GENERAL ASPECTS OF HISTORY AND PHILOSOPHY OF MEDICINE
History of Medicine. 2017. Vol. 4. № 1. DOI: 10.17720/2409-5583.t4.1.2017.09i Ancient medicine after Herophilus. Part 2. The natural philosophical foundations, theory and practice of the Methodic school doctors1 Dmitry A. Balalykin FSAEI HE I.M. Sechenov First MSMU MOH Russia (Sechenov University) 8 Trubetskaya St., building 2, Moscow 119991, Russia Institute of World History, Russian Academy of Sciences 32a Leninsky Prospekt, Moscow 119334, Russia
This article attempts to reconstruct the main phases of the history of the Methodic school doctors. Representatives of this medical school, just like the empirical doctors, rejected the teleological principle of the human body and the possibility of extrapolating data obtained from anatomical dissections to clinical practice. They also rejected the Hippocratic principle of the etiology and individual character of diseases. In the author’s opinion, rejecting the study of the dead in the interest of learning about the living is related to the particularities of the “world map” of the Methodic doctors, the theoretical teaching basis of whom was natural philosophical atomism and whose clinical thinking was based on a symptomatic approach. The author of the article points out that we learned many concepts of the philosophy of atomism through the works of Aristotle as well. The atomistic world map helps make conclusions about the difference between a living and a dead body that are determined by the presence (or absence) of the movement of atoms. The Methodic doctors, guided by the world map based on atomistic natural philosophy, rejected the practical use of anatomic dissections and consequently, the necessity of conducting them. The Methodic doctors needed theories that would logically explain the phenomena they observed, while for rationalistic doctors theoretical medicine was a motive for experimental studies, whose results would become its foundation. The productivity of natural philosophical trends in the history of medicine was determined by how much the methodology proposed by the doctors responded to the practical tasks of the art of healing. Critical understanding of the medical experience in ancient medical practice became possible thanks to the apodictic research method used by Galen. The integral theoretical- practical system he created became the historical boundary that separated Ancient Greek rational medicine from the rational medicine of the proto-scientific period (the 2th‒16th centuries). Keywords: history of medicine, empirical doctors, rationalistic doctors, natural philosophy
For quotation: Balalykin D.A. Ancient medicine after Herophilus. Part 2. The natural philosophical foundations, theory and practice of the Methodic school doctors. History of Medicine. 2017. Vol. 4. № 1. P. 82–99.
About the author Dmitry Alekseevich Balalykin – Doctor of Medical Sciences, Doctor of Historical Sciences, Professor, Chairman at the Department of the History of Medicine, National History and Culturology, FSAEI HE I.M. Sechenov First MSMU MOH Russia (Sechenov University); Institute of World History RAS (Moscow). E-mail: [email protected]
Introduction Early Stoicism on this school [1]. 2 We now Part 1 of this article presented a detailed move on to attempt to reconstruct the history analysis of the theory and practice of the school of the empiricist doctors, which emerged in the 2 Part 2 of this article was to have examined the influence 3rd century BC, and shed light on the key aspects of the main Stoic doctrines on the development of specific of the infl uence of the natural philosophy of aspects of the theory and practice of the empiricist doctors. However, since the publication of Part 1, the third volume 1 The research has been conducted with financial support from of the Works of Galen in Russian, containing the first the Russian Science Foundation (RSF) as part of the project translation into the language of the first five books of his № 15-18-30005 titled “The Legacies of Aristotle as Constitutive treatise On the Doctrines of Hippocrates and Plato, has Element of European Rationality in Historical perspective.” appeared. Our introduction to that volume relates the theory and practice of the empiricist doctors to the basic concepts of Stoic philosophy, and analyses the history of the school Received: 16.01.2017 of the pneumatic doctors, whose views were an attempt at a © D.A. Balalykin compromise between Stoic natural philosophy and the ideas ORCID: 0000–0002–1813–8206 of the rationalist Hippocratics on medical practice [3].
82 History of Medicine. 2017. Vol. 4. № 1 of the school of the Methodic doctors ‒ the ‘turning’ and ‘intercontact’, as Democritus does. second-most important opponents of Galen (His denial of the reality of colour is a corollary (after the empiricist doctors). The theoretical from this position; for, according to him, things basis of this school’s teaching was the natural get coloured by ‘turning’.)” 6 This approach philosophy of atomism .3 It should be noted underplays the potential of true knowledge, and that it was the later, Epicurean, version of this, from the viewpoint of medicine, makes it atomism, rather than that of the founders of the impossible to describe the physiological changes philosophy, Leucippus and Democritus, that taking place in the body. Democritus’s successor, had a formative infl uence on the teaching of the philosopher Epicurus, developed and added the Methodic doctors .4 This infl uence needs to to his predecessor’s ideas. In analysing the subject be analysed and related to the specifi c medical matter of this article, it is interesting to consider theory and practice of the Methodic doctors. Epicurus’s physics, in particular those aspects In addition, the Methodic doctors, like the of it that infl uenced the development of medical empiricists, categorically rejected the notion thought. Valentin Asmus wrote, “The theoretical of the natural teleology of the human body and basis of Epicurus’s philosophy could only have the possibility of applying information obtained been a materialism hostile to any religious from anatomical dissections to clinical practice. mysticism and popular polytheism, while the For both, the diff erence between a living and philosopher himself had to stand up against the a dead body was so fundamental that there hostile proponents of supersensory knowledge. was no value in studying a corpse in order to All these features made Epicurus’s philosophy learn about the living. This attitude may have an outstanding doctrine of the Ancient Greek been a consequence of certain features of their Enlightenment. “Epicurus,” wrote Marx and worldview. Furthermore, the stark materialism Engels in The German Ideology, “was the true of the atomic theory led the Methodic doctors radical enlightener of antiquity; he openly to an even more consistent denial of the attacked the ancient religion, and it was from Hippocratic principle of aetiology and the him, too, that the atheism of the Romans, insofar individual nature of disease progression. as it existed, was derived. For this reason, too, Lucretius praised Epicurus as the hero who was Characteristics of Epicurean atomism the fi rst to overthrow the gods and trample religion Epicurus’s views are described in detail in underfoot; for this reason among all church many Russian and foreign studies of classical fathers… Epicurus has always had the reputation philosophy [6‒10]. Aristotle provides an of being the atheist philosopher par excellence…” 7 assessment of atomical philosophy (particularly [7, p. 318‒319]. Bertrand Russell wrote, “Epicurus that of Democritus). Of importance to attempts was a materialist, but not a determinist … The to reconstruct the history of classical medicine Epicureans contributed practically nothing to is his interest in its postulates of signifi cance natural knowledge. They served a useful purpose to understanding the processes of movement: by their protest against the increasing devotion “…no element arises from another element… of the later pagans to magic, astrology, and The common body is a principle of all things, divination; but they remained, like their founder, diff ering from part to part in size and in shape.” 5 dogmatic, limited, and without genuine interest The atomists asserted that only “atoms and the in anything outside individual happiness” 8 [9, p. void” were real, and, writes Aristotle, explained 265–266]. This mechanistic understanding of the all qualitative change through these concepts: laws of matter rejected the notion of the natural “…it is possible to construct alteration and coming- to-be with them, if one transposes the same by 6 English translation taken from: Aristotle: “On Generation and Corruption,” p. 6, in The Complete Works of Aristotle. 3 See, for example, [4]. 7 The translation from Marx and Engels is taken from 4 For more details on this, see, for example, [3] and [5]. https://www.marxists.org/archive/marx/works/1845/ 5 English translation taken from: Aristotle: “Physics”, p. german-ideology/ch03a.htm. 40, in The Complete Works of Aristotle (Revised Oxford 8 English translation taken from A History of Western Translation). Ed. Jonathan Barnes. Princeton University Philosophy, London: George Allen & Unwin Ltd, 1945, pp. Press: Princeton, NJ, 2014. 270.
83 Dmitry A. Balalykin teleology of living beings, and has been positively Concepts in Epicurus’s philosophy derive from evaluated by many historians of philosophy of the senses rather than logic. Sensation, being the second half of the 20th century, irrespective obvious, accurately refl ects surrounding reality. of their ideological positions. Clearly, historians Even imaginative representations are true in a way. of medicine can consider this viewpoint typical of They represent the combination of real images of the atomists. things entering through the pores. In this context, Epicurus’s ideas on the Furthermore, thinking about sensations principles of knowledge and its criteria are may be extremely dangerous (or may lead of particular signifi cance. Epicurus called to confusion): “Falsehood and error always this part of his philosophy the “canonic.” He depend upon the intrusion of opinion
84 History of Medicine. 2017. Vol. 4. № 1 randomness did not exist (his physics was strictly number of possible or likely explanations. Such deterministic), whereas Epicurus theorised multiple explanations cannot involve unnatural that atoms could spontaneously swerve away assumptions or contradictions with sensory from their linear trajectory. In swerving, atoms information confi rmed from experience. collided, and multiple collisions could result in According to William B. Jensen, “Epicurean conglomerations of atoms and the formation atomism was predicated on fi ve basic of physical structures. Epicurus’s physics thus assumptions: a. There is an absolute lower limit to posited atoms and their intrinsic properties as particle divisibility – i. e., true minimal particles fi rst principles. Atoms were in constant motion, called ‘atoms’ which are not only indivisible so it could be assumed that the physical bodies but also immutable and thus permanent. b. formed as a result of conglomerations of atoms There is an interparticle void or vacuum. c. All were constantly on the point of collapse: the interparticle interactions are due to collision atoms within a body were still moving. This followed by mechanical entanglement. d. The theory provides a physical explanation for the only fundamental atomic properties are size, ageing process, death, and the decomposition of shape, and motion – all others are secondary the human body. Naturally, some animals (e. g., psychological responses to various atomic humans) live longer than others (e. g., dogs). complexes. e. There is no dichotomy between Furthermore, people live to diff erent ages. The mind and matter, thus implying that the soul atomists explained this by arguing that the rate is both material and mortal. Thus we see that of decay diff ers because diff erent atoms move at Epicurean atomism was both materialistic and diff erent speeds. strongly reductionistic” [10, p. 1–2] .13 Epicurus Epicurus saw the soul as a body resembling believed that atoms are morphologically diverse: the wind and consisting of very fi ne particles he proposed the existence of tiny particles dispersed throughout the human body (as a kind of various geometric shapes (round, square, of body within a body). An Epicurean doctor thus polygonal, etc.). Perhaps this was one of the had a systemic explanation of the sensitivity of reasons why it was the Epicurean version of parts of the body and how it was controlled. All atomism that infl uenced doctors. If atoms came natural philosophical systems class reason, the in multiple shapes, it was easy to imagine how control of voluntary movement, and the control the specifi c shapes of the organs and other parts of sensory, passionate impulses as functions of the body observed by doctors on a daily basis of the soul. However, their views on how the were formed from them. In addition, the notion soul works and performs these functions diff er that atoms were morphologically diverse made it signifi cantly. How doctors from a particular school easier to explain how strictures arose (as “jams” of medicine explained the nature of development in the traffi c of atoms through the pores). of physiological processes depended on the A signifi cant contribution to our specifi c features of their worldview, which, in understanding of the applied importance of turn, was based on various natural philosophical Epicurus’s philosophy was made by the well- doctrines .11 Sensation, Epicurus believed, was known French academic Gilles Deleuze [14‒16]. key to understanding: “For in the study of nature He shows that Epicurus’s interpretation of the we must not conform to empty assumptions and problem of atomic movement had important arbitrary laws, but follow the promptings of the consequences for the theory of knowledge. facts.” 12 Epicurus saw ideas (eidôla) as multiplicities This view gives rise to a method based on of atoms, which are the objective elements of analogies, which allows for not just one correct thought. In Epicureanism there was a certain explanation of an observable phenomenon but a continuity between perception and conception. A description of the boundaries of compounds, or of the outlines of physical objects, 11 For more details on these mechanisms in the Platonics and Stoics, see [5] and [13]. 12 English translation taken from Diogenes Laertius, Lives 13 Later, we will see that Epicurean reductionism had of Eminent Philosophers (tr. R. D. Hicks), London: William a significant influence on the worldview of the doctors Heinemann, 1925, Vol. II, p. 579, 615. adhering to atomistic natural philosophy.
85 Dmitry A. Balalykin must take into account the continuous nature of thought) by other atoms as a result of collisions. atomic motion. After all, such boundaries can Unimpeded, atoms move at an extremely fast be indeterminate, and “fi ner than the objects of natural speed (“as swiftly as thought”). Second, which they are the outlines.” Epicurus describes he believed that atoms can swerve, and that this the outlines as “tupoi” 14; later, he uses the term explains their numerous collisions. Deleuze “eidôla.” Michael James Bennett refers to eidôla explains this concept as follows:”…we must as “homoschematic types” [17]. As such, eidôla conceive of an originary direction for each atom, are conceived as “fi lms of very fi ne atoms that as a synthesis which would give to the movement maintain for a relatively long time the schematic of the atom its initial direction, without which outline of whatever compound they were the there would be no collision. This synthesis is edge of.” In solid compounds (e. g. the human necessarily accomplished in a time smaller than body), atoms often collide and thus bunch together the minimum of continuous time. This is the and are prevented from achieving their maximal clinamen” [16, р. 269]. The clinamen, writes speed. At the edges of bodies, atoms moving Deleuze, is “the reciprocal determination which through the void encounter less resistance, so is produced ‘in a time smaller than the minimum they can reach their maximal speed 15 and quickly of continuous time thinkable’.” 16 travel a signifi cant distance. Epicurus claims that Deleuze’s description of the movement of “both perceiving and thinking occur through eidôla (“as swiftly as thought”), illustrating the action of eidôla upon percipient beings: his contention that Epicurus sees ideas as ‘it is when something from the external objects “multiplicities of atoms,” is very useful to [i.e., an image] enters into us that we see and historians of medicine [16, рp. 274‒275]. think about their shapes’.” Clearly, perception Notably, understanding Epicurus’s belief that and conception, according to Epicurus, are sensations are true makes it possible to explain derived from the action of eidôla. Accordingly, the Methodic doctors’ focus on symptoms. perceptions of eidôla are always true ideas, as For them, a doctor’s perception of the various eidôla are epistemologically primary. In contrast, outward manifestations of a disease equated to claims (or reasoning) about what exists can be an understanding of its nature. This was entirely false: “Falsehood… or going-astray… always logical: an eidôla – an image of a patient suff ering comes from an added opinion”. For Epicurus, from a particular ailment – was perceived by “added opinions” always have a negative sense: an experienced doctor as an integral, cohesive at best, they add nothing to true perception; at impression. Within the Epicurean view of the worst, they distort it. After all, eidôla, in all their material world, there was no reason to doubt multiplicity, are primary truth-value bearers, and that the disease symptoms detected by the cannot be false. Epicurus corrects the ideas on doctor were also the disease itself. As such, the movement of atoms held by Democritus, who contemplating internal processes hidden from thought that atoms did not have an innate natural sight was not appropriate, as it could lead to false speed. Their motion, Democritus believed, is added opinions. Therefore, there was no need caused by the accelerations resulting from their for experimental research aimed at explaining collisions. Aristotle criticised Democritus’s disease development [16]. lack of a logical explanation for these collisions The atomistic worldview saw a clear for it was required to explain the reason for this diff erence between the living and the dead: the interaction between atoms. Epicurus made two presence or absence of atomic motion. As all very important refi nements to Democritus’s healthy and pathological processes in the body theory. (Essentially, he established the theory of were determined by the nature of this motion, it atomic motion that would be applied in medicine.) made no sense to study the dead to learn about First, he attributes weight to atoms, and the living. Accordingly, the Methodic doctors, describes to them natural motion, which can be with their worldview based on atomistic natural impeded (rather than stimulated, as Democritus 16 English translation taken from Gilles Deleuze, Difference 14 Literally “stamps”. and Repetition (tr. Paul Patton), London: Bloomsbury, 15 I.e., “as swiftly as possible”. 1994, p. 242
86 History of Medicine. 2017. Vol. 4. № 1 philosophy, believed that there was no practical was a prominent member. He was made acting benefi t to anatomical dissection. head of the Academy when Plato went to Sicily, Previously, we discussed the eff ectiveness and lost narrowly to Xenocrates in the election of the natural philosophical movements in the for a new head of the Academy following Plato’s history of medicine that off ered a methodology death [19]. appropriate to the practical objectives of the art Historians believe that Heraclides was an of healing [3]. The apodeictic method – which adherent of atomism in its Epicurean version. in classical medical practice took the form of But is there not a contradiction here: how could a combination of anatomical dissections, a Heraclides have been both a supporter of Plato rational theory of general pathology, and clinical and a convinced materialist, who advanced classifi cation – was of particular signifi cance [18]. atomistic natural philosophy? We cannot give Such classifi cation involved a critical evaluation a defi nite answer to this question. Here, fi nding of doctoral experience. In medical practice, it the historical truth is made more diffi cult not was based on a combination of cataphatic and only by the paucity of primary evidence, but also apophatic methods of analysis .17 Presenting the by the extremely contradictory views of modern issue in this way seems all the more appropriate, researchers. For example, Roberto Polito, in as Galen’s comprehensive theoretical and attempting to support the incorrect theory that practical system itself marks a historical boundary the representatives of the diff erent schools of separating the period when Greek rational natural philosophy held identical views within medicine emerged from the rational medicine the context of their infl uence of medicine, of the protoscientifi c period (the 2nd to 16th uses the curious term “geometrical atomism” century). The natural philosophy of atomism did with regard to Plato’s ideas on the nature of not allow for such approaches [5]. matter .18 Plato, writes Polito, makes use of Empedocles’s theory of four basic elements, but The Methodic school and the influence of “Empedocles’ elements are not primary, but atomism on the development of its teaching themselves reducible to more basic principles, In the 1st century BC, another major classical elementary triangles.” Polito uses the term school of medicine emerged: that of the Methodic “corpuscles” to describe the structures made doctors. up of the geometrical fi gures of the four primary It is generally believed that the fi rst person elements, which combine in diff erent ways, to use atomistic natural philosophy to explain thus forming physical objects. In using the term vital processes and the causes of diseases was “geometrical atomism” with regard to Plato, he Asclepiades of Bithynia. We do not know his has in mind the fact that the geometrical fi gures exact dates, but most researchers believe that he of which Plato believed the basic elements took was at the height of his popularity between 70 the form constituted very small particles. These and 50 BC. Accordingly, Themison, his pupil, ultimately made up physical objects, including would have been in his prime in around 130 to 120 the human body. Such speculative constructs BC. The Methodic school of medicine takes its can only confuse historians of medicine. It must name from the basic idea of Asclepiades and his be said that such multiple interpretations from pupils that a doctor’s task is to identify the most diff erent authors only complicate the search for successful method of treatment for a specifi c the right answer. The researcher is left hostage illness, and to strictly follow it in future practice. to a presentist bias in favour of the natural Roberto Polito believes that Asclepiades’s philosophy of atomism, which was closer to the views were signifi cantly infl uenced by the ideas of physics of the 17th to 19th centuries than rival Heraclides Ponticus [19]. Unfortunately, we know schools of Ancient Greek physics. little about Heraclides. For a signifi cant time, he However, these explanations are of little was associated with Plato’s Academy, of which he use in understanding how representatives of diff erent classical schools of medicine thought – 17 The principles followed by Rufus of Ephesus and Galen in taking anamneses are an example of this. For more details, 18 It may be recalled that Plato used geometrical figures to see [3]. describe the basic elements.
87 Dmitry A. Balalykin after all, what we have here is essentially a of atomism, as the basis of the Methodic question of the terms describing the views of doctors’ worldview, also rendered the question of particular philosophers. What is important aetiology, diff erent forms of pathogenesis, and, to us is that the atomistic doctrine posits two ultimately, the complex classifi cation of diseases main theories: fi rst, that the human body is irrelevant. The founders of the Methodic school made up of tiny indivisible particles (atoms), proposed that processes in the human body can and, second, that those atoms are in constant, be explained using three (and only three!) types random motion. The specifi c features of how of pathogenesis. First, diseases can result from Democritus and Epicurus describe this motion breathing problems (i. e., impediments to the are of secondary importance to historians of movement of atoms inside and outside the body). medicine. What is signifi cant is the nature of In a healthy body, atoms move in their natural their doctrine, which rejected a teleological way, albeit chaotically. With a disease caused (i. e., purpose-based) explanation of how the by a change in breathing, the atoms’ shapes human body worked. Democritus asserts that and movement change, allowing the condition atoms moved chaotically in diff erent directions, in question to enter the body. The second way forming physical bodies when colliding and in which diseases can occur is as a result of bunching together. According to Epicurus, obstruction of the internal pores – tiny channels they are constantly falling, and, as they do so, invisible to the naked eye through which atoms they collide and can change their trajectory move within the body. In a healthy person, and bunch together to form physical bodies. atoms move freely through these pores within the Obviously, such nuances in the interpretation of body, but pathogens cause the pores to narrow, atomism had little bearing on the development impeding the atoms’ circulation .19 The third of medical thought. The principal diff erence in cause of pathological processes, according the Platonic and Aristotelian explanations of to the Methodic doctors, is a combination of how physical bodies are formed is the idea that the fi rst two, with breathing problems being the movements of the tiny particles making up combined with a narrowing of the pores. These the human body have a purpose. For medicine, explanations give rise to a number of questions, the most important aspect of atomism was the primarily with regard to how the atoms move. If chaotic nature of this motion. In this context, atoms move chaotically in any case, how could praising the atomists for the “science” of their the normal state of chaos in a healthy body be approach makes no sense. The mechanism diff erentiated from the abnormal state in a sick and determinism inherent in their doctrine body? Furthermore, medical practice called mean that in practice they eschewed the study for specifi c ideas of pathogenetic processes that of physiological processes. Some historians of could be related to the clinical manifestations philosophy claim that experimental practice was observed by doctors. In other words, how could not an option at the time of Democritus and these three simplistic types of pathogenesis Epicurus [8]. However, such practice did exist describe the full range of diseases encountered in classical medicine (such as the anatomical by doctors in their everyday practice? Galen dissections of Herophilos, who received a asked these questions when criticising the highly conventional philosophical education at Methodic doctors’ ideas. He also stressed the the Academy and the Lyceum). Previously, we need for therapeutic interventions to be based discussed how the empiricist doctors consciously on the nature of the illness. Naturally, doing avoided anatomical dissection [3]. The so using the three universal types of disease Methodic doctors, who avoided experimental proposed by the Methodic doctors would have practice in principle, did so just as deliberately: been impossible. if the functions of the human body were not physiologically essential, experimentation was 19 We may compare the flows of atoms to traffic: normally, the unnecessary. Their rejection of the teleological atoms permeate the whole human body as they flow unimpeded explanation of the workings of the human body through the pores, but sometimes “jams” can occur, leading meant that they had no need of anatomical to any number of major pathological accumulations of atoms experiments. Accordingly, the natural philosophy within the pores and their intersections.
88 History of Medicine. 2017. Vol. 4. № 1
The main achievement of Asclepiades, hand, the logic behind selecting the best who was strongly infl uenced by the physical treatment method assumed the existence of theories of Heraclides Ponticus and Epicurus, certain regularities, which doctors could detect was undoubtedly in paving the way for a new through their practical work. direction in the medical thought of his day, Asclepiades’s logic was as follows: all physical which was soon to challenge the empiricists objects, including the human body, consist of and rationalists. It was Asclepiades who was the atoms, which can diff er in shape and weight; the fi rst person to propose the theory (developed human body (like other bodies) is a combination by his pupils) that diseases develop in three of them, which is subject to objective laws. This ways. With his natural philosophical views, he does not mean that the functions of the body was critical of Hippocrates’s humoral theory, have a teleological purpose: they are the result and rejected the notion of natural teleology. of chance. The existence of such laws (as such) However, he did not deny the importance of cannot be denied: it is clear that the body works understanding causation: without this, the in a particular way. People are born and die, idea of choosing the best method to treat a drink, reproduce, and perform their bodily specifi c illness would have made no sense. The functions; a patient has a pulse, which changes problem was that causation, as Asclepiades and when he falls ill and varies with diff erent types the other Methodic doctors saw it, could not of fever – all this can and needs to be observed. be compared with causation in the teleological The issue for the Methodic doctors was that sense, as seen by a doctor adhering to the ideas these processes are not predestined: they of Plato and Hippocrates. The teleology of occurr because of a random, though physically Plato and Aristotle was based on the idea that determined, combination of atoms. At the same the functions of the living body are governed by time, Asclepiades and his followers accepted the internal laws. The reason physiological processes notion that outward manifestations of disease take place in the way they do is that they have (i. e. symptoms) could be used to help to get an an intrinsic purpose: they were designed by God idea of the processes taking place in the body, in the best way possible for life. Aristotle focuses unseen by a doctor. Here, the Methodic doctors on the hierarchy and types of movement, but in fundamentally diff ered from the empiricist fact these are merely details of the teleological doctors. Outward manifestations of disease understanding of the human body. Within the were explained through an understanding of context of this worldview, the aetiology of the pathogenesis – in this sense, the Methodic disease was seen as a natural factor impeding the doctors can also be said to represent “theoretical normal performance of the functions of parts of medicine.” This fact, combined with the paucity the human body. Galen’s theory built on this of sources on medicine in the Hellenistic period, idea, and is key to diff erentiating between health sometimes makes it hard to decide which school and disease. of medicine a particular doctor belonged to. Asclepiades considered the empiricist Another issue is that the theory of the Methodic doctors’ belief in the inherent value of practical doctors ruled out a pathogenetic 20 approach experience, which rendered medical theory to a theory of health and disease. Evidently, the unnecessary, to be senseless. He appreciated Methodic doctors ultimately made the same Hippocrates’s works, but only as a practical fundamental error as the empiricist doctors: guide to the art of healing. The inconsistencies they equated the complex of symptoms visible in the individual books in the Hippocratic to a doctor with the disease itself. Previously, we Corpus gave Asclepiades reason to be dismissive highlighted the presence of elements of clinical of his predecessors and critical of their incorrect thought and diff erential diagnosis in Galen’s interpretations of Hippocrates’s ideas. clinical practice [5]. This lay behind the capacity Asclepiades believed that the human body for explanation of Galen’s system, which was can be described in terms of the constant based on the teachings of Plato and Hippocrates. movement of atoms. On one hand, the atomists thought that atoms move chaotically and 20 The term “pathogenetic” in this context is used in its become entangled by chance; on the other modern sense.
89 Dmitry A. Balalykin
Methodism did not have this ability, but the of interest in that it incorporates the legacy of limited therapeutic arsenal of the doctors meant Hippocrates into the framework of Methodic that it made a signifi cant impression with its teaching .21 Unlike the empiricist doctors, the common sense. Ultimately, patients want doctors Methodic doctors did not reject theoretical to alleviate their suff ering. Vivian Nutton writes medicine: they put forward their own version of that Asclepiades used the slogan “swiftly, safely, it, based on the natural philosophy of atomism. pleasantly” to describe his therapy. Its practical The followers of this school of medicine read implementation was based on fi ve principles: the works of the great doctors of the past 1) diet, clearly developing ideas in the extremely carefully, and strove to borrow from Hippocratic Corpus, and based on regulated them everything that they found useful and intake of food and wine; 2) light, but strictly did not contradict the main elements of their regular, exercise at home; 3) passive exercise teaching. In addition, the fact that the works supervised by a doctor, for patients unable to of the Methodic doctors were written in two exercise independently (such activities were languages is of huge historical signifi cance. based on exercises on swings specially developed The rationalist followers of Hippocrates and by Asclepiades, which remained popular with the empiricist doctors were mainly Greeks who doctors up to the modern era); 4) massage; had come to Rome. The principles of their 5) regular bathing, for which diff erent forms teaching are set out in texts written in Greek of passive exercise were also developed (in this by natives of continental Greece, its colonies, sense, Asclepiades may be regarded as a and the new cultural centres of the Hellenistic genuine pioneer of the use hydrotherapy in period. In contrast, the fundamental works most rehabilitation) [4]. representative of the teaching of the Methodic If we also take into account the fact that school were written both in Greek and in Latin. Asclepiades recommended listening to music For example, the treatise On Acute and Chronic and drinking wine to counter depression, warned Diseases, by Caelius Aurelianus, was written in against taking very cold baths, and said that Latin, even though its author lived in North recovering patients needed as much attention as Africa. Evidently, many of the Methodic doctors those at the height of their illness, he seems to already associated their work with Rome. On the have been a reasonable and prudent doctor. other hand, Greek, the language of science and culture at the time, was the main language of, Modification of the teaching by Themison and for example, Soranus of Ephesus and Julianus Thessalus. of Alexandria. Another popular medical author The theory and practice of the Methodic doctors of the 1st to 2nd centuries was the Methodic in the 1st-2nd centuries AD: Galen’s criticism doctor Marcus Modius Asiaticus ,22 whose Galen was contemptuous of the “third sect,” professional expertise earned him the nickname as he called the Methodic doctors. However, “Champion of the Method” even while he was there was a serious competitive aspect to his still alive. He received the agnomen Asiaticus – contempt, and sometimes, depending on the “the Asian” – because he lived and worked in patient’s social status, a “fi ght for survival”. Smyrna, a major city and rival to Ephesus for the Galen’s main rival in Rome in the 170s, Statilius status of cultural capital of Asia Minor [4]. Attalus, was a Methodic doctor. One of the Galen, in his On the Sects, provides a foremost authorities on medicine of the time, “genealogy” of the development of Methodism. Soranus of Ephesus, was also an adherent of The founder of the school, he says, was Themison the Methodic school [20]. One of the most popular works on medicine – forty-eight books 21 Asclepiades of Bithynia had an ambiguous attitude to the on the “Aphorisms” of Hippocrates – was Hippocratic Corpus: on one hand, he rejected all the natural written by Julianus, of Alexandria, (c. 150), a philosophical ideas of its authors, including the principle of the doctrine of aetiology, but, on the other hand, he pupil and follower of the well-known Methodic considered Hippocrates an excellent doctor, and his works doctor Apollonius of Cyprus. His work is a the most important source of information on the practical comprehensive and cogent exposition of the art of healing. doctrine of Methodism. Julianus’s work is also 22 Russian historians make no mention of him.
90 History of Medicine. 2017. Vol. 4. № 1 of Laodicea, “taking his cue from the rational he was not necessarily a rationalist Herophilean. Asclepiades”. The “sect” (as Galen calls the He denied that digestion could be explained Methodic school) was completed by Thessalus through the concept of internal heat, believing of Tralles, who was followed by the doctors that food in the stomach simply disintegrated Mnaseas and Dionysius. It is worth noting that and turned into juice. Alexander regarded blood Themison was born in Laodicea. This town is as a simple homogeneous substance, in contrast fi rst mentioned as a centre of medical education to the Aristotelian tradition. He also believed practice in connection with the well-known that semen is a derivative of blood. 23 All this, doctors Zeuxis and Alexander Philalethes, both of except for his theory on the nature of semen ,24 whom practised in the 1st century BC. Heinrich is reason to regard him as a representative of the von Staden calls them “Herophileans”, and links Methodic school. Another reason for describing them to the expansion of medical learning from Alexander Philalethes as a Methodic doctor Alexandria to Asia Minor [21, p. 460]. However, is his On Gynecology, comprising at least two the fact that doctors made use of Herophilos’s books. Since the time of Hippocrates, doctors teaching about the pulse in their practice is not had been interested in whether health problems enough to call them Herophileans. Furthermore, specifi c to women, which are fundamentally historically, the medical tradition in Asia Minor diff erent from general medical conditions in developed much earlier than in Alexandria: their origin, can be considered a separate group. Kos, Knidos, Ephesus and Miletus were already Alexander recognised that doctors did indeed centres of medical learning in the 5th century encounter such specifi c conditions; the problems BC. The fact that Herophilos’s sphygomological associated with birth and obstetrics, the need to ideas, which had important practical signifi cance treat vaginal discharges, and so on, could not be even outside the context of the infl uence of any denied. However, he did not regard “women’s natural philosophical views on medicine, were health problems” as a special branch of medicine. widely adopted by the doctors of Asia Minor Such an approach was also characteristic of the should not surprise us. The doctors of Laodicea Methodic doctors. might be called followers of Herophilos had they, Our sources do not state directly that Themison for example, performed anatomical dissections studied under Zeuxis or Alexander Philalethes. and written theoretical works about it. As they Were documentary evidence that they worked did not, the spread of Herophilos’s ideas about together to be found, it would be striking proof the pulse may be regarded as part of the normal that the Methodic school already held a dominant exchange of knowledge between doctors in the position by the end of the 1st century BC. In the Eastern Mediterranean. At the same time, we absence of such evidence, the existence of a link do know that there was an important centre of between Themison and the leaders of Laodicean learning in Laodicea from the 1st century BC medicine remains only a hypothesis. to the 1st century AD, for it was founded by An interesting fi gure in the history of Zeuxis and developed by Alexander Philalethes. medicine in the 1st century AD is Aristoxenus The well-known geographer Strabo (64 BC – (a pupil of Alexander Philalethes), who is 23 AD) mentions both leaders of the Laodicean also associated with Laodicea. Like many school as his contemporaries. Here, “school” of his colleagues, Aristoxenus wrote a book. means a centre for the development of medical Titled On Herophilos and his School, its was learning, in both an administrative and a more critical than doxographical. Aristoxenus geographical sense. We know that Alexander criticises practically all the Herophileans – Philalethes studied under Asclepiades of Bithynia Bacchius, Zeno, Chrysermus, Apollonius Mys and followed his teacher in many ways. For and Heraclides of Erythrae. Galen was able to example, he viewed general pathology in terms 23 of the notion of “pores” – numerous invisible In his treatise On the Seed, he calls semen “the foam of blood.” channels that can only be imagined, running 24 Epicurus thought that semen was derived from all parts of throughout the human body. Although Alexander the body. This exception is of little importance: at various Philalethes devoted particular attention to the times, even convinced Hippocratic doctors shared the pulse theory, seeing great practical benefi t in it, pangenic theory of sperm formation.
91 Dmitry A. Balalykin read the complete text of Aristoxenus’s works, Other well-known specialists generally and is rather sceptical of him in his works on regarded by historians as Methodic doctors the nature and clinical signifi cance of the pulse. include Laecanius Arius of Tarsus, Julius Bassus, Essentially, Galen criticises Aristoxenus for his Niceratus, Petronius Musa, Diodotus, Sextius tendency to over-theorise, commenting that Niger and Dioscorides, author of a major work he “wants to give a defi nition in a dialectical on pharmacology, which remained relevant up to manner but does not himself observe the the Renaissance [4]. laws of dialectic” [19, р. 561]. Aristoxenus Each leader of the Methodic school, believed that it is necessary to understand the naturally, introduced something new, slightly essence of defi nitions before addressing the modifying its characteristic features. We can clinical signifi cance of a problem. In his view, assume that the basic doctrine of these three types there are two types of defi nition: “proper”, or of pathogenesis was proposed by Asclepiades of “substantial”, and “conceptual,” or “subjective” Bithynia, and, possibly, one of the Laodiceans – (“descriptive outlines”). It may be suggested Zeuxis or Alexander Philalethes. Clearly, neither that behind this division lies a criticism of the Asclepiades nor his successors (Themison defi nitions of the pulse proposed by Herophilos and Thessalus) were interested in anatomical and his many supporters. dissections. This is another argument in support of Another well-known pupil of Alexander our previous explanation of why the Alexandrian Philalethes was Demosthenes, who also bore the practice of dissection was not developed in the epithet “Philalethes” .25 Demosthenes Philalethes post-Herophilean age. It was not so much a practised in the mid-1st century AD, indicating matter of religious prohibitions: as we saw earlier, that the Laodicean centre was an established the empiricist doctors saw no value for learning in school of medicine then. Here, “school” implies dissection. As a result of their natural philosophical a prolonged existence and maintenance of an beliefs, their worldview, the Methodic doctors educational tradition in a specifi c geographic would have regarded anatomical research in the area, through the transfer of knowledge from same way: with indiff erence or hostility. teacher to pupil (in this sense, historians speak The doctors of the period, in principle, had of the Kos, Knidos and Croton schools of an idea of the workings of the human body; they medicine). Demosthenes Philalethes made a had the writings of Herophilos available to them. fundamental contribution to the development of Not everyone, however, valued anatomy: a doctor ophthalmology. His works in the fi eld infl uenced believing that physiological processes were the the views of Rufus of Ephesus and Galen. result of the random motion of invisible atoms His written legacy has enjoyed rare historical would have rejected in principle teleological good fortune: it has been well preserved and explanations of healthy and pathological reproduced in many later sources. Both Aëtius processes. The atomists might have thought that of Amida (fl . 6th century) and Paul of Aegina there was some logic to this randomness, but only (fl . 7th century) borrowed from the Laodicean of a mechanistic sort. Thus there was no intrinsic physician. Demosthenes’s works were published purpose to the functions of the part of the body in Latin relatively early. Max Wellmann believed and no need for experimental study of them. that they were translated into the language in the This attitude lay behind the theoretical ideas of late 4th century by Vindicianus (a friend of Saint Themison, who signifi cantly added to the basic Augustine), and were well known in this form doctrine of the Methodic school [4, 22]. in Western Europe in the 10th to 13th centuries. Themison believed that to be successful, In addition, Demosthenes had a keen interest a doctor needed to provide eff ective medical in pulse theory (which was popular with doctors assistance. Common sense led him to deny the of the time): he wrote a work on the subject in need for nosological classifi cations, irrespective three volumes. To all appearances, he followed of how many illnesses there were and what they his teacher, Alexander Philalethes, in his were called, if the scope for providing appropriate interpretation of the theory. assistance to the patient depended on the doctor’s limited therapeutic options. Doctors needed 25 “Philalethes” literally means “lover of truth”. to assess the symptoms of suff ering carefully:
92 History of Medicine. 2017. Vol. 4. № 1 they needed to understand of what exactly the from “looseness” are caused by a change in the patient needed to be cured. At the same time, confi guration of the pores, aff ecting the circulation there was no point in contemplating the hidden of atoms (body tissue thus becoming “loosened”). causes or mechanisms of development of the Both cases lead to the same outcome: the pores illness, as doing so would not help to improve become blocked with an accumulation of atoms, the treatment. Meanwhile, the empiricist doctors resulting in swellings, oedemas, etc. These rejected all theory, preferring to draw on similar accumulations can be compared to the formation cases from past practical experience. This reliance of thrombi in the vascular system. “Mixed-type” on past experience, believed Themison, was not diseases arise from a combination of stricture enough; after all, it was clear that some diseases and tissue looseness. It is not hard to see that shared common features, while others diff ered Themison’s pathogenetic theory diff ered little signifi cantly. Based on his observation, Themison from the views of Asclepiades. It could not have proposed the concept of “commonalities,” been otherwise: both were atomists, and the according to which general features of the diff erences in their opinions on practical work progression of the disease were to be identifi ed were relatively unimportant. from a large number of observations of individual Themison also divided diseases into the acute clinical cases [4]. Accordingly, all diseases were and the chronic, the former being associated more divided into groups based on such commonalities. with “stricture,” and the latter with “looseness.” A classifi cation of diseases based on observations of This mechanical explanation holds that a stricture “commonality,” rather than on any pathogenetic can appear suddenly within a single pore, whereas logic, emerged. This determined the principles of it takes time for a state of tissue looseness, therapy: specifi c therapeutic interventions were involving multiple pores, to develop. related to commonalities of diseases. As with the Themison believed that there are three empiricist doctors, the basic clinical approach stages to the progression of a disease: its initial was symptomatic treatment. development, when the symptoms increase; Like the rationalist doctors, and unlike the a middle period, when the symptoms remain empiricist physicians, the Methodic doctors constant; and a fi nal stage, with the agony of may be regarded as adherents of theoretical death, should the disease prove fatal, or a sharp medicine. However, Themison understood this decrease in the intensity of the symptoms, should theory diff erently from the rationalists, for whom the patient get better. (with the clearest examples being Herophilos We can clearly see how logical Themison’s and Galen) it served as an inspiration to engage theory of the “commonalities” of diseases appears in experimental studies, and was informed by in light of the Epicurean method of analogy. The their results. (It was within this framework that basic principle of this school is obvious: successful medicine emerged as a science.) The Methodic treatment was based on a tried-and-tested doctors sought theory that logically explained the method. This method, applied after the symptoms phenomena they observed. The speculative nature observed by the doctor had been compared with of this theory was not a problem for them, as there the classifi cation of commonalities, lay at the was no need to verify it through experiments. heart of the Methodic doctrine. Themison identifi ed three basic categories An extremely important innovation of disease, based on their type of pathogenesis introduced by Themison was the concept (“stricture”, “looseness”, or a mixed state). At issue of the diatritos – a three-day phase in the here, of course, were diff erent types of impediment course of a disease. It is likely that Themison’s to the free movement of atoms through the pores concept of the diatritos was a development of running through the human body. Hippocrates’s idea of crisis, which the latter Diseases arising from “stricture” are caused based on observations of the progression of by the pores becoming too narrow for atoms to fevers. Later, Galen reinterpreted the concept pass through them. It may be recalled that the of the crisis as an indication of the best time for Epicurean version of atomism envisaged the therapeutic intervention .26 Themison’s idea was existence of atoms of all kinds of shapes and sizes within the human body. Diseases arising 26 For more details, see [23].
93 Dmitry A. Balalykin that the course of an illness is marked by certain atomist, this would mean a signifi cant change of changes every three days. By understanding emphasis in our interpretation of the legacy of them, a doctor can address the symptoms of the Alexandrian medicine of the 3rd century BC. the disease more eff ectively using the remedies Galen regarded many of the treatment methods available. There is a clear link between the idea used by the Methodic doctors as inherited from of the diatritos and the pathogenetic concepts of Erasistratus. Elsewhere, he writes, “Straton was “stricture” and “looseness.” An acute disease convinced of the benefi ts of fasting, advanced caused by stricture of the pores can after three by Erasistratus, in the treatment of any disease. days either start to resolve or enter a more This can be clearly seen from the contemporary prolonged phase as individual strictures build comments of those who considered opening veins up to create looseness in a particular part of the equivalent to fasting” [24, p. 433–434]. body. Galen reserved his strongest criticism for the The widespread use of fasting during the use of fasting in the acute phase of an illness. fi rst diatritos infuriated Galen. This treatment First, it artifi cially weakened the patient, and in method appears to have been quite popular with certain cases could be contraindicated. Second, the Methodic doctors of his day. To give Galen the Methodic doctors resorted to it when, in his due, his criticism was not unfounded: he Galen’s view, an urgent surgical remedy, in the always backed up his arguments with examples form of a phlebotomy, was required: “For even from practical experience. For example, in one if it is true that an amelioration of the disease of his works Galen writes the following about follows when the veins are emptied by fasting, we the Methodic doctors: “In addition to these shall nevertheless omit it, for this reason: that it is patients, these enemies of phlebotomy were far better for those who have once evacuated the busy conducting to her death in the same way a excess to avoid fasting, which causes much distress fourth woman whose menstrual catharsis had to patients and brings sleeplessness and vexation, been suppressed for a long time. They kept her to say nothing of disturbances of the stomach and without food, particularly for the fi rst three days; corruption of the humours in it, and sometimes for, it is true, she had a continuous fever as well. even suppression of urine” 28 [24, p. 434]. On the fourth day they gave her a minute quantity The Methodic doctors prescribed fasting of slops; then on the fi fth day they again ordered rather than performing a phlebotomy, wasting fasting. At this point, in a violent paroxysm, valuable time during which their patients might she sprang up delirious and rushed out of doors have been saved (as in cases of apoplexy). Bearing shrieking, so that those present could hardly in mind their ideas on pathogenesis, however, restrain her. Nature, however, saved this woman the approach used by the Methodic doctors at least, by pouring out blood copiously from her made sense. Apoplexy, for example, could be nostrils” [23, p. 428‒429] .27 interpreted as looseness of the brain tissue as In a number of his works, Galen calls the a result of strictures. The doctor’s task would Methodic doctors of his time “Erasistrateans,” therefore have been to “normalise the movement “followers of Erasistratus,” etc., as if it goes of atoms through the pores” of the aff ected part without saying. However, we are not aware of any of the body. Within the framework of Themison’s contemporary academic work in which, on the theory, this could have been achieved by reducing basis either of quotations or of an interpretation the number of atoms in the body. (The human of the sources, Erasistratus is described as a body lost atoms via urine, faeces and sweat.) supporter of atomism. Evidently, Galen knew Atoms entered the body through food, so fasting more about him than academics today do. At during the fi rst diatritos was prescribed to solve the same time, this issue deserves careful study: this problem. were it to be proven that Erasistratus was an Another method of countering looseness, popular with the Methodic doctors, was the 27 English translation taken from: Galen, “On Venesection against the Erasistrateans at Rome”, quoted in Peter Brain’s 28 English translation taken from Galen, “On Venesection Galen on Bloodletting, Cambridge: Cambridge University against the Erasistrateans at Rome,” quoted in P. Brain, op. Press, 1986, p. 40. cit., p. 44.
94 History of Medicine. 2017. Vol. 4. № 1 use of tight bandages. The idea was that the “(1) an excessively dry, tense and stringent state pressure on the part of the body with too (status strictus); (2) an excessively fl uid, relaxed, many atoms would make the atoms move to a atonic state (status laxus); and (3) a condition healthy part where there were fewer of them. involving both types of abnormality (status A tight bandage applied to a relatively large part mixtus)” [25, р. 538]. of the body, thought the Methodic doctors, The next leader of the Methodic school was “drove” excess blood to another part of the Thessalus, a native of Tralles, a wealthy city in body, thereby resolving the problem of how to Asia Minor renowned for its wool. Galen made redistribute the “excess” atoms. This treatment reference to this fact when scornfully describing approach also outraged Galen: “We say that Thessalus as “the son of a wool carder.” With bandaging organs will not help in getting this nickname, Galen highlighted the ignorance rid of excess blood without opening veins… of Thessalus, who claimed that one could Erasistratus spoke very vaguely: ‘the dressing learn medicine in six months before perfecting should be wool, and cover all the organs except one’s art in practice. Whether Thessalus the armpits and groin’. In this case, we can only actually thought this, we do not know. It may speculate about which [patient] this applies be that Galen was thus mocking another of his to and whose blood can be displaced in the opinions (such as his panegyric on the Methodic body in this manner. Maybe this is not always doctrine, which was apparently so logical that possible and dressing should not be used on the it made it possible to master the profession of organs? But is this not just what we have already doctor quickly). Galen was generally hostile said about what Erasistratus wrote, and which towards Thessalus, and made numerous you are now also saying? Can it really be true sarcastic remarks about him. In his On the Sects, that someone whose forearms, shins and hands he satirically describes Themison’s horror on are inflamed with hypervolemia needs to have meeting Thessalus and seeing what the latter blood removed, while others simply need their has done to the Methodic school. Here, Galen organs bandaged?” [24, p. 454‒455]. Galen was mocks Thessalus’s development of Themison’s particularly angered by the use of the Methodic theory of commonalities. Unfortunately, doctors’ favourite treatment approach (fasting Galen’s works remain one of the main sources and bandages) for acute illnesses, when of information on the Methodic doctors. We will neglecting phlebotomy in favour of bandages attempt to gain an understanding of Thessalus’s was most dangerous to the patient’s life. medical views while ignoring Galen’s attitude to Thus, the Methodic doctrine, positing the his opponents. existence of certain universal features in all The fi rst important aspect of Thessalus’s diseases, was established by the mid-1st century. teaching was his refi nement of the theory of According to Don Todman, those features could “commonalities”, which he subdivided and made be divided into three groups: 1) excess pressure more specifi c. The principle underlying this in parts of the body; 2) excess weakness of parts subdivision is that diseases treatable with dietetic of the body; and 3) and a combination of the methods are assigned to one “commonality,” two. These three groups of outward features and conditions requiring surgery to another. can be compared to the three universal types of The “commonality” of surgical problems is pathogenesis according to Themison (stricture, subdivided into the external (e. g., a splinter, looseness, and a combination of stricture and which can be treated by extraction) and the looseness), as well as to the three universal types internal. The latter, in turn, are subdivided into of aetiology according to Asclepiades of Bithynia those of a change of place (e. g., a sprain or [20]. What is important is that, without rejecting fracture), which can be cured by repositioning medical theory, they nevertheless concluded (i. e., by putting the relevant part of the body that there was no point in studying anatomy and back in its place); those of excess (tumours or physiology. excrescences), which have to be removed to Abraham Goldstein slightly refi nes this reduce the relevant part of the body to its normal interpretation of the Methodic doctrine. size and those of insuffi ciency (fi stula or ulcers), According to him, it envisaged three states: which the doctor has to repair (i. e. increase the
95 Dmitry A. Balalykin relevant part of the body to its normal size). A However, there was some sense to Thessalus’s fi fth surgical commonality deals with wounds thinking: a treatment approach needs to be through which poison enters the body (e. g., a fl exible, and a doctor needs to react to changes in prick from a poisonous plant or a snake bite). a patient’s condition, changing the therapeutic Thessales called this commonality prophylactic approach if necessary. Some doctors considering surgery; evidently, he clearly understood the themselves followers of Hippocrates might need to prevent poison from entering the body, have continued with their prescriptions for no and to surgically clean the wound. good reason. We can surmise that between the Thessalus subdivided dietetic commonalities 1st century BC and the 1st century AD there into two groups: active and passive. The active were works by Methodic doctors on this issue. include illnesses associated with excessive, It is no coincidence that during this period the sometimes pathological, excretions (here, the supporters of rational medicine were disdainfully diet therapy was not only corrective, but also labelled “dogmatics”. Following the examples of compensatory). The passive includes illnesses Karl Sudhoff and Theodor Meyer-Steinig, this requiring only a correction of diet, using the nickname was used to describe the followers usual methods of fasting or avoiding particular of Hippocrates up to the end of the twentieth types of food. century. The second important addition made by It may be suggested that the nickname Thessalus to the teaching of the Methodic “dogmatics”, which stuck to the rationalist doctors is the notion of metasynkrisis – the idea doctors after their opponents had given it to that the state of the pores in the human body them, was no accident. Consider the concept can be affected by particular treatment methods of the crisis of a disease found in the texts (if diseases are caused by strictures or blockages of the Hippocratic Corpus, and Galen’s of pores, it is a doctor’s job to correct this). modification of it [23]. The modern meaning The Methodic doctors believed that an acute of this concept is the “peak” of a disease – i. e., disease transforms into a chronic one through the period when the pathogenetic processes an increase in pore blockages in line with the that determine the nature of the disease reach level of severity and the size of the part of the their height. Appropriate therapy brings a body affected by the pathological process; turning point, and the patient starts to recover. thus, an individual stricture transforms into Hippocrates understands a “crisis” to be a kind general looseness. Therefore, for a therapeutic of bifurcation, following which the course of intervention to lead to an improvement in the the disease can alter significantly, not only in patient’s health, the strictures in the pores terms of an improvement or deterioration in have to be eliminated, by changing the size and the patient’s condition, but also with regard to configuration of the pores. It is also necessary complications of the observable clinical picture. to reduce the number of atoms accumulating In other words, the disease changes. Today we in the region of the strictures, by removing this can talk not only of reconvalescence or agony, “thrombus.” Atoms are tiny units of matter, and but also of comorbidity. Hippocrates, of course, how many there are of them in the human body did not have such broad assessment options, so is determined by the amount ingested with food his theory of crises appears in his works as a kind every day. Food is the source of the material of “road map”: observation of a patient in a state replacing the part of the body losing atoms via of crisis can confirm a diagnosis and satisfy a excretion every day. Reducing the number of doctor that the clinical decisions already made different types of atoms entering the body with were correct. Naturally, Hippocrates was well food is simple: the patient has to fast for the first aware that a state of crisis could also reveal the three days of the illness (the initial diatritos). opposite: that the diagnosis was incorrect and For the second three days (the next diatritos), the therapy useless. However, a desire not to go the opposite approach is taken. to deeply into this issue can be sensed in the Galen was scornful of this idea: he considered Corpus texts. Hippocrates’s works in general it senseless to fi rst starve patients for no reason, are rather didactic, stressing a “read this and and then to stuff them with food. learn the right way to do things” approach.
96 History of Medicine. 2017. Vol. 4. № 1
It could not have been otherwise: differential carefully, and to employ the necessary diagnosis, and the concepts of primary and remedies. However, the most effective and concomitant illnesses, comorbidity, etc., did potent remedies need to be applied right at the not appear in clinical medicine until much later. moment of crisis: any earlier would be too soon It should be stated that an element of clinical for them to have the desired effect; any later interpretation is present in the Hippocratic would be useless. Galen intuitively understood Corpus. The principles of the teaching were that complex, interdependent processes take established by highly educated professionals place within the body, and that therapeutic with a critical mindset, but used by ordinary interventions need to target them. Galen sought doctors who were not always well trained. to fulfill as best as possible Hippocrates’s aim Historians of medicine need to be aware that of curing by affecting the cause of the disease. the principle of consistent application of a Thessalus and Themison sought to counter treatment regimen (even if chosen based on symptoms, an aim that, in Galen’s view, put the a Hippocratic desire to affect the course of Methodic doctors on a par with the empiricist the disease) could be adhered to too keenly physicians: both fought the consequence, not by some doctors. A doctor blindly sticking to the cause, ultimately adhering to symptomatic a regimen and unwilling to pay heed to any therapy. deterioration in the patient’s health deserved Naturally, Galen thought Thessalus’s to be called a “dogmatic”. Clearly, such diatritos theory absurd. The idea that the course dogmatism, sanctified by its connection with of any disease could be divided into three-day Hippocrates and indifferent to developments in cycles, at the end of which one could reliably actual clinical cases, also made Themison and assess whether the treatment was appropriate Thessalus a target for criticism. or needed correcting, contradicted the very At the same time, Galen clearly had good essence of Galen’s understanding of the nature reason to criticise the Methodic doctors. We of health and disease. And what if a crisis took have seen how their clinical thought was based on place on the night between the fourth and fi fth a symptomatic approach, which linked them to days? By Thessalus’s logic, such developments the empirical physicians, despite the Methodic meant nothing, and doctors had to wait until the doctors’ positive attitude to theoretical end of the second three-day cycle in order to get medicine. The problem was that the natural an accurate picture. But what if, after a crisis philosophy of atomism, when applied to specific at the start of the fi fth day, the onset of agony aspects of physiology and pathophysiology, occurred on the sixth? Knowing that Thessalus’s produced theory that was entirely speculative. guidelines meant missed opportunities must have As a result, attempts at classification based on infuriated Galen: his descriptions of meetings at this theory were useless in terms of developing a which he argued with the Methodists are full of pathogenetically based approach to treatment. such emotion. Galen was highly dissatisfied with this, and Our sources do not explain why Thessalus devoted the full force of his exceptional talent chose a three-day cycle. It may be that the roots to an attempt to understand disease in terms of this idea too can be found in his worldview. of aetiology and pathogenesis. This attempt Here, we may consider the categories of stricture led to his interpretation of the crisis: for and looseness in the atomic description of the Galen, it was ultimately the moment when universal atomistic accounts of pathogenesis. therapeutic intervention was most effective. It may be that three days was the time taken Galen’s understanding of the nature of a crisis in such accounts for the parts of the body is entirely Hippocratic: it is a sort of bifurcation with blocked pores to change their state – the in the course of a disease, a point after which metasynkrisis that was one of the foundations everything can change. However, he brilliantly of his theory. It may be that the mechanistic conjectured that this bifurcation depends on the explanations of the movement of atoms in the development of the pathogenetic mechanism human body in some way led Thessalus to the of the disease. Thus, Galen believed, doctors idea of the diatritos, rather than some other need to observe their patients’ state of health division of time.
97 Dmitry A. Balalykin
Conclusions fi rst to understand whose views had the greatest infl uence on the future development of medicine, Historians of medicine should bear in mind and have a direct gnoseological link with modern that any systematic criticism in specialist literature science. Second, they need to understand why always (or almost always) has its reasons: one some doctors followed this example, while needs to analyse the sources very carefully in order others did not. Here, we can see a kind of chain to identify them. Medicine is a particular specialist running through the history of medicine, from fi eld. No doctors want to be their own or their Alcmaeon to Hippocrates to Herophilos to Galen patients’ enemies; all seek to cure their patients to the scientifi c revolution of the 17th to 19th quickly, painlessly, and eff ectively. There was no centuries. [1, 13]. In saying this, it must be added great danger of unscrupulousness or fact-juggling that the development of the schools of both the in disputes on an abstract philosophical topic empiricist and Methodic doctors was a kind of (although, perhaps, there was danger of a fi st historical dead end, a fruitless branch on the tree fi ght with angry opponents). The main issue in of the history of medicine. On the other hand, any serious medical discussion is that of life and while there are solid epistemological grounds death. Philinus of Kos, Asclepiades of Bithynia, for this view, it is no reason for us to dismiss the Apollonius Mys, and other doctors practising experience of our ancient colleagues who went during the period “from Herophilos to Galen” down the wrong track. Our objective, therefore, were respected people, experienced physicians has been to examine the practical ideas of each who spent thousands of hours in contemplation school of medicine in conjunction with their at the bedsides of the seriously ill. Their writings natural philosophical platform. Without doing so, are an attempt based on extensive personal it is impossible to understand why the doctors of experience to understand and fi nd the best ways the past acted as they did and not otherwise, or to to help their patients. Historians of medicine need reconstruct their mentality and worldview.
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About the author Dmitry Alekseevich Balalykin – Doctor of Medical Sciences, Doctor of Historical Sciences, Professor, Chairman at the Department of the History of Medicine, National History and Culturology, FSAEI HE I.M. Sechenov First MSMU MOH Russia (Sechenov University); Institute of World History RAS (Moscow).
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