Monday, July 18, 2011

2011.07.28

M. Horstmanshoff (ed.), Hippocrates and Medical Education: Selected Papers Presented at the XIIth International Hippocrates Colloquium, Universiteit Leiden, 24-26 August 2005. Studies in Ancient Medicine, 35. Leiden: Brill, 2010. Pp. 420. ISBN 9789004172487. $200.00.

Reviewed by Nicole Wilson, University of Calgary (nicole.j.wilson@ucalgary.ca)

Version at BMCR home site

Table of Contents

Hippocrates and Medical Education is the publication resulting from the XIIth International Hippocrates Colloquium organized by the University of Leiden, 24-26 August 2005. The theme brought about a hundred papers, of which twenty-three were revised (and some translated into English) for publication. Inspired by the legacy of the name and idea of Hippocrates, the Colloquium "would take the term 'Hippocratic' very broadly" (x). The resulting papers address time periods ranging from the 5th century BCE to 18th century CE. As noted by its editor, Manfred Horstmanshoff, this book is the first dedicated to the topic of ancient medical education.1 The topics on this theme are as varied as the time periods covered and the book is divided into four main sections. Part One, 'Doctors and Laymen', addresses the interaction and competition between physicians and non-physicians. The chapters of Part Two, 'Teachers and Pupils', address the didactic calling of physicians and the Hippocratic treatises. Part Three, 'Teaching of Surgery and Obstetrics', has the most specific theme, with its papers covering the surgical and obstetric treatises of the Hippocratic Corpus. Part Four 'Galen and the Hippocratic Tradition' is the most extensive and the chapters cover almost sixteen hundred years. These chapters seem to lack a theme as cohesive as the previous sections, other than providing a chronological progression of medical education from Galen to Boerhaave. This, however, does not diminish the importance of the arguments made. With its wide variety of topics and time periods, scholars of ancient medicine and its reception will find much benefit to this volume.

That said, any work, even one of this size, cannot cover all aspects of an area of research. Manfred Horstmanshoff acknowledges in his preface the significant gap in the volume: a study of social context. With over twenty different authors in the volume, some do touch on this aspect of ancient medical education, but only sparingly. One element of cultural context that is highlighted by various authors is the debate concerning the place of medicine and the physician. Was he an intellectual, a craftsman, a philosopher, rhetorician, or all of the above? The physician's role in ancient society was complex and his education was not limited to anatomy.

The training of physicians, or lack of training as the case may be, created an issue of trust in the medical techne, even in antiquity. Natacha Massar, in her chapter, notes that the 'lack of official training and of diplomas in Antiquity has often been pointed out' (169), an observation that is seconded by Louise Cilliers (406). That said, the 2nd century CE Roman physician Galen does provide us with some information about the training of physicians, if not their certificates. But, as Gabriele Marasco notes, Galen's account is 'highly individual' (205), and we cannot assume all physicians were trained as thoroughly as Galen. On the same note, we cannot assume that they were not. This volume provides both survey and in-depth analysis of what, how, and from whom ancient physicians learned their trade.

The first paper of the volume stands outside the four sections listed above. Jacques Jouanna's look at a fresco from the cathedral of Anagni serves as an indication that this book uses a variety of different source material apart from the Hippocratic Corpus and the other medical texts exhibiting Hippocrates' influence on medical education. This chapter unsurprisingly affirms the approach to be seen often in this book of approaching Hippocrates through his most devoted student, Galen. Many of the following chapters, including the entire fourth section of the book, acknowledge or address Galen's involvement in the spread of Hippocratic medicine. While this is not in itself novel, chapters like Jouanna's approach the topic with new evidence – addressing the basic question as to why Hippocrates and Hippocratic medicine drew so much fascination. He gives two reasons: the respect for tradition and its foundation in reason. It is because of Hippocrates that Greek medicine is defined as a techne. That said, and as many authors in this volume attest, it was a battle for the physician to defend medicine's place as a craft. Even though the treatises of the Corpus are not by one single doctor, school of medicine, or even time period, the coherence developed by the Corpus itself makes it the foundation for medical education.

The four sections to follow address the influence of Hippocrates and the Hippocratic tradition and the methods by which physicians learned their trade. The first section reveals that ancient physicians were trained in various other aspects of education, such as grammar, philosophy, and rhetoric. Moreover, they were called upon to distinguish and defend themselves, and their craft, at various times. Ineke Sluiter shows that Galen resisted the tradition of seeing grammar and medicine as sister disciplines. Instead, for fear that 'he could easily come under the suspicion of having too great an interest in grammar' (50), Galen promoted himself as a philosophical physician and not a grammatical one. It is clear to Sluiter that by the second century CE there was more prestige in being a physician than a philologist. Lesley Dean-Jones' novel approach to the Hippocratic treatise Physicians, a text traditionally interpreted as being for students, argues that the text is a pedagogical treatise for novice instructors - what she terms 'the equivalent of their local GP' (72): This change in interpretation explains the text's tone and the information provided. The use of rhetoric is explored by Pankaj K. Agarwalla. He uses the Corpus to show that while many of the Hippocratic treatises criticize the use of rhetoric, they expect the physician to use his rhetorical skills as a sign of competence. The physician's use of, what he terms, 'rhetoric of anti-rhetoric' (74) allows the physician to defend not only his medical ideas, but the craft of medicine as a whole. The need to defend medicine is echoed by Adriaan Rademaker's analysis of the treatise The Art. He reveals that ancient physicians had a mastery over language, which they used to defend their craft. Pilar Pérez Cañizares argues that the treatise The Affections is a medical treatise for use by non-physicians. They, along with physicians, could have turned to the lost treatise Remedies for therapies.

Section Two addresses the pedagogical practices and training of ancient physicians. Robert Alessi's analysis of the authorship of the Hippocratic treatises Epidemics 2, 4, and 6 reveals the extent to which the personality and interests of the author/teacher can be found in the passages. The use of the discussion of errors in the Hippocratic treatises is the focus of Roberto Lo Presti's contribution. Ancient physicians were constantly exposing themselves to the risk of error, and therefore used them as a teaching tool and source of knowledge. Natacha Massar, focusing her attention on the fourth century and Hellenistic period, reveals the importance of choosing a good master for training, as it was the first step in establishing a reputation for the doctor-to-be. She argues that the influence of one's master was a widely recognized practice and could help a new physician persuade laymen of his qualifications or give authority to his treatises. This support from the network of other trainees and patients developed during training could also provide support claims of competence. Ann Ellis Hanson argues that the existence of private letters, didactic texts, and collections of recipes in Egypt dating to later Antiquity provide evidence for an interest in medicine by a wide range of people outside of medicine. This evidence implies participation in a literate culture, but also shows that the doctors of Egypt were being trained with approaches similar to those seen in the Mediterranean, such as Galen. A medical curriculum for the Greek part of the Roman Empire, especially Alexandria, is provided by Gabriele Marasco. This chapter is probably the most thorough in terms of a general outline of how physicians in antiquity would have learned their craft, but it also outlines the other areas of education they would have had to have learned in addition to medicine and anatomy. Physicians would have been trained in philosophy, grammar, rhetoric, oratory, and even poetry.

Part Three, provides a detailed look at the surgical and obstetrical treatises of the Corpus. Elizabeth Craik and John Scarborough analyze the approaches to teaching surgery through the Hippocratic Corpus and later commentaries respectively. Craik begins her analysis with the mythical surgical teacher, the centaur Chiron, and then turns her attention towards the actual surgical treatises. She reveals that the lack of the verb didasko shows that the focus of the treatises is on the attitudes towards training, not the training itself. Scarborough clearly shows through the medical commentaries from the late fifth, sixth, and early seventh centuries, that physicians in later Antiquity learned from, but also criticized the treatises from the 5th century BCE. The last three chapters of this section focus their attention on the treatises dealing with midwifery and obstetrics. The image of the ideal midwife as presented in Soranus in comparison to the image from other sources, such as inscriptions is analyzed by Christian Laes. Recipes for remedies are the focus of Laurence M.V. Totelin's chapter. He argues that the written recipes found in the gynaecological treatises of the Corpus are meant as, what he terms, 'aide-mémoire' (297) and do not contain all of the required information need to prepare the drug. Instead, knowledge of these treatments would have been required by the reader, both iatroi and laymen. Daniela Fausti analyzes the method and scientific coherence of the treatises Generation, Nature of the Child and Diseases 4 to show that they were most likely written by the same author, a recognition made in the edition by Littré.2

Part Four is the most populous of the four sections. Ralph M. Rosen looks at the influence of satire in Galen, while Caroline Petit assesses Pseudo-Galen's use of Hippocrates in his Introduction. This simplified version of Hippocrates reveals a 'two-speed system' (357) for medical pedagogy in the Roman era: the lengthy, philosophical course of Galen and the rapid and more practical course of study by the majority of students in the Roman world. A mini-source book of Galen passages that reveal the physician's approach to teaching and studying medicine is created by Juan Antonio López Férez. Louise Cilliers' chapter uses the letters of Marcellus to show the distrust of physicians during the Late Roman Empire due to the different sources, training, and variety of healers available at the time. The importance of philosophy to a medical education in Late Antique Alexandria and the influence of this technique on the Islamic authors of the medieval period, most notably Avicenna (Ibn Sīnā, d. 1037) are discussed by Peter E. Pormann . Karine van 't Land reveals the advantage that non-academic surgeons had through analysis of two late medieval Middle Dutch surgical handbooks. Lay surgeons were more approachable and were not restrained by professional barriers. The renewed importance given to Hippocrates due to growing criticism of Galen in eighteenth century Spain is the focus of Jesús Angel y Espinós' chapter. Finally, Roberto Lo Presti shows how Herman Boerhaave argued for the study of Hippocratic treatises and moulded the image of Hippocrates to legitimatize his approach to medical didactics.

This book is an excellent source of information, from surveys of medical training and education programs, to specific analysis of certain treatises. While most helpful to a scholar of ancient medicine, the later chapters dealing with Hippocratic reception may find a wider audience in scholars of the history of medicine in general. The bibliography is extensive and in all relevant languages.



Notes:


1.   Following the article by F. Kudlien (1970), 'Medical education in classical antiquity' in: C.D. O'Malley (ed.), The History of Medical Education. University of California Press: 3-37.
2.   In his edition of 1851, Volume VII, E. Littré adopted continuous numeration of the chapters.

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