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13 The concepts of “spirit” (with respect to “vital”, “animal” and “vegetative”) and “pneuma” are synonymous in some ways. “Pneuma” is a broader concept since it is not only present inside the human body, but in the surrounding environment as well. A tradition has been established in historiography which prefers the concept of “spirit” to the term “pneuma” with respect to three types of endogenous pneuma. Hence we would rather use the phrase “animal spirit”, “vital spirit” and “vegetative spirit” with respect to pneuma inside the body (see: Balalykin, D.A., “The First Book of Galen’s Treatise On the doctrins of Hippocrates and Plato”, Voprosy Filosofii 8, 2015: 124–143; (In Russ.)). That being said, the use of the concepts of “animal pneuma”, “vital pneuma”, “vegetative pneuma” is not erroneous. The use of the concept of “psychic spirit” as synonymous with “animal spirit”is also not erroneous.
14 Gusev, E.I., Grechko, V.E. and Burd, G.S., Nervnye bolezni (Nervous diseases), ed. Gusev, E.I. (Moscow: Meditsina, 1988), 259–260. (In Russ.)
15 Ibid.
16 Bolezni nervnoy sistemy: Rukovodstvo dlya vrachey: V 2 t. (Diseases of the nervous system: Guide for doctors: In 2 vols.), Vol. 1, ed. Yakhno, N.N., 4th ed. (Moscow: Meditsina, 2007), 232. (In Russ.)
17 Ibid., 233.
18 Ibid., 259–261.
19 Galen, On the Doctrines of Hippocrates and Plato, Corpus Medicorum Graecorum V, 4, 1, 2, ed., trans. and commentary de Lacy, P. (Berlin: Akademie Verlag, 2005).
20 See: Kuhn, The Structure of Scientific Revolutions.
21 Stepin, Filosofiya nauki. Obshchie problemy, 384.
22 Ibid.
23 Ferngren, G., Medicine and Health Care in Early Christianity (Baltimore: Johns Hopkins University Press, 2009), 264.
24 Nutton, V., “Medicine”, in The Cambridge Ancient History, Vol. XI, ch. 33 (2000).
25 Hammond, N., History of Ancient Greece (Moscow: Tsentrpoligraf, 2003). (In Russ.)
Chapter 1
Philosophical basis of Galen’s medical doctrines
1.1 Galen’s perspective on the Hippocratic tradition
Galen follows in the tracks of Hippocrates in the fundamental principles of his theoretical and practical work. This continuity is not limited to methods of medical treatment alone. The essentially multidisciplinary physician’s training was always typical of the Hippocratic tradition—from the time of Hippocrates himself, to the time of Galen, when medicine finally established itself as a complex theoretical and practical system based on anatomical and physiological data. The principles of professional ethics and deontology also had been established by 4th century B.C. This line of ancient medicine was brilliantly demonstrated by Galen in his treatise The Best Doctor is Also a Philosopher:
What grounds are there then left for any doctor who wishes to be trained in the art in a way worth of Hippocrates not to be a philosopher? He must be practiced in logical theory in order to discover the nature of the body, the difference between disease, and the indications as to treatment. He must despise money and cultivate temperance in order to stay the course. He must, therefore, know all the parts of philosophy: the logical, the physical and the ethical.1
Another crucial task in the analysis of medicine in Hippocrates’ time is the question of its ties to natural philosophy. Those ties were not clear-cut. After all, some schools of natural philosophy by no means offered medicine the necessary methodological tools. The term “philosophy of medicine”, whose advocates were opponents of Hippocrates, even gained a foothold in historiography. One could reach the conclusion that the medicine of Hippocrates is exclusively practical, devoid of any theorising. That view is certainly wrong. Indeed, Hippocrates wrangles a lot with the “philosophers”, but it is important to understand with which ones in particular, and about what specifically:
Certain physicians and philosophers assert that nobody can know medicine who is ignorant what a man is; he who would treat patients properly must, they say, learn this. But the question they raise is one for philosophy; it is the province of those who, like Empedocles, have written on natural science. But my view is, first, that all that philosophers or physicians have said or written on natural science no more pertains to medicine than to painting. I also hold that clear knowledge about natural science can be acquired from medicine and from no other source, and that one can attain this knowledge when medicine itself has been properly comprehended, but till then it is quite impossible—I mean to possess this information, what man is, by what causes he is made, and similar points accurately. Since this at least I think a physician must know, and be at great pains to know, about natural science, if he is going to perform aught of his duty, what man is in relation to foods and drinks, and to habits generally, and what will be the effects of each on each individual.2
It is well-known that works assembled into the Hippocratic Corpus, were written by multiple authors: Hippocrates himself, his son-in-law Polybus and one or two of his followers.3 This is due to the difference in philosophical persuasions expressed in different texts: in some texts, the influence of Pythagoreans is apparent, while in some it is the influence of Diogenes of Apollonia, with his idea of air being the one source of all being, etc. However, the treatises containing the exposition of views on the principles of the development of diseases and approaches to their treatment are not contradictory in nature. And this is despite that they are often the result of “collective creation”. For instance, the treatise On the Nature of Man was started by Hippocrates and finished by Polybus. It also contains later inclusions penned by an unknown member of the Kos school after Polybus. In the context of analysing Galen’s idea, besides the treatise On the Nature of Man, the treatise On Ancient Medicine is of vital significance for us. Both these treatises are distinguished by preciseness of methodology, structuredness and clarity of argument.
The Hippocratic treatises On Ancient Medicine and On the Nature of Man assert the view that medicine should not be built on theoretical concepts about human nature, initially founded on some theory of natural philosophy. The task of the physician is to carefully observe the response of the human body to various external effects, assess the results of these observations and double-check them in practice. Thus the inversion of the cause-effect relationship occurs in the world of the scientist—from empirical observation to generalisations and not vice-versa.
Galen considers Hippocrates himself the author of the first part of the treatise On the Nature of Man, and Polybus—the son-in-law of the great physician4—the author of the second part. This work criticises those who speak of the nature of man as if of something beyond the frontiers of knowledge in medicine. Hippocrates and Polybus sharply rebuke monist natural philosophers who reduce all pathological processes to a single source, making ample use of contradictions between various theories to prove their inadequacies. The fallacious theory of “perpetual affection”5 arose from this misconception. Authors of the treatise chastise physicians who believe that man consists of a single one element, proving the fundamental meaning of the theory of the four liquids (blood, phlegm, yellow bile and black bile).
On his part, Galen stresses the importance of the idea of four primary elements as the foundation of the physics of the human body:
Combination and conformation in the bodies of animals are threefold: first of the so-called homoiomeres, i.e. arteries, veins, nerves, bones, cartilages, ligaments, membranes and flesh; second of the organs, i.e. brain, heart, lung, liver, stomach, spleen, eyes and kidneys; third of the whole body. Each of these organic parts is compounded from certain other parts that are simple in terms of sense perception, and each of these from the primary elements. Thus the differentia of flesh itself, qua flesh, is only in the combination of the primary elements; qua where it is part of an organ, it is on account of conformation and magnitude. And the differentiae of the organs themselves are also in these things.6
He believes that human nature cannot be described by the concept of a single source, otherwise the human being would not suffer due to the absence of a mechanism for disease development. This in turn distorts the approach to medical practice. One substance by itself cannot produce so many changes that can manifest in the multitude of diseases observed by the physician. Even if a certain number of alternatives of such variability were to exist, there would then be a single medicine for all diseases, which would correct the state of this single substance. However, it is clear to any reasonable physician that this is not so:
IX.6.63. For a person who knows that there is not one simple form of soul in us, such as the desiderative in plants or the rational in gods, but that men have both of these and the spirited besides as a third, knows along with this the number and nature of the virtues and how they are acquired, just as the person who knows the natural constitution of our bodies—that the natural state of every animate body results from the right proportion of the elements in the homoeomerous parts, and in the organic members from the quantity and size of the homoeomerous parts, and also from the conformation and position of each, the proportion of the things mentioned being of cource preserved in every animal in the way that is appropriate to it—that person unaided will succeed in finding the right treatment and prophylaxis for every desease. (PHP, 585, 587)7
All this by no means contradicts the positive evaluation of the first ancient rationalistic natural philosophy systems with their concept of the primary element. First of all, the primary element in said systems is understood not so much as a universal architectural material which constitutes man and the objects that surround him. This is about the physical prime cause of existence and, most important, the development and movement of matter, which replaces the arbitrary function of anthropomorphic deities. Secondly, the prime cause calls into existence numerous secondary consequences which complicate the cosmology of any school of natural philosophy as it develops. Thirdly, we consider as the foundation of the development of ancient medicine the movement of natural philosophy from early Ionian physics to the Platonic idea of the Creator-God (Demiurge) and the Aristotelian principle of the “primum mobile”, which shaped the methodology of knowledge in medicine. The idea of purposeful, functionally driven movement is arguably the most important in this context. The purpose of medicine, according to Hippocrates, consists in the following:
It is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their diseases, realising that in such cases medicine is powerless.8
Here the need to define health arises: Hippocrates thought it was most reasonable to define it in close relation to the concept of “disease”. Health is defined in the Hippocratic Corpus and by the apophatic method (i.e., through negation) as the absence of suffering, and cataphatically (i.e., through affirmation) as the existence of a body as a balanced mixture of elements. Galen subsequently employs the concept of the “good mixture” to describe health. Consequently, “disease” is defined as the antithesis of “health”, i.e., as the suffering of the human body through the disruption of the dynamic equilibrium of three tetrads (elements, liquids, essences). Here we see the continuity of Hippocrates’ idea and the preceding rationalistic theories about health and disease. According to Alcmaeon of Croton (the first in the history of medicine to attempt to construct a rational theory of general pathology), “isonomy” (ισότητα; i.e., “equilibrium” of the properties wet, dry, cold, hot, etc) is indicative of “health”, whereas “monarchy” (µοναρχία, i.e., the “dominance” of one these properties) shifts the equilibrium and, as a result, leads to disease. Indeed crucial thesis, which still compounds the base of medical knowledge, is dynamical condition of the organism.
The novelty in Hippocrates’ theory lay in the fundamental addition to the idea of equilibrium (or its shift) of the concept of the mixing (“crasis”) of basic substances which constitute the human body. Internal equilibrium of primary elements and liquids, their balance, in particular, indicated the “good mixture”, i.e., the state of health. Therefore, in the Hippocratic Corpus we are faced with a more complex system of general pathologies, which raises questions about the balance between internal states of the body, on one hand, and external effects on the other hand. Various external factors (from sudden deviations in diet to changes in climate in the form of extreme cold or heat) could have a damaging effect which disrupts the internal balance of the state of the body. All this required assessment by the physician. The key concept here was the category of “transition” (µετάβαση), which became a crucial component of the Hippocratic theory of pathology. The physician was supposed to pay close attention to history taking in order to determine the lifestyle the patient was used to before the onset of the disease. The boundaries between the normal and pathological states of the body in the works of Hippocratic physicians are not clear-cut: health is a fragile equilibrium which can be easily disrupted. Galen notes in the treatise On the Doctrines of Hippocrates and Plato that, according to his information, Hippocrates was the first to point out the primary importance of the proper relationship between the components for the state of human health:
VIII.4.7. Hippocrates was the first of all the physicians and philosophers known to us who <…> said that the deseases of the primary bodies are caused improper mixture. (РНР, 499, 501)
The concept of the “first symptoms” of disease was extremely important for Hippocratic medicine. Hippocrates understood very well that pathological processes may develop gradually and not manifest themselves in all of the variety of symptoms right away. Therefore the physician should not waste time and should begin intervention from the moment the first symptoms of disease appear in order to restore the balance and provide the necessary assistance:
Opportune moments in medicine, generally speaking, are many and varied, just as are the diseases and affections and their treatments. The most acute ones are when you must help patients that are losing consciousness, that are unable to pass urine or stools, that are choking, or when you must deliver a woman that is giving birth or aborting, or in other cases like these. These opportune moments are acute, and a little later does not suffice, for a little later most patients die.9
At the heart of this desire to begin treating the patient during the period of perceived health before the disease manifests itself in full force is the physician’s intuition. In the Hippocratic Corpus, “health” is a relative concept in which quantitative distinctions stand out: health can be more or less. Again, here we note the development of the idea of antagonistic states, inherent to the natural philosophy of Alcmaeon and Empedocles: balance against dominance, and mixture against separation. Once more, we emphasise the quantitative and not the qualitative nature of these changes—and therein lays the novelty of Hippocrates’ views, which are based on the principle of mixing. The body is considered healthy or sick only based on more or less stability and resistance to external effects. J. Jouanna points out that without a qualitative difference between normal and pathology, the sick in the Hippocratic system is simply the weakest among healthy people, which introduces the principle of the continuity between the normal and pathological state, which was redefined in the 19th century by A. Comte as “Broussais’ principle”.10
At the onset of the first signs, based on the earliest symptoms, the experienced physician must try to predict how the pathological process will develop: “For if disease and treatment start together, the disease will not win the race”.11 In the magical, occult tradition, disease is chaos and tempest caused by the invasion of evil spirits. Disease is terrifying particularly because of its unpredictability and the random nature of its development; it is as capricious as the demon causing it. In contrast, for Hippocrates and Galen, disease is consistent violation of equilibrium processes, which spreads throughout the body from the point of its origin. This is particularly why the concept of the change in the equilibrium of the liquids, when the generalisation of the pathological process was defined by the spread of the predominant liquid inside the body, seemed so organic to Hippocratic physicians. This led to the fundamental principle of curing the “opposite with the opposite”—the elimination of excess in one and deficiency in the other. In the treatise On the Nature of Man, Hippocrates clearly explains this principle using concrete examples:
...One must know that diseases due to repletion are cured by evacuation, and those due to evacuation are cured by repletion; those due to exercise are cured by rest, and those due to idleness are cured by exercise. To know the whole matter, the physician must set himself against the established character of diseases, of constitutions, of seasons and of ages; he must relax what is tense and make tense what is relaxed. For in this way the diseased part would rest most, and this, in my opinion, constitutes treatment.12
In the treatise On Airs, Hippocrates continues this reasoning saying that
…For knowledge of the cause of a disease will enable one to administer to the body what things are advantageous. Indeed this sort of medicine is quite natural. For example, hunger is a disease, as everything is called a disease which makes a man suffer. Then the remedy for hunger is that which makes hunger to cease. This is eating; so that by eating must hunger be cured. Again, drink stays thirst; and again repletion is cured by depletion, depletion by repletion, fatigue by rest. To sum up in a single sentence, opposites are cures for opposites.13
The Hippocratic method of treatment is based on the use of agents which, by their effect, are opposite to pathological processes.
An integral part of the art of medicine was prognosis—the investigation of disease in the context of its development over time: commencement, intensification, reaching the peak, going through crisis, i.e., the decisive stage, when the disease can be combated. Consequently, the disease either ended with decline and recovery, or the commencement of the terminal condition and death of the patient. It is plain to see that the concept of “crisis” in the Hippocratic tradition is used in a sense different from the modern sense: it is not an anxious moment between life and death, but simply a stage in the development of the disease, which determines whether the disease can be cured:
One must examine the beginning of a disease, whether it comes to full flower immediately—it is clear in the advancement—and examine the advancements according to their periods. From this the crises too are clear, as well as from the exacerbations within the periods (i.e., whether or not they are earlier and whether or not they continue a longer time, and whether or not they are more severe).14
The Aphorisms of Hippocrates also state that:
Take the patient too into account and decide whether he will stand the regimen at the height of the disease; whether his strength will give out first and he will not stand the regimen, or whether the disease will give way first and abate its severity.15
Hippocrates understood very well that full recovery of the sick is not always possible. From here arises the idea of the relativity of “recovery”, which is based on the understanding of the continuity and fragility of the equilibrium of the boundaries between health and disease. A woman that has been cured of chronic bleeding could remain barren; the motor activity of a leg could be restored after treatment of a fractured leg, but the patient will remain chronic limping—we see a lot of these examples in the Hippocratic Corpus. The fundamental principle which forms the basis of the physician’s thinking in the Hippocratic tradition was best described by J. Jouanna as the transition from “observation of the visible to reconstruction of the invisible”. This task clearly remains fundamental to the physician since the time of Hippocrates.
Methods of diagnosing diseases, according to Hippocrates, include thorough collection and assessment of medical history, external examination of the patient and, in certain cases, physical methods of diagnosis—palpation and auscultation.16 The principle of diagnosis is the interpretation of the plurality of external symptoms of the disease, medical history and objective examination, based on the theory of the development diseases. The latter in particular forms the natural philosophical foundation of the physician’s views, which is understood in accordance with practical needs. In the Hippocratic Corpus, this is the theory of primary elements which constitute the fabric of the human body, and the theory of the humors, whose balance ensures normal or pathological functioning of the parts and the human body as a whole. Medical history is also vital in the context of Hippocratic ideas about the influence of climate and location on health and disease. It should not be supposed that auscultation of body cavities (direct auscultation) and probing of parts of the skin affected by the pathological process (palpation) during Hippocrates’ time was always used by every physician when examining each patient—that is, of course, not the case. However, the recognition of the importance of diagnostic information obtained during physical examination of the patient was already clear. Here we are speaking of ingenious foresight, which later became the standard method:
When the fifteenth day after the pus has broken out into the cavity arrives, wash this patient in copious hot water, and seat him on a chair that does not move; have someone else hold his arms, and you shake him by the shoulders, listening on which of his sides there is a sound; prefer to incise on the left side, for it is less dangerous.17
If you administer an infusion, fumigation, or vapour-bath, no pus appears; this is how you can tell that there is not pus, but water. If you apply your ear for a long time and listen to the sides, it seethes inside like vinegar. The patient suffers in the way described for a definite time; then there is a break into the cavity18:
Residual swellings on the upper eyelids when the others have subsided: relapse. If they are hard and red on their tips, especially so. The viscous ones and those that protrude are included among them, as in the case of19;
Women, numb on the touch, very dry, without thirst, with heavy flows, develop abscess20, etc.
The forte of the Hippocratic physician was his ability to carefully observe a patient and meticulously record the results of his observations. The empirical method therefore became the source of information for two types of generalisations: firstly, ideas about anatomy, physiology and general pathology of the human being as a whole and, secondly, the understanding of individual peculiarities of the progression of any disease. Some parts of the Hippocratic Corpus provide the physician with the modus operandi for observing the patient and correct interpretation of the observed phenomena. To illustrate the above, we shall consider one of the fragments from the book On The Physician’s Surgery, which is in its own way a manual for beginning examination of the patient, when first we examine the similarity and difference (with the healthy state); the most significant, easiest are those that are recognisable with all methods, which can be visible, tangible and heard; that which can be replaced with sight, touch, hearing, the nose, tongue, mind; that which can be recognisable with all possible means of knowledge.21 The following excerpt from the book Epidemics, is still relevant to this day as the physician’s guideline: “The task is to bring the body under consideration. Vision, hearing, nose, touch, tongue, reasoning arrive at knowledge”.22 The first possible visual signs of disease which, according to Hippocrates, the physician was supposed to pay attention to upon meeting the patient, are: first, the colour and appearance of the face of the patient, secondly, the posture of the patient lying in the bed, then the movement of the patient’s hands. The description of the changes in facial features of the patient, which suggest impending death, still referred to as the Hippocratic Facies, is the most brilliant example of the meaningful set of empirical observations. When the physician’s finger presses on the swelling after treating a fracture, “the swelling on the extreme parts hardens, and after pressing with the finger, the redness ceases, but soon returns”; with various oedema, “if you press anywhere with a finger, you will leave a dent, and its sign is as if in dough”. In the absence of a thermometer, touching the skin of the patient helped determine the body temperature of the patient: the Prognostics mentions patients “who are not hot at touch”. When examining excrement and discharges of patients for prognosis and diagnosis purposes, the Hippocratic physician smelled and, when necessary, even tasted the sweat, faeces, urine, vomit, phlegm, pus, and in women, vaginal discharges. The list of senses which the physician must take recourse to for diagnostic purposes is complemented in the Hippocratic Corpus by reference to “nous” (νοῦς) as the capacity for thought (λόγος). After all possible manipulations, the physician has to ponder and analyse the results obtained during examination, while being maximally critical to his observations: “You must take into account both the good signs and the bad that occur and from them make your predictions; for in this way you will prophesy aright”.23
The Hippocratic Corpus puts together descriptions of a large number of diagnostic features that are still relevant to the modern-day physician. This circumstance, in my opinion, lays bare the fundamental distinction of the history of medicine from the history of other natural sciences: facts suggest the considerable relevance of the physician’s experience in the protoscientific period. The history of medicine requires very careful application of the logic of uneven development, revolutions in knowledge—the continuity of knowledge and experience is typical for it to a larger extent as compared to physics, for instance.
