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Pre-Hippocratic Medicine: The Philosopher-Scientist

Greek secular, rational medicine, which reached its summit in the time of Hippocrates, was undoubtedly preceded by a long tradition. But we do not know precisely the nature of medicine, or even science, in the centuries between the Homeric period of the ninth or eighth century B.C. and the advent of the philosopher-scientists in the sixth century. Interchanges among Crete, Mycenae, Egypt, and Asia had always contained interlacings of religious and empiric healing methods, so it is likely that this cross-fertilization continued. A few bits of information from Hesiod's Works and Days of the eighth century suggest the prevalence of a kind of folk medicine which combined basic hygienic rules with pragmatic use of foods and plants, but it also included religious and magical associations. Therefore, when one comes upon the sixth century—about which we have direct and indirect information on the philosopher-scientists—one is impressed by what appears to be a sudden new approach: an attempt to give all phenomena natural rather than supernatural explanations.

By the time of Thales (640?-546 B.C.), the first true scientist-philosopher of the Greeks, his birthplace Miletos on the Aegean west coast of Asia Minor had become a great port of trade, with an international population and exceptional thinkers and teachers. It was on the periphery of the Greek world, and in that sense typical of the areas in which the new philosophies seem to have developed: the Aegean islands, the Asiatic coast, and Italy and Sicily, in centers which must have been growing over centuries.

Meanwhile, the practice of medicine was probably carried on by itinerant craftsmen, as in Homer's time. Information was transmitted orally from generation to generation, and by the time of Hippocrates (mid-fifth century B.C.) practitioners were engaged in a variety of methods of differing effectiveness. At the same time, medical teaching groups, or "schools," were developing throughout the Greek world and were heirs of both the empiric tradition and the philosophic inquiries of the philosopher-scientists.

Our information about Thales is based on what others wrote about him and quoted from his teachings. ("What is difficult? To know thyself. What is easy? To advise another.") The man who emerges from these accounts had an extraordinarily wide range of interests and a profound effect on his contemporaries and followers. It is no wonder that he was considered among the seven greatest sages.

Thales believed that the basic element in all animal and plant life was water, from which came earth and air. He made many contributions to mathematics, astronomy, navigation, and geometry, and is said to have developed several of the geometric theorems later used by Euclid. The most significant attribute of his work, for which he has been called the "Father of Science," is that his explanations of phenomena did not fall back on supernatural agency. Although he accepted the idea of a God, he did not use religious means to seek or establish the natural processes of the universe or of humans.

At Miletos, two especially influential thinkers followed Thales: Anaximander (fl. c. 560 B.C.) and Anaximenes (fl. c. 546 B.C.). Anaximander (extending the rational views of Thales) taught that all living creatures had their beginnings in water. Even man originally came from a water organism. Anaximander also espoused the doctrine that the universe was constituted of opposite forces in balance and that it was governed by universal laws. His pupil Anaximenes considered air rather than water the primary element and therefore the essential requirement for life.

Heraclitos (fl. c. 500 B.C.), the outstanding philosopher of Ephesos, to the north of Miletos, considered fire rather than water or air as the principal element, but he underlined Anaximander's concept of opposites by suggesting that tensions between opposing forces were essential to the universe and to life. Change was the only constant.

By the sixth century B.C., four basic elements had become generally accepted as the components of all substances: water, earth, fire, and air, each of which had its corresponding characteristic—wet, dry, hot, cold. This doctrine of the four elements and their qualities (later projected into the four humors) continued to affect medical theory for many centuries, even into recent times.

There were many other leaders of what was referred to as the Ionian school because it sprang from the islands and territories to which the ancient mainland Ionians had migrated. Each inquired rationally into the makeup of humans as well as the cosmic environment.

At the western borders of the Greek world in the sixth century, an Italic "school" of philosophers was centered in Sicily and southern Italy. The most famous group was at Crotona, where Pythagoras came to teach. A center of philosophy may have been there before he arrived, but the influence of Pythagoras and the teachings of his followers were to have a profound effect on medicine.

Pythagoras (fl. c. 530 B.C.) was born on the island of Samos just off the coast of Asia Minor, but he emigrated west to Crotona in southern Italy because of his opposition to the tyrant Polycrates. He and his followers formed not only a school of philosophy but also a religious cult that allied itself with the ancient mystical teachings of Orpheos.

The Pythagoreans in the west focused principally on the soul and the spiritual universe, whereas Thales in the east was concerned with matter. Humans were fallen gods eventually capable of returning to divinity, for although the body decayed the soul was continually reborn—even in animals. All life was therefore sacred, and surgical procedures were forbidden since they might interfere with the soul. Their belief in reincarnation resembles some religious ideas developing in India (where the Buddha also lived in the sixth century B.C.).

The basic principle of the Pythagorean universe was not any of the elemental substances but rather the science of numbers, which determined what happened in living creatures as well as in the cosmos. Each number had a special significance beyond its own function in mathematical process. For instance, I represented God, 2 stood for matter. Therefore 12 was the universe, divisible by 4 three times. The Pythagoreans also established scientific theories of sound and of musical octaves. Furthermore, as proponents of the mythical teachings of Orpheos, they felt that music should play an important role in their discipline.

Balance in all things was the goal of correct behavior. Opposite pairs of substances and qualities achieved the balance; therefore the number 4 was important to health, and the concept of four elements with four qualities received further impetus, particularly when supported by so influential a school.

As a logical concomitant of Pythagorean beliefs, diet was vegetarian and frugal, but there were a few curious prohibitions against some foods, such as beans. The explanation given by Diogenes Laertius (third century A.D.) was that in mythical times the bean had been a symbol of the head and therefore of the mind, which might have made it taboo to this sect. Cabbage, anise, and squill were recommended to maintain health and treat illness, and external applications of plant substances were also permissible, but the chief Pythagorean therapy consisted of diet, exercise, music, and meditation.

Other "schools" of medicine (that is, associations of philosophers, medical teachers, practitioners, and students) had been developing nearby in Sicily, in Cyrene on the African coast, and in Rhodes, Cnidos, and Cos at the eastern periphery of the Greek world. But Crotona was the most famous of philosophic centers according to Herodotos. Democedes, one of the best-known practitioners among the Greeks, was educated at Crotona, and his reputation increased after he went to Aegina and to Athens. He was persuaded to come to Samos by its ruler Polycrates, but when Samos was taken by the Persians Democedes was brought along to the court of Darius. There chance brought him to the attention of the king, whose ankle injury he was able to treat successfully, as well as his daughter's abscessed breast. We do not know his method of treatment, but Egyptian physicians had previously been unsuccessful in relieving the king's difficulties.

A younger member of the Crotona school (possibly of the fifth century B.C.) was Alcmaeon, whose principal focus was on man, not the cosmos. His book Concerning Nature may be the beginning of Greek medical literature, but only a few fragments survive. Works by a number of later writers—especially Aristotle—are the principal sources for what was contained in Alcmaeon's teachings. He held a general philosophic attitude: health is harmony; disease is a disturbance of the harmony. But he also believed that investigation (including dissection), not just philosophy, was needed in order to understand the body. His combination of direct observation and experimental testing stands out as unique in his time.

Although many remarkable facts emerged from his dissections (probably on animals), his most striking contribution was to establish the connection between the sense organs and the brain. Even the optic nerves and their chiasm (crossing) were clearly delineated. Going further he concluded that the brain was the organ of the mind, not only perceiving sensations but also responsible for thought and memory. About a century later, Aristotle, one of the greatest philosopher-scientists in history, disagreed entirely with Alcmaeon, believing instead that the heart was the center of sensation.

Alcmaeon was also a hostage of his age. For instance, he speculated that sleep occurred when the blood vessels in the brain were filled; withdrawal of blood from the brain caused waking. Along with his careful dissections of the eye and demonstrations of the pathways connecting the brain and the eye, he reported that the eye contains both water and fire. However, he condemned the commonly accepted belief of the time that semen originated in the brain. His doctrine of the balancing of opposite qualities and its effect on health were in agreement with Pythagorean teachings. But the breadth of his detailed examinations and rational concepts opened a new view on the acquisition of medical knowledge. He can be called virtually the first medical scientist.

Further south in Sicily another Greek Italic center of medicine flourished. The best-known member of this group was Empedocles (c. 493-c. 433 B.C.). Many fragments of his writings survive, and much other information about him is contained in later commentaries. From these sources historians have obtained a picture of an aristocratic leader of enormous egotism but also of exceptional knowledge and ability. He went about dressed in purple finery and decorated with flowers, boasting in verse of his own godlike nature and power of accomplishment. Yet, he did work prodigious feats for his city and its citizens. During a time when it was as still possible for one person to encompass many fields he seemed to outdistance anyone else in being many-sided. Poet, statesman, priest, philosopher, scientist, physician—he excelled in all.

His treatises were written in verse, a common practice, and he preached the Pythagorean doctrines concerning purity of mind, body, and behavior, as well as the virtues of regulated, temperate diet and exercise. His teaching that gained the widest influence was the concept that all things inanimate and animate were comprised of four basic elements: water, air, fire, and earth. Although this belief was accepted before Empedocles, he is often credited with its origination.

The elements according to Empedocles are joined together during life and separate after death. Substances are formed by attraction and repulsion of the elements in different proportions. He saw that the element air had substance and could exert pressure. The flow of blood through the body was connected in some way with propulsion by air. Respiration occurred not only through the nose and mouth but also through respiratory pores in the skin; after Hippocrates, a system of medicine called Methodist was developed from this idea. Even today some speak of the opening of the pores in hot weather and their closing in the cold.

The theories espoused by the followers of Empedocles led to further elaboration and were a step toward the concept that matter is composed of atoms. For instance, Anaxagoras (c. 500-c. 428 B.C.) held that each element was composed of many small invisible particles or seeds which were released from a food by digestion and then reconstituted into components of the body—such as bone and muscle. However, it was Democritos and Leucippos later in the fifth century B.C. who advanced the fully developed theory that all matter is made up of atoms of different size, weight, shape, and position. All animate and inanimate objects were originally created by the collisions and combinations of atoms. Democritos also dealt with diet, health and illness, and his speculative writings had a great influence on medical as well as scientific thought.

Of the other philosopher-scientist groups flourishing in the sixth and fifth centuries, two of the most important in influence were at Cnidos on the Asia Minor shore, and at Cos on an island off the coast. However, their fame may have come late in the fifth century B.C. because the historian Herodotos, who wrote in the mid-fifth century, spoke of the "schools" at Cyrene in Africa and Crotona in Italy but made no mention of either Cnidos or Cos.

It was on Cos that Hippocrates lived and taught. The writings of the Coan teachers, presumably by Hippocrates or by others of his time, are called the Corpus Hippocraticum and will be considered in a later section.

Neighboring Cnidos on the mainland was the location of a group of teachers and students that was probably as important as Cos and slightly older. The "Cnidian Sentences" was a collection of medical treatises which has not survived and is only known to us by mention in the Corpus Hippocraticum and through later commentators on Hippocrates, especially Galen in the second century A.D. Scholars consider it probable that some writings attributed to Hippocrates actually came from Cnidos.

For a long time historians have assumed that Cos and Cnidos were rival centers, but more recent analysis suggests that the two groups may not have been much different or even competitive. Nevertheless, a summary of the attitudes which scholars heretofore have believed were prevalent at the two locations may help clarify medical principles in the Greek world.

In Cnidos diseases were supposed to have been elaborately categorized according to the organ affected, a system with some resemblance to the practice in the Mesopotamian lands east of Cnidos. Treatments which were linked with and listed with each disease were simple and sparse.

In contrast, the Hippocratists, it was assumed, made virtually no classifications and used empiric rather than theoretical bases for the management of patients. With respect to treatment, however, Hippocratic methods were not much different from the Cnidian.

In addition, according to Galen, the system at Cnidos emphasized elaborate diagnosis based on symptoms, so that virtually every symptom was a disease. For instance, there were seven diseases of the bile, twelve of the bladder, and four types of consumption (which usually meant the spitting of blood). Although descriptions of the patient's history were complete and clear, the accent was on the disease rather than the patient (Hippocratic methods emphasized the patient rather than the disease, with great attention paid to observing and evaluating the physical findings). Wherever these Cnidian characteristics are found in the body of the Hippocratic works, they have been attributed by some scholars to Cnidian origin. Two treatises, On Diet and Acute Diseases and On Diseases, have been particularly singled out as probable contributions from Cnidos.

Some of the outstanding leaders of that school were Euryphon, Ctesias, Chrysippos, Polycrates, Endoxos, and Nichomachos, the father of Aristotle. According to Galen, Euryphon, a great anatomist, was one of the most famous physicians of his time and made many contributions to the "Cnidian Sentences." Ctesias, a younger contemporary of Hippocrates, attained fame as a physician in the Persian court of Artaxerxes Mnemon, and he wrote a commentary on Hippocrates which contained a number of disagreements with the methods and conclusions.

However, the most famous name that has come down to us is Hippocrates of Cos. Whether the teachings with which he has been associated are the work of one man or of many is not known. When the Hippocratic writings were collected in the great library of Alexandria in the fourth century B.C., the works of others were presumably also attributed to Hippocrates. So when we speak of Hippocrates we are probably referring to more than one man. Nevertheless, there is some evidence that he did exist and that he may indeed have been the extraordinary person later generations considered him. In any case, he typifies in his teachings, his life, and his behavior the ideal to which all healers strive and which all patients seek in their doctors.

Before considering the principles and methods of Hippocrates, it is appropriate to describe the common medical practices of his time.





Albert S. Lyons

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