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HIPPOCRATES AND GALEN

17 May

As we have seen, medicine begins with Hippocrates. For more than two thousand years doctors have revered his memory, yet we know so little about him that some have dismissed him as a mythical figure. The truth is that we are not absolutely sure whether Hippocrates existed or whether later doctors invented him. Hippocrates of Cos (a tiny island in the Mediterranean) apparently lived from around 460 to around 375 bc. Later generations believed some sixty works by him survived, but modern scholars argue that these works were written over a period of two hundred years or so, and that it is quite possible that none of them are actually by Hippocrates. It is not difficult, however, to identify a number of respects in which the first Hippocratics represent an entirely new approach to medicine. First, Hippocrates and his immediate followers insisted that disease always had a natural, rather than a supernatural origin. There was no point, then, in relying on religious ceremonies, prayers, or charms to cure disease. Instead the doctor had to identify the cause of the disease and work to counteract it. Their starting assumption was that every- thing had a natural cause. Second, the Hippocratic authors were committed to a programme of careful observation.

One set of books, the Epidemics, is a series of case studies of individual patients and particular outbreaks of disease. Observation extended, for example, to a very careful study of the development of the chicken embryo in the egg, conducted by opening an egg each day for twenty days, for the light it might cast on the development of the human embryo. Hippocrates and his successors established a tradition of medical observation and education that descends unbroken to the present day. For Hippocrates and his contemporaries there were two funda- mental branches to medicine. First there was the type of medicine that involved hands-on manipulation of the body: lancing a boil, setting a bone, reducing a dislocation. They had considerable skills at dealing with injuries, which were common in warfare and gym- nastics. When Pausanias visited Delphi in the second century bc he reported that ‘Among the votive offerings to Apollo was a representa- tion in bronze of a man’s body in an advanced state of decay, with the flesh already fallen off and nothing left but the bones. The Delphians said that it was an offering of Hippocrates the physician.’ Pausanius obviously had difficulty describing this strange sculpture, but it sounds very much like what we would call a skeleton (we will look at the history of the word later), a representation of the body ideal for teaching hands-on medicine. Second, there was the type of medicine that was concerned with the inner workings of the body. The skeleton was envisaged as sup- porting a number of containers that were, at least in illness if not in health, full of fluid. In a work contemporary with Hippocrates we are told that: Every part of the body which is covered by flesh or muscle contains a cavity.

Every separate organ, whether covered by skin or muscle, is hollow, and in health is filled with life-giving spirit; in sickness it is pervaded by unhealthy humours. The arms, for example, possess such a cavity, as do the thighs and legs. Even those parts which are relatively poorly covered with flesh contain such cavities. Thus the trunk is hollow and contains the liver, the skull contains the brain and the thorax the lungs. Thus the divisions of the body may be likened to a series of vessels, each containing within it various organs, some of which are harmful and some beneficial to their possessor. These cavities were connected together in ways that now puzzle us. Thus the pupils of Hippocrates would let blood from the vein in the right elbow to relieve pain in the liver, and blood from the vein in the left elbow to relieve pain in the spleen because they believed these blood vessels were directly connected to these organs. At least this is how we would describe what they would do: they did not distinguish between veins and arteries, having a general term for blood vessels, and did not have a word for organs, using instead a word that means ‘shapes’. Hippocrates and his immediate successors shared two further assumptions. The first was that you should manage the conduct of daily life so that the right amount and type of food, drink, exercise, sleep and so forth encouraged health, and when disease set in you should try to counteract excess or deficiency –– so they prescribed exercise for someone who rested too much, or dieting for someone who ate too much. This seems to be the original context in which the fundamental principle that opposites are cured by opposites –– what the Middle Ages was to call the Law of Hippocrates –– was first formulated. Second, you could eliminate excess fluids from the body by inducing vomiting (using emetics), by inducing diarrhoea (using purgatives and enemas), or by letting blood.

There were two classical methods of letting blood. The first was the cutting of a vein; the second was ‘cupping’ where the surface of the skin was scratched and a cup applied to it and a sucking force introduced, either by directly sucking air out of a hole in the base of the cup, or by first heating the cup and then letting it cool while attached to the body –– this removed blood more slowly and cautiously than did venesection. Much later a third method was to be introduced: leeches were applied to suck blood from the body. The followers of Hippocrates also had an inter- est in cautery, the application of hot irons to parts of the body. These four forms of treatment (emetics, purgatives, bloodletting, and cautery) were to remain the fundamental therapies for almost two thousand years; three of the four were to remain the standard thera- pies for far longer than that. (Cautery was largely abandoned in the Renaissance, but Laennec, the inventor of the stethoscope, offered it to patients suffering from phthisis (tuberculosis), knowing that con- ventional remedies were ineffectual. He made 12 to 15 burns on the chest with an incandescent copper rod.) It seems likely that these procedures all predated Hippocrates: the Scythians practised cautery, and we have a Greek perfume bottle from c.475 bc which shows a doctor engaged in venesection, with a cupping bowl hanging on the wall behind him. What the Hippocratics provided was an account of why these therapies worked: it never occurred to them that they did not.

4.  This eighteenth-century caricature, by Pier Leone Ghezzi, shows a Dr Romanelli, who was employed by Cardinal Giovanni Francesco Albani. He is holding an enema syringe.

HIPPOCRATES AND GALEN

5. A Greek vase from c.475 bc showing a doctor’s surgery. All the Hippocratics shared a belief that the human body was an integrated whole. In order to understand what was going on inside it you had to study the fluids that came out of it (vomit, urine, blood, phlegm, etc.), but it was assumed that a whole range of other indica- tors might serve as signs indicating internal processes. Here is a pas- sage from a treatise called Epidemics I (c.410 bc) that is amongst those preserved by later generations of doctors because they believed it to be by Hippocrates himself. The author describes an outbreak of causus (perhaps enterric fever) in the autumn. Those affected suffered from fever, fits, insomnia, thirst, nausea, delirium, cold sweats, constipation, and they passed urine ‘which was black and fine’; death often occurred on the sixth day, or the eleventh, or the twentieth. The disease was very widespread. Of those who contracted it death was most common among youths, young men, men in the prime of life, those with smooth skins, those of a pallid complexion, those with straight hair, those with black hair, those with black eyes, those who had been given to violent and loose living, those with thin voices, those with rough voices, those with lisps and the choleric.

Many women also succumbed to this malady. Much of this seems irrelevant to us; and reading through this list it is hard for us to avoid the impression that anybody and everybody died of the disease. But the Hippocratics believed that people who lisp are particularly liable to diarrhoea, and the author of Epidemics I evidently felt that any one of the characteristics he so carefully enumerated –– age, skin colour and texture, hair colour and texture, eye colour, voice, temper, lifestyle –– might prove to have prognostic significance. For these were either indicators of the internal composition of the body or (in the case of lifestyle) influences upon it. Thus survival or death depended on interpreting a range of signs that the same text lists as follows: First we must consider the nature of man in general and of each individual and the characteristics of each disease. Then we must con- sider the patient, what food is given to him and who gives it –– for this may make it easier for him to take or more difficult –– the conditions of climate or locality both in general and in particular, the patient’s customs, mode of life, pursuits and age. Then we must consider his speech, his mannerisms, his silences, his thoughts, his habits of speech or wakefulness and his dreams, their nature and time. Next we must note if he plucks his hair, scratches, or weeps. We must observe his paroxysms, his stools, urine, sputum and vomit. We look for any change in the state of the malady, how often such changes occur and their nature, and the particular changes which induce death or a crisis. Observe, too, sweat- ing, shivering, chill, cough, sneezing, hiccough, the kind of breathing, belching, wind, whether silent or noisy, hemorrhages and hemorrhoids. We must determine the significance of all these signs.

At the heart of this enterprise was prognosis. Doctors knew they would be blamed if patients died unless they took the precaution of announ- cing in advance that treatment was hopeless. They needed to know, therefore, ‘for a patient with fever to grind his teeth, unless this be a habit continued from childhood, is a sign of madness and death. If this occurs during delirium, it is a sign that the disease has already taken a fatal turn.’ The preoccupation with prognosis reflected an imperfect recognition of the limits of the doctor’s capacity to intervene. Galen (ad 131–201) said prognosis properly included the subdisciplines of diagnosis (identifying the patient’s present condition) and a form of mnemonics (identifying the patient’s past conditions); but both were subsidiary to prognosis. Skill at prognosis, in traditional Hippocratic/ Galenic medicine, in fact served as a substitute for skill in therapy. Hippocratic doctors were able to reliably identify the signs of imminent death. But they could do nothing to delay its arrival. The Hippocratics were good at setting bones and lancing boils, at hands-on manipulation. But none of their therapies directed at internal conditions worked. Moreover, for all their careful observa- tion and all their prognostic skills, their basic model of the internal workings of the body was a decisive obstacle to their going on to develop any effective remedies.

Yet their basic repertoire of remedies continued to be the staple of medical practice until the mid- nineteenth century. The story of Hippocratic medicine after the first Hippocratics is one of intellectual development, but therapeutic continuity. Because in later centuries all doctors came to agree with each other, because a unified medical profession eventually came to exer- cise an effective monopoly over treatment, it is easy to assume that from the beginning doctors thought alike. But in fact, within these shared assumptions, there was considerable disagreement amongst the first Hippocratics, and disagreement remained commonplace throughout the classical period. It is not until 1200 that a single body of medical doctrine established an unchallenged predominance both in Islam and in Christendom. Some early doctors, including perhaps Hippocrates himself, believed that health and disease were all a matter of pneuma or vital spirit. Others were particularly concerned with two fluids that they believed were pernicious in excess, phlegm, which was particularly problematic in the winter, and associated with upper respiratory tract problems, and bile, which was particularly problem- atic in the summer, and associated with stomach problems, and they sought to explain other diseases with reference to these fluids: epi- lepsy, for example, was held to be brought on by phlegm. Around the time of Hippocrates’ birth a philosopher called Alcmaeon of Croton had argued that health depended on a balance or equilibrium between three sets of opposing forces –– hot and cold, dry and wet, sweet and sour –– while the supremacy of any one of them (the lan- guage he uses is political for his term for supremacy is monarchia) would cause disease.

It seems to have been Hippocrates’ son-in-law, Polybus, who, in a text called The Nature of Man, first argued that there were four humours or fluids which needed to be brought into balance to estab- lish health (blood, phlegm, yellow bile or choler, and black bile or melancholy), that each of these four humours tended to be pre- dominant at a different age in life and a different season of the year, and that each represented a pair of the fundamental qualities that a philosopher called Empedocles had argued went to make up the universe: the hot and cold, the dry and wet. Thus blood was hot and wet, phlegm cold and wet, yellow bile hot and dry, black bile cold and dry. Each tended to congregate in a different organ: blood and all the other humours were manufactured in the liver; phlegm went to the brain, yellow bile to the gallbladder and black bile to the spleen. From the first it was assumed that predominance of any one humour would have psychological effects, black bile, for example, leading to melancholy. It might be thought that there was an inevitable tension between a four-humour system and, where the fluids were concerned, a three- fold therapeutic practice (bloodletting, emetics, and purgatives), and perhaps practice was more in line with an earlier system which had thought in terms of three humours –– blood, bile and phlegm. Black bile was apparently a new discovery, later defined by Galen as the dregs or sediment of the blood, that which lay at the bottom if blood was allowed to stand and separate. Black bile, we may suspect, was invented to bring medicine into harmony with the cosmology of Empedocles. But it was also believed that all four humours were to be found, in varying proportions, in the blood, and that they separated out when blood was left to stand. It was thus easy for bloodletting to come to be regarded as the sovereign remedy, far more important than emetics and purgatives.

In Galen’s view ‘Whatever sickens the body from internal evil has a twofold explanation, either plethora or dyspepsia.’ Dyspepsia resulted from eating the wrong foods; plethora from consuming more food than one burnt up or excreted. Why, in the case of one patient, did a severe wound heal without becoming infected, while in the case of another a tiny scratch became infected, red, swollen, and potentially fatal? Because the second patient was already suffering from a plethora, an excess in the blood. Without this the scratch would have been insignificant. Bloodletting thus became a cure for almost all conditions. Celsus, for example, in the first century ad, recommended bloodletting for severe fever, paralysis, spasm, difficulty in breathing or talking, pain, rupture of internal organs, all acute (as opposed to chronic) diseases, trauma, vomiting of blood. It was still being used as a nearly universal remedy in the middle of the nineteenth century. In the ancient world bloodletting had its opponents. The followers of Erasistratus (c.330–255 bc) thought bloodletting was dangerous, and preferred to get rid of excessive blood by fasting. But the main disputes were over where to let the blood from, for some said it should be from close to the affected organ, some from as far away as possible, and over how much to let: the leading authorities were prepared to let blood up to the point when the patient fainted. Dis- putes over these matters were to continue as long as the tradition of ancient medicine survived. In 1799 Benjamin Rush (one of the signa- tories of the Declaration of Independence) was advocating ‘heroic’ bloodletting, and was accused by some of killing his patient, George Washington, through his commitment to this practice.

The dispute was still not over whether to let blood, but rather over how much to let and where from. A critic of excessive bloodletting still regarded moderate bleeding as the pre-eminent medical remedy in 1839, and around 1870 the naturalist Charles Waterton attributed to frequent bloodletting his success in keeping himself ‘in as perfect health as a man can be’. Through the centuries, many doctors recommended a regular regime of prophylactic bloodletting, particularly in the spring. In Philadelphia in the 1830s it was still the custom, as it would have been in a medieval monastery, for people to go en masse to the doctors to be bled each spring. Such bleeding was held to be essential for those who did not vent their excess of this humour by natural means: in the case of women, in their periods, and in men in nosebleeds, varicose veins, and haemorrhoids. These last three were seen as examples of natural self-therapy. It is obvious to us, in the twenty-first century, that a nosebleed, a bleeding vein, or a bleeding bottom needs treat- ment; for centuries, by contrast, these were welcomed as ways in which the body healed itself. Women who had ceased to have periods (an interruption in periods, without pregnancy, in someone of child- bearing age was regarded as extremely dangerous) and men who had no haemorrhoids had to turn to doctors for an artificial substitute. The goal of ancient medicine was a balance of humours. An early text, Airs, Waters, Places, argued that different climates would tend to produce a predominance of different humours, hence different physiological types and national characters.

This process was seen as complex, even contradictory. Thus Galen held that the Germans and Celts, because they lived in a cold, wet climate, had soft, white skin, while the Ethiopians and Arabs had hard, dry, and black skin. But the Germans and Celts bottled up their internal heat within themselves: ‘Whatever internal heat they have has retreated, along with the blood, into the internal organs; and there the blood churns about, confined in a small space, and boils; and thus they become spirited, bold, and quick-tempered.’ To achieve a healthy body and disposition you thus needed to counteract the effects of the climate and the season –– in summer, and in Germany, you would want to cool your blood; in winter, and in Africa, to heat it. Under normal circumstances our control over our bodies depended upon manipulation of what Galen called the non-naturals, contrasting them to the naturals (over which we have no control –– climate, season, age, sex, etc.) and the unnaturals (those conditions that were directly associated with disease). The non-naturals were food and drink, the environment (e.g. exposure to the air), sleep and wak- ing, exercise and rest, evacuations (including sexual), the passions and emotions. A major difference between medicine in the time of Galen and medicine six centuries earlier, in the time of Hippocrates, was that Galen was convinced that we could fundamentally control the conditions needed for health; this involved sharply downplaying the role of climate and season compared to the views expressed by the Hippocratic writers, for whom a change in the direction of the wind had been sufficient to explain an outbreak of illness –– Sydenham’s wish to link diseases to times and places represented a return to Hippocrates and a rejection of Galen. Just as the humoral theory implied that certain humoral imbal- ances fostered certain states of mind, so it assumed that certain mental conditions (e.g. anger) had physiological consequences. Mental health and physical health were thus regarded as inseparable, indeed as strictly indistinguishable. This is particularly clear from the records of Dr Johannes Storch, who practised in the German town of Eisenach in the 1730s. These contain numerous cases of women prescribed bloodletting after a fit of anger or a fright –– both, it was believed, stopped the normal flow of menstrual blood, with possibly fatal con- sequences. One young woman of 21 was frightened ‘by a dog which barked loudly at her at the time when her menses were flowing’. The flow was interrupted and did not recover; a few months later she was suffering from ‘heart-throbbing, tiredness, bad colour, strong and uncommon sweating, with a strongly itching scorbutic blister’. Within the year she was dead.

The dog’s bark had proved as fatal as any bite. Galen, and all doctors after Galen, thus advocated proper diet. Galen recommended a diet designed to thin the humours, consisting of fish, fowl, barley, beans, onions, and garlic for all chronic diseases. They recommended sensible exercise. Galen abhorred gymnastics as too violent –– the claim that gymnastics was the science of health and medicine the science of disease seemed to him to take no account of sports injuries –– but recommended instead ‘exercise with the small ball’, a game of catch. They recommended the regular use of laxatives and prophylactic bloodletting. But they also recommended control of the passions, particularly anger. Galen says: In my youth . . . I once saw a man in a hurry to open a door. When he could not get it to open, he began to bite the key, to kick the door, to curse the gods; his eyes went wild like those of a madman, and he was all but frothing at the mouth like a wild boar. The sight caused me to hate anger so much that I would never appear thus disfigured by it. He had particular contempt for those who struck out at their slaves. His father frequently berated friends who had bruised their hands in the act of hitting servants in the teeth. He would say they deserved to suffer convulsions and to die from the inflammations they had sustained. Once I even saw a man lose his temper and strike his servant in the eye with a pencil, causing him to lose the sight of one eye. And it is related of the emperor Hadrian that he once struck one of his household staff in the eye with a pencil, causing him to lose the sight of one eye. When Hadrian realized what had happened, he summoned the servant and agreed to grant him a gift of his own request in exchange for the loss he had suffered.

But the injured party was silent. Hadrian repeated his offer: that he should request anything he wished. At which the servant grew bold and said that he wanted nothing but his eye back. In Galen’s eyes such behaviour unmanned those guilty of it. His mother, temperamentally the opposite of his father (an architect), was ‘so bad tempered she would sometimes bite her maids’. This preoccupation with the passions might seem a purely autobiographical obsession of Galen’s, reflecting his desire to be like his father not his mother. We could also relate it to his professional circumstances. He found himself in constant competition with doc- tors from different schools. He would put on public exhibitions to demonstrate the superiority of his understanding of anatomy, and accost other doctors to engage them in public disputations. In such circumstances winning involved a cool head; a display of anger or irritation could only make one look weak and inadequate. But the idea of self-control was also central to his understanding of human biology. In many respects Galen was a Platonist: he admired the Timaeus and thought it evident that the human body had been designed by a divine architect. He agreed with Plato, who thought there were three principles of life in the human body, reason (located in the brain), spirit (located in the heart), and appetite (located in the liver), reject- ing Aristotle’s argument that all life was centred in the heart (Aristo- tle thought the function of the brain was to refrigerate the blood). But he was completely unpersuaded by Plato’s arguments for the immortality of the soul, preferring to regard it as ‘a mixture or faculty of the body’, and so mortal. For later generations of Muslim and Christian medical commentators, Galen’s account of the relationship between mind and body was profoundly unsettling. Not for nothing did it become a saying amongst Renaissance Christians that where there are three doctors you will find two atheists, while in the seven- teenth century Thomas Browne’s Religio Medici, the religion of a doctor, is intended as a paradox or puzzle. For Galen, unlike Plato, your body is who you are. Understanding how the body worked was thus the key, not only to physical health, but also to psychological well-being.

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