The History of Healing: Hippocrates’ Sense of Humour (Part II)

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Theatre masks in the Vatican Museum

Circus tightrope walkers are excellent at what they do. But if you aim and shoot a cannonball at them, they will certainly fall down either because of panic or from the deluxe pain brought by the projectile. The simple scientific explanation for such a tragedy is mechanically charming: a body at rest will tend to stay at rest unless acted upon by an outside body. Newton’s law of inertia, in other words. That is to say, something has caused their imbalance, hence their fall. So if the thought ever occurred to you, here’s my advice: don’t do it, for obvious legal reasons. Launch pillows instead if you really want to try the law.

In the previous essay, we left off with a brief discussion of the Hippocratic idea of balance and the theory of the four humours. This segment of the series will tackle three aspects of this Hippocratic package: 1.) its origins and roots; 2.) importance in the healing arts; and 3.) overall contribution to a theory of health.

When we think of Greece nowadays, our minds instantly recall that peninsula that hosts the ruins of the Parthenon and a national economy. Names of famous thinkers will also likely come up. Comedy and tragedy, sure. Young John Travolta, definitely. The Olympics, that too. Needless to say, the subjects we think of are objects from and of a distant past. Of a Greece that was once and still is the envy of many civilizations. Of a Greece that marched to the frontiers of expansion when Macedonian Alexander tested the limits of human ambition. The things that constitute our idea of Greece have now become part of what we call classics. An esteemed vista of knowledge and culture often consulted when modernity goes awkward and in need of inspiration. “Think of democracy!” politicians remind us in their bid to establish themselves as heirs of Greek political maturity.  An archaeology of knowledge will thus inevitably point to different parts of the world where traces of Greece can be found. But a necessary prefix is required in order to differentiate the past from the current milieu of cultural life. Ancient will do for our purpose.

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Image taken from http://www.worldatlas.com

While its peninsular geography was important in shaping its destiny, it was the extension of its cultural tendrils far and wide the Mediterranean that pushed the Ancient Greeks to the forefront of history. Simply put, Ancient Greece wasn’t limited to the Greece that we know of today: its lightning shot through all directions. If we travel east of the peninsula and cross the Aegean sea, we land on what is now the coastal borders of Turkey, which were once loci of Greek colonies. The Ancient Greeks that inhabited these lands were called the Ionians (one of the four major Ancient Greek tribes, along with the Aeolians, Archaens, and Dorians). Taking a different route, and sailing south from the Greek peninsula we then arrive at the island of Crete, where the mysterious Minoans once lived. Further southeast, we land on Egypt, which was already an established and prosperous civilization when the Ancient Greeks were just starting to find their footing. The logical thing to do when you’re an upstart civilization surrounded by such rich polities is to establish commercial relations. This the Ancient Greeks did. Ships were launched and ports were filled. New scents, colors, flavours, and especially ideas traveled to and fro the treacherous waves of the Mediterranean. A silk sea, for an analogy.

This opportune placement in the Mediterranean meant that the Ancient Greeks had many things to hold on to, for them to keep their balance. Herodotus highlights the importance of this network when he identified Egypt as the source of most of the Greek gods’ names, “the naming of almost all the gods has come to Hellas from Egypt.” Now that they had names, it was time for the gods to have their properly registered residence, a home, so to speak. And so they settled in Mount Olympus. However, there are reasons to believe that this mythical mountainous migration was derived from earlier sources. In Greek Myths and Mesopotamia, Charles Penglase uncovers the hidden literary webs that trace the origins of Mount Olympus back to the Ancient Mesopotamian idea of Ekur, or “mountain house”.

These religious connections have important ramifications in the overall intellectual development of Ancient Greece. In those days, there was still no science like the one we have today. Instead, their mode of inquiry was religious; the intellectual character of their worldviews was shaped by their beliefs. For example, the Ancient Egyptians knew that silt and mineral deposits along the Nile were incredibly important to agriculture, yet their explanation as to why was relegated to the domain of religion: it was all thanks to the god Osiris. If harvest was good, praise Osiris; if harvest was bad, please to Osiris. This intellectual mode may be judged as backwards today, but in those days, it represented a huge cultural leap that marked a new market for ideas and mythology, especially for cosmogonic beliefs. And this in turn opened new territories for intellectual exploration otherwise hampered by the level of technological and material advance at that time. The Ancient Babylonians didn’t have the devices necessary to explore the far reaches of the universe, but what they saw with their eyes were already enough. They kept looking up and recorded their heavenly observations with religious zeal, thinking that the stars and the movements of planets would lead them close to an understanding of the gods. It is this desire to understand the realm of the divines that led to the birth of astronomy.

Having identified two fertile locations for germination, the seed of Ancient Greek intellect stretched out its roots and dug deep into the ancient cultures of Egypt and Mesopotamia. It began to sprout in no time, enjoying full cultural and intellectual nourishment from the banks of the Nile and the Fertile Crescent.

Ancient Egypt and Mesopotamia played different roles in the growth of Ancient Greek intellectual life. Egypt being the more prominent in terms of education and training. We read from the Roman writer Gaius Julius Hyginus the story of the Athenian Agnodice, a female physician who received her medical education in Egypt, and was denied practice in her native Athens simply because she was a woman. Athenian women could save lives, but in the process lose theirs. So much for fabled ideal of Greek democracy, eh? Unlike in Athens, it wasn’t unusual for women to become physicians in Ancient Egypt. In fact, some of them even went so far as to have important royal appointments. Perhaps the most distinguished of them all was Merit-Ptah, who in 2700 BC became the main physician in the pharaoh’s court. This open and welcome attitude towards scholarship for either sexes set the impetus for further intellectual flourish, as the inclusion of women in the ranks of scholars meant that Ancient Egypt had more human resource at their disposal. This was an obviously inviting set up, and soon, a slew of scholars hungry for knowledge made their way to the gift of the Nile, hoping to have a share of this brain bounty. Of course, the Ancient Greeks wouldn’t allow themselves to be left out, so they also set sail in droves and joined in. Years later, they even set up their own institutions. The famous anatomists Erasistratus (early pioneer in neuroscience) and Herophilos (early pioneer in experimental medicine) opened a famous medical school in Alexandria in the 3rd century BC.

The Ionian side of the story had more to do with the brains necessary to kick start the development of Ancient Greek thought. The first Ancient Greek philosophers, after all, were mostly from Ionia. Think of Thales of Miletus who urged others to consult nature in the explanation of phenomena (and in one case with the help of a cat!). Perhaps it was the proximity of the Ionian settlements to Ancient Babylonia and Ancient Persia that allowed them to have this impressive number of thinkers. It just goes to show that if there are more pathways for the movement of knowledge then more minds are cultivated.

If we imagine a map and identify the points of interest thus far discussed – Egypt, Greece, and Ionia – we see that we can construct a triangle. And one of the most distinct theorems associated with the triangle is Ancient Greek by export, though arguably not exactly by origin. Everyone who has had the most basic lessons in trigonometry is sure to have encountered the Pythogorean theorem. It describes the relationships of the sides of a right triangle. But the theorem’s namesake did more than just do trials with triangles; Pythagoras founded a movement, which would later adopt his name, that was fundamental in the growth of Ancient Greek medical thought. But before we get to that, we need to acknowledge a new node in the Mediterranean network that we have just constructed. Off to the west of the Greek mainland, in what is now south of Italy, was Magna Graecia, a sort of headquarters for the Pythagoreans.

Pythagoras was an Ionian Greek from the island of Samos. He would later embark on a trip to Ancient Egypt where he would receive further and advanced education. The Athenian orator Isocrates recalls in his speech Busiris the Egyptian educational excursion undertook by Pythagoras:

“On a visit to Egypt he [Pythagoras] became a student of the religion of the people, and was first to bring to the Greeks all philosophy, and more conspicuously than others he seriously interested himself in sacrifices and in ceremonial purity, since he believed that even if he should gain thereby no greater reward from the gods, among men, at any rate, his reputation would be greatly enhanced. And this indeed happened to him. For so greatly did he surpass all others in reputation that all the younger men desired to be his pupils, and their elders were more pleased to see their sons staying in his company than attending to their private affairs. And these reports we cannot disbelieve; for even now persons who profess to be followers of his teaching are more admired when silent than are those who have the greatest renown for eloquence.”

From the above quote, a picture of Pythagoras emerges: a first-rate scholar desirous of nothing but the acquisition of knowledge, willing to adapt to the necessary lifestyle in order to do so. This is the kind of character that Pythagoras would later bring to Magna Graecia and instill among his followers when he set up camp there. The Pythagorean school of thought had two fundamental characteristics: mystical and mathematical. They, particularly their head honcho, believed that there was a governing numerical essence in the universe, and that this is the manifestation of a divine will. The central problem of the universe was mathematics and doing mathematics was to understand the logic of the divine. It was an idea that had its roots in the many religions of the Mediterranean and Asia Minor, but was modified to accommodate and allocate a central role for mathematics. Despite the novelty and independence of the Pythagoreans both in philosophy and practice, they still showed signs of their Ancient Egyptian roots. For like in Ancient Egypt, women were welcome to join their philosophical pursuits. His Ancient Egyptian education led Pythagoras to believe that the philosophical life was also for women. He even learned from them. According to Diomedes Laertius’ in his Lives of Eminent Philosophers, the philosopher Aristoxenus claimed that “Pythagoras got most of his moral doctrines from the Delphic priestess Themistoclea.”

The Pythagorean contribution to modern mathematics is paramount. One of 20th century’s most prominent philosophers of mathematics, Bertrand Russel, points to the Pythagoreans as the main culprit for the proliferation and growth of mathematics as an intellectual culture. He says that “It is to this gentleman [Pythagoras] that we owe pure mathematics.” But it would be a great disservice to the legacy of the Pythagoreans to say that they only limited their excursions to mathematics and mysticism. For their scholarship stretched throughout a vast borderless plain of knowledge. And unbeknownst to many, they also contributed to Ancient Greek medicine, and that which they presented was important in preparing for the arrival of Hippocratic medicine.

Pythagoras imposed upon his followers a vegetarian regimen, for he believed in the transmutation of living animal souls (humans included). Scholars suggest that Pythagoras only prohibited the consumption of noble animals, while giving the OK signal for sacrificed ones. Whether he advocated for a lenient or strict dietary observation is still up for debate and historians are still far from reaching any appreciable conclusion. Perhaps they never will. But this is rather distracting, and it blurs the important corollary brought by this dietary program. The fundamental idea here is not what is permitted or not, but the essence inherent in such a suggestion: the consideration of what is to be introduced into the body via consumption.

Food consumption is not as straightforward as chewing food and gulping it down. There is an active mental component to it that seeks to understand the various properties and attributes of the different food products taken in. Nutrition is the primary concern. But that’s not all. Calculating total calorie intake from each meal is a modern preoccupation practiced by lots of health enthusiasts. “Is it organically grown?” is also a lingering concern for many. Taste, while still the primary sensation enjoyed when eating, becomes less important once other factors are set on the table. That’s why dietitians will often advise their clients to avoid the delicious temptation of fastfood meals, for they argue that underneath the inviting delight of fastfood flavour is a health disaster waiting to happen. What emerges from this dilemma is the issue of imbalance. Nutrition is sacrificed for the sake of a delicious experience.

The idea of balance has a long and rich tradition in Ancient Greek thought and it can be traced back to the earliest Pre-Socratic thinkers. In order to understand in full the power of this idea there is a need to review Heraclitus’ doctrine, “no man ever steps on the same river twice”. (Note of interest: Heraclitus was from Ephesus, an Ionian colony). One can say that they are indeed standing on the river Nile, but it is never the same river Nile as the water molecules that constitute the river are constantly in flux, in persistent motion. So the water molecules that touch the person’s body at one point in time are not the same across a span of a minute, an hour, and a day, hence, it is not the same river. Change becomes central. Change becomes a concern. When applied to the idea of the body, and compounded with Heraclitus’ other philosophical idea, that of the unity of opposites, it can be understood that the body’s inner constitutions are always in motion towards equilibrium. New cells are born and old ones die, old friends are lost and new ones are gained. This illustrates that the unity of opposites keep the body functional and the organism alive. Animals can hardly live without inhaling and exhaling. Nutrients retrieved from food are rather useless when the same food products are not expelled as waste, for the body will be poisoned. The overall theme presented here is a dialectic understanding of balance in the body – that it is rather impossible to achieve real balance, but the body can only reach a certain degree of balance within a range, as the body is constantly acting and reacting via the opposite processes that keep it alive.

An alleged Pythagorean, Alcmaeon of Croton, was the first to develop a medical theory of balance that would later become the precursor of the Hippocratic four humours theory. In Metaphysics, Aristotle writes that Alcmaeon held the belief that “the majority of things in the world of men are in pairs.” These pairs act as opposites in Alcmaeon’s system, and their optimal configuration is called isonomia, a state of balance. When one part of a pair reaches monarchia, or becomes dominant over the other, then health problems surface. To stay healthy, therefore, is to maintain isonomia in the body. This idea has translated well across time and is even part of the medical canon today. Body temperature is a metric of balance that is always monitored to assess someone’s well-being. Another popular metric that incorporates balance is the Body Mass Index (BMI), where the relationship between one’s height and weight is checked to assess a person’s body fat level.

An Asclepiad (a follower of Asclepius, the Greek god of healing) from the Ionian island of Kos heard about this innovation and took interest. His name was Hippocrates.

Hippocrates developed a new program out of Alcmaeon’s ideas. The novelty in what Hippocrates brought was a medical epistemology that put a premium on naturalistic analysis, and a method that insisted in knowing the complete physical and natural reality of a patient. In Plato’s dialogue Phaedrus, Socrates and Phaedrus are seen exchanging ideas on what it means to understand and how it can be done. Socrates asks Phaedrus, “Now do you think one can acquire any appreciable knowledge of the nature of the soul without knowing the nature of the whole man?” To which Phaedrus replies, “If Hippocrates the Asclepiad is to be trusted, one cannot know the nature of the body, either, except in that way.” An incomplete knowledge of the man is as good as nothing. For the Hippocratic physician, the medical arts was not simply to redress injuries and cure diseases; being a physician meant participating in philosophical life. Not only did this demand a higher standard of medical mastery, but it also opened the necessary exploration of a patient’s external conditions: their everyday realities and history. The importance placed on this mode added an necessary analytical dimension for diagnostics which made medical judgment more accurate in terms of identifying possible sources of complaints. An accurate description of disease leads to accurate remedies. You can’t treat a niggling cough by applying muscle relaxant on the left gastrocnemius. (I apologize for the anatomy pun.)

Understanding the overall context was crucial in this new program. It also demanded a surgical eye for the slightest details often overlooked. Hippocrates instructs the learner of medicine that a patient’s history also included the trivial minutiae that fill the gamut of a patient’s daily routines:

“Wherefore it appears to me necessary to every physician to be skilled in nature, and strive to know, if he would wish to perform his duties, what man is in relation to the articles of food and drink, and to his other occupations, and what are the effects of each of them to every one. And it is not enough to know simply that cheese is a bad article of food, as disagreeing with whoever eats of it to satiety, but what sort of disturbance it creates, and wherefore, and with what principle in man it disagrees; for there are many other articles of food and drink naturally bad which affect man in a different manner.”

Small details like the food taken in at lunch or the beverage downed at dinner are necessary information to evaluate when assessing a patient’s condition. Knowledge of what these do to the body are also of equal importance, as Hippocrates reminds us that “Whoever does not know what effect these things produce upon a man, cannot know the consequences which result from them, nor how to apply them.”

Expertise in natural philosophy is thereby required of the physician in order to arrive at sound medical judgments. If this program is followed in the ideal Hippocratic manner, then not only are physicians well prepared to deliver accurate diagnoses, but they’re also able to make reasonable prognoses. That is, by understanding a patient’s life history, the physician can rightly predict the outcomes of particular conditions and ailments enabling them to prescribe the best possible health regimen to maximize the chance of recovery and healing. Prognosis, Hippocrates remarked, is “a most excellent thing for the physician to cultivate.” For modern ears, the emphasis on prognosis might sound morbid, but to Hippocrates and the Ancient Greeks, it only represented an encouragement to achieve the Ancient Greek concept of eudaimonia, or the life well-lived. The Ancient Greeks accepted the inevitability of death, but the uncertainty of its arrival left some anxious. An informed and well delivered prognosis can set the patient’s heart at ease and inspire the journey to achieve eudaimonia, albeit on a deadline.

One can say that Hippocrates definitely had an affinity for dark humour. An affinity that he didn’t include in the canon that made his legacy so lasting across medical history.

Comments and conclusion on a patient’s condition was made by weighing the four humours found in the patient’s body. The humours acted as Heraclitan opposites; their equilibrium ensured the healthy stability of the body, and the monarchia of one led to diseases and injuries. But why four? In Ancient Greek thought, there were various contending postulates on how many opposites there exactly were. In Antidosis, Isocrates tallies the number of humours believed and proposed by philosophers: “Empedocles that it is made up of four, with strife and love operating among them; Ion, of not more than three; Alcmaeon, of only two; Parmenides and Melissus, of one; and Gorgias, of none at all.” It is from Empedocles where Hippocrates got the idea of the four humours. But while the form and number is retained, Hippocrates amended the content of this idea in order to fit his medical purpose. He made each humour correspond to the different seasons, temperaments, qualities, and internal organs. These became important points to remember when deciding what treatment was best for a patient. Here’s a chart taken from the website of the US National Library of Medicine that lists the unique properties of each of humour:

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The way Hippocrates and his followers rendered medical judgment was by correlating observed symptoms with the properties of the humours. If a man was showing aberrant sexual behavior, it may be that the sanguine humour, which is blood, is in a state of excess. A Hippocratic physician might confront this in two ways: first would be to pull the humour back down to a level of balance by drawing blood; and second would be to influence the increase of the phlegmatic humour thereby diluting the quality of blood (hot and moist vs cold and moist). In the case of yellow bile going monarchia, Hippocrates had this to say: “Thus, when there is an out-pouring of the bitter principle, which we call yellow bile, great nausea, burning and weakness prevail. When the patient gets rid of it, sometimes by purgation, either spontaneous or by medicine, if the purging be seasonable he manifestly gets rid both of the pains and of the heat.” The instructions and suggestions laid down by the four humours theory provided learners of the medical arts the important criteria from which they can base their conclusions. For patients, this also opened opportunities for monitoring, transparency, and accountability. Being able to check if their physician’s diagnosis was in consonance with the theory inspired an attitude of critical vigilance. Socrates embodied this spirit of rational skepticism when Plato put these words in his mouth, “we ought not to be content with the authority of Hippocrates, but to see also if our reason agrees with him on examination.” Lest it be misconstrued that Socrates is in any way rejecting medicine, an immediate clarification must be made: what Plato is simply illustrating here is that the medical arts is rational, and that its movement and growth is reason. Thus, to question the authority of a physician, as long as it is within the bounds of reason, is to ensure that the philosophical life is alive and well in the practice of medicine.

While this radical shift in medical practice was taking place, a nascent theory of health was slowly announcing itself into the scene. No more was Steve’s cough caused by an upset god. Nor was Philomena’s sore leg the workings of a malicious muse. Little by little, the roles gods played in the comedy of life was being replaced by humours. Hippocrates goes straight to the point by saying that “Health is primarily that state in which these constituent substances are in the correct proportion to each other, both in strength and quantity, and are well mixed.” No room for the supernatural. No room for the irrational.  The humours drowned the laughter of gods into the background and restored smiles into the faces of patients who were now receiving better health care and medical attention.

One after another, the divines started to fall from their high pedestals, as Hippocrates came in like a wrecking ball, putting them all off balance. There was no space in medicine for theological tightrope anymore.

It was time for the next act.

 

(The complete bibliography for this series will be provided in the last essay.)

This article is dedicated to my good friend, Roxy. 

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