17 May

Hot, cold, dry, wet seem to us simple terms, in principle susceptible to measurement. Galen was much interested in the question of whether the young were hotter and colder than the old. He believed he had trained himself to so exactly remember heat that he could compare the warmth of the same person several years apart, and he decided, after extended observation, that, as we might say, their temperature was the same. Or rather he decided something quite different, for though the temperature was the same, there are differences in the quality of the heat . . . that of children is more vaporous, large in quantity, and sweet to the touch; while that of people in their prime verges on the sharp, and is not gentle at all . . . [it is] small, dry, and less gentle. Neither therefore is hotter in any simple sense, but the former appears so . . . Heat was for Galen a complex, not a simple, quality. We should not be surprised, then, that Celsus, when he comes to discuss fever, hastens to stress that a patient should not be regarded as feverish just because he feels hot –– he may have been working hard, sleeping, or he may be suffering from fear or anxiety.

We can only conclude he has a fever if he not only feels hot and has a rapid pulse, but if also the surface of the skin is dry in patches, if both the forehead feels hot, and it feels hot deep under the heart, if the breath streams out of the nostrils with burning heat, if there is a change of colour whether to unusual redness or to pallor, if the eyes are heavy and either very dry or somewhat moist, if sweat, when there is any, comes in patches, if the pulse is irregular . . . Consequently it will not do just to touch the patient’s skin. The doctor must face him ‘in a good light, so that he may note all the signs from his face as he lies in bed’. The thermometer was invented by Sanctorius Sanctorius, a friend of Galileo’s, in the seventeenth cen- tury; but we can be sure that if Celsus had had a thermometer he would not have felt that it alone could provide proof of a fever. Indeed it is striking that the thermometer only became a standard clinical tool with the death of Hippocratic medicine, spreading from Berlin (where Ludwig Traube introduced it around 1850) to New York (1865) and Leeds (1867). In 1791 Jean-Charles-Marguerite- Guillaume de Grimaud was still arguing that the patient’s tempera- ture as measured by a thermometer was of little interest. Nothing could substitute for the physician’s hand. ‘The doctor must apply himself, above all, to distinguishing in feverish heat qualities that may be perceived only by a highly practised touch, and which elude whatever means physics may offer.’ Thus feverish heat is acrid and irritating; it gives the same impression as ‘smoke in the eyes’.

What would seem to us one of the simplest of all substances, water, was almost infinitely complex for Hippocratic doctors, who recog- nized, perfectly sensibly, that it varied immensely from place to place: the title of Airs, Waters, Places identifies it as one of the three crucial environmental variables. ‘No two sorts of waters can be alike,’ asserts this author, ‘but some will be sweet, some salt and astringent and some from warm springs.’ Water from marshes and lakes will be ‘warm, thick and of an unpleasant smell in summer’ and ‘productive of biliousness. In winter it will be cold, icy and muddied by melting snow and ice’ and ‘productive of phlegm and hoarseness’. There is also water from rock springs (‘hard, heating in its effect, difficult to pass and causes constipation’); water from high ground (‘cool in summer and warm in winter’, and, if it flows towards the north-east, ‘sparkling, sweet-smelling and light’); water which is salty and hard (good for the phlegmatic); rain water (‘very sweet, very light, and also very fine and sparkling’ but unfortunately it also ‘quickly becomes rotten on standing’); water from snow and ice (‘always harmful [for] in the process of freezing the lightest and finest part has been dried up and lost’); while water from large rivers or from lakes into which many streams flow is particularly likely to produce a sediment of sand or slime and to cause stone, gravel in the kidneys, strangury, pain in the loins and rupture. Before drinking water, then, you needed to know exactly where it had come from.

To live in a town which was forced to take water from a lake would be to condemn oneself to a potentially endless cycle of colds and diarrhoea. The Romans may have used aqueducts to deliver adequate supplies of fairly clean water to large cities, but water did not begin to be treated to make it safe to drink until after Pasteur’s germ theory of disease. Before then water was sometimes filtered, or even chemically treated, to prevent it from smelling foul, but not to kill germs. So we can easily agree with the Hippocratics that water was a major cause of disease, but not with their explanation that it might not only be too salt, too sweet, or too astringent, too hard or too soft, but also too hot or cold, too light or heavy. Five hundred years after Airs, Water, Places, Celsus sums up this analysis of water with what appears to be admirable simplicity by classifying water in terms of degrees of heaviness, except for the fact that he defines heavy waters as those which have the most nourishment and are hardest to digest. Rain water is the lightest, then spring water, next water from a river, then from a well, after that from snow or ice; heavier still is water from a lake, the heaviest from a marsh . . . by weighing the lightness of water becomes evident, and of water of equal weight, that is the better which most quickly heats or cools, also in which pulse is most quickly cooked. Heaviness, here, both is and is not a matter of weight.

When it came to more complicated foods even more numerous factors had to be taken into account. Thus, according to an early fourteenth-century manuscript produced for use in Bohemia, but itself a translation of an eleventh-century Arabic original, The Almanac of Health, roosters are dry and hot; not surprisingly then they are recommended for people of a frigid complexion, in old age, in winter, and in northern regions, such as Bohemia. But could we have predicted that the best roosters are those that crow temperately, or that rooster meat can cause irritation of the stomach that can be avoided if the birds are tired out before they are slaughtered, presumably by chasing them around the farmyard? Clearly an old, cold man suffering through a northern winter could not just order rooster for dinner: his cook needed to have known the rooster in life and in death. And a doctor who advised his patient to eat rooster, and found him the next day suffering from indigestion, could easily dismiss the problem, saying the rooster selected had been too vocal or insufficiently exercised.

The multiplication of relevant factors meant that the Hippocratic doctor could always explain away failure. When Taddeo Alderotti (d. 1295) was called out to treat the count of Arezzo, who had been taken ill, he found the patient improving, and left him in the care of his students. The next day he returned to find him at the point of death. How could his prognosis have been so seriously mistaken? He searched around until he discovered that he had not noticed an open window, at which point he was satisfied that the cold night air provided an adequate explanation. If doctors were just like astrologers (in fact they were normally one and the same people) in having available numerous tactics for explain- ing away failure, medicine was rather different from astrology in that it appeared to give patients control over their own fate. Since health lay in a balance of humours, and such a balance could be obtained through a correct regimen (a correct management of the non- naturals) everyone ought to be able to achieve health. Just as we might think that someone with a hangover has brought it upon themself, so ancient medicine (at least after the Alexandrian revolution in anatomy) implied that someone who was ill was in some degree responsible for their own condition.

Although we believe that people who choose to live high-pressure lives may bring on heart attacks, we rarely blame people for getting cancer or arthritis; ancient medicine, by contrast, implied that all diseases reflected deficiencies in lifestyle. In some respects this empowered patients. Are you an old man who wants to make love to a young woman? Then eat the right food first –– pigeon breasts are particularly recommended. (You will find a more detailed menu in the Roman author Terence’s play Clizia; in the Renaissance Machiavelli translated the play, and the advice would have seemed entirely up to date.) Are you a scholar, living a sedentary life, and so prone to the scholar’s disease, melancholy? Then you need exercise: a sea voyage perhaps (travelling in a coach or a boat was, like rocking, taken to be a form of exercise), or regular horse-riding. When Montaigne wrote an essay ‘On Coaches’ he expected you to understand that coach journeys can have a therapeutic function. In the eighteenth century Adam Smith, the founder of economics, prescribed horse-riding to himself to counteract the deleterious consequences of too much book-reading, and it must be said this still seems a sensible prescription. As a result the burden of responsibility often lay heavy upon the patient. ‘Physicians come to a case in full health of body and mind’ says the author of the Hippocratic Science of Medicine, taking it for granted that no one would hire a doctor who was not able to ensure his own health. Patients, by contrast, are full of disease and starved of nourishment; they prefer an immediate alleviation of pain to a remedy that will return them to health. Although they have no wish to die, they have not the courage to be patient.

[Note the automatic and unthinking reference to the three topics with which medicine concerns itself: the alleviation of pain, the restoration of health, the deferral of death.] Such is their condition when they receive the physician’s order. Which then is more likely? That they will carry out the doctor’s orders or do something else? Is it not more likely that they will disobey their doctors rather than that the doctors . . . will prescribe the wrong remedies. There can be no doubt that the patients are likely to be unable to obey and, by their disobedience, bring about their own deaths. Medicine defined itself as a science by transferring responsibility for failure, firmly and remorselessly, from doctor to patient. One last example may serve to illustrate what it was like to live in a world, not of quantities, but of qualities. As we have seen, Praxagoras was the first to understand the pulse as an involuntary movement of heart and arteries, and his pupil Herophilus was the first to use it as a diagnostic tool, classifying pulses by magnitude, strength, rate, and rhythm.

It was only for the third of these measures that his timepiece would have been useful. Galen went further. He wrote at enormous length on the pulse: a thousand printed pages survive. In The Pulse for Beginners he explains that arteries have three dimensions –– length, depth, breadth. In other words, in order to understand the pulse he immediately thinks of the anatomy of the body as exposed by dissec- tion. The pulse itself must be considered in terms of its strength, hardness, speed, interval, regularity, and rhythm. Thus a pulse could in theory be large, long, broad, deep, vigorous, soft, quick, frequent, even, regular or, at the opposite extreme, small, short, narrow, shallow, faint, hard, slow, sparse, uneven, and irregular. In anger, he tells us, the pulse is deep, large, vigorous, quick, and frequent; in pleuritis quick, fre- quent, hard, and, consequently, you can be deceived into thinking it is vigorous (for remember, strength and hardness are different dimen- sions of the pulse). Galen devised evocative terms to identify particu- lar types of pulse. Thus the ‘anting’ pulse is extremely faint, frequent, and small. Such a pulse appears quick but is not: speed and frequency again are different dimensions. To train oneself to identify different types of waters by their taste, or different types of pulse (and Galen thought the pulse the most valuable of all diagnostic tools), was to acquire a level of connoisseur- ship that in our society we would expect to find only in a wine merchant or a restaurant critic. Galen himself says that his knowledge of pulses is not something that can adequately be expressed in words. It involved a distinctive and elaborate expertise of the touch. But was this expertise real? Galen spent years trying to decide whether he could ‘feel’ the contraction of the artery as well as its expansion. For later generations the question of just what one could and could not feel was to be a matter of unending dispute, a dispute which parallel- led the unending dispute over how much one should bleed and where from. In Galen’s own day the empiricists insisted that there was an enormous gap between the faint fluttering sensation at the end of one’s fingertips and a general theoretical claim about the heart and the arteries. In the eighteenth century we find frequent expressions of scepticism.

Duchemin de l’Etang in 1768, after months of study, decided that the study of the pulse was treacherous: ‘I began to sus- pect that there might be a bit of enthusiasm and imagination behind the whole matter.’ William Heberden in 1772 advised the Royal College of Physicians to attend only to ‘the frequency or quickness of the pulse’, which is the only quality that is identical in all parts of the body. He protested that ‘the minute distinctions of the several pulses exist chiefly in the imagination of the makers’. One might think there was something peculiarly modern about Heberden’s desire to make the pulse something one could measure, but Herophilus had meas- ured pulse beats. In doing so he had had to measure smaller units of time than anyone had previously conceived of: the beat of an infant’s pulse was, he thought, the irreducible minimum unit in the meas- urement of time. By the early seventeenth century Sanctorius Sanctorius (he of the thermometer) had a pendulum machine to measure the pulse rate, and John Floyer had developed a suitable watch by 1707. In 1733 the first accurate measurements of blood pressure were taken (although measuring the blood pressure involved killing the animal; the first proper measurement in humans dates to 1828, and was on a limb about to be amputated). By the mid-nineteenth century machines that measured both pulse rate and the difference between systolic and diastolic pressure (the sphygmograph) were in widespread use, while the modern method of measuring blood pressure dates to 1896. But eighteenth-century expressions of scepticism about the value of the pulse, and early attempts to reduce the pulse to measurable quantities, were in part a response to attempts to restore to the pulse an import- ance that few after Galen had been prepared to give it. For centuries doctors had preferred to diagnose from samples of urine rather than from subtle distinctions in the pulse.

It was easy to produce a colour chart that showed how to interpret different shades of urine; impos- sible to portray or quantify the subtle sensations that Galen had claimed to feel in his fingertips. Elaborate forms of sensory expertise have not entirely disappeared from medicine. Doctors are still trained to identify a wide range of bumps and murmurs through their stethoscopes (Laennec was so proud of his invention that he claimed one could learn much more from a stethoscope than by feeling the pulse); but in our world there are very few forms of scientific knowledge that cannot be expressed in pictures or numbers, but depend instead on taste, touch, sound, or smell. As late as early 1930s, however, the young Karl Stern in Frankfurt was still being trained in a medicine that depended on sensory expertise: There was . . . an entire world of touch which we had never perceived before. In feeling differences of radial pulse you could train yourself to feel dozens of different waves with their characteristic peaks, blunt and sharp, steep and slanting, and the corresponding valleys. There were so many ways in which the margin of the liver came up towards your palpating finger. There were extraordinary varieties of smell. There was not just pallor, but there seemed to be hundreds of hues of yellow and gray. Hippocratic doctors thought the body’s excretions were the best indication of what was happening within, and bodily excretions often assault the senses.

Not surprisingly, Hippocratic doctors had little choice but to use all their senses. Prognosis tells us that, for example, ‘the best kind of pus is that which is white, smooth, homogeneous and least foul smelling. That of the opposite sort is the worst.’ (Only after Lister did doctors come to think of all pus as bad.) Ancient Greek doctors listened to the lungs by pressing an ear to the patient’s chest: modern doctors still hear through their stethoscopes the sound ‘like leather’ that characterizes certain lung diseases and was first described by the early Hippocratics. They tasted ear wax: if it was sweet death was imminent, if bitter recovery could be expected. Galen rejected the claim that the heart was a muscle, not only on the grounds that one could not control its beat, but also on the grounds that if one cooked and ate a heart it tasted nothing like flesh. The four humours (blood, phlegm, yellow and black bile) each had to be exam- ined with care. According to Avicenna, phlegm could be sweet, salty, acid, watery, mucilaginous. According to Maurus of Salerno in the twelfth century, blood could be viscous, hot or cold, slippery, foamy, fast or slow to coagulate. You had to observe the layers into which it separated, and once it had separated the solids should be washed and their texture felt –– slippery blood was a sign of leprosy. When Celsus inspected urine he noted its colour, whether it was thick or thin, its smell, and its texture (was it slimy?): black, thick, malodorous urine was a harbinger of death. Sight was particularly important. We have seen Celsus stress that the doctor must have a good view of his patient. Every doctor was trained to look out for the change in facial appearance that marked the imminence of death: the nose becoming pointed, the temples sunken, the eyes hollowed, the ears cold and flaccid with the tips drooping slightly, the skin of the forehead hard and tight. You could see death approaching. But touch was also fundamental.

The first Hippocratics always palpated the hypochondrium, literally the parts under the cartilage, that is, the sides of the abdomen under the ribs. In a memorial statue of a doctor from the second century ad we can see him reaching out to his patient to touch him here, where he is evi- dently swollen. The Hippocratic text Prognosis discusses at length what you could expect to learn by feeling a patient here, and con- cludes: ‘In brief, then, painful hard large swellings [of the hypochon- drium] mean danger of a speedy death; soft, painless swellings which pit on pressure mean protracted illness.’ A hypochondriac was origin- ally someone with something wrong with their hypochondrium; it was only in the nineteenth century, when the hypochondrium ceased to be of medical interest, that the term was freed to refer to someone who was mistaken in their belief that they had something wrong with them (there had long been a term in French for such people: they were malades imaginaires). An early Hippocratic, if he could have watched Karl Stern, in the 1930s, as he felt for the margin of the liver with his finger, would have understood him to be palpating the hypochondrium. Since the humours were classified in terms of hot and cold, dry and wet, then these were all directly experienced by touch. Galen thought long and hard about whether our experience of hot and cold, dry and wet was objective or subjective. His conclusion was that it was objective because human beings had been designed to be, when in health, at the objective midpoint between the four extremes: healthy humans were neither hot nor cold, neither dry nor wet when compared to other humans; but they were also so when compared to the universe as a whole. Moreover in the body it was crucially the skin, and of the skin it was above all the skin of the palm of the hand which had reliable sensation: the hands ‘were designed to be the instrument of assessment of all perceptible objects’, created as ‘the


6.  The tombstone of Jason, an Athenian doctor of the second century ad. On the right is a cupping vessel, not to scale.

organ of touch suited to the most intelligent of all animals. It there- fore had to be equidistant from all extremes.’ Skin provides ‘the standard or yardstick against which to examine all other parts of the animal’. To function as the yardstick, however, the doctor himself had to be in perfect health, his own body a proper balance of the humours, his skin neither cold nor clammy, neither feverish nor dry. For Galen medicine was above all a tactile science. In medieval Europe this hands-on idea of medicine came under immense pressure. From the early thirteenth century surgery was normally separated from medicine (as it had briefly been at the very beginning –– in the original Hippocratic Oath doctors promise not to use a knife): this was not entirely true in Italy, where the occasional university degree in surgery was bestowed; but throughout Northern Europe medicine and surgery soon became different professions, and surgery was normally taught outside the universities, though it too was taught on the basis of Greek and Arabic texts. Underlying this was a conviction that the educated should not engage in manual activity. To define surgery, as Guglielmo da Saliecto did, as ‘a science teaching how to operate manually on the flesh, nerves, and bones of man’ was to mark its liminal status as requiring both education and manual labour. As surgery and medicine became for the first time separate professions, the very act of touching seemed an activity for a surgeon not a doctor. When Vita and Letizia da Villa Casale took their young son, who was suffering from a hernia, to the doctor he told them to go to a surgeon for ‘touching and cutting’. What made possible this retreat from touch, this novel situation where doctors were no longer in touch with their patients, was a new conviction that diagnosis was possible on the basis of a urine sample alone. The urine bottle was now the symbol of the doctor, where once it had been the cupping vessel or the hand on the hypochon- drium. In the new Latin Kingdom of Jerusalem in 1245, the law provided that if a patient died under medical treatment, the doctor should be whipped around the streets, holding a urine bottle in his hand, and then hanged. Sick people regularly sent samples of their urine to the doctor, making a bedside visit unnecessary. William of England wrote a text entitled If one cannot Inspect the Urine. The answer was not to visit the patient, but to cast his horoscope. In seventeenth-century England, there were plenty of medical practi- tioners who were happy to diagnose on the basis of a urine sample and an astrological chart. A sample of urine had become an epitome of the patient’s whole body, a genuine substitute for it. When doctors did visit their patients, taking their pulse represented a form of polite touching: even Galen had recommended taking the pulse at the wrist as that did not require the patient to undress. When called to advise the emperor he hesitated even to touch his wrist until he was urged to do so. One of the factors at work in this retreat by doctors from physical contact with the bodies of their patients was certainly a fear of contact between the sexes. In the earliest Hippocratic texts, doctors conduct vaginal examinations themselves; soon though they expect women to conduct them on their behalf. The Athenian Agnodice was, accord- ing to legend, one of Herophilus’ pupils. Distressed by the anguish of women who would rather die than be examined by a man, she cross- dressed in order to study medicine so that she would be able to treat women. In an Arab manuscript an illustration of the use of a vaginal speculum shows a woman conducting the examination, and there were apparently Arab female physicians, and female specialists in opthalmology and surgery. Nevertheless, in both East and West, there were men who also practised gynaecology and obstetrics, and when in 1322 a female unlicensed healer in France claimed she should be allowed to practise medicine as she would not endanger female mod- esty her plea was rejected –– the first woman to qualify as a doctor in modern times was Elizabeth Blackwell in America in 1849. Through the Middle Ages, it seems, male doctors were prepared, on occasion, to palpate the hypochondria of their female patients, but in the early modern period such contact was increasingly regarded as inappropri- ate. Greater even than the new prohibition against touching was the prohibition against seeing. In 1603 Edward Jorden described a phys- ician and a surgeon treating a tumour on a young maiden’s back. The physician ‘modestly put his hands under her clothes’ to feel it; the surgeon wanted to ‘take up her clothes, and to see it bare’, a suggestion at which she was ‘greatly offended’.

7.  A doctor inspecting urine in a urine bottle – the patient is not present. This image first appears  in 1493, and is reproduced from Johannes  de Ketham, Fasciculus Mediciniae (Venice, 1522).

It is only in the light of medicine’s retreat from direct contact with the body that we can understand the medical practice of Johannes Storch (b. 1681), the eighteenth-century German doctor we met in Chapter 1, who published extensively on women’s diseases. In the majority of his cases, Storch never met his patient, relying on letters and messages, or the reports and requests of intermediaries. Even when a patient came to Storch, or Storch went to see a patient, Barbara Duden tells us, in most instances he did not touch her for the purposes of examination. Here too he acted on the basis of what the patient said and what he could find out in further conversation. The importance of words and the public nature of the complaint stand in sharp contrast to the unimportance of a medical examination and what one can almost call a taboo against touching . . . When women occasionally show him (never at his request) parts of their bodies (a lump on a breast, a hernia, a lump on her right side) they do so ‘with great embarrassment’, ‘with great modesty and embarrassment’, ‘bashful[ly]’. Of one he records, ‘since she was expected to die, she agreed to have her naked body looked at and touched’. In this society (and many other early modern societies may have been similar) only the dead were exposed to the hand and the eye. Only in the nineteenth century did the living become once more exposed to the doctor’s touch, and even then great caution had to be used; as we have seen, the original function of Laennec’s stethoscope was to overcome the fact that he could not possibly put his ear to a woman’s chest. Family doctors, visiting patients in their homes in the United States in the 1890s, usually contented themselves with feeling the pulse and inspecting the tongue.

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