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Diagnosis in Hippocrates' Epidemics

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Diagnosis in Hippocrates' Epidemics
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DIAGNOSIS IN HIPPOCRATES' EPIDEMICS


By

ANTHONY MARK STRAZZULLA



















A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF
FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF MASTER OF ARTS

UNIVERSITY OF FLORIDA


2006















ACKNOWLEDGEMENTS

I would like to begin by thanking all of my professors, especially Dr.

Konstantinos Kapparis, Dr. Timothy Johnson, and Dr. Robert Wagman, who served on

my committee. They have all helped me immensely throughout my undergraduate and

graduate career. Next, I would like to thank my fiancee, Brenda, for her constant support.

I am indebted to my parents and siblings, who have always encouraged me and helped

me to achieve my goals. Lastly, I need to thank all of my friends for helping me to

remain (somewhat) sane while in graduate school.
















TABLE OF CONTENTS

ACKNOW LEDGEM ENTS .................. .................. ................... ii

A B S T R A C T .................................. ................... ........... iv

CHAPTER

1 IN TR O D U C TIO N ............................................ ............ 1

2 HIPPOCRATES AND THE HIPPOCRATIC CORPUS................. 3

3 MEDICINE IN THE FIFTH CENTURY BCE......................... 9

4 DISEASES IN ANCIENT GREECE ....................................... 19

5 ANCIENT AND MODERN DIAGNOSES ........... ...............29

6 C O N CLU SIO N ....................................................... ... 37

REFERENCES.......... ..................... ............................39

BIOGRAPHICAL SKETCH ............... ................... .............. 40














Abstract of Thesis Presented to the Graduate School of the University of Florida in
Partial Fulfillment of the Requirements for the Degree of Master of Arts

DIAGNOSIS IN HIPPOCRATES' EPIDEMICS

By

Anthony Mark Strazzulla

May 2006

Chair: Konstantinos Kapparis
Major Department: Classics

Applying a modern diagnosis to an ancient patient in Hippocrates' Epidemics is

more difficult than it may initially seem. Obviously, Hippocrates and his contemporaries

were not looking for the same tell-tale symptoms that today's physicians use to assign

specific diseases and syndromes. All that we are able to know about the patient is what

the ancient physician deemed important. Diseases, as described in the Hippocratic texts,

do not easily translate into modem medical terminology. The greatest obstacle is the

method of classifying diseases mentioned by ancient physicians, which is by symptoms.

Modem medicine classifies diseases by their cause, thereby identifying each disease with

greater accuracy. Additionally, the Hippocratic physicians utilized extremely vague

categories of symptoms, thereby often omitting what is crucial for an accurate modem

diagnosis. Another problem is that the meanings of some medical terms are hard to

define and their definitions sometimes changed over time. In spite of the differences

between the Hippocratic method of diagnosis and modern diagnosis, it is possible to

obtain a modern diagnosis with limited success.









In order to be somewhat successful in diagnosing these ancient cases, it is

necessary to understand and appreciate this art before transposing it into modem

medicine. First, we must have a fundamental understanding of the texts and the

physicians who wrote them. In order to understand these physicians, a basic

understanding of medical knowledge in the 5th century BCE is required. It is helpful to

understand the ancient and modern ideas about diseases, including their causes and

common varieties. Lastly, methods of diagnosis must be discussed. With this

information in mind, one is able to comprehend the ancient cases and apply modern

medical knowledge in hope of finding a modem diagnosis.















CHAPTER 1
INTRODUCTION

Since ancient times, physicians and others with an interest in medicine have

derived great pleasure from reading the works of Hippocrates. A favorite pastime must

be attempting to apply current medical knowledge to ancient ideas. While it is quite easy

to compare and contrast the views of the reader and the author, the true challenge lies in

the ancient case histories. Applying a modern diagnosis to an ancient patient is much

more difficult than it may initially seem. Obviously, Hippocrates and his contemporaries

were not looking for the same tell-tale symptoms that later physicians use to assign

specific diseases and syndromes. All that we are able to know about the patient is what

the ancient physician deemed important.

Diseases, as described in the Hippocratic Corpus, do not easily translate into

modern medical terminology.1 The greatest obstacle is the method of classifying

diseases mentioned by ancient physicians, which is by symptoms. Modem medicine

classifies diseases by their cause, thereby identifying each disease with greater accuracy.

This better avoids the problem of classifying different diseases as the same. Since

ancient medicine classifies diseases by symptoms, it incurs the very problem which

modern medicine is able to avoid. Additionally, the Hippocratic physicians utilized

extremely vague categories of symptoms, thereby often omitting what is crucial for an




1 Nutton (lr 14) 22.






2


accurate modern diagnosis.2 Another problem is that the meanings of some medical

terms are hard to define and their definitions sometimes changed over time.3 Modem

advances in medicine have actually made diagnosing the cases of the Hippocratic Corpus

even more difficult. Knowledge of a vast number of rare pathologies makes any

diagnosis based on a vague description even more inconclusive.

In spite of the differences between the Hippocratic method of diagnosis and

modern diagnosis, it is possible to obtain a modern diagnosis with limited success. The

author of Epidemics I says that r TiXvrn 5d1 TpIov, T6 v6onJpa Kai 6 voicov Kai 6 irTpdq,

"the skill is of three parts: the disease, the patient, and the doctor."4 In order to be

somewhat successful in diagnosing these ancient cases, one must understand all of these

factors. It is necessary to understand and appreciate this art before transposing it into

modern medicine. First, we must have a fundamental understanding of the texts and the

physicians who wrote them. In order to understand these physicians, a basic

understanding of medical knowledge in the 5th century BCE is required. It is helpful to

understand the ancient and modern ideas about diseases, including their causes and

common varieties. Lastly, methods of diagnosis must be discussed. With this

information in mind, one is able to comprehend the ancient cases and apply modern

medical knowledge in hope of finding a modem diagnosis.







2 Nutton (2i 14) 22; Grmek (1989) 6.

3 See Grmek (1989) 6-7 for examples.

4 Hipp. Epidemics I.11.12-13.















CHAPTER 2
HIPPOCRATES AND THE HIPPOCRATIC CORPUS

There is a vast difference between what is known and what is commonly known

about Hippocrates and the Hippocratic Corpus. In reality, we know practically nothing

about him or about what he may or may not have written; however, common belief

encompasses much more. This is due to several factors: The desire to know as much as

possible about historical figures compels the fabrication of false, but plausible,

information, especially when very little is known. "The Greek habit of composing

imaginary speeches or letters by famous persons from the past as school exercises and

public display pieces gradually blurred the distinction between the genuine and the

false."2 Over time, works of questionable authorship tend to be attracted to the genuine

works, eventually blurring the distinction between what is genuine and what is not.

Lastly, there is a longstanding tradition that emphasizes certain works and compels the

belief that they had been written by Hippocrates himself. The end result is a man

shrouded in mystery and a vast body of literature of questionable authorship.

Hippocrates is mentioned several times in Greek literature. Plato makes

references to him in Protagoras and Phaedrus. Protagoras was written in the early

fourth century and is set around 430 BCE, roughly fifty years earlier during Hippocrates'





1 Nutton (2" 114 53.

2 Nutton ('" 114) 53.









time.3 Plato confirms that Hippocrates was from Cos, that his medical prowess was well-

known, and that he would teach the art of medicine for payment.4 Plato also identifies

Hippocrates as an Aesclepiad, a member of a guild of physicians that traces its heritage to

Asclepius, and a teacher who accepted any student for a price. In Phaedrus, Hippocrates

is named as the representative physician, even during his lifetime, and he is said to have

an organistic approach to medicine, of which Socrates approves.5 Aristotle mentions

Hippocrates once, claiming that he was a great physician and short in stature and making

the point his greatness was the result of his ability as a physician, not wealth, birth, or

size.6 Aristotle's student Meno wrote a compendium of early Greek medicine that

mentions Hippocrates' opinion on the cause of disease.7 A group of letters and speeches

from around 350 BCE serves as a major source for Soranus of Ephesus' biography of

Hippocrates, which was written around 100 BCE.8 Later biographies include one in the

tenth-century Suda and another from the twelfth-century written by Tzetzes.9








3 Nutton (k 1 1-4 55.

4Plato Protagoras 31 lb-c; cf. Nutton (2i" 14) 56.

5 Plato Phaedrus 270c-d; cf. Carrick (2001) 76, Nutton (2" 114) 57.

6 Aristotle Politics 1326a.14-15; cf. Carrick (2001) 76. This is the only physical description of
Hippocrates, adding to the difficulty in associating any ancient statues with him.

7 It is believed that a passage from this work containing an account of Hippocrates' medical doctrines is
reproduced in Anonymous Londinensis 5.35-6.42 (ed. Diel). See Carrick (2001) 78; Lloyd (1991) 199-
200, and Nutton (2" 114) 59.

SNutton (2ki"4) 54.

9 Jones (1984) xlii.









Hippocrates was born in Cos, perhaps around 460, and he belonged to a guild of

physicians called Asclepiadae.10 He learned medicine from his father, Heraclides, and

from Herodicus. During his lifetime, he traveled all over Greece and his help was sought

by Perdiccas, king of Macedonia, and Artaxerxes, king of Persia. He was present during

the plague at Athens and for plagues in other places. Hippocrates probably died in

Thessaly around 399 BC and was buried near Larissa. 11

The Hippocratic Corpus is composed of about sixty works in Ionic Greek. 12 The

uncertainty as to the number is due to the erroneous separation and combination of texts

in antiquity. Today's standard Hippocratic Corpus dates back to 1526, when the first

edition was published by the Aldine press in Venice. The surviving manuscripts contain

only individual selections from the Hippocratic Corpus. A majority of the passages in

the 1526 edition were accredited to Hippocrates by the first century AD, perhaps earlier.

Most of the works in the Hippocratic Corpus were probably written between 420 and 350

BCE, corresponding to the lifetime of Hippocrates and the following decades. Some

works, on the other hand, are probably from the third or second centuries BC or even as

late as the first or second century CE.








10Aulus Gellius N.A. XVII.21 says that he was older than Socrates, which would put his birth before 470;
Jones (1984) xlii-xliii.

1 Carrick (2001) 78; however, Jones (1984) xliii asserts that Hippocrates was born in 460 and lived for a
long, but unknown, period of time, citing possible ages of 85, 90, 104, and 109 years. This would place his
death between 375 and 351. If he were born before Socrates, as Aulus Gellius suggests, and died in or
around 399, this would give him a long, yet still reasonable, lifespan.
12 Nutton (2 114) 60-61.









The Hippocratic Corpus contains the first works actually written by the

physicians themselves describing the profession and their role.13 Some works in the

Hippocratic Corpus

show signs of a great mind, dignified and revered with all the severity of the
Periclean period, which, without being distinctly original, transformed the best
tendencies in Greek medicine into something which has ever since been the
admiration of doctors and scientific men... Prognostic, Regimen in Acute
Diseases, and Epidemics I and III fit the last category. 14

These works are generally grave and austere in style and scientific in content.15

Language is typically used to express thought, not to adorn it, except in more dramatic

passages and those which were clearly written to be circulated, such as the Constitutions

in the Epidemics. Both superstition and philosophy are normally excluded.

Determining which, if any, of the extant texts were written by Hippocrates

himself is nearly impossible.16 Ancient scholars, such as Aristotle and the author of the

Anonymous Londinensis papyrus, and others could not agree which texts were genuine

either. The selections that Galen deemed authentic based on language, style, and content

were regarded as such until the mid-nineteenth century.17 "But for all Galen's diligence

and learning this was an ultimately circular procedure; Aristotle had already denied the

reliability of its starting point."18




13 Nutton (k 1i14) 63.
14 Jones (1984) xiv.

15 Jones (1984) xv.

16 For an in-depth discussion of the Hippocratic question, see Lloyd (1991) 194-223.

17 Nutton (2 111) 61-62.

18Nutton (ik !4) 62.









The Epidemics are the most extensive collection of medical cases from

antiquity. 19 Hippocrates (or one of his associates) was the first physician to record case

histories.20 They present necessary information so that the author and his readers could

estimate the severity of a disease, predict its outcome, and treat it, if possible. This

includes close observation of symptoms and consequences, remarks on remedies, and

recording of atmospheric phenomena.21 Plagues occurred in ancient Greece; however,

the Epidemics primarily relate endemic, not epidemic, diseases, as even the plague of

Athens is not discussed. Considering the purpose of these works, it is understandable that

the focus is the disease, and not the patients. 22 The author writes as an observer of

natural phenomena more than as a physician; however, there is no reason to assume that

the patients were not treated. Treatment is occasionally mentioned or hinted at, but not

discussed because it is irrelevant to the purpose of Epidemics.

The Epidemics were written at three different dates: books I and III ca. 410 BCE;

books II, IV, and VII ca. 400 BCE, and books V and VI between 358 and 348 BCE.23

Some of these may have been written by the same author, while others were composed

from the same material, as some cases from Epidemics V and VII are nearly identical, but

with slightly different wording. Only the oldest part of the collection, Epidemics I and II,

containing forty-two cases, will be discussed here.




19 Nutton (2" 114) 22.

20 Gordon (1949) 519.

21 Jones (1984) xv.
22 Jones (1984) xviii-xix.

23 Nutton (2" 14) 60. These are only general groupings by date. The precise order in which these works
were written is heavily debated.















CHAPTER 3
MEDICINE IN THE FIFTH CENTURY BCE

The advancement of Greek medicine leading into the fourth century was the

product of the increased influence of reason and generally decreasing influences of

religion and philosophy. At the earliest stages, religion was the major contributing factor.

What is not understood is attributed to the divine, and what is understood is natural; this

changes over generations as knowledge increases. 1 "But this realization did not come all

at once, and in the science of medicine it was peculiarly slow. There is something

arresting in the spread of an epidemic and in the onset of epilepsy or of a pernicious

fever. It is hard for most minds, even scientific minds, not to see the working of a god in

them." An excellent example of this is found in Thucydides' Peloponnesian War:2 The

plague of Athens in 430 BCE was seen as a turning point in the war, after which Athens

eventually surrendered. Additionally, there was also a surge in the popularity of

Asclepius, the god of healing, around this period. Reason did, however, have a firm basis

early on. The efficacy of human means to relieve pain is so obvious that even in Homer,

the first literary authority for Greek medicine, rational treatment is fully recognized.

Philosophy eventually superseded religion and sought for uniformity in all phenomena,

leading to guesswork and neglect of fact in an attempt to frame a comprehensive theory.3



1 Daremberg (1870) 82, trans. Jones (1984) x.
2 Thucydides Peloponnesian War 2.47-2.55.

3 Jones (1984) xi.









Charles Daremberg said in Histoire des sciences medicales, "the philosophers tried to

explain nature while shutting their eyes."4 As the influence of the philosophers

decreased, so did the desire to find universal theories that apply equally to the cosmos

and to medicine. Experience in the practice of medicine eventually was becoming the

predominant influence on medical theories, thereby allowing for all future advancements.

The Hippocratic Corpus contains both medicine and philosophy. Some treatises

try to explain medical phenomena with apriori assumptions, while others do not. Celsus

says in his introduction that "Hippocrates... separated this discipline from the study of

wisdom, and he was a man distinguished in skill and eloquence"5 He also says that

Hippocrates separated medicine and philosophy, and the best works produced by the

Hippocratic school lack philosophic assumptions as much as they lack religious dogma.6

Physicians in ancient Greece were only one type of healers, as there was also a

variety of religious healers. As such, they had to compete against other physicians and

other healers for patients. It was crucial for physicians to make good first-impressions

and maintain an impeccable reputation. As in any other profession, one must be a skilled

speaker and interact well with others in order to accomplish this. A physician's

reputation was maintained by either satisfying their patients or at least being able to

foretell negative outcomes.7 By predicting the course and outcome of a patient's illness,

the ancient physicians were able to build public confidence in their skill and maintain a

steady clientele. Prognosis is more than a means of impressing patients: It is one of the

4 Jones (1984) xi.

5Hippocrates... ab studio sapientiae disciplinam hanc separavit, vir et arte andfacundia insignis
6 Jones (1984) xii.

7 Nutton (- 4) 88.









most distinctive and important features of Hippocratic medicine.8 It is crucial to

understanding the patient's ailment and knowing the necessary treatment, which must be

adapted as the patient's condition progresses. It is this understanding of the condition

that separates the physician from other kinds of healers. The importance of prognosis is

clearly reflected in the writings of the Hippocratic Corpus: Aphorisms, Coan Prognoses,

Dentition, Prorrhetic I, Prognostic, and Airs, Waters, and Places all deal with the art of

prognosis, and the Epidemics were written to assist in giving an accurate prognosis.

Physicians differed in several respects. Plato divides physicians into slaves and

non-slaves, with each treating their own class. 9 He also acknowledges that a free-born

doctor would also treat slaves, as shown within the Hippocratic Corpus. Some doctors

stayed within their own communities, while many others traveled extensively. 10 Some

worked alone, and others were members of guilds. Physicians could have one of several

different sources of income: Some were wealthy enough to treat patients without a fee,

some were paid by patients, and others paid by the state. Those who were paid by the

state would either tend to an army or navy while on campaign or serve as a "public

doctor".1 Athens even paid doctors to reside in the city. 12







8 Gordon (1949) 504; Nutton (21" 14) 89.

9 Plato Laws 720a-d, cf. Nutton (2 i 14) 100.

10 Nutton (2 1 14) 87.

11 Herodotus [History 3, 129-37] says that both Athens and Aegina had a system of public doctors in by the
late sixth century. Democedes held both of these positions at one time.
12 Plato Gorgias 455b, 456b; XenophonMemoirs 4, 2, 5.









"The Hippocratic physiology of the body is based both on observation and on a

wide range of analogies with the world around."13 Ancient physicians needed to develop

an understanding of physiology using only what they knew. They were able to witness

natural processes around them, but it was more difficult to watch the human body work;

consequently, they had to apply what they knew about the world outside of the human

body to the inside of the human body. An added difficulty is that religious considerations

made it nearly impossible to examine the inside of the human body through dissection.

They were only able to gain experience in this area when they were fortunate enough to

come upon a patient with substantial wounds, often from battle, and either perform

surgery or briefly examine the corpse. In order for these physicians to achieve anything

else, they would have had to disregard religious restrictions and experience a paradigm

shift, a total change in their way of thinking. 14

The theory of fluids or humors became predominant in Hippocratic medicine. 15

The major advantage of this theory is that it had tangible evidence: The presence of or

difference in bodily fluids is easily recognizable. For example, pus or variations in

sputum, urine, or excreta can all be seen and touched. The location where the fluid exited

the body is also significant, as it seemed to show the point of bodily weakness. The

identity and quality of the humors varies throughout the Hippocratic Corpus and not all

of its authors subscribe to a version of it.



13 Nutton (2k 11) 77.
14 "Paradigm shift" is Thomas Kuhn's term for the radical change in the way one looks at nature that forms
the basis of a scientific revolution. See Kuhn, Thomas S. (1996) The Structure of Scientific Revolutions.
Chicago.

15 Nutton (ii 14) 78.









Two humors were quickly and almost universally accepted, while others were the

topic of much debate. Although there was no set number of important humors, phlegm

and bile were of primary concern to physicians because they were both undoubtedly

related to sickness.16 Phlegm (Gk.
associated with heat, inflammation, and swelling; however, by the fifth century, became

to be considered as something cold, white, and sticky. Phlegm was seen to block air

passages and thought to cause arthritis when it settled in a joint. Bile, which can be seen

in vomit and diarrhea, was thought to deteriorate interior surfaces of the body, because of

the stinging sensation produced when it is evacuated. Menecrates (fl. mid-4th c.) believed

that the body was composted of two hot elements, blood and bile, and two cold elements,

breath and phlegm. In Diseases IV, the author identifies the humors as blood, bile,

phlegm, and water, which no others identified as one of the humors. Toward the end of

the fifth century, some believed bile to be of two types, red and black. Later, black bile

was considered a separate humor. Red bile was considered good when it was in

equilibrium, but black bile was often considered to be innately bad. This is the origin of

the established theory.17

The predominant Hippocratic theory of the four humors, which is outlined in The

Nature ofMan, is derived from the cosmogenic theory of Empedocles, a pre-Socratic

philosopher who lived ca. 490-430 BCE. Empedocles' four elements, which composed

all types of matter, were earth, air, fire, and water and they were associated with four





16 Nutton (2 14) 79-82, 84.

17 Carrick (2001) 29.









qualities, hot, cold, wet, and dry.18 Nature ofMan is the only Hippocratic work that

explains the theory of four humours and is also the first in which it is mentioned. The

author does not say that man is made of Empedocles' four elements or anything else that

does not clearly show itself in man, as that is beyond the domain of medicine.

The four humors have characteristic qualities. Like Empedocles' elements, each

humor is assigned two of the "primary opposites," which are hot and cold and moist and

wet. 19 Additionally, each humor is assigned to a season, which shares its primary

opposites, in which it is supposedly abundant:

Table 3-1. The humors and their associated qualities.20

Humor Element Season Primary opposites
Blood Air Spring Hot, moist
Phlegm Water Winter Cold, moist
Black bile Earth Autumn Cold, dry
Yellow bile Fire Summer Hot, dry


This classification of the four humors represents a well-balanced system that is easy to

understand and provides the basis for treatment.

The application of the humoral theory is well-summarized by Paul Carrick's

seven principles: equilibrium, seasonal influence, contraries, innate heat, natural healing,

pepsis, and critical days. 21 An individual is in good health when his humors are in

equilibrium, for disequilibrium causes sickness. The qualities of the seasons are applied

to the humors, as shown above, and the seasons influence health. Illnesses are countered


18 Nutton ki 1i4) 81, 90-91.

19 Longrigg (1993) 91-92.
20 Carrick (2001) 31.

21 Carrick (2001) 29-34.









by their contraries, e.g. an excess of black bile, which is cold and dry, could be treated

with beverages and warm baths. The body has an innate heat, which creates and moves

the humors and causes digestion. Nature strives to heal an ill individual, and it is the

responsibility to assist, not impede, this process. When there is an excess of one humor,

the excess thickens via the process ofpepsis, or coction, and is then expelled. This

process is neither completely chemical nor mechanical.22 Lastly, each illness has critical

days, on which the illness will change for better or worse, at predictable intervals. 23 This

could be accompanied by an expulsion of residue. 24 Afterwards, there might be a relapse

and another crisis. This basic understanding of the humors and the application of the

theory allows a more in-depth look at good heath, sickness, and treatment.

Determining the difference between healthy and ill is not as simple as it may

appear. Whether phlegm and bile were present only in the sick or in both sick and

healthy bodies was undetermined, with proponents on each side.25 Some believed that

good health, even with an imbalance of humors, was the normal state and sickness arose

when peccant material settled in a region;26 however, others believed that perfect health

was rare, as an athlete could only remain at his best level of fitness with great diligence

and people were usually at least slightly ill.27 Similarly, the author of Nature of Man




22 Jones (1984) li.
23 Carrick (2001) 29-34.

24 Jones (1984) lii.

25 Nutton (2k 114) 81.
26 Hipp. Sacred Disease 8-10; Places in Man, passim; cf. Nutton (2i 114) 81.

27 Hipp. Aphorisms 1.3-6; cf. Nutton (21 i4) 81.









identifies illness as when there is any imbalance of the humors.28 Many others accept

that a slight imbalance of the humors is perfectly normal and that there is no immediate

transition from well to ill that corresponds to a slight shift in equilibrium of the humors.

This position is held by the author of Regimen.29

Vivian Nutton says that "on the whole, ancient medicine depended on the

recuperative powers of the body and the self-limiting nature of many acute illnesses."30

This idea is echoed in Epidemics VI, case V: "Nature is the physician of diseases. Nature

finds ways and means all by itself, not as a result of thought."31 The physicians had to

find ways to treat their patients without hindering any natural healing process. After

identifying an illness, the physician had to decide whether or not he was able to treat the

patient. Any treatment would be avoided if it were highly unlikely that it would be

successful or that it would cause more harm than good. Not treating a patient under these

circumstances was acceptable to most or all of the authors of the Hippocratic Corpus.32

"No blame was attached to a reasoned refusal to treat, and at least one author in the

Corpus believed that it was essential to reject any case judged to be incurable: another

advised that a decision to treat should be accompanied by an announcement of the likely






28 Hipp. Nature of Man IV; cf. Nutton (21 '14) 81.

29 Hipp. Regimen 1, 12-24; cf. Nutton (21 1'4) 81.

30 Nutton (2i 14) 35.
31 Carrick (2001) 33.

32 Nutton (21 14) 92; cf. Epidemics I.11.









outcome."33 Plato saw this as a true indication of skill, to acknowledge the limits of

one's power.34

Greek methods of treatment sometimes strive to cure illness allopathically, by

having the opposite effect of the present illness.35 When the humors are not at

equilibrium, it must be restored by either removing what is in excess or by increasing

what is deficient. "One of the distinctive features of Greek medicine is its insistence on

dietetics as central to all therapeutics."36 In the fifth century, the role of dietetics in

Greek medicine advanced well beyond that of the Egyptians and Babylonians, who

focused on the quantity of food consumed. Plato credits Herodicus of Selymbria, a

gymnastic trainer, with these advancements.37 Regimen, Nutriment, and Regimen in

Acute Diseases all suggest the modification of diet from the onset of disease.38 The

usage of food to affect the balance of humors is no different than the usage of drugs.

Nutton remarks that the distinction between the two can be almost entirely subjective at

times. Patients were often treated hydromel, oxymel, wine, and barley water/gruel. 39

Purgatives and emetics were used to remove substances from the body. Fomentations

and baths were also used to alter the humors. Another common method of treatment is

phlebotomy, the cutting of an artery and allowing the patient to bleed, sometimes to the


33 Nutton (2i 14) 66; cf. Fractures 36; Women's Diseases 1, 71.

34 Plato Republic 360e-361a.

35 Nutton k( 114) 97.
36 Nutton (2 114) 96.

37 Plato Republic 405d-406c.

38 Nutton (2 114) 97.

39 Jones (1984) xix-xx.






18


point of unconsciousness. While it is unlikely that the patient benefited from this

procedure, it did not worsen his condition noticeably in many cases. With this basic

understanding of the humors and treatment, we may now consider health and disease in

ancient Greece.















CHAPTER 4
DISEASES IN ANCIENT GREECE

Not surprisingly, our modem idea of disease does not directly correlate to Greek

medicine. For the Greeks, specific sets of symptoms eventually became diseases. The

physicians understood diseases as natural processes that act on the human body, while

others sometimes considered them to be separate from than realm of medicine, especially

in a religious context.1 The physicians used these diseases as mere guidelines to classify

similar afflictions. Additionally, they knew that these diseases were somehow related to

the geographical and atmospheric environment and that they typically ran a predictable

course.2 Experience showed them that patients often had to somehow modify their daily

life in order to recover. They were not able to know anything beyond this; consequently,

it was necessary for them to resort to hypotheses to explain the workings of diseases. "In

doing so [the physician] was obeying a human instinct which assures us that progress

requires the use of stop-gaps where complete and accurate knowledge is unattainable, and

that a working hypothesis, although wrong, is better than no hypothesis at all." Let us

now consider what the ancient Greek physicians' hypotheses were.

Ancient Greek explanations of disease vary even within the Hippocratic Corpus.

Disease is not the result of invisible forces or the gods, but processes that occur within

the natural world. In general, it is the product of an individual's nutrition and interaction



1 Nutton (2"l4) 28.
2 Jones (1984) ix.









with his environment, which causes problems with the body's system of fluids and

conduits.3 These problems can be the result of matter settling in a particular place, the

presence of bad gases, or a surplus or deficiency of an otherwise beneficial fluid. 4 All of

the Hippocratic authors give natural explanations for disease that are general enough to

explain all or most conditions. The author of the Anonymous Londinensis papyrus

acknowledges that there is much argument over the cause of disease. Popular theories

are that it is the product of residues (either pathological or produced as the body's natural

secretions) or of changes in the body's elements. Physicians tend to believe in the theory

of residues, while the philosophers tend to believe in the theory of elements. The

majority of Greek medical writers believed that epidemics were caused by bad air.

According to Meno, Hippocrates believed that disease was the resulted of badly digested

or unwisely selected food, which produces bad air within the body. Some of the other

works and their explanations are as follows: The author ofBl ei/th\ supports the theory

that Hippocrates supposedly held. Places in Man cites seven types of flux of the humors,

originating in the head and settling elsewhere in the body, as cause of disease. The

author of Diseases gives three causes: imbalance of humors (primarily with relation to

diet), violent causes (falls, fatigue, or wounds), and the atmospheric conditions.5

For the ancient Greeks, the factors affecting health were behavior and

environment. Behavior includes any action a person may do throughout the day,

especially eating and exercising. Naturally, eating good foods in moderation and



3 Kosak (2000) 38; Nutton (2i 114) 77.

4 Nutton (2 1114) 26, 29, 72, 78.

5 Carrick (2001) 29.









exercising sufficiently were the focus. Environment requires considerably more

explanation. In Regimen, the author says that a doctor must become acquainted with both

the patient and his surroundings, which include the season, winds, weather, region, and

even sunrise and sunset. 6 Airs, Waters, andPlaces provides guidelines for predicting

the types of diseases are likely to be found in a region, based on geographical and

environmental factors. Within the Epidemics there is a collection of passages known as

the Constitutions, which contains detailed and eloquent descriptions of the climate and

geography of various regions. The best are found in books I and III; however, all of the

books contain similar information. This idea of environment is intertwined with the idea

of contagion. Many individuals may respond to the same environmental conditions, but

many individuals grouped together have no greater chance of becoming ill than a small

group does.7 It is the constitution and behavior of the individual and the impact of the

environment that count, not the population density. While the notion of contagion is

present, it is not as important a factor as one might expect. Thucydides mentions it in his

description of the plague of Athens in 430 BCE, other authors use person-to-person

contact to explain why some become sick while others do not, and it was also commonly

used to describe religious pollution. 8 In spite of this, the Hippocratic physicians do not

apply it to their hypotheses. 9 Another related missing consideration is the association of

cities to health. None of the Hippocratic authors recognize a connection between health

and the high population density of cities, which we now know to increase the danger of

6 Nutton (21r 1) 75-76.

7 Kosak (2000) 38.

8 Kosak (2000) 38; Nutton (2 114) 28; cf. Thucydides Peloponnesian War 2.51.5.

9 Kosak (2000) 38.









infectious diseases significantly. In spite of their focus on and knowledge of geography

and climate, none of the authors in the Corpus maintain that any one Greek state is

healthier than the other. While it is beneficial to understand what the Greeks thought of

disease and factors affecting health, it equally important, if not more, to apply some

modern medical knowledge to what we know about fifth- and fourth-century Greece, so

that we will be better prepared to take on individual case histories in the following

chapter.

For each civilization, there are certain factors that affect the health of the

population as a whole. Quite often, many of these are beyond their control: Humans are

most vulnerable to their environment when they are either very young or growing old,

and the elderly are subjected to number of maladies which rarely affect the young and

middle-aged. Location and type of community in which they live predispose them to a

particular set of illnesses. Additionally, where and how people live determines what they

eat, which can also have a negative effect on health at times.

The age structure of ancient Greece affected the types of conditions seen by

physicians on a regular basis. In spite of a high infant mortality rate, children who

survived through their first year often lived into their thirties or forties.10 Many historical

figures are known to have lived much longer. Diseases that become prevalent in aging

individuals would not have been extremely common. Additionally, the gradual

deterioration of mind and body was expected as part of aging, so it is not given much


10 Nutton ('" 14) 22.









special attention.11 Consequently, we can expect diseases and conditions that affect

people of all ages in most cases.

Both urban and rural areas carry certain sets of risks. Before and during

Hippocrates' time, large cities were quite rare.12 The largest of these, such as Athens,

Corinth, Syracuse, and Carthage, had over 15,000 inhabitants. Most cities were much

smaller, having 2,000 or fewer people living within the city, and approximately 6,000 at

most including surrounding areas. It is important to note that population density is more

important than the size of the population. The larger cities attracted people from great

distances, thereby replenishing a population that was not self-sustaining.13 Additionally,

the population of these cities grew substantially in times of crisis because of the influx of

nearby people, as in Athens during the plague.14 Mirko Grmek argues that increasing

populations and urbanization in the sixth and early fifth centuries caused an increase of

disease in Greece and a lowered life expectancy, as many diseases only flourish when

population density is high. 15 Hippocrates' cities, on the other hand, were small, self-

sufficient, agrarian communities. 16 They were more exposed to diseases carried by the

region's fauna, but at less risk of contracting highly-contagious diseases from others.

The locations of the communities also played a significant role. Those near malarial




11 Nutton 21 14) 23.

12 Nutton (2 1i14 19.

13 Nutton (1" 14) 22.
14 Thucydides Peloponnesian War 2.52.

15 Grmek (1989) 92, 98-9, 104; Kosak (2000) 35.

16 Nutton (2 114) 20.









lowlands were especially sickly.17 This will be discussed in detail later in this chapter.

The authors of the Hippocratic Corpus do relate cities to health, but only with regard to

their geography. 18 Cities are not considered to be any better or worse than the country

for one's health. For the Greeks, the health of a city was related to the wind, sun, and

water supply. Even in the Epidemics, which are often specific to one particular city the

authors do not give specific examples of cities or towns when discussing geographic

factors. Moreover, whereas the authors of AWP and R describe places which they deem

to be most healthy, the authors of the Epidemics offer no advice on where to live."

Another major factor in the general health is malnutrition, which often results

from climactic changes.19 During the winter months, fruits, vegetables, and seafood

could become scarce. A poor harvest or harsh winter could easily obliterate a significant

portion of a city's food supply, greatly affecting health. The Greeks made this

association, as the similarity between the words limos (dearth) and loimos (disease)

suggests. Malnutrition decreases the population's resistance to disease; consequently,

outbreaks are often associated with local famines, periods of siege, and armies, either

when camped or on campaign.20 This concludes the general factors that affected health

in ancient Greece, so we can now consider specific diseases, both ancient and modem.

Before we begin to discuss the specific diseases, we must once again remind

ourselves that the Greeks' diseases were determined by symptoms, not causes, and that

the terminology is often extremely vague. For example, (peiolq is usually translated as

17 Nutton (2r14) 21.

18 Kosak (2000) 36.

19Nutton (2Il 4 21.

20 Nutton (21 i14) 25.










tuberculosis, but it could be one of many diseases. 21 All skin lesions were typically

grouped together and there is no guarantee of consistent usage of terminology among

physicians. In spite of these difficulties, we are still able to recognize many modern

diseases in the ancient writings. Some common examples include coughs, colds,

pneumonia, pleurisy, diarrhea, jaundice and other liver infections, parasitic digestive tract

infections, tapeworms, ulcers, and leprosy (Hansen's disease).22 Kidney and bladder

dysfunction are mentioned frequently.23 Eye diseases, such as glaucoma, trachoma, and

conjunctivitis are commonly mentioned.24 Strokes, epilepsy, migraines, headaches and

other nervous and mental disorders are described in both medical and non-medical

texts.25

Fevers (nupeTol) are the most extensively depicted condition.26 This broad

category includes any condition causing a feeling of excessive heat, either by the patient

or the doctor.27 These fevers were classified by their periodicity, that is, the pattern of

the highs. Some fevers maintained a constant high and then resolved, while others peak

at highly-predictable intervals, such as two (nupET6q d61pr q~piv6c), three (nupEr6q

TpITdToq) or four days (nupuT6q TETapTdToq). W. H. S. Jones states that these fevers are




21 Nutton (2"14) 29-30.

22 Descriptions of disfiguring skin diseases in texts from Babylonia, Egypt, and Israel from before 800 BCE
are more likely to be psoriasis than leprosy. See Nutton (2i 114) 29.
23 Nutton (2'1i 14 30.

24 Nutton (2 1i14) 31.

25 Nutton (2 1i14) 31.

26 Nutton (2" 1 4) 31.

27 Nutton (2 11114 31-32.









indicative of malaria and his view is maintained by more recent scholarship.28 The most

dreaded fever is the semitertian, which Celsus describes:

Tertianarum vero duo genera sunt. Alterum eodem modo, quo quartana, et
incipiens et desinens, illo tantum interposito discrimine, quod unum diem praestat
integrum, tertio redit. Alterum long perniciosius, quod tertio quidem die
revertitur, ex quadraginta et octo horisfere triginta et sex per accessionem
occupat interdum etiam vel minus velplus, neque ex toto in remissione desistit,
sed tantum levius est. Id genus plerique medici rj4irTproaTov appellant.29

There are indeed two types of tertian fevers. One, beginning and ending in the
same manner as a quartan fever, with only this difference admitted, that it
provides one free day and returns on the third. The other is more dangerous by
far, as it indeed returns on the third day, out of forty-eight hours, it occupies about
thirty-six hours with the attack, sometimes even more or less, and it does not
cease in the entire remission, but it is only lighter. Most doctors call this time
semitertian.

The semitertian fever, which is commonly known as the malignant tertian fever, is

indicative of falciparum malaria.30 Malarial cachexia, the result of a chronic malarial

infection, with symptoms of anemia, weakness, dark complexion, and enlarged spleen is

frequently found in the Hippocratic Corpus.31 The common varieties of malaria in the

Mediterranean are Plasmodium vivax, P. malariae, and P. falciparum, which is the most

hazardous.32 The Greeks were certainly familiar with the effects of these diseases:

Upstairs rooms are known to be healthier, severe fevers are especially common in years

having wet springs and hot summers (first providing an ideal breeding ground for


28 Jones (1984) Ivii; Sallares (2" '4) 311. See Jones (1977) 63-68 for a detailed discussion of various fevers
and associated variants of malaria.
29 Celsus De Medicina III.3.2.

30 Sallares (2i '14) 314. The presence of Plasmodiumfalciparum, which causes falciparum malaria, in
ancient Greece is still debated. Both Jones and Sallares believe that P. falciparum was present. See
Sallares (2k)114 311.
31 Jones (1984) Iviii; Jones (1977) 98-101.

32 Nutton (2k 14) 32.









mosquitoes, then forcing them to relocate), and areas near fresh-water marshes are more

dangerous than salt-water marches. The chill associated with fevers is described in two

ways: The cold sensation is o5Tyo and the associated shivering is (ppiKr. Melancholia

(IJEAayXoAia), as its name suggests, was thought to be caused by black bile.33 This

causes physical and mental prostration and is now associated with malaria. In addition to

fevers, there are several other conditions worth mentioning.

Colds, both with and without associated fevers, were common, but the presence of

influenza is unknown.34 The description of the epidemic cough at Perinthus in

Epidemics IV appears very similar to influenza; however, it is stated that relapses into

pneumonia were rare. Especially in older individuals, the influenza virus or an associated

bacterial infection causes pneumonia.

Various types of inflammation are often described.35 The two most common

forms are tpuoinEAaq and OEpJaoia. Both varieties are warm, but the former is a

superficial and yellow and the latter is considered internal and red.

Common digestive problems are 51dppola and 5uoEvrTpia.36 Diarrhoia is simply

the production of loose stool. Dysenteria, however, is a more serious condition that is

associated with fever, ulceration, and the blood in the stool. This may be associated with

typhoid or paratyphoid.





33 Jones (1984) Iviii.

34 Jones (1984) lv.

35 Jones (1984) Iviii-lix.
36 Jone (1984) lix.









Madness is communicated by various words.37 Although each of these probably

each had a more specific meaning, only vague distinctions can be drawn. One group

emphasises delirium: napaqippopal, napaqppovoo, napavoco, napaKpouco, napaKoni,

iKpaJvopal, and pavia. The other group places emphasis on speech: Aipoq, napdAqpog,

napaArppo, napaAiy0, and A6yol noAAof. The most common of these in Epidemics I is

napaKpouo.

Combinations of the proceeding symptoms with many others constitute diseases

for the Greek physician. A sound knowledge of diseases allowed him to provide his

patients with an accurate prognosis when the symptoms resembled a known case and also

to treat the patient to the best of his ability. Hippocrates' Epidemics served as a practical

guide to a handful of diseases. With Greek medical theories and an understanding of

ancient diseases in mind, let us now turn our attention toward the Epidemics their method

of diagnosis.


37 Jones (1984) lix.















CHAPTER 5
ANCIENT AND MODERN DIAGNOSES

The Epidemics include representative cases in order to help the physician

recognize known sickness and know how to effectively predict their outcome and, if

possible, treat them. The earliest books of the collection, I and III, contain cases in two

different formats. Epidemics I begins with three Constitutions. These are nicely-written,

graphic descriptions of the climate and illness of a specific region, Thasos, in this case.

The style of these passages indicates that they were written to be read by others. At the

end of the second Constitution, the author includes a short didactic passage regarding

crises in serious diseases, the physician's modus operandi, and head pains. The

remainder of the book is occupied by fourteen individual case histories. These are not

written in the style of the first part of the book as sentences are very brief and abrupt.

Epidemics III has twelve case histories, followed by a Constitution, and sixteen more

individual cases. In all of these cases, the author gives what he deems to be the most

significant features:

The following were the circumstances attending the diseases, from which I
framed my judgments, learning from the common nature of all and the particular
nature of the individual, from the disease, the patient, the regimen prescribed, and
the prescriber-for these make a diagnosis more favourable or les; from the
constitution, both as a whole and with respect to the parts, of the weather and of
each region; from the custom, mode of life, practices and ages of each patient;
from talk, manner, silence, thoughts, sleep or absence of sleep, the nature and
time of dreams, pluckings, scratching, tears; from the exacerbations, stools,
urine, sputa, vomit, the antecedents and consequences of each member in the
successions of diseases, and the abscessions to a fatal issue or a crisis, sweat,
rigor, chill, cough, sneezes, hiccoughs, breathing, belchings, flatulence, silent or

1 Hipp. Epidemics I.11.1-1.12.16.









noisy, hemorrhages, and hemorrhoids. From these things must we consider what
their consequents also will be.2

The author stresses individual symptoms, distinguishing between the essential and non-

essential.3 Some of the symptoms noted by the author are helpful for applying a modern

diagnosis, such as patterns of fevers, sudden changes (especially with respect to

consciousness), how the patient breathes, etc.4 The differing goals and methods of

ancient and modem diagnosis must be discussed in more detail before we apply them to

the case histories found in the Epidemics.

The ancient physician, using the few tools available to him, achieves diagnosis

through inspection, palpitation, auscultation, taste, and smell during his bedside

observation.5 The appearance of the patient, including facial expression, posture, skin

tone and abnormalities, and ocular disorders, is carefully recorded. Several observations

denoted grave diseases: the physician considered patients who were found either with

gross facial discoloration, lying supine with limbs extended, waving their hands

frantically in front of his face, or randomly moving his fingers to be at great risk of death.

All quality of all bodily fluids and excreta is also noted. Pulses, which are measured on

the temples, arms, chest, abdomen, and wrists, are used as an indication of temperature;

however, little attention was paid to the pulse rate independent of temperature.

Palpitation allows examination of the kidneys, liver, spleen, and uterus, and also reveals

fluid in the abdominal cavity. Direct auscultation, the placing of the physician's ear


2 Hipp. Epidemics 1.23.1-18, trans. Jones (1984) 181.

3 Gordon (1949) 522.

4 Nutton (2"1 11) 90.

5 Gordon (1949) 522-523.









against the patient's chest, allows him to check for the presence of fluid in the lungs.

Additionally, the taste and small of all excreta, including sweat, sputum, vomit, feces,

urine, and pus, to assist in diagnosis. For example, the presence of sweet-tasting urine

denotes the diabetes. The thoroughness of the ancient physician in the recording of

symptoms is extremely impressive.

While the goal of ancient diagnosis was to accurately record all of the symptoms

of an ailment in order to facilitate precise prognosis, modern diagnosis attempts to

identify the cause of the illness so that effective treatment can be rendered. The

observation of symptoms is as important today as it was in Hippocrates' time. Modern

medicine uses the process of differential diagnosis in an effort to precisely identify the

cause of the disease. After the patient's symptoms are recorded, those which are deemed

most important are compared with the vast number of known diseases. Once possible

diseases are identified, the physician then uses a process of elimination to find the

specific disease. Using the information that the author provides and differential

diagnosis, let us now turn our attention toward Epidemics I and III to examine the cases

and, if possible, apply a modem diagnosis. We will begin with the Constitutions in

Epidemics I.

In the first case of the first Constitution, the author tells us about an illness that

affected the people of Thasos.6 He first summarizes the weather for one year, and then

he describes the illness, which occurred during the early spring. There are not many

symptoms to describe, but they are clear and, in this case, easily recognizable. The first

symptom mentioned is a fever that affected a few patients. The next symptom is much


6 Hipp. Epidemics 1.1.1-29.









more helpful: indppaTa 6i napd T6 WTa noAAo~liv irTp6ppona Kai i 6pdpOTipWV ToToi

nAduiOololv, "and there were swellings by the ears on one side for many and on both sides

for most."7 He then identifies those who were afflicted: tyifVTO 5 TaOTa IJEIpaKiOII,

viololv, 6Kp6,ouoI, Kai TOUTOV TOTOI nEpi naAaioTplv Kai yupJv6ala nAaicTIor" yuvaii 56~

6Alynolv tyfvETO, "these happened to boys, young men, men in their prime, and to moist

of those about the palaestra and gymnasium. It happened to a few women."8 The

patients also had P3iXq npai, dry coughs and (pwvai 3paYXc56EEq, hoarse voices. The

final symptom makes the illness perfectly clear: (pAEypovai pJT' 65 vnqg iq 6pXIv

&TEp6pponol, ToToI 6 iq 6dppoTipoug, "there was painful inflammation in the testicle on

one side, but in both for some." Again, our symptoms are fever, swellings near the ears,

sore throats, and, in some cases, swollen testicles. This is clearly an outbreak of mumps,

the symptoms of which are swollen salivary glands with a secondary severe sore throat,

fever, headache, and swollen testicles in approximately twenty percent of post-pubescent

males. Mumps is transmitted through saliva droplets, it makes sense that it would be

easily spread while the men and boys exercise and wrestle. This is one of the easiest

cases in the Epidemics to diagnose.

The second case of this Constitution is much more difficult.9 The author prefaces

this case by informing us that the illness had been affecting some people for a long time

and others who had been suspected of having it eventually developed symptoms. The

outcome of this disease was not good: 6nieavov 6E noAoi nAToirol TOUTCOV, "but many




SHipp. Epidemics 1.1.10-12.

SHipp. Epidemics I.1.20-22.

9 Hipp. Epidemics 1.2.1-35.









more of these people died."10 We are told that this is (peiolq, consumption, but

6nievnoKOV 5M 6iUTipow iq CI] E'ielrTal 6ldyEIV TO TOIaUTa, "they were dying faster

than those [conditions] like it were accustomed to progress."11 Some of the symptoms of

this disease include nupET6q OplJTplTdiOg, semitertian fever, which peaks on alternating

days but remains rather high on the low days, sweating, cold extremities, digestive

problems, and sputa. Additionally, most patients also had a painful sore throat. The

symptoms worsened until the patient died. The key to diagnosing this disease is the

semitertian fever, which is caused by Plasmodiumfalciparum. Falciparum malaria can

damage the brain, lungs, and kidneys. Cerebral malaria, which can only be caused by P.

falciparum, is especially dangerous and produces high fevers, headaches, drowsiness,

delerium, confusion, and coma. The presence of these symptoms further strengthen the

argument for the existence ofP. falciparum in ancient Greece: dypunvol TO ouvoAov Kai

pdloTa OUiTOI Kai ndAlv K(O)paT)5EEq, "all together they were wakefullness, and

especially [the semitertians], and then they were comatose."12 If it were not for the clear

presence of the malarial fever, it would be considerably more difficult to diagnose this

case because of the combination wide range of symptoms resulting from damage to the

brain, lungs, and kidneys.

The first individual case exhibits an interesting symptom, as does the fifteenth

case in the last part of Epidemics III. In the former case, the author says: TOUTC nvEopa

516 TmAOq, d)onEp dvaKaAEoplJvw, dpai6v pIya, "throughout the end, his breathing, as if




10 Hipp. Epidemics 1.2.6-7.

1 Hipp. Epidemics 1.2.9-10.
12 Hipp. Epidemics 1.7.16-17









he were recalling it, was slight and great."13 In the latter: TEOCapECKal6EK6Tn nvE0pJa

6pai6v, iJ ya 516 Xp6vou Kai n6Aiv ppaXOnvooq... TaITn 516 Ti/AEO nvEOuJa 6pai6v, pJiya,

"on the fourteenth day, breath was slight, great for a time and again short of breath...

throughout the end, her breath was slight and great."14 These descriptions appear to be of

Cheyne-Stokes breathing, in which breathing quickens, retards, stops, and restarts over

thirty seconds to two minutes. The first patient died on the following day, which was the

sixth day of his suffering, and the second patient died one week later, a total of three

weeks from the first sign of illness. Cheyne-Stokes breathing is common in patients

dying of congestive heart failure, which can have many causes and varied symptoms.

The eighth individual case is also difficult to diagnose, but is worthwhile to

consider.15 Erasinos became ill with a fever discomfort after dinner and suffered until his

death on the fifth day. He suffered from delerium on most days. His hypochondria were

swollen and painful and his urine was black. The black urine and swollen, painful

hypochondria may be evidence of kidney failure of unknown etiology. In this, and

similar, cases, the brevity of the description and lack of a history make diagnosis

extremely difficult.

The following case is of a different nature than all previous cases.16 Krito of

Thasus experienced a sharp pain in his big toe while walking. He became nauseous,

began to shiver, and became delirious. On the second day, his entire foot was swollen

with black blisters, he had a severe fever, and he was still delirious. Krito died later that

13 Hipp. Epidemics 1.26.39-40.
14 Hipp. Epidemics III.17.327-328, 334.

15 Hipp. Epidemics 1.26.209-225.

16 Hipp. Epidemics 1.26.226-234.









day. The immediate pain and subsequent swelling seem to indicate a poisonous bite or

sting. It was probably not an allergic reaction to an otherwise harmless wound, as

anaphylactis, the common allergic reaction to stings and bites, would have taken his life

very quickly. A more detailed description of the patient's toe would help to better

diagnose this case.

The key to the fourth case in Epidemics III may lie in the patient's history, which

is briefly mentioned.17 The author says: iK 5n nd6TOV nUpETwov ouvEXEwCV yVOpJivCV 6

n6voq napcowiv9r, "the pain of fevers grew worse from drinking." We are also told that,

on the second day, Onox6v6piov 56ES6v oUVETd69, EppEnEv iq T6 0OC0, "the right

hypochondrion drew tight and was sinking inwards." The right hypochondrium, located

just below the ribs, corresponds to the site of the liver. A history of heavy drinking

leading to chronic liver failure with rapid progression within the last few days seems

appropriate for this case.

The Constitution of Epidemics III contains a horrifying condition. After the

description of the climate, the author begins to describe the condition: npcoi 6 TOO nrpoq

6pa ToToi YEVOIJVOICOI 4pjXE Iv tpuoninAaTa no6d, ToToI pijv pIET npoopdolog, ToToI 6'

ou, KaKOfrEa' noMoIq 9i KTEIVE, "early in the spring, at the same time as the cold spurts,

there were many abominable instances of erysipelass1, some with causes and some

without; it killed many."19 More detail is given in the following section: nohhoTol pJV TO

tpuoainEAaq pIET npopdaoloq ini oToil TUXOuOI Kai ndvu ini opiKpoToa TpOpJCaTI'Oq (p' 6AC


17 Hipp. Epidemics III.1.98-109.

18 This is a transliteration of the Greek word and refers to a type of streptococcal cellulitis in modem
medicine. Here I am using it to denote cellulitis of unknown etiology.

19 Hipp. Epidemics III.3.1-3.









TC oaClJpaTI, "many had erysipelas with a cause in accidents and in very little wounds in

the whole body."20 From this statement, it appears that the cellulitis typically originates

at the site of a cut or scrape. The condition is worse than it originally seems: TO

EpuainEAaq noAi TaKU n6vTroBv inEVilJETO. TOal IJEV ouv nAfirTOIaIv a0TCV 6noc-r6alE

iSq tnuriJaTa ouvininTov oapKcov Kai vE pov Kai 6cT icv EKnTcYlIE( IJEyEYdal, "the

erysipelas was spreading very quickly from every direction. For most of the patients the

rising [of the inflammations] were falling together into abscesses. There was a great

decay of flesh, muscles, and bones."21 Our problem has gone from mere cellulitis to

necrotizing fasciitis. This is similar to necrotizing cellulitis, but penetrates deeper and

enters the surface of underlying muscles. These infections are caused by bacteria such as

varieties of Streptococcus and Clostridium and originiate at lascerations, as our author

mentions. The author succinctly generalizes the outcome with ri 65 TaUTa (PO3PEp6TEpa ri

KaKiO, "these were more frightening than dangerous," goes on to describe the result of

the infections, including the loss of large areas of skin, amputation, and death.22 The

mortality rate for these necrotizing infections is approximately thirty percent.















20 Hipp. Epidemics III.4.1-3.

21 Hipp. Epidemics III.4.6-10.

22 Hipp. Epidemics III.4.17.















CHAPTER 6
CONCLUSION

The best attempt at diagnosing the case histories in Hippocrates' Epidemics is

rooted in a firm understanding of the text, its authorss, and the beliefs of the time. The

ability to understand the Greek, with all of the technical terms that are specific to medical

treatises, is of utmost importance. The primary literature is the basis of our

understanding of ancient Greek medicine and it should not be neglected. There is an

abundance of literature on Hippocrates, the "Hippocratic question," the Hippocratic

Corpus, and ancient medicine to assist in the acquisition of this understanding. It is only

with this material in mind that one has a chance of truly understanding Hippocratic

writings.

As we have seen, some cases are very easy to diagnose, while some are quite

puzzling, even to gifted physicians. All that we are able to know about the patients is

what we are told, so our attempt at diagnosis relies completely on the ancient physician's

accurate recording of the symptoms, which was his diagnosis. Positive diagnoses are

only possible when the ancient physician managed to record unmistakable symptoms of

modern diseases, such as mumps and falciparum malaria. Even then, there is a degree of

uncertainty, as we are constantly discovering slight variations of modem diseases. In all

other cases, there is no way to be absolutely certain of the patient's illness. Regardless of

outcome, to spend time reading the Epidemics carefully is a pleasure. Whether we






38


experience the satisfaction of believing that we have successfully diagnosed a case or the

challenge of a case that cannot be solved, the experience is truly rewarding.















REFERENCES

Carrick, P. (2001) Medical Ethics in the Ancient World. Washington

Craik, E. (1998) Hippocrates: Places in Man. Oxford

Daremberg, C. (1870) Histoire des sciences medicales. Paris; trans. Jones, W. H. S.
(1984) Hippocrates I

Gordon, B. L. (1949) Medicine throughout Antiquity. Philadelphia

Glare, P. G. W., ed. (1982) OxfordLatin Dictionary. Oxford

Grmek, M. D. (1989) Diseases in the Ancient Greek World. Trans: M. Muellner and
L. Muellner. Baltimore

Hope, V. M. and E. Marshall eds. Polis nosousa: Death and Disease in the Ancient City.
New York

Jones, W. H. S. (1977) Malaria and Greek History. New York

------, (1984) Hippocrates I. Cambridge

Kosak, J. C. (2000) "Fifth-century Greek Ideals on City and Disease," in Hope and
Marshall (2000), 35-54.

Liddell, H. G., R. Scott, and H. S. Jones. (1996) A Greek-English Lexicon. Oxford

Lloyd, G. E. R. (1991) Methods and Problems in Greek Science. New York

Longrigg, J. (1993) Greek Rational Medicine: Philosophy and medicine from Alcmaeon
to the Alexandrians. New York

Nutton, V. (2004) Ancient Medicine. New York

Sallares, R, A. Bouwman, and C. Anderung. (2004) The Spread ofMalaria to Sn.,tnlh ii
Europe in Antiquity: New Approaches to Old Problems. Medical History 48(3): 311-328

Spencer, W. G. (1935) CelsusI. Cambridge















BIOGRAPHICAL SKETCH

Anthony Strazzulla was born on August 2nd, 1981, in Monroe, Michigan. He

moved to Palm Bay, Florida, in 1996 and later to Indian Harbour Beach, where he

graduated from Satellite High School in 2000. He graduated from the University of

Florida with a Bachelor of Arts degree in classics and history in 2004. He will receive a

Master of Arts in Latin from the University of Florida in May, 2006.




Full Text

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DIAGNOSIS IN HIPPOCRATES EPIDEMICS By ANTHONY MARK STRAZZULLA A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS UNIVERSITY OF FLORIDA 2006

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ACKNOWLEDGEMENTS I would like to begin by thanking all of my professors, especially Dr. Konstantinos Kapparis, Dr. Timothy Johnson, and Dr. Robert Wagm an, who served on my committee. They have all helped me immensely throughout my undergraduate and graduate career. Next, I would like to thank my fiance, Brenda, for her constant support. I am indebted to my parents and siblings, who have always encouraged me and helped me to achieve my goals. Lastly, I need to thank all of my friends for helping me to remain (somewhat) sane while in graduate school. ii

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TABLE OF CONTENTS ACKNOWLEDGEMENTSii ABSTRACTiv CHAPTER 1 INTRODUCTION. 1 2 HIPPOCRATES AND THE HIPPOCRATIC CORPUS.............. 3 3 MEDICINE IN THE FIFTH CENTURY BCE..... 9 4 DISEASES IN ANCIENT GREECE ............... 19 5 ANCIENT AND MODERN DIAGNOSES ..........................29 6 CONCLUSION.. REFERENCES...39 BIOGRAPHICAL SKETCH. 40 iii

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Abstract of Thesis Presented to the Graduate School of th e University of Florida in Partial Fulfillment of the Requirement s for the Degree of Master of Arts DIAGNOSIS IN HIPPOCRATES EPIDEMICS By Anthony Mark Strazzulla May 2006 Chair: Konstantinos Kapparis Major Department: Classics Applying a modern diagnosis to an ancient patient in Hippocrates Epidemics is more difficult than it may initially seem. Obviously, Hippocrates and his contemporaries were not looking for the same tell-tale symp toms that todays phys icians use to assign specific diseases and syndromes. All that we are able to know about the patient is what the ancient physician deemed important. Diseas es, as described in the Hippocratic texts, do not easily translate into modern medica l terminology. The greatest obstacle is the method of classifying diseases mentioned by ancient physicians, which is by symptoms. Modern medicine classifies di seases by their cause, thereby identifying each disease with greater accuracy. Additiona lly, the Hippocratic physicians utilized extremely vague categories of symptoms, thereby often omitting what is crucial for an accurate modern diagnosis. Another problem is that the mean ings of some medica l terms are hard to define and their definitions sometimes change d over time. In spite of the differences between the Hippocratic method of diagnosis and modern diagnosis, it is possible to obtain a modern diagnosis with limited success. iv

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In order to be somewhat successful in diagnosing these ancient cases, it is necessary to understand and a ppreciate this art before transposing it into modern medicine. First, we must have a fund amental understanding of the texts and the physicians who wrote them. In order to understand these physicians, a basic understanding of medical knowledge in the 5 th century BCE is required. It is helpful to understand the ancient and modern ideas a bout diseases, including their causes and common varieties. Lastly, methods of di agnosis must be discussed. With this information in mind, one is able to comp rehend the ancient cases and apply modern medical knowledge in hope of finding a modern diagnosis. v

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CHAPTER 1 INTRODUCTION Since ancient times, physicians and others with an interest in medicine have derived great pleasure from reading the work s of Hippocrates. A favorite pastime must be attempting to apply current medical knowledg e to ancient ideas. While it is quite easy to compare and contrast the views of the reader and the author, the true challenge lies in the ancient case histories. Applying a modern diagnosis to an ancient patient is much more difficult than it may initially seem. Obviously, Hippocrates and his contemporaries were not looking for the same tell-tale symp toms that later physicians use to assign specific diseases and syndromes. All that we are able to know about the patient is what the ancient physician deemed important. Diseases, as described in the Hippocratic Corpus, do not easily translate into modern medical terminology. 1 The greatest obstacle is the method of classifying diseases mentioned by ancient physicians, which is by symptoms. Modern medicine classifies diseases by their cause, thereby id entifying each disease with greater accuracy. This better avoids the problem of classify ing different diseases as the same. Since ancient medicine classifies diseases by symptoms, it incurs the very problem which modern medicine is able to avoid. Add itionally, the Hippocratic physicians utilized extremely vague categories of symptoms, ther eby often omitting what is crucial for an 1 Nutton (2004) 22. 1

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2 accurate modern diagnosis. 2 Another problem is that th e meanings of some medical terms are hard to define and their definitions sometimes changed over time. 3 Modern advances in medicine have actually made diagnosing the cases of the Hippocratic Corpus even more difficult. Knowledge of a vast number of rare pathologies makes any diagnosis based on a vague description even more inconclusive. In spite of the differences between the Hippocratic method of diagnosis and modern diagnosis, it is possible to obtain a modern diagnosis with limited success. The author of Epidemics I says that , the skill is of three parts: the disease, the paitient, and the doctor. 4 In order to be somewhat successful in diagnosing these anci ent cases, one must understand all of these factors. It is necessary to understand and a ppreciate this art befo re transposing it into modern medicine. First, we must have a fundamental understanding of the texts and the physicians who wrote them. In order to understand these physicians, a basic understanding of medical knowledge in the 5 th century BCE is required. It is helpful to understand the ancient and modern ideas a bout diseases, including their causes and common varieties. Lastly, methods of di agnosis must be discussed. With this information in mind, one is able to comp rehend the ancient cases and apply modern medical knowledge in hope of finding a modern diagnosis. 2 Nutton (2004) 22; Grmek (1989) 6. 3 See Grmek (1989) 6-7 for examples. 4 Hipp. Epidemics I.11.12-13.

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CHAPTER 2 HIPPOCRATES AND THE HIPPOCRATIC CORPUS There is a vast difference between what is known and what is commonly known about Hippocrates and the Hippocratic Corpus. 1 In reality, we know practically nothing about him or about what he may or ma y not have written; however, common belief encompasses much more. This is due to severa l factors: The desire to know as much as possible about historical figures compels th e fabrication of false, but plausible, information, especially when very little is known. The Greek habit of composing imaginary speeches or letters by famous persons from the past as school exercises and public display pieces gradually blurred the distinction between the genuine and the false. 2 Over time, works of questionable author ship tend to be attracted to the genuine works, eventually blurring the distinction be tween what is genuine and what is not. Lastly, there is a longstanding tradition that emphasizes certain works and compels the belief that they had been written by Hippocra tes himself. The end result is a man shrouded in mystery and a vast body of literature of questionable authorship. Hippocrates is mentioned several times in Greek literature. Plato makes references to him in Protagoras and Phaedrus. Protagoras was written in the early fourth century and is set around 430 BCE, roughl y fifty years earlier during Hippocrates 1 Nutton (2004) 53. 2 Nutton (2004) 53. 3

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4 time. 3 Plato confirms that Hippocrates was from Cos, that his medical prowess was wellknown, and that he would teach th e art of medicine for payment. 4 Plato also identifies Hippocrates as an Aesclepiad, a member of a guild of physicians that traces its heritage to Asclepius, and a teacher who accepte d any student for a price. In Phaedrus Hippocrates is named as the representative physician, even during his lifetime, and he is said to have an organistic approach to medici ne, of which Socrates approves. 5 Aristotle mentions Hippocrates once, claiming that he was a grea t physician and short in stature and making the point his greatness was the result of his ability as a physician, not wealth, birth, or size. 6 Aristotles student Meno wrote a compe ndium of early Greek medicine that mentions Hippocrates opinion on the cause of disease. 7 A group of letters and speeches from around 350 BCE serves as a major source for Soranus of Ephesus biography of Hippocrates, which was written around 100 BCE. 8 Later biographies include one in the tenth-century Suda and another from the twelfth-century written by Tzetzes. 9 3 Nutton (2004) 55. 4 Plato Protagoras 311b-c; cf. Nutton (2004) 56. 5 Plato Phaedrus 270c-d; cf. Carrick (2001) 76, Nutton (2004) 57. 6 Aristotle Politics 1326a.14-15; cf. Carrick (2001) 76. This is the only physical description of Hippocrates, adding to the difficulty in associating any ancient statues with him. 7 It is believed that a passage from this work containing an account of Hippocrates medical doctrines is reproduced in Anonymous Londinensis 5.35-6.42 (ed. Diel). See Carrick (2001) 78; Lloyd (1991) 199200, and Nutton (2004) 59. 8 Nutton (2004) 54. 9 Jones (1984) xlii.

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5 Hippocrates was born in Cos, perhaps ar ound 460, and he belonged to a guild of physicians called Asclepiadae. 10 He learned medicine from his father, Heraclides, and from Herodicus. During his lifetime, he tr aveled all over Greece a nd his help was sought by Perdiccas, king of Macedonia, and Artaxerx es, king of Persia. He was present during the plague at Athens and for plagues in ot her places. Hippocrates probably died in Thessaly around 399 BC and was buried near Larissa. 11 The Hippocratic Corpus is composed of about sixty works in Ionic Greek. 12 The uncertainty as to the number is due to the erroneous separation and combination of texts in antiquity. Todays standard Hippocratic Corpus dates back to 1526, when the first edition was published by the Aldine press in Venice. The surviving manuscripts contain only individual selections from the Hippocratic Corpus A majority of the passages in the 1526 edition were accredited to Hippocrates by the first century AD, perhaps earlier. Most of the works in the Hippocratic Corpus were probably written between 420 and 350 BCE, corresponding to the lifetime of Hippocra tes and the following decades. Some works, on the other hand, are probably from the third or second centuries BC or even as late as the first or second century CE. 10 Aulus Gellius N.A. XVII.21 says that he was older th an Socrates, which would put his birth before 470; Jones (1984) xlii-xliii. 11 Carrick (2001) 78; however, Jones (1984) xliii asserts that Hippocrates was born in 460 and lived for a long, but unknown period of time, citing possible ages of 85, 90, 104, and 109 years. This would place his death between 375 and 351. If he were born before Socrates, as Aulus Gellius suggests, and died in or around 399, this would give him a long, yet still reasonable, lifespan. 12 Nutton (2004) 60-61.

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6 The Hippocratic Corpus contains the first works actually written by the physicians themselves describing the profession a nd their role. 13 Some works in the Hippocratic Corpus show signs of a great mind, dignified and revered with all the severity of the Periclean period, which, without being dis tinctly original, tr ansformed the best tendencies in Greek medicine into some thing which has ever since been the admiration of doctors and scientific men Prognostic Regimen in Acute Diseases and Epidemics I and III fit th e last category. 14 These works are generally grave and auster e in style and scientific in content. 15 Language is typically used to express thought, not to adorn it, except in more dramatic passages and those which were clearly written to be circulated, such as the Constitutions in the Epidemics Both superstition and philosophy are normally excluded. Determining which, if any, of the exta nt texts were written by Hippocrates himself is nearly impossible. 16 Ancient scholars, such as Ar istotle and the author of the Anonymous Londinensis papyrus, and others could not agree which texts were genuine either. The selections that Galen deemed authentic based on language, style, and content were regarded as such until the mid-nineteenth century. 17 But for all Galens diligence and learning this was an ultimately circular procedure; Aristotle had already denied the reliability of its starting point. 18 13 Nutton (2004) 63. 14 Jones (1984) xiv. 15 Jones (1984) xv. 16 For an in-depth discussion of the Hippocratic question, see Lloyd (1991) 194-223. 17 Nutton (2004) 61-62. 18 Nutton (2004) 62.

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7 The Epidemics are the most extensive coll ection of medical cases from antiquity. 19 Hippocrates (or one of his associates) was the first physician to record case histories. 20 They present necessary information so that the author and his readers could estimate the severity of a disease, predict its outcome, and treat it, if possible. This includes close observation of symptoms a nd consequences, remarks on remedies, and recording of atmospheric phenomena. 21 Plagues occurred in ancient Greece; however, the Epidemics primarily relate endemic, not epidem ic, diseases, as even the plague of Athens is not discussed. Considering the purpos e of these works, it is understandable that the focus is the disease, and not the patients. 22 The author writes as an observer of natural phenomena more than as a physician; however, there is no reason to assume that the patients were not treated. Treatment is occasionally mentioned or hinted at, but not discussed because it is ir relevant to the purpose of Epidemics The Epidemics were written at three different dates: books I and III ca. 410 BCE; books II, IV, and VII ca. 400 BCE, and books V and VI between 358 and 348 BCE. 23 Some of these may have been written by the same author, while others were composed from the same material, as some cases from Epidemics V and VII are nearly identical, but with slightly different wording. Only the oldest part of the collection, Epidemics I and II, containing forty-two cases, will be discussed here. 19 Nutton (2004) 22. 20 Gordon (1949) 519. 21 Jones (1984) xv. 22 Jones (1984) xviii-xix. 23 Nutton (2004) 60. These are only general groupings by date. The precise order in which these works were written is heavily debated.

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CHAPTER 3 MEDICINE IN THE FIFTH CENTURY BCE The advancement of Greek medicine l eading into the fourth century was the product of the increased influence of reas on and generally decreas ing influences of religion and philosophy. At the earliest stages, religion was the major contributing factor. What is not understood is attrib uted to the divine, and what is understood is natural; this changes over generations as knowledge increases. 1 But this realization did not come all at once, and in the science of medicine it was peculiarly slow. There is something arresting in the spread of an epidemic and in the onset of epilepsy or of a pernicious fever. It is hard for most minds, even scie ntific minds, not to see the working of a god in them. An excellent example of this is found in Thucydides Peloponnesian War : 2 The plague of Athens in 430 BCE was seen as a tu rning point in the war, after which Athens eventually surrendered. Add itionally, there was also a surge in the popularity of Asclepius, the god of healing, around this period. Reason did, however, have a firm basis early on. The efficacy of human means to relieve pain is so obvious that even in Homer, the first literary authority for Greek medi cine, rational treatment is fully recognized. Philosophy eventually superseded religion a nd sought for uniformity in all phenomena, leading to guesswork and neglec t of fact in an attempt to frame a comprehensive theory. 3 1 Daremberg (1870) 82, trans. Jones (1984) x. 2 Thucydides Peloponnesian War 2.47-2.55. 3 Jones (1984) xi. 9

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10 Charles Daremberg said in Histoire des sciences medicales the philosophers tried to explain nature while shutting their eyes. 4 As the influence of the philosophers decreased, so did the desire to find universal theories that apply equally to the cosmos and to medicine. Experience in the practi ce of medicine eventually was becoming the predominant influence on medical theories, th ereby allowing for all future advancements. The Hippocratic Corpus contains both medicine and philosophy. Some treatises try to explain medical phenomena with a priori assumptions, while others do not. Celsus says in his introduction that Hippocrates separated this discipline from the study of wisdom, and he was a man distinguished in skill and eloquence 5 He also says that Hippocrates separated medicine and philosophy, and the best works produced by the Hippocratic school lack philosophic assumptions as much as they lack religious dogma. 6 Physicians in ancient Greece were only one type of healers, as there was also a variety of religious healers. As such, they had to compete against other physicians and other healers for patients. It was crucial for physicians to make good first-impressions and maintain an impeccable reputation. As in any other profession, one must be a skilled speaker and interact well w ith others in order to accomplish this. A physicians reputation was maintained by either satisfying their patients or at least being able to foretell negative outcomes. 7 By predicting the course and outcome of a patients illness, the ancient physicians were able to build publ ic confidence in their skill and maintain a steady clientele. Prognosis is more than a m eans of impressing patients: It is one of the 4 Jones (1984) xi. 5 Hippocrates ab studio sapientiae disciplinam hanc separavit, vir et arte and facundia insignis 6 Jones (1984) xii. 7 Nutton (2004) 88.

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11 most distinctive and important f eatures of Hippocratic medicine. 8 It is crucial to understanding the patients ailment and knowing the necessary treatment, which must be adapted as the patients condition progresses. It is this understa nding of the condition that separates the physician from other kinds of healers. The importance of prognosis is clearly reflected in the writings of the Hippocratic Corpus : Aphorisms Coan Prognoses, Dentition Prorrhetic I Prognostic and Airs, Waters, and Places all deal with the art of prognosis, and the Epidemics were written to assist in giving an accurate prognosis. Physicians differed in several respects. Plato divides physicians into slaves and non-slaves, with each tr eating their own class. 9 He also acknowledges that a free-born doctor would also treat slav es, as shown within the Hippocratic Corpus. Some doctors stayed within their own communities, wh ile many others traveled extensively. 10 Some worked alone, and others were members of gu ilds. Physicians could have one of several different sources of income: Some were w ealthy enough to treat pati ents without a fee, some were paid by patients, and others paid by the state. Those who were paid by the state would either tend to an army or navy while on campaign or serve as a public doctor. 11 Athens even paid doctors to reside in the city. 12 8 Gordon (1949) 504; Nutton (2004) 89. 9 Plato Laws 720a-d, cf. Nutton (2004) 100. 10 Nutton (2004) 87. 11 Herodotus [ History 3, 129-37] says that both Athens and Aegina had a system of public doctors in by the late sixth century. Democedes held both of these positions at one time. 12 Plato Gorgias 455b, 456b; Xenophon Memoirs 4, 2, 5.

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12 The Hippocratic physiology of the body is based both on observation and on a wide range of analogies with the world around. 13 Ancient physicians needed to develop an understanding of physiology using only what they knew. They were able to witness natural processes around them, but it was mo re difficult to watch the human body work; consequently, they had to apply what they knew about the world outside of the human body to the inside of the human body. An added difficulty is that reli gious considerations made it nearly impossible to examine the in side of the human body through dissection. They were only able to gain experience in this area when they were fortunate enough to come upon a patient with substantial wounds, often from ba ttle, and either perform surgery or briefly examine the corpse. In order for these physicians to achieve anything else, they would have had to disregard reli gious restrictions and experience a paradigm shift, a total change in their way of thinking. 14 The theory of fluids or humors became predominant in Hippocratic medicine. 15 The major advantage of this theory is that it had tangible evidence: The presence of or difference in bodily fluids is easily recognizab le. For example, pus or variations in sputum, urine, or excreta can all be seen a nd touched. The location where the fluid exited the body is also significant, as it seemed to show the point of bodily weakness. The identity and quality of the humors varies throughout the Hippocratic Corpus and not all of its authors subscribe to a version of it. 13 Nutton (2004) 77. 14 Paradigm shift is Thomas Kuhns term for the radi cal change in the way one looks at nature that forms the basis of a scientific revolution. See Kuhn, Thomas S. (1996) The Structure of Scientific Revolutions Chicago. 15 Nutton (2004) 78.

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13 Two humors were quickly and almost uni versally accepted, while others were the topic of much debate. Although there was no set number of important humors, phlegm and bile were of primary concern to physicians because they were both undoubtedly related to sickness. 16 Phlegm (Gk. for flame, fire, inflammation), was originally associated with heat, inflammation, and swelling; however, by the fifth century, became to be considered as someth ing cold, white, and sticky. Phlegm was seen to block air passages and thought to cause arthritis when it se ttled in a joint. Bile, which can be seen in vomit and diarrhea, was thought to deteriorat e interior surfaces of the body, because of the stinging sensation produced when it is evacuated. Menecrates ( fl. mid-4 th c.) believed that the body was composted of two hot elem ents, blood and bile, and two cold elements, breath and phlegm. In Diseases IV, the author identifies the humors as blood, bile, phlegm, and water, which no others identified as one of the humors. Toward the end of the fifth century, some believed bile to be of two types, red and black. Later, black bile was considered a separate humor. Red b ile was considered good when it was in equilibrium, but black bile was often considered to be innately bad. Th is is the origin of the established theory. 17 The predominant Hippocratic theory of the four humo rs, which is outlined in The Nature of Man, is derived from the cosmogenic theo ry of Empedocles, a pre-Socratic philosopher who lived ca. 490-430 BCE. Empedo cles four elements, which composed all types of matter, were eart h, air, fire, and water and they were associated with four 16 Nutton (2004) 79-82, 84. 17 Carrick (2001) 29.

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14 qualities, hot, cold, wet, and dry. 18 Nature of Man is the only Hippocratic work that explains the theory of four humours and is al so the first in which it is mentioned. The author does not say that man is made of Empedocles four elements or anything else that does not clearly show itself in man, as that is beyond the domain of medicine. The four humors have characteristic quali ties. Like Empedocles elements, each humor is assigned two of the primary opposite s, which are hot and cold and moist and wet. 19 Additionally, each humor is assigned to a season, which shares its primary opposites, in which it is supposedly abundant: Table 3-1. The humors and their associated qualities. 20 Humor Element Season Primary opposites Blood Air Spring Hot, moist Phlegm Water Winter Cold, moist Black bile Earth Autumn Cold, dry Yellow bile Fire Summer Hot, dry This classification of the four humors repres ents a well-balanced system that is easy to understand and provides the basis for treatment. The application of the humoral theory is well-summarized by Paul Carricks seven principles: equilibrium, seasonal influenc e, contraries, innate heat, natural healing, pepsis and critical days. 21 An individual is in good health when his humors are in equilibrium, for disequilibrium causes sickness. The qualities of the seasons are applied to the humors, as shown above, and the seasons influence health. Illnesses are countered 18 Nutton (2004) 81, 90-91. 19 Longrigg (1993) 91-92. 20 Carrick (2001) 31. 21 Carrick (2001) 29-34.

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15 by their contraries, e.g. an excess of black bi le, which is cold and dry, could be treated with beverages and warm baths. The body ha s an innate heat, which creates and moves the humors and causes digestion. Nature strive s to heal an ill individual, and it is the responsibility to assist, not impede, this proce ss. When there is an excess of one humor, the excess thickens via the process of pepsis or coction, and is then expelled. This process is neither completely chemical nor mechanical. 22 Lastly, each illness has critical days, on which the illness will change for be tter or worse, at predictable intervals. 23 This could be accompanied by an expulsion of residue. 24 Afterwards, there might be a relapse and another crisis. This ba sic understanding of the humors and the application of the theory allows a more in-depth look at good heath, sickness, and treatment. Determining the difference between healt hy and ill is not as simple as it may appear. Whether phlegm and bile were pres ent only in the sick or in both sick and healthy bodies was undetermined, with proponents on each side. 25 Some believed that good health, even with an imbalance of humo rs, was the normal state and sickness arose when peccant material settled in a region; 26 however, others believe d that perfect health was rare, as an athlete could onl y remain at his best level of fitness with great diligence and people were usually at least slightly ill. 27 Similarly, the author of Nature of Man 22 Jones (1984) li. 23 Carrick (2001) 29-34. 24 Jones (1984) lii. 25 Nutton (2004) 81. 26 Hipp. Sacred Disease 8-10; Places in Man passim; cf. Nutton (2004) 81. 27 Hipp. Aphorisms 1.3-6; cf. Nutton (2004) 81.

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16 identifies illness as when there is any imbalance of the humors. 28 Many others accept that a slight imbalance of the humors is pe rfectly normal and that there is no immediate transition from well to ill that corresponds to a slight shift in equilibrium of the humors. This position is held by the author of Regimen 29 Vivian Nutton says that on the whol e, ancient medicine depended on the recuperative powers of the body and the self -limiting nature of many acute illnesses. 30 This idea is echoed in Epidemics VI, case V: Nature is the p hysician of diseases. Nature finds ways and means all by itsel f, not as a result of thought. 31 The physicians had to find ways to treat their patients without hinde ring any natural healing process. After identifying an illness, the physician had to deci de whether or not he was able to treat the patient. Any treatment would be avoided if it were highly unlikely that it would be successful or that it would cause more harm than good. Not treating a patient under these circumstances was acceptable to most or a ll of the authors of the Hippocratic Corpus. 32 No blame was attached to a reasoned refusal to treat, and at leas t one author in the Corpus believed that it was essential to reje ct any case judged to be incurable: another advised that a decision to treat should be accompanied by an announcement of the likely 28 Hipp. Nature of Man IV; cf. Nutton (2004) 81. 29 Hipp. Regimen 1, 12-24; cf. Nutton (2004) 81. 30 Nutton (2004) 35. 31 Carrick (2001) 33. 32 Nutton (2004) 92; cf. Epidemics I.11.

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17 outcome. 33 Plato saw this as a true indication of skill, to acknowledge the limits of ones power. 34 Greek methods of treatment sometimes stri ve to cure illne ss allopathically, by having the opposite effect of the present illness. 35 When the humors are not at equilibrium, it must be restored by either removing what is in excess or by increasing what is deficient. One of the distinctive f eatures of Greek medicine is its insistence on dietetics as central to all therapeutics. 36 In the fifth century, th e role of dietetics in Greek medicine advanced well beyond that of the Egyptians and Babylonians, who focused on the quantity of food consumed. Plato credits Herodicus of Selymbria, a gymnastic trainer, with these advancements. 37 Regimen, Nutriment and Regimen in Acute Diseases all suggest the modification of diet from the onset of disease. 38 The usage of food to affect the balance of humors is no different than the usage of drugs. Nutton remarks that the distinction between th e two can be almost entirely subjective at times. Patients were often treated hydrom el, oxymel, wine, and barley water/gruel. 39 Purgatives and emetics were used to rem ove substances from the body. Fomentations and baths were also used to alter the humo rs. Another common method of treatment is phlebotomy, the cutting of an artery and allo wing the patient to bleed, sometimes to the 33 Nutton (2004) 66; cf. Fractures 36; Womens Diseases 1, 71. 34 Plato Republic 360e-361a. 35 Nutton (2004) 97. 36 Nutton (2004) 96. 37 Plato Republic 405d-406c. 38 Nutton (2004) 97. 39 Jones (1984) xix-xx.

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18 point of unconsciousness. While it is unlikel y that the patient benefited from this procedure, it did not worsen his condition noticeably in many cases. With this basic understanding of the humors and treatment, we may now consider health and disease in ancient Greece.

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CHAPTER 4 DISEASES IN ANCIENT GREECE Not surprisingly, our modern idea of diseas e does not directly correlate to Greek medicine. For the Greeks, specific sets of symptoms eventually became diseases. The physicians understood diseases as natural processes that act on the human body, while others sometimes considered them to be separate from than realm of medicine, especially in a religious context. 1 The physicians used these diseases as mere guidelines to classify similar afflictions. Additionally, they knew that these diseases were somehow related to the geographical and atmospheric environment and that they typically ran a predictable course. 2 Experience showed them that patients often had to somehow modify their daily life in order to recover. They were not ab le to know anything beyond this; consequently, it was necessary for them to resort to hypothese s to explain the workings of diseases. In doing so [the physician] was obeying a human instinct which assures us that progress requires the use of stop-gaps where complete and accurate knowledge is unattainable, and that a working hypothesis, although wrong, is be tter than no hypothesis at all. Let us now consider what the ancient Greek physicians hypotheses were. Ancient Greek explanations of disease vary even within the Hippocratic Corpus. Disease is not the result of invisible forces or the gods, but processes that occur within the natural world. In general, it is the product of an indivi duals nutrition and interaction 1 Nutton (2004) 28. 2 Jones (1984) ix. 19

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20 with his environment, which causes problem s with the bodys system of fluids and conduits. 3 These problems can be the result of ma tter settling in a particular place, the presence of bad gases, or a surplus or de ficiency of an otherw ise beneficial fluid. 4 All of the Hippocratic authors give natural explana tions for disease that are general enough to explain all or most conditions. The aut hor of the Anonymous Londinensis papyrus acknowledges that there is much argument ove r the cause of disease. Popular theories are that it is the product of residues (either pathological or produced as the bodys natural secretions) or of changes in the bodys elements Physicians tend to believe in the theory of residues, while the philos ophers tend to believe in the theory of elements. The majority of Greek medical writers believed that epidemics were caused by bad air. According to Meno, Hippocrates believed that di sease was the resulted of badly digested or unwisely selected food, which produces ba d air within the body. Some of the other works and their explanations are as follows: The author of Breaths supports the theory that Hippocrates supposedly held. Places in Man cites seven types of flux of the humors, originating in the head and settling elsewh ere in the body, as cause of disease. The author of Diseases gives three causes: imbalance of humors (primarily with relation to diet), violent causes (falls, fatigue, or wounds), and the atmospheric conditions. 5 For the ancient Greeks, the factors af fecting health were behavior and environment. Behavior includes any action a person may do throughout the day, especially eating and exercising. Naturally, eating good foods in moderation and 3 Kosak (2000) 38; Nutton (2004) 77. 4 Nutton (2004) 26, 29, 72, 78. 5 Carrick (2001) 29.

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21 exercising sufficiently were the focus. Environment requires considerably more explanation. In Regimen the author says that a doctor must become acquainted with both the patient and his surroundings, which include the season, winds, weather, region, and even sunrise and sunset. 6 Airs, Waters, and Places provides guidelines for predicting the types of diseases are likely to be found in a region, based on geographical and environmental factors. Within the Epidemics there is a collecti on of passages known as the Constitutions which contains detailed and eloquent descriptions of the climate and geography of various regions. The best are found in books I and III; however, all of the books contain similar information. This idea of environment is inte rtwined with the idea of contagion. Many individuals may respond to the same environmental conditions, but many individuals grouped together have no greater chance of becoming ill than a small group does. 7 It is the constitution and behavior of the individual and the impact of the environment that count, not the population de nsity. While the noti on of contagion is present, it is not as important a factor as one might expect. Thucydides mentions it in his description of the plague of Athens in 430 BCE, other authors use person-to-person contact to explain why some become sick while others do not, and it was also commonly used to describe religious pollution. 8 In spite of this, the Hippocratic physicians do not apply it to their hypotheses. 9 Another related missing consid eration is the association of cities to health. None of the Hippocratic authors recognize a conn ection between health and the high population density of cities, which we now know to increase the danger of 6 Nutton (2004) 75-76. 7 Kosak (2000) 38. 8 Kosak (2000) 38; Nutton (2004) 28; cf. Thucydides Peloponnesian War 2.51.5. 9 Kosak (2000) 38.

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22 infectious diseases significantly. In spite of their focus on and knowledge of geography and climate, none of the aut hors in the Corpus maintain that any one Greek state is healthier than the other. Wh ile it is beneficial to unders tand what the Greeks thought of disease and factors affecting health, it equally important, if not more, to apply some modern medical knowledge to what we know a bout fifthand fourth -century Greece, so that we will be better prep ared to take on individual case histories in the following chapter. For each civilization, there are certain f actors that affect the health of the population as a whole. Quite often, many of these are beyond their control: Humans are most vulnerable to their environment when they are either very young or growing old, and the elderly are subjected to number of maladies which rarely affect the young and middle-aged. Location and type of community in which they live predispose them to a particular set of illnesses. Additionally, where and how people live determines what they eat, which can also have a negative effect on health at times. The age structure of ancient Greece aff ected the types of conditions seen by physicians on a regular basis. In spite of a high infant mortality rate, children who survived through their first year often lived into their thirties or forties. 10 Many historical figures are known to have lived much longer. Diseases that become prevalent in aging individuals would not have been extr emely common. Additionally, the gradual deterioration of mind and body was expected as part of aging, so it is not given much 10 Nutton (2004) 22.

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23 special attention. 11 Consequently, we can expect di seases and conditions that affect people of all ages in most cases. Both urban and rural area s carry certain sets of ri sks. Before and during Hippocrates time, large cities were quite rare. 12 The largest of these, such as Athens, Corinth, Syracuse, and Carthage, had over 15,000 inhabitants. Most cities were much smaller, having 2,000 or fewer people living w ithin the city, and approximately 6,000 at most including surrounding areas. It is importa nt to note that populat ion density is more important than the size of the population. Th e larger cities attract ed people from great distances, thereby replen ishing a population that was not self-sustaining. 13 Additionally, the population of these cities grew substantially in times of cr isis because of the influx of nearby people, as in At hens during the plague. 14 Mirko Grmek argues that increasing populations and urbanization in the sixth and early fifth centu ries caused an increase of disease in Greece and a lowered life expectan cy, as many diseases only flourish when population density is high. 15 Hippocrates cities, on the other hand, were small, selfsufficient, agrarian communities. 16 They were more exposed to diseases carried by the regions fauna, but at less risk of contracting highly-conta gious diseases from others. The locations of the communities also played a significant role. Those near malarial 11 Nutton (2004) 23. 12 Nutton (2004) 19. 13 Nutton (2004) 22. 14 Thucydides Peloponnesian War 2.52. 15 Grmek (1989) 92, 98-9, 104; Kosak (2000) 35. 16 Nutton (2004) 20.

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24 lowlands were especially sickly. 17 This will be discussed in detail later in this chapter. The authors of the Hippocratic Corpus do relate cities to healt h, but only with regard to their geography. 18 Cities are not considered to be any better or worse than the country for ones health. For the Greeks, the health of a city was related to the wind, sun, and water supply. Even in the Epidemics which are often specific to one particular city the authors do not give specific examples of cities or towns when discussing geographic factors. Moreover, whereas the authors of AWP and R describe places which they deem to be most healthy, the authors of the Epidemics offer no advice on where to live. Another major factor in the general health is malnut rition, which often results from climactic changes. 19 During the winter months, fruits, vegetables, and seafood could become scarce. A poor harvest or hars h winter could easily obl iterate a significant portion of a citys food suppl y, greatly affecting health. The Greeks made this association, as the similarity between the words limos (dearth) and loimos (disease) suggests. Malnutrition decrea ses the populations resistance to disease; consequently, outbreaks are often associated with local fami nes, periods of siege, and armies, either when camped or on campaign. 20 This concludes the general factors that affected health in ancient Greece, so we can now consider specific diseases, both ancient and modern. Before we begin to discuss the specif ic diseases, we must once again remind ourselves that the Greeks diseases were de termined by symptoms, not causes, and that the terminology is often extremely vague. For example, is usually translated as 17 Nutton (2004) 21. 18 Kosak (2000) 36. 19 Nutton (2004) 21. 20 Nutton (2004) 25.

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25 tuberculosis, but it could be one of many diseases. 21 All skin lesions were typically grouped together and there is no guarantee of consistent usage of terminology among physicians. In spite of these difficulties, we are still able to recognize many modern diseases in the ancient writings. Some common examples include coughs, colds, pneumonia, pleurisy, diarrhea, jaundice and other liver infections, parasitic digestive tract infections, tapeworms, ulcers, and leprosy (Hansens disease). 22 Kidney and bladder dysfunction are mentioned frequently. 23 Eye diseases, such as glaucoma, trachoma, and conjunctivitis are commonly mentioned. 24 Strokes, epilepsy, migraines, headaches and other nervous and mental disorders are de scribed in both medical and non-medical texts. 25 Fevers () are the most extensively depicted condition. 26 This broad category includes any condition causing a feeling of excessive heat, either by the patient or the doctor. 27 These fevers were classified by thei r periodicity, that is, the pattern of the highs. Some fevers maintained a constant high and then resolved, while others peak at highly-predictable intervals, such as two ( ), three ( ) or four days ( ). W. H. S. Jones stat es that these fevers are 21 Nutton (2004) 29-30. 22 Descriptions of disfiguring skin diseases in texts from Babylonia, Egypt, and Israel from before 800 BCE are more likely to be psoriasis than leprosy. See Nutton (2004) 29. 23 Nutton (2004) 30. 24 Nutton (2004) 31. 25 Nutton (2004) 31. 26 Nutton (2004) 31. 27 Nutton (2004) 31-32.

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26 indicative of malaria and his view is maintained by more recent scholarship. 28 The most dreaded fever is the semitertian, which Celsus describes: Tertianarum vero duo genera sunt. Alterum eodem modo, quo quartana, et incipiens et desinens, illo tantum interposito discrimine, quod unum diem praestat integrum, tertio redit. Alterum longe perniciosius, quod tertio quidem die revertitur, ex quadraginta et octo horis fere triginta et sex per accessionem occupat interdum etiam vel minus vel plus neque ex toto in remissione desistit, sed tantum levius est. Id genus plerique medici appellant 29 There are indeed two types of tertian fevers. One, beginning and ending in the same manner as a quartan fever, with only this difference admitted, that it provides one free day and returns on the third. The other is more dangerous by far, as it indeed returns on the third day, out of forty-ei ght hours, it o ccupies about thirty-six hours with the attack, sometim es even more or less, and it does not cease in the entire remission, but it is only lighter. Most doctors call this time semitertian. The semitertian fever, which is commonly known as the malignant tertian fever, is indicative of falciparum malaria. 30 Malarial cachexia, the result of a chronic malarial infection, with symptoms of anemia, weakness, dark complexion, and enlarged spleen is frequently found in the Hippocratic Corpus. 31 The common varieties of malaria in the Mediterranean are Plasmodium vivax, P. malariae, and P. falciparum which is the most hazardous. 32 The Greeks were certainly familiar with the effects of these diseases: Upstairs rooms are known to be healthier, se vere fevers are especi ally common in years having wet springs and hot summers (first providing an ideal breeding ground for 28 Jones (1984) lvii; Sallares (2004) 311. See Jones (1977) 63-68 for a detailed discussion of various fevers and associated variants of malaria. 29 Celsus De Medicina III.3.2. 30 Sallares (2004) 314. The presence of Plasmodium falciparum which causes falciparum malaria, in ancient Greece is still debated. Bo th Jones and Sallares believe that P. falciparum was present. See Sallares (2004) 311. 31 Jones (1984) lviii; Jones (1977) 98-101. 32 Nutton (2004) 32.

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27 mosquitoes, then forcing them to relocate), and areas near fresh-water marshes are more dangerous than salt-water marches. The chill associated with fevers is described in two ways: The cold sensation is and the associated shivering is Melancholia (), as its name suggests, was t hought to be caused by black bile. 33 This causes physical and mental prostr ation and is now associated w ith malaria. In addition to fevers, there are several other conditions worth mentioning. Colds, both with and without associated fevers, were common, but the presence of influenza is unknown. 34 The description of the epidemic cough at Perinthus in Epidemics IV appears very similar to influenza; however, it is stated that relapses into pneumonia were rare. Especially in older individuals, the infl uenza virus or an associated bacterial infection causes pneumonia. Various types of inflammation are often described. 35 The two most common forms are and Both varieties are warm, but the former is a superficial and yellow and the latter is considered internal and red. Common digestive problems are and 36 Diarrhoia is simply the production of loose stool. Dysenteria however, is a more se rious condition that is associated with fever, ulcerati on, and the blood in the stool. This may be associated with typhoid or paratyphoid. 33 Jones (1984) lviii. 34 Jones (1984) lv. 35 Jones (1984) lviii-lix. 36 Jone (1984) lix.

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28 Madness is communicated by various words. 37 Although each of these probably each had a more specific meaning, only vague distinctions can be drawn. One group emphasises delirium: , , , and The other group places emphasis on speech: , , and The most common of these in Epidemics I is Combinations of the preceeding symptoms with many others constitute diseases for the Greek physician. A sound knowledge of diseases allowed him to provide his patients with an accurate prognosis when the symptoms resembled a known case and also to treat the patient to the best of his ability. Hippocrates Epidemics served as a practical guide to a handful of diseases. With Greek medical theories a nd an understanding of ancient diseases in mind, let us now turn our attention toward the Epidemics their method of diagnosis. 37 Jones (1984) lix.

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CHAPTER 5 ANCIENT AND MODERN DIAGNOSES The Epidemics include representative cases in order to help the physician recognize known sickness and know how to e ffectively predict their outcome and, if possible, treat them. The earliest books of the collection, I and III, contain cases in two different formats. Epidemics I begins with three Constitutions These are nicely-written, graphic descriptions of the climate and illness of a specific region, Thasos, in this case. The style of these passages indicates that they were written to be r ead by others. At the end of the second Constitution the author includes a short didactic passage regarding crises in serious diseases, the physicians modus operandi and head pains. 1 The remainder of the book is occupied by fourteen individual case histories. These are not written in the style of the first part of the book as sentence s are very brief and abrupt. Epidemics III has twelve case histories, followed by a Constitution and sixteen more individual cases. In all of these cases, the author gives what he deems to be the most significant features: The following were the circumstances attending the diseases, from which I framed my judgments, learning from the co mmon nature of all and the particular nature of the individual, from the disease, the patient, the regimen prescribed, and the prescriberfor these make a diagnosis more favourable or les; from the constitution, both as a whole and with resp ect to the parts, of the weather and of each region; from the custom, mode of lif e, practices and ages of each patient; from talk, manner, silence, thoughts, sleep or absence of sleep, the nature and time of dreams, pluckings, scratchings, tears; from the exacerbations, stools, urine, sputa, vomit, the antecedents a nd consequences of each member in the successions of diseases, and the abscessions to a fatal issue or a crisis, sweat, rigor, chill, cough, sneezes, hi ccoughs, breathing, belchings, flatulence, silent or 1 Hipp. Epidemics I.11.1-I.12.16. 29

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30 noisy, hemorrhages, and hemorrhoids. From these things must we consider what their consequents also will be. 2 The author stresses individual symptoms, distinguishing between the essential and nonessential. 3 Some of the symptoms noted by the au thor are helpful for applying a modern diagnosis, such as patterns of fevers, s udden changes (especially with respect to consciousness), how the patient breathes, etc. 4 The differing goals and methods of ancient and modern diagnosis must be discusse d in more detail before we apply them to the case histories found in the Epidemics The ancient physician, using the few tools available to him, achieves diagnosis through inspection, palpitation, auscultati on, taste, and smell during his bedside observation. 5 The appearance of the patient, incl uding facial expression, posture, skin tone and abnormalities, and ocular disorders, is carefully recorded. Several observations denoted grave diseases: the physician consid ered patients who were found either with gross facial discoloration, lying supine with limbs extended, waving their hands frantically in front of his face, or randomly moving his fingers to be at great risk of death. All quality of all bodily fluids and excreta is also noted. Pulses, which are measured on the temples, arms, chest, abdomen, and wrists, are used as an indication of temperature; however, little attention was paid to the pulse rate inde pendent of temperature. Palpitation allows examination of the kidneys, liver, spleen, and uterus, and also reveals fluid in the abdominal cavit y. Direct auscultation, the placing of the physicians ear 2 Hipp. Epidemics I.23.1-18, trans. Jones (1984) 181. 3 Gordon (1949) 522. 4 Nutton (2004) 90. 5 Gordon (1949) 522-523.

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31 against the patients chest, allows him to ch eck for the presence of fluid in the lungs. Additionally, the taste and small of all excret a, including sweat, sputum, vomit, feces, urine, and pus, to assist in diagnosis. Fo r example, the presence of sweet-tasting urine denotes the diabetes. The thoroughness of th e ancient physician in the recording of symptoms is extremely impressive. While the goal of ancient diagnosis was to accurately record all of the symptoms of an ailment in order to facilitate prec ise prognosis, modern diagnosis attempts to identify the cause of the illness so that effective treatment can be rendered. The observation of symptoms is as important today as it was in Hippocrates time. Modern medicine uses the process of differential dia gnosis in an effort to precisely identify the cause of the disease. After the patients sy mptoms are recorded, those which are deemed most important are compared with the va st number of known diseases. Once possible diseases are identified, the physician then uses a process of elimination to find the specific disease. Using the information th at the author provides and differential diagnosis, let us now turn our attention toward Epidemics I and III to examine the cases and, if possible, apply a modern di agnosis. We will begin with the Constitutions in Epidemics I. In the first case of the first Constitution, the author tells us about an illness that affected the people of Thasos. 6 He first summarizes the weather for one year, and then he describes the illness, which occurred during the early spring. There are not many symptoms to describe, but they are clear and, in this case, easily recognizable. The first symptom mentioned is a fever th at affected a few patients. The next symptom is much 6 Hipp. Epidemics I.1.1-29.

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32 more helpful: and there were swellings by the ears on one side for many and on both sides for most. 7 He then identifies those who were afflicted: , , these happened to boys, young men, men in their prime, and to moist of those about the palaestra and gymna sium. It happened to a few women. 8 The patients also had dry coughs and hoarse voices. The final symptom makes the illness perfectly clear: , there was painful inflammation in the testicle on one side, but in both for some. Again, our sy mptoms are fever, swellings near the ears, sore throats, and, in some cases swollen testicles. This is clearly an outbreak of mumps, the symptoms of which are swollen salivary gl ands with a secondary severe sore throat, fever, headache, and swollen testicles in a pproximately twenty percent of post-pubescent males. Mumps is transmitted through saliva droplets, it makes sense that it would be easily spread while the men and boys exercise and wrestle. This is one of the easiest cases in the Epidemics to diagnose. The second case of this Constitution is much more difficult. 9 The author prefaces this case by informing us that the illness ha d been affecting some people for a long time and others who had been suspected of having it eventually developed symptoms. The outcome of this disease was not good: but many 7 Hipp. Epidemics I.1.10-12. 8 Hipp. Epidemics I.1.20-22. 9 Hipp. Epidemics I.2.1-35.

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33 more of these people died. 10 We are told that this is consumption, but they were dying faster than those [conditions] like it were accustomed to progress. 11 Some of the symptoms of this disease include semitertian fever, which peaks on alternating days but remains rather high on the low da ys, sweating, cold extremities, digestive problems, and sputa. Additionally, most patie nts also had a painful sore throat. The symptoms worsened until the patient died. The key to diagnosing this disease is the semitertian fever, which is caused by Plasmodium falciparum Falciparum malaria can damage the brain, lungs, and kidneys. Cerebr al malaria, which can only be caused by P. falciparum is especially dangerous and produces high fevers, headaches, drowsiness, delerium, confusion, and coma. The presence of these symptoms further strengthen the argument for the existance of P. falciparum in ancient Greece: all together they we re wakefullness, and especially [the semitertians], and then they were comatose. 12 If it were not for the clear presence of the malarial fever, it would be considerably more difficult to diagnose this case because of the combination wide range of symptoms resulting from damage to the brain, lungs, and kidneys. The first individual case exhibits an in teresting symptom, as does the fifteenth case in the last part of Epidemics III. In the former case, the author says: , throughout the end, his breathing, as if 10 Hipp. Epidemics I.2.6-7. 11 Hipp. Epidemics I.2.9-10. 12 Hipp. Epidemics I.7.16-17

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34 he were recalling it, was slight and great. 13 In the latter: , on the fourteenth day, breath was slight, gr eat for a time and again short of breath throughout the end, her breath was slight and great. 14 These descriptions appear to be of Cheyne-Stokes breathing, in wh ich breathing quickens, retards, stops, and restarts over thirty seconds to two minutes. The first patient died on the following day, which was the sixth day of his sufferning, and the second patient died one week later, a total of three weeks from the first sign of illness. Cheyne-Stokes breathing is common in patients dying of congestive heart failure, which can have many causes and varied symptoms. The eighth individual case is also diffic ult to diagnose, but is worthwile to consider. 15 Erasinos became ill with a fever discomfort after dinner and suffered until his death on the fifth day. He suffered from de lerium on most days. His hypochondria were swollen and painful and his urine was blac k. The black urine and swollen, painful hypochondria may be evidence of kidney failure of unknown etiology. In this, and similar, cases, the brevity of the description and lack of a history make diagnosis extremely difficult. The following case is of a different nature than all previous cases. 16 Krito of Thasus experienced a sharp pain in his big toe while walking. He became nauseous, began to shiver, and became delirious. On the second day, his entire foot was swollen with black blisters, he had a severe fever, and he was still delirious. Krito died later that 13 Hipp. Epidemics I.26.39-40. 14 Hipp. Epidemics III.17.327-328, 334. 15 Hipp. Epidemics I.26.209-225. 16 Hipp. Epidemics I.26.226-234.

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35 day. The immediate pain and subsequent sw elling seem to indicate a poisonous bite or sting. It was probably not an allergic reaction to an otherwise harmless wound, as anaphylactis, the common allergic reaction to stings and bites, would have taken his life very quickly. A more detailed description of the patients toe would help to better diagnose this case. The key to the fourth case in Epidemics III may lie in the patients history, which is briefly mentioned. 17 The author says: the pain of fevers grew worse from drinking. We are also told that, on the second day, , the right hypochondrion drew tight and was sinking inwards. The right hypochondrium, located just below the ribs, corresponds to the site of the liver. A history of heavy drinking leading to chronic liver failure with rapid progression within the last few days seems appropriate for this case. The Constitution of Epidemics III contains a horrify ing condition. After the description of the climate, the author begins to describe the condition: , , early in the spring, at the sa me time as the cold spurts, there were many abominable instances of erysipelas 18 some with causes and some without; it killed many. 19 More detail is given in the following section: 17 Hipp. Epidemics III.1.98-109. 18 This is a transliteration of the Greek word and refe rs to a type of streptococcal cellulitis in modern medicine. Here I am using it to denote cellulitis of unknown etiology. 19 Hipp. Epidemics III.3.1-3.

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36 many had erysipelas with a cause in accidents and in very little wounds in the whole body. 20 From this statement, it appears that the cellulitis typically originates at the site of a cut or scrape. The cond ition is worse than it originally seems: the erysipelas was spreading very quickly from every direction. For most of the patients the rising [of the inflammations] we re falling together into abscesses. There was a great decay of flesh, muscles, and bones. 21 Our problem has gone from mere cellulitis to necrotizing fasciitis. This is similar to n ecrotizing cellulitis, but penetrates deeper and enters the surface of underlying muscles. Thes e infections are caused by bacteria such as varieties of Streptococcus and Clostridium and originiate at las cerations, as our author mentions. The author succinctly generalizes the outcome with these were more frightening than dange rous, goes on to describe the result of the infections, including the loss of la rge areas of skin, amputation, and death. 22 The mortality rate for these necrotizing infec tions is approximately thirty percent. 20 Hipp. Epidemics III.4.1-3. 21 Hipp. Epidemics III.4.6-10. 22 Hipp. Epidemics III.4.17.

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CHAPTER 6 CONCLUSION The best attempt at diagnosing th e case histories in Hippocrates Epidemics is rooted in a firm understanding of the text, its author(s), and the beli efs of the time. The ability to understand the Greek, w ith all of the technical terms that are specific to medical treatises, is of utmost impor tance. The primary litera ture is the basis of our understanding of ancient Greek medicine and it should not be neglected. There is an abundance of literature on Hippocrates, the Hippocratic question, the Hippocratic Corpus and ancient medicine to assist in the acq uisition of this unders tanding. It is only with this material in mind that one ha s a chance of truly understanding Hippocratic writings. As we have seen, some cases are very easy to diagnose, while some are quite puzzling, even to gifted physicia ns. All that we are able to know about the patients is what we are told, so our attempt at diagnosis relies completely on the ancient physicians accurate recording of the symptoms, which was his diagnosis. Positive diagnoses are only possible when the ancient physician mana ged to record unmistakeable symptoms of modern diseases, such as mumps and falciparum malaria. Even then, there is a degree of uncertainty, as we are constantly discovering slight variations of modern diseases. In all other cases, there is no way to be absolutely certain of the patients illness. Regardless of outcome, to spend time reading the Epidemics carefully is a pleasure. Whether we 37

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38 experience the satisfaction of believing that we have successfully diagnosed a case or the challenge of a case that cannot be solv ed, the experience is truly rewarding.

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REFERENCES Carrick, P. (2001) Medical Ethics in the Ancient World Washington Craik, E. (1998) Hippocrates: Places in Man. Oxford Daremberg, C. (1870) Histoire des sciences medicales. Paris; trans. Jones, W. H. S. (1984) Hippocrates I Gordon, B. L. (1949) Medicine throughout Antiquity Philadelphia Glare, P. G. W., ed. (1982) Oxford Latin Dictionary Oxford Grmek, M. D. (1989) Diseases in the Ancient Greek World Trans: M. Muellner and L. Muellner. Baltimore Hope, V. M. and E. Marshall eds. Polis nosousa: Death and Dise ase in the Ancient City New York Jones, W. H. S. (1977) Malaria and Greek History New York ------, (1984) Hippocrates I Cambridge Kosak, J. C. (2000) Fifth-century Greek Id eals on City and Disease, in Hope and Marshall (2000), 35-54. Liddell, H. G., R. Scott, and H. S. Jones (1996) A Greek-English Lexicon. Oxford Lloyd, G. E. R. (1991) Methods and Problems in Greek Science. New York Longrigg, J. (1993) Greek Rational Medicine: Philosophy and medicine from Alcmaeon to the Alexandrians. New York Nutton, V. (2004) Ancient Medicine New York Sallares, R, A. Bouwman, and C. Anderung (2004) The Spread of Malaria to Southern Europe in Antiquity: New Approaches to Old Problems. Medical History 48(3): 311-328 Spencer, W. G. (1935) Celsus I Cambridge 39

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BIOGRAPHICAL SKETCH Anthony Strazzulla was born on August 2 nd 1981, in Monroe, Michigan. He moved to Palm Bay, Florida, in 1996 and la ter to Indian Harbour Beach, where he graduated from Satellite High School in 2000. He graduated from the University of Florida with a Bachelor of Arts degree in cl assics and history in 2004. He will receive a Master of Arts in Latin from the University of Florida in May, 2006. 40