does it originate from large rivers fed by others, or from lakes, or mountain streams? Qualities of spring water depend on the terrain from which it emerges, and orientation to the sun and prevailing winds. Each kind of water has a specific power (dunamis) to act on the human body. Water can be hot or cold, but also cold in summer and hot in winter or vice versa. It can be clear or cloudy, odorless or foul, thick or thin, sweet or salty, soft or hard. Water can even be weighed on a scale and its powers discerned from its lightness or heaviness. The text suggests actual measurements. Physicians are warned about the effect of freezing, which by the experiment I mentioned was known to remove water’s lightest parts, making it unhealthy. The water people habitually use can even alter their constitution. Hard waters produce hard cavities.If the commitment to progress is one theme of this first medicine, a second is to have practically invented the idea of the individual. A human being is constantly changing and every one of us is different. A doctor cannot be too alert to a patient's individuality. The physician's art is to know how much a body can tolerate, and that differs with each individual. “If the Greeks have a dislike for the individual and a preference for the typical,” Ludwig Edelstein observed, apropos a thesis of Jacob Burckhardt, “the counterbalance is provided by medicine” “This classical empiricism is medicine's own creation and... its original contribution to the development of Greek thought.”8
A third theme of Hippocratic medicine is to abolish the notion that disease is punishment from the gods. “It is not a god that injures the body, but disease,” wrote the Hippocratic author of On the Sacred Disease, a treatise on epilepsy.
Elsewhere, “Every disease is produced by a natural cause.” These texts are not irreligious or ideologically secular; for instance, Sacred Disease does not say epilepsy is natural, but that it is no more divine than any disease. “I do not believe that the so-called sacred disease is any more divine (theios) or sacred than any other disease, but that on the contrary, just as other diseases have a nature and a definite cause, so does this one, too, have a nature and a cause.”9For polytheists, something is “divine” if it is a power operating in nature. A disease is divine in being caused by factors that are themselves divine: climate, wind, heat or cold, wet or dry. These are the great constants of life, and beyond human control. Other causes, for instance, constitution, are susceptible to our agency (e.g., dietetics). The divinity of disease is for it to have a phusis, that is, a natural consistency, a characteristic pattern of origin and change.
Only some of the Hippocratic treatises expound what became the distinctive concept of ancient medicine, namely, the theory of four humors. Other authors in the same collection denounce the theory as “technical gibberish” and advance alternatives. Much later though, Galen favored it, calling it Hippocrates's fundamental teaching, which guaranteed its authority thereafter. According to this theory health is a balance of four corporeal substances—black and yellow bile, blood, and phlegm. Disease is some disorder in their proportions, and can be treated by due application of their opposite.10
Whatever we think of its content, Galen's humoral theory has a methodological significance that should not be neglected. It provided the first stable model of what a theory in natural philosophy looks like, which it did by the theoretical goals it set for itself. One was to impose order on unruly phenomena, in this case, the variety of disease. A second implicit theoretical goal was to posit principles that are simpler and more readily understood (the mixing of four humors) than the unruly phenomena (evidence of health and sickness). A historian of science aptly observes that what should impress us “is not its ultimate wrongness, but the basic rightness of what [the theory] tried to do.”11