Читать книгу: «Galen on Apodictics»

ibidem-Press, Stuttgart

Contents

Foreword

Introduction

Chapter 1 Philosophical basis of Galen’s medical doctrines

1.1 Galen’s perspective on the Hippocratic tradition

1.2 The significance of the doctrines of Plato and Aristotle in shaping Galen’s views

1.3 The doctrine of Homoiomereia as the foundation of Galen’s views on the microstructure of tissue

Chapter 2 Understanding Galen’s clinical experience and apodeixis

2.1 The semiotics of diseases. Theory of pathogenesis as a reflection of the principle of causality

2.2 A comprehensive understanding of philosophical theory and medical practice

2.3 The unity of mind and body in Galen’s medicine and philisophy

Chapter 3 Anatomical dissections as evidence in a philosophical polemic

3.1 Galen’s method of investigation

3.2 The Empiricist school as the opponent of the Hippocratic tradition

3.3 The structure of proof in Galen

3.4 Galen’s understanding of the natural functions of the body as a realisation of the teleological principle

3.5 Galen’s clinical practice and physiological experiments

Conclusion

Bibliography

Foreword

Alexander L. Gungov

The main objective of Dmitry Alekseevich Balalykin’s book, which appears as the seventh volume of Studies in Medical Philosophy at ibidem Verlag, consists in presenting the philosophical grounds for Galen’s integral theoretical and practical system, emphasizing the understanding and application of the apodictic method. The author clearly states that his concept of apodictics in ancient medicine consists in the understanding of “a combination of the use of anatomical dissections, the physiological experiment, the rational doctrine of general pathology and clinical systematization.” As a physician and distinguished historian of medicine, Balalykin is perfectly up to engaging with the medical side of Galen’s works. In terms of philosophy, the most significant part of Galen’s apodictic method is the “rational doctrine of general pathology and clinical systematization”, which is interpreted by Balalykin with appropriate erudition and skills.

Balalykin examines the ontological, epistemological, logical, and natural-philosophical conceptions of Plato, Aristotle, Anaxagoras, Empedocles, Stoicism (in particular works of Chrysippus), and the ancient аtomism as sources of Galen’s philosophical views (or as philosophical ideas that Galen does not accept but opposes), and their decisive influence on his theoretical medical concepts and clinical findings and claims. Balalykin pays special attention to the notions of eidos, lekton, entelechia, and cataleptic impression, as well as to Aristotle’s doctrine of the four types of causes. In regard to the apodictic method, various types of evidence known in antiquity are considered in his book: apodictic, aimed at reaching the truth; dialectical, meant to get to plausible conclusions, which could serve as hypotheses for further quests in the name of truth or for didactic and other practical purposes, including convincing interlocutors; rhetorical, dedicated to persuasion; and sophistic, striving to win a dispute at any cost, even by means of manipulation and deliberate misleading. In connection with the apodictic method, Aristotle’s categorical syllogism is discussed, whereas Stoic hypothetical syllogism is analyzed as a part of the dialectical method.

The author puts at the heart of his study of the transition from philosophical foundations to medical conclusions the ancient natural philosophical teaching of the three tetrads, followed by a number of ancient thinkers: the four elements—earth, fire, air, and water; the four humors—blood, phlegm, and yellow and black biles; and the four substances—hot, cold, dry, and moist. The book analyzes the fundamental philosophical and medical significance of the balance and imbalance between the members of each tetrad. Balance and imbalance are traced as being inseparable from the theory of homoiomereia in view of what in modern medical language would correspond to a certain extent to nosology, etiology, pathogenesis, therapy, and prognosis. Last but not least, the importance of the Platonic concept of the tripartite nature of the human soul for the understanding of causation in medicine, classification of diseases, control exercised by the higher rational and immortal part of the soul on the health and disorder of the body, as well as the unified origin of somatic and psychic disorders are underlined.

Balalykin has succeeded in structuring and conducting his research in view of the decisive influence of the rich array of philosophical ideas from Classical Greece and the Hellenistic period on Galen's medical theory and clinical practice. He is not tempted to interpret the theoretical legacy of the ancient physician only from the point of view of modern medicine or predominantly in the context of the development of ancient medicine per se, whereas putting into brackets such a seemingly distant and lateral area as ancient philosophy. The author reveals the formation of ontology of health and disorder on the basis of the principle of balance and imbalance within the four tetrads, as well as according to the theory of homoiomereia that defines the structure of the macro- and the microcosm. The quantitative idea of health and disease, as well as the presence of degrees of health and disorder, depend on these principles. Homoiomeres define the anatomical structure of the human body, where there are simple homoiomerous structures and tissues and complex non-homoiomerous organs. By carrying out an ontological line of reasoning, Balalykin repeatedly argues that these principles have allowed Galen to outline his concept of general pathology and to classify diseases. The author convincingly demonstrates that Galen's understanding of the causes of diseases starts from the same ontological basis. From the perspective of the ancient physician we cannot speak of the contemporary meaning of etiology, as in Galen’s classification of causes there is a trend of universalization, whereas etiology deals with the specific causes of pathology within a certain nosologic unit. However, Galen's understanding of the causes of diseases allows him to persist in treatment aimed at eliminating the causes of a pathology (today known as “etiological treatment”) and not simply at eliminating the symptoms. At the level of medical causality, the author makes a point of the four types of causes in Aristotle, shows how they have been transformed by Galen and, foremost, discusses the final cause that the ancient physician considers as a teleology of function of an organ or of the body as a whole. The doctrine of teleology, along with and inseparable from the principle of balance of the three tetrads and the principle of homoiomereia, are the main grounds for Galen’s rejection of the explanation of the ancient Methodists regarding the causes of disease. The assertion of the Methodist physicians, who have adopted the ontology of ancient atomism that the general pathology is due to clogged pores in a certain part of the human body, is unacceptable to him. He is a follower of Plato and Aristotle and the mechanics of the atomism does not correspond to the teleology of function, inherent in the body in the states of health and disease alike. Balalykin explains that the principle of teleology should not be confused with the Stoic determinism of physicians from the Empiric school that is set by blind fate and is completely beyond any rational control. Thus, the author unambiguously shows: the philosophical preconditions at the level of ontology preset Galen's position on medical causality. Furthermore, he clarifies that the mechanisms of diseases, pathogenesis, depend on the same ontological arguments.

According to Balalykin the respective central concepts of Plato’s and Aristotle’s ontology and epistemology, eidos and entelechia, become decisive for the formation of the apodictic method in Galen. The creation and functioning of the sensory world after a model of the non-sensory eidos that guarantees realization in the sensory world of certain patterns, perceptible by the human mind, gives Galen the opportunity to follow in the medical theory and practice a method based on a cognizable necessity. The feasibility of apodictic method is reinforced by the Aristotelian entelechia, which justifies teleological changes both in healthy and diseased persons, and also the state of a person between health and disease. The author points out why Empirics, criticized by Galen, following the Stoic view of lekton adhere to the situational understanding of diseases and cannot perceive the apodictic method that yields the necessary conclusions. Instead, they are forced to rely on a dialectical method that provides nothing more than probabilistic conclusions. Stoic lekton has no ontological status of necessity, unlike eidos and entelechia, because it is not material in character, and for the Stoics this is equivalent to a lack of reality. This means that disease observations—diagnosis of the disease, as well as its treatment decisions—are lektons with probabilistic value. The non-acceptance in principle of the theory leads to the underestimation of medical causality and disinterest in the mechanisms of diseases among physicians from the Empiric school. Moreover, these philosophical reasons limit the diagnostic and therapeutic actions of Empirics to addressing pathological symptoms using their own experience gained in similar situations or the experience of their counterparts, applied depending on the available pharmacological and dietary agents that have proven their effects in such symptomatology. Here, the author is a very shrewd observer when he perceives an essential dialectical feature (‘dialectical’ not in the sense of the ancient dialectic, but of Georg Hegel’s speculative dialectic) according to which the Empirics, by denying the possibility of knowing general principles, are not able to apply individualized treatment and are inevitably entangled in repetitive patterns. Balalykin intuitively and completely justifiably perceives that this paradoxical situation expresses the fact of the transformation of one-sided rational statements into their opposites. The Empirics, following dogmatic one-sided constructions of Stoicism and insisting on the significance of only a singular disease situation, allow an insurmountable gulf between the singular and the universal, thus falling into the lifeless generalization of oversimplification. Galen’s approach, based on Plato’s and Aristotelian philosophical views, freely overcomes the rational one-sidedness and rises up to the level of rational speculative dialectic by perceiving the unity between singular, particular, and universal. The singular symptoms of a patient manifest themselves in an inseparable and individualized unity with the universal and indispensable features of the given disease (according to the modern terminology of the “nosological unit”) and thus form the particular type of a specific patient’s disease. The interpretation of schematization during treatment by the Empirics proves that the assumption and knowledge of universal features of diseases and their treatment does not prevent, but on the contrary supports the application of an individual approach to diagnosis and treatment.

In studying Galen’s apodictics, Balalykin addresses a purely logical problem. He points out that Galen holds on to making necessary conclusions through categorical syllogism, which provides true knowledge, while physicians from the Empiric school, in conformity with their understanding of probable and solely plausible knowledge, use hypothetical syllogism. The author is quite right that in both forms of hypothetical syllogism, pure hypothetical syllogism and hypothetical categorical syllogism, there is an element of hypothesis that gives some probability to the conclusion reached. Nevertheless, it should be taken into consideration that the very inferences of these types of syllogism produce necessary conclusions. The two forms of the inference are known as modus ponens and modus tollens, which are accepted as valid both by traditional formal logic and by its modern symbolic version. Furthermore, the categoricalness of the strict categorical syllogism’s premises is not necessarily identical with their truthfulness and leaves room for a certain dose of probability. There is Aristotle’s well-known claim about the middle term of the categorical syllogism being identified by dialectical means of the art of topics. The truthfulness of categorical syllogism (not just logical validity) is borne not only by the formal laws of this type of inference, but by the overall context in which it takes place. Similarly, the probability of a hypothetical syllogism (again, not just logical validity) depends on the context of its application. We should not neglect the practical reliability of the negative modus of the hypothetical categorical syllogism modus tollens in clinical practice. During the differential diagnostics procedure diseases with similar symptoms are excluded in order to determine the real disease(s). The exclusion is done by the modus tollens rule whereby the absence of a necessary symptom or sign leads to an absence of the corresponding disease. In terms of logical validity, this is a completely necessary and correct conclusion. In medical practice, it excels the positive modus ponens, where the inference is driven from the presence of the cause of a disease to the disease itself, because even the presence of the necessary cause of a disease cannot lead to the disease in the case that the sufficient cause is not also present. However, when discussing the necessary validity of the eliminating modus tollens, we should not forget that it is a common situation in diagnostic practice when the absence of a symptom or sign (in the case it is not a pathognomonic symptom or sign) does not guarantee the absence of the disease we are looking for. This means that the decision to reject or affirm the presence of a disease goes beyond logical necessity, but that does not at all mean, as the author clearly demonstrates, that the decision is not subject to the apodictic method.

It would be entirely justified to state that Galen on Apodictics masterfully demonstrates the philosophical impetus in the formation of the apodictic method in Galen’s clinical practice and theoretical treatises and outlines this method as “an expression of a new type of rationality in the field of medicine” during the Roman Empire. No doubt, Balalykin’s book is a significant and valuable contribution to studies in the field of philosophical analysis of Galen’s works on an international scale and deserves excited and committed readers.

Introduction

Modern academic literature generally accept the existence of a unified branch of science—the “history and philosophy of science”. Unfortunately, historians concerned with separate areas of natural science have very little interest in philosophical methodology: they are often concerned with specifics and do not seek to generalise and identify common patterns in the development of the subject under investigation.

The history of medicine is dominated by a tendency for narrowly specialised analysis, which is generally typical for the history of natural sciences. Among medical professionals studying history, priority interest is payed to the events directly influencing the modern image of medical science and practice. There are extensive studies in historiography devoted to the history of surgery, cardiology, immunology, the establishment of medical education, etc.1 By virtue of mental inertia, their chronological framework mainly covers the 19th–20th centuries, and interest in earlier epochs is rare.

The same applies to studies on the philosophy of science. For example, V.S. Stepin considered it obvious that the history of modern science begins from the 17th century, and he masterfully dissertated on the categorical grid which describes the context of events in the 17th–19th centuries.

I presume this conviction has to do with the fact that most scientists came to the philosophy of science from physics and mathematics. They operate with familiar facts from the history of natural science disciplines. However, can data from the history and philosophy of physics be unambiguously extrapolated to the history and philosophy of medicine? Interdisciplinary research, which constitutes part of this work, enables to answer this question negatively.

Obviously the mainstream in historiography often leads to the study of the history of medicine beyond the general context of the development of natural science, global social and cultural processes, which in actuality have had a certain influence on the mindset of scholars and their research program. For example, the subject of substantive discussions becomes the fact itself of referring to the work of ancient and medieval scientists as “scientific”. Researchers who refuse to recognise Hippocrates, Galen or Avicenna as scientists refer to the modern-day definition of the concept of “science”, which involves the use of the experimental method and language of mathematical explanations.

B. Russell defines the concept of “science” as knowledge above all. It is widely accepted that this is knowledge of a special kind, which seeks to find general laws linking multiple separate facts. However, the view of science as knowledge is gradually being sidelined by the view of science as a force which controls nature. A person of science (Russell does not mean everyone, as many people of science are not scientists—he is talking about a person of science as he should be)—is an attentive, careful and consistent person. He only relies on experience in his conclusions and is not prepared to make sweeping generalisations. Such person does not accept theory just because it is elegant, symmetrical and is synthetic in nature, but examines it in detail and in real applications.2

According to André Comte-Sponville, science is a collection of knowledge, theories and hypotheses relating to the same subject or same field (for example, nature, living beings, the Earth, society, etc.). Science not so much states as it constructs this knowledge, in line with historical context, logically organising or proving it (to the extent to which it can be proven), achieving for it, if not universal, at least group recognition from competent minds (this is what distinguishes philosophy from all other sciences because the clash of competent minds is possible in philosophy), finally recognising that all sciences, except mathematics, are empirically falsifiable. Add to this the fact that the scientific approach usually counterposes the so-called common sense (scientific knowledge is not always self evident), and the following simplified definition could be made: science is an organised collection of verifiable paradoxes and corrected errors. An integral part of the essence of science is progress because science develops through “conjectures and refutations”.3

Clearly, the given definitions (there are many such definitions) are fully applicable to the works of scientists from the ancient world. However, it is clear that the physics of Aristotle is different from the physics of Newton or the physics of Einstein.

Today, the so-called standard conception of science is generally accepted. According to this conсeption, science and scientific knowledge are characterised, first of all, by objectivity. The world of natural phenomena is considered factual and objective. The goal of science is the precise description and explanation of objects and phenomena, processes and relationships existing in nature. Secondly, science establishes (this particularly guarantees objectivity) the laws of nature. Thirdly, scientific knowledge is formed in the process of impartial gathering of facts and relationships between them, the establishment of empirical laws based on said gathering of facts and further elaboration of scientific theory based on said laws.

The objectivity of scientific knowledge, in my opinion, is clear for the doctor who draws knowledge from a physiological experiment and clinical practice.

The scientific (even in the modern understanding of medicine or, for example, mathematics) nature of the actions and discourse of great doctors of the past is often so obvious that the term “protoscience” has gained a foothold in professional literature. It is generally used to describe the entire period of development of natural science, when the time before the advent of scientific revolutions is referred to as the “protoscientific” or “prescientific” period. Therefore, on one hand, the value and historical role of the work of scientists in the ancient and medieval ages is recognised, and on the other hand, the dissimilarity between the work of Aristotle or Soranus of Ephesus and the modern type of scientific research is also stated.

Active discussion over the clear definition of the concept of “protoscience” itself continues. I think T. Kuhn’s theory of paradigm shift is key in understanding the structure of scientific revolutions. This theory is also subject to constant review and certain criticism. Against this backdrop, it is often quite difficult to discern ontological and gnosiological links between events and protoscientific methods and the modern-day development of certain disciplines.

When K. Popper’s book titled Conjectures and Refutations: The Growth of Scientific Knowledge4 came out, the term “protoscience” got a somewhat disparaging shade of meaning—“pseudoscience” or “something, which is not real science”. Furthermore, the understanding of the history of natural science before the 17th century as the development of some “not exactly scientific ideas”, taking cue from K. Popper, is typical for many historians working in the second half of the 20th century. This is a part of presentists methodology ‒ to think only modern science is real.

I use the term “protoscience” following another, long-standing historiographical tradition under which certain works of ancient scholars are taken as ideas that are ontologically very close to modern ideas. I argue that they may be considered as partially commensurable with them. Remember, according to the modern conception of science, rationality, objectivity, reproducibility and verifiability, logical rigour, preciseness and logical interrelation of various elements are considered the hallmarks scientific knowledge. These characteristics are sometimes supplemented with utility, which reflects the essence of science as part of culture. These attributes are characterised by the ideals of scientific rigour. The task of science is to reveal patterns and general principles which facilitate not only the observation and stating of facts, but also their explanation. Such an approach defines very stringent requirements for historians and philosophers: the scientist must articulate inferences based on the analysis of sources.

When it comes to the fundamental methodological difference between the modern science and protoscience in the ancient world, two principal points are normally highlighted: the experimental method of studying specific natural phenomena and mathematical processing of the obtained data. The latter involves systematisation and description of observable phenomena using mathematical formulae and equations. But here another question arises: from this perspective, can modern-day medicine be considered science? After all, to this day, mathematical explanation of observable processes has not become part of the everyday practice of the doctor. Furthermore, I can boldly predict that it never will.

A fundamental division of modern science and science of antiquity has become general in historiography (it is considered as a result of the scientific revolution of the 18th and 19th centuries). Brief analysis of the numerous arguments of supporters of this point of view shows that they relate primarily to questions of the methodology of knowledge: in their opinion, it was believed in antiquity that the comprehension of the world around was possible only through notion sciences (philosophy and mathematics)—natural (intrinsic) was contrasted with technical (artificial, created by man)5. In particular, it is suggested that science of antiquity adhere to the “empirical” method of studying nature, in contrast to the “experimental” method inherent in modern science. This thesis is generally illustrated by examples from the history of physics and, sometimes, mathematics.

On the other hand, the judgment of early Ionian physics (6th century BC), as the starting point of nature research nucleation from a rational methodology, also became general in modern historiography. In this case, the rationalism of ancient science means the union of astronomical, biological, etc. phenomena by not mystical, but natural physical causes. The three natural sciences specialties—mathematics, astronomy and medicine—are considered to be the most ancient; its appearance is directly related to the early Ionian physics. As early as the beginning of the 4th century BC we see the existence of an absolutely clear system of mathematical knowledge, an astronomical theory based on practical observations, and medicine of Hippocrates. It is in the context of the analysis of its history in the special literature that the discussion of the problem of the apodictic method of knowledge begins. In the 1960s, G. Lloyd6 for the first time very pointedly and reasonably raised the question of the separation of mystical and occult chiliastic practices from the development of ancient Greek rational medicine. And here it becomes clear that it is precisely the development of medicine that historians and philosophers can judge most reliably in view of the quality of the source base: nothing like Hippocratic Corpus is at the disposal of scientists studying the birth of other disciplines. Thus, it turned out that the historically accurate picture of the history of medicine has the best background. Further, G. Lloyd raised the question of the apodictic method of knowledge in the rational medicine of antiquity. It also dealt with the absolute opposition of a clear, structured logical proof to sophistic tricks. Ideally, the apodictic method in medicine should, according to the degree of evidence of the proof, approach the mathematical method. In this sense, the application of the “apodictic” concept to medicine can be regarded as a rather free extrapolation of the concept from the mathematical science vocabulary. However, the Hippocratic Corpus has already shown obvious evidence, with which to argue is as difficult as with a mathematical formula—an anatomical autopsy has become such. G. Lloyd, in fact, was the first who absolutely clearly defined the dissection as a medical apodictic. In addition, a significant number of arguments by G. Lloyd, based on a thorough analysis of sources, relate to the principles of analysis and reflection on clinical experience.

J. Longrigg asserted the incomprehensible differences, comparing medical schools of antiquity. He linked only very definite theories with later history of medicine. In the last decades of 20th century the concept of “ancient Greek rational medicine”, which denoted precisely this direction, was firmly established in historiography.

It means a clear separation of Alkmeon and Hippocrates medicine, which is based on a completely clear natural-philosophical theory, from temple healing, ritual incubation, invoking spirits and other non-rational chiliastic practices. Apodictic (in the understanding of G. Lloyd) cautiously and not quite consistently begins to recognize the basis of the methodology of rational medicine of antiquity. The reason for this caution, I think, is the difficulty with a clear classification of practical knowledge. However, after J. Jouanna was able to describe the basic principles of the clinical practice of Hippocrates7 these difficulties can be considered overcome. I suggest to use the term “clinical systematics”: this is how we can describe the principle of understanding the whole set of practical knowledge about diseases and its treatment, specific to the Hippocratic school. Its development is underway, Galen only emphasizes the hierarchical, logically built and striving to match the particular and the general (that is, “systematic”) nature of the comprehension of practical experience.

The works of V. Nutton have an outstanding meaning in the development of the study of the history and methods of ancient medicine. Due to decades of hard work of V. Nutton, his co-authors, students and followers, the problem of historically reliable reconstruction of the main events of almost a thousand-year-old history of ancient medicine was, in general, solved.8

The availability of sources that allow making an impression about the development of ancient medicine after Hippocrates leaves much to be desired. It is with this that I associate the fact that in modern scholarly literature there is a tendency to consider hippocratics-rationalists and, for example, doctors-empiricist, equivalent historical phenomena. The connection between clinical practice and philosophical theory in the teachings of various medical schools is often misunderstood, their mutual exclusivity is sometimes underestimated. The main sources containing information about antiquity medicine from the 3rd century BC and later, are the works of Galen: 111 out of more than 500 reached us. However, fewer than half were translated into English, fewer than 30 texts into Russian.

13 The concepts of “spirit” (with respect to “vital”, “animal” and “vegetative”) and “pneuma” are synonymous in some ways. “Pneuma” is a broader concept since it is not only present inside the human body, but in the surrounding environment as well. A tradition has been established in historiography which prefers the concept of “spirit” to the term “pneuma” with respect to three types of endogenous pneuma. Hence we would rather use the phrase “animal spirit”, “vital spirit” and “vegetative spirit” with respect to pneuma inside the body (see: Balalykin, D.A., “The First Book of Galen’s Treatise On the doctrins of Hippocrates and Plato”, Voprosy Filosofii 8, 2015: 124–143; (In Russ.)). That being said, the use of the concepts of “animal pneuma”, “vital pneuma”, “vegetative pneuma” is not erroneous. The use of the concept of “psychic spirit” as synonymous with “animal spirit”is also not erroneous.

14 Gusev, E.I., Grechko, V.E. and Burd, G.S., Nervnye bolezni (Nervous diseases), ed. Gusev, E.I. (Moscow: Meditsina, 1988), 259–260. (In Russ.)

15 Ibid.

16 Bolezni nervnoy sistemy: Rukovodstvo dlya vrachey: V 2 t. (Diseases of the nervous system: Guide for doctors: In 2 vols.), Vol. 1, ed. Yakhno, N.N., 4th ed. (Moscow: Meditsina, 2007), 232. (In Russ.)

17 Ibid., 233.

18 Ibid., 259–261.

19 Galen, On the Doctrines of Hippocrates and Plato, Corpus Medicorum Graecorum V, 4, 1, 2, ed., trans. and commentary de Lacy, P. (Berlin: Akademie Verlag, 2005).

20 See: Kuhn, The Structure of Scientific Revolutions.

21 Stepin, Filosofiya nauki. Obshchie problemy, 384.

22 Ibid.

23 Ferngren, G., Medicine and Health Care in Early Christianity (Baltimore: Johns Hopkins University Press, 2009), 264.

24 Nutton, V., “Medicine”, in The Cambridge Ancient History, Vol. XI, ch. 33 (2000).

25 Hammond, N., History of Ancient Greece (Moscow: Tsentrpoligraf, 2003). (In Russ.)

Chapter 1
Philosophical basis of Galen’s medical doctrines
1.1 Galen’s perspective on the Hippocratic tradition

Galen follows in the tracks of Hippocrates in the fundamental principles of his theoretical and practical work. This continuity is not limited to methods of medical treatment alone. The essentially multidisciplinary physician’s training was always typical of the Hippocratic tradition—from the time of Hippocrates himself, to the time of Galen, when medicine finally established itself as a complex theoretical and practical system based on anatomical and physiological data. The principles of professional ethics and deontology also had been established by 4th century B.C. This line of ancient medicine was brilliantly demonstrated by Galen in his treatise The Best Doctor is Also a Philosopher:

What grounds are there then left for any doctor who wishes to be trained in the art in a way worth of Hippocrates not to be a philosopher? He must be practiced in logical theory in order to discover the nature of the body, the difference between disease, and the indications as to treatment. He must despise money and cultivate temperance in order to stay the course. He must, therefore, know all the parts of philosophy: the logical, the physical and the ethical.1

Another crucial task in the analysis of medicine in Hippocrates’ time is the question of its ties to natural philosophy. Those ties were not clear-cut. After all, some schools of natural philosophy by no means offered medicine the necessary methodological tools. The term “philosophy of medicine”, whose advocates were opponents of Hippocrates, even gained a foothold in historiography. One could reach the conclusion that the medicine of Hippocrates is exclusively practical, devoid of any theorising. That view is certainly wrong. Indeed, Hippocrates wrangles a lot with the “philosophers”, but it is important to understand with which ones in particular, and about what specifically:

Certain physicians and philosophers assert that nobody can know medicine who is ignorant what a man is; he who would treat patients properly must, they say, learn this. But the question they raise is one for philosophy; it is the province of those who, like Empedocles, have written on natural science. But my view is, first, that all that philosophers or physicians have said or written on natural science no more pertains to medicine than to painting. I also hold that clear knowledge about natural science can be acquired from medicine and from no other source, and that one can attain this knowledge when medicine itself has been properly comprehended, but till then it is quite impossible—I mean to possess this information, what man is, by what causes he is made, and similar points accurately. Since this at least I think a physician must know, and be at great pains to know, about natural science, if he is going to perform aught of his duty, what man is in relation to foods and drinks, and to habits generally, and what will be the effects of each on each individual.2

It is well-known that works assembled into the Hippocratic Corpus, were written by multiple authors: Hippocrates himself, his son-in-law Polybus and one or two of his followers.3 This is due to the difference in philosophical persuasions expressed in different texts: in some texts, the influence of Pythagoreans is apparent, while in some it is the influence of Diogenes of Apollonia, with his idea of air being the one source of all being, etc. However, the treatises containing the exposition of views on the principles of the development of diseases and approaches to their treatment are not contradictory in nature. And this is despite that they are often the result of “collective creation”. For instance, the treatise On the Nature of Man was started by Hippocrates and finished by Polybus. It also contains later inclusions penned by an unknown member of the Kos school after Polybus. In the context of analysing Galen’s idea, besides the treatise On the Nature of Man, the treatise On Ancient Medicine is of vital significance for us. Both these treatises are distinguished by preciseness of methodology, structuredness and clarity of argument.

The Hippocratic treatises On Ancient Medicine and On the Nature of Man assert the view that medicine should not be built on theoretical concepts about human nature, initially founded on some theory of natural philosophy. The task of the physician is to carefully observe the response of the human body to various external effects, assess the results of these observations and double-check them in practice. Thus the inversion of the cause-effect relationship occurs in the world of the scientist—from empirical observation to generalisations and not vice-versa.

Galen considers Hippocrates himself the author of the first part of the treatise On the Nature of Man, and Polybus—the son-in-law of the great physician4—the author of the second part. This work criticises those who speak of the nature of man as if of something beyond the frontiers of knowledge in medicine. Hippocrates and Polybus sharply rebuke monist natural philosophers who reduce all pathological processes to a single source, making ample use of contradictions between various theories to prove their inadequacies. The fallacious theory of “perpetual affection”5 arose from this misconception. Authors of the treatise chastise physicians who believe that man consists of a single one element, proving the fundamental meaning of the theory of the four liquids (blood, phlegm, yellow bile and black bile).

On his part, Galen stresses the importance of the idea of four primary elements as the foundation of the physics of the human body:

Combination and conformation in the bodies of animals are threefold: first of the so-called homoiomeres, i.e. arteries, veins, nerves, bones, cartilages, ligaments, membranes and flesh; second of the organs, i.e. brain, heart, lung, liver, stomach, spleen, eyes and kidneys; third of the whole body. Each of these organic parts is compounded from certain other parts that are simple in terms of sense perception, and each of these from the primary elements. Thus the differentia of flesh itself, qua flesh, is only in the combination of the primary elements; qua where it is part of an organ, it is on account of conformation and magnitude. And the differentiae of the organs themselves are also in these things.6

He believes that human nature cannot be described by the concept of a single source, otherwise the human being would not suffer due to the absence of a mechanism for disease development. This in turn distorts the approach to medical practice. One substance by itself cannot produce so many changes that can manifest in the multitude of diseases observed by the physician. Even if a certain number of alternatives of such variability were to exist, there would then be a single medicine for all diseases, which would correct the state of this single substance. However, it is clear to any reasonable physician that this is not so:

IX.6.63. For a person who knows that there is not one simple form of soul in us, such as the desiderative in plants or the rational in gods, but that men have both of these and the spirited besides as a third, knows along with this the number and nature of the virtues and how they are acquired, just as the person who knows the natural constitution of our bodies—that the natural state of every animate body results from the right proportion of the elements in the homoeomerous parts, and in the organic members from the quantity and size of the homoeomerous parts, and also from the conformation and position of each, the proportion of the things mentioned being of cource preserved in every animal in the way that is appropriate to it—that person unaided will succeed in finding the right treatment and prophylaxis for every desease. (PHP, 585, 587)7

All this by no means contradicts the positive evaluation of the first ancient rationalistic natural philosophy systems with their concept of the primary element. First of all, the primary element in said systems is understood not so much as a universal architectural material which constitutes man and the objects that surround him. This is about the physical prime cause of existence and, most important, the development and movement of matter, which replaces the arbitrary function of anthropomorphic deities. Secondly, the prime cause calls into existence numerous secondary consequences which complicate the cosmology of any school of natural philosophy as it develops. Thirdly, we consider as the foundation of the development of ancient medicine the movement of natural philosophy from early Ionian physics to the Platonic idea of the Creator-God (Demiurge) and the Aristotelian principle of the “primum mobile”, which shaped the methodology of knowledge in medicine. The idea of purposeful, functionally driven movement is arguably the most important in this context. The purpose of medicine, according to Hippocrates, consists in the following:

It is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their diseases, realising that in such cases medicine is powerless.8

Here the need to define health arises: Hippocrates thought it was most reasonable to define it in close relation to the concept of “disease”. Health is defined in the Hippocratic Corpus and by the apophatic method (i.e., through negation) as the absence of suffering, and cataphatically (i.e., through affirmation) as the existence of a body as a balanced mixture of elements. Galen subsequently employs the concept of the “good mixture” to describe health. Consequently, “disease” is defined as the antithesis of “health”, i.e., as the suffering of the human body through the disruption of the dynamic equilibrium of three tetrads (elements, liquids, essences). Here we see the continuity of Hippocrates’ idea and the preceding rationalistic theories about health and disease. According to Alcmaeon of Croton (the first in the history of medicine to attempt to construct a rational theory of general pathology), “isonomy” (ισότητα; i.e., “equilibrium” of the properties wet, dry, cold, hot, etc) is indicative of “health”, whereas “monarchy” (µοναρχία, i.e., the “dominance” of one these properties) shifts the equilibrium and, as a result, leads to disease. Indeed crucial thesis, which still compounds the base of medical knowledge, is dynamical condition of the organism.

The novelty in Hippocrates’ theory lay in the fundamental addition to the idea of equilibrium (or its shift) of the concept of the mixing (“crasis”) of basic substances which constitute the human body. Internal equilibrium of primary elements and liquids, their balance, in particular, indicated the “good mixture”, i.e., the state of health. Therefore, in the Hippocratic Corpus we are faced with a more complex system of general pathologies, which raises questions about the balance between internal states of the body, on one hand, and external effects on the other hand. Various external factors (from sudden deviations in diet to changes in climate in the form of extreme cold or heat) could have a damaging effect which disrupts the internal balance of the state of the body. All this required assessment by the physician. The key concept here was the category of “transition” (µετάβαση), which became a crucial component of the Hippocratic theory of pathology. The physician was supposed to pay close attention to history taking in order to determine the lifestyle the patient was used to before the onset of the disease. The boundaries between the normal and pathological states of the body in the works of Hippocratic physicians are not clear-cut: health is a fragile equilibrium which can be easily disrupted. Galen notes in the treatise On the Doctrines of Hippocrates and Plato that, according to his information, Hippocrates was the first to point out the primary importance of the proper relationship between the components for the state of human health:

VIII.4.7. Hippocrates was the first of all the physicians and philosophers known to us who <…> said that the deseases of the primary bodies are caused improper mixture. (РНР, 499, 501)

The concept of the “first symptoms” of disease was extremely important for Hippocratic medicine. Hippocrates understood very well that pathological processes may develop gradually and not manifest themselves in all of the variety of symptoms right away. Therefore the physician should not waste time and should begin intervention from the moment the first symptoms of disease appear in order to restore the balance and provide the necessary assistance:

Opportune moments in medicine, generally speaking, are many and varied, just as are the diseases and affections and their treatments. The most acute ones are when you must help patients that are losing consciousness, that are unable to pass urine or stools, that are choking, or when you must deliver a woman that is giving birth or aborting, or in other cases like these. These opportune moments are acute, and a little later does not suffice, for a little later most patients die.9

At the heart of this desire to begin treating the patient during the period of perceived health before the disease manifests itself in full force is the physician’s intuition. In the Hippocratic Corpus, “health” is a relative concept in which quantitative distinctions stand out: health can be more or less. Again, here we note the development of the idea of antagonistic states, inherent to the natural philosophy of Alcmaeon and Empedocles: balance against dominance, and mixture against separation. Once more, we emphasise the quantitative and not the qualitative nature of these changes—and therein lays the novelty of Hippocrates’ views, which are based on the principle of mixing. The body is considered healthy or sick only based on more or less stability and resistance to external effects. J. Jouanna points out that without a qualitative difference between normal and pathology, the sick in the Hippocratic system is simply the weakest among healthy people, which introduces the principle of the continuity between the normal and pathological state, which was redefined in the 19th century by A. Comte as “Broussais’ principle”.10

At the onset of the first signs, based on the earliest symptoms, the experienced physician must try to predict how the pathological process will develop: “For if disease and treatment start together, the disease will not win the race”.11 In the magical, occult tradition, disease is chaos and tempest caused by the invasion of evil spirits. Disease is terrifying particularly because of its unpredictability and the random nature of its development; it is as capricious as the demon causing it. In contrast, for Hippocrates and Galen, disease is consistent violation of equilibrium processes, which spreads throughout the body from the point of its origin. This is particularly why the concept of the change in the equilibrium of the liquids, when the generalisation of the pathological process was defined by the spread of the predominant liquid inside the body, seemed so organic to Hippocratic physicians. This led to the fundamental principle of curing the “opposite with the opposite”—the elimination of excess in one and deficiency in the other. In the treatise On the Nature of Man, Hippocrates clearly explains this principle using concrete examples:

...One must know that diseases due to repletion are cured by evacuation, and those due to evacuation are cured by repletion; those due to exercise are cured by rest, and those due to idleness are cured by exercise. To know the whole matter, the physician must set himself against the established character of diseases, of constitutions, of seasons and of ages; he must relax what is tense and make tense what is relaxed. For in this way the diseased part would rest most, and this, in my opinion, constitutes treatment.12

In the treatise On Airs, Hippocrates continues this reasoning saying that

…For knowledge of the cause of a disease will enable one to administer to the body what things are advantageous. Indeed this sort of medicine is quite natural. For example, hunger is a disease, as everything is called a disease which makes a man suffer. Then the remedy for hunger is that which makes hunger to cease. This is eating; so that by eating must hunger be cured. Again, drink stays thirst; and again repletion is cured by depletion, depletion by repletion, fatigue by rest. To sum up in a single sentence, opposites are cures for opposites.13

The Hippocratic method of treatment is based on the use of agents which, by their effect, are opposite to pathological processes.

An integral part of the art of medicine was prognosis—the investigation of disease in the context of its development over time: commencement, intensification, reaching the peak, going through crisis, i.e., the decisive stage, when the disease can be combated. Consequently, the disease either ended with decline and recovery, or the commencement of the terminal condition and death of the patient. It is plain to see that the concept of “crisis” in the Hippocratic tradition is used in a sense different from the modern sense: it is not an anxious moment between life and death, but simply a stage in the development of the disease, which determines whether the disease can be cured:

One must examine the beginning of a disease, whether it comes to full flower immediately—it is clear in the advancement—and examine the advancements according to their periods. From this the crises too are clear, as well as from the exacerbations within the periods (i.e., whether or not they are earlier and whether or not they continue a longer time, and whether or not they are more severe).14

The Aphorisms of Hippocrates also state that:

Take the patient too into account and decide whether he will stand the regimen at the height of the disease; whether his strength will give out first and he will not stand the regimen, or whether the disease will give way first and abate its severity.15

Hippocrates understood very well that full recovery of the sick is not always possible. From here arises the idea of the relativity of “recovery”, which is based on the understanding of the continuity and fragility of the equilibrium of the boundaries between health and disease. A woman that has been cured of chronic bleeding could remain barren; the motor activity of a leg could be restored after treatment of a fractured leg, but the patient will remain chronic limping—we see a lot of these examples in the Hippocratic Corpus. The fundamental principle which forms the basis of the physician’s thinking in the Hippocratic tradition was best described by J. Jouanna as the transition from “observation of the visible to reconstruction of the invisible”. This task clearly remains fundamental to the physician since the time of Hippocrates.

Methods of diagnosing diseases, according to Hippocrates, include thorough collection and assessment of medical history, external examination of the patient and, in certain cases, physical methods of diagnosis—palpation and auscultation.16 The principle of diagnosis is the interpretation of the plurality of external symptoms of the disease, medical history and objective examination, based on the theory of the development diseases. The latter in particular forms the natural philosophical foundation of the physician’s views, which is understood in accordance with practical needs. In the Hippocratic Corpus, this is the theory of primary elements which constitute the fabric of the human body, and the theory of the humors, whose balance ensures normal or pathological functioning of the parts and the human body as a whole. Medical history is also vital in the context of Hippocratic ideas about the influence of climate and location on health and disease. It should not be supposed that auscultation of body cavities (direct auscultation) and probing of parts of the skin affected by the pathological process (palpation) during Hippocrates’ time was always used by every physician when examining each patient—that is, of course, not the case. However, the recognition of the importance of diagnostic information obtained during physical examination of the patient was already clear. Here we are speaking of ingenious foresight, which later became the standard method:

When the fifteenth day after the pus has broken out into the cavity arrives, wash this patient in copious hot water, and seat him on a chair that does not move; have someone else hold his arms, and you shake him by the shoulders, listening on which of his sides there is a sound; prefer to incise on the left side, for it is less dangerous.17

If you administer an infusion, fumigation, or vapour-bath, no pus appears; this is how you can tell that there is not pus, but water. If you apply your ear for a long time and listen to the sides, it seethes inside like vinegar. The patient suffers in the way described for a definite time; then there is a break into the cavity18:

Residual swellings on the upper eyelids when the others have subsided: relapse. If they are hard and red on their tips, especially so. The viscous ones and those that protrude are included among them, as in the case of19;

Women, numb on the touch, very dry, without thirst, with heavy flows, develop abscess20, etc.

The forte of the Hippocratic physician was his ability to carefully observe a patient and meticulously record the results of his observations. The empirical method therefore became the source of information for two types of generalisations: firstly, ideas about anatomy, physiology and general pathology of the human being as a whole and, secondly, the understanding of individual peculiarities of the progression of any disease. Some parts of the Hippocratic Corpus provide the physician with the modus operandi for observing the patient and correct interpretation of the observed phenomena. To illustrate the above, we shall consider one of the fragments from the book On The Physician’s Surgery, which is in its own way a manual for beginning examination of the patient, when first we examine the similarity and difference (with the healthy state); the most significant, easiest are those that are recognisable with all methods, which can be visible, tangible and heard; that which can be replaced with sight, touch, hearing, the nose, tongue, mind; that which can be recognisable with all possible means of knowledge.21 The following excerpt from the book Epidemics, is still relevant to this day as the physician’s guideline: “The task is to bring the body under consideration. Vision, hearing, nose, touch, tongue, reasoning arrive at knowledge”.22 The first possible visual signs of disease which, according to Hippocrates, the physician was supposed to pay attention to upon meeting the patient, are: first, the colour and appearance of the face of the patient, secondly, the posture of the patient lying in the bed, then the movement of the patient’s hands. The description of the changes in facial features of the patient, which suggest impending death, still referred to as the Hippocratic Facies, is the most brilliant example of the meaningful set of empirical observations. When the physician’s finger presses on the swelling after treating a fracture, “the swelling on the extreme parts hardens, and after pressing with the finger, the redness ceases, but soon returns”; with various oedema, “if you press anywhere with a finger, you will leave a dent, and its sign is as if in dough”. In the absence of a thermometer, touching the skin of the patient helped determine the body temperature of the patient: the Prognostics mentions patients “who are not hot at touch”. When examining excrement and discharges of patients for prognosis and diagnosis purposes, the Hippocratic physician smelled and, when necessary, even tasted the sweat, faeces, urine, vomit, phlegm, pus, and in women, vaginal discharges. The list of senses which the physician must take recourse to for diagnostic purposes is complemented in the Hippocratic Corpus by reference to “nous” (νοῦς) as the capacity for thought (λόγος). After all possible manipulations, the physician has to ponder and analyse the results obtained during examination, while being maximally critical to his observations: “You must take into account both the good signs and the bad that occur and from them make your predictions; for in this way you will prophesy aright”.23

The Hippocratic Corpus puts together descriptions of a large number of diagnostic features that are still relevant to the modern-day physician. This circumstance, in my opinion, lays bare the fundamental distinction of the history of medicine from the history of other natural sciences: facts suggest the considerable relevance of the physician’s experience in the protoscientific period. The history of medicine requires very careful application of the logic of uneven development, revolutions in knowledge—the continuity of knowledge and experience is typical for it to a larger extent as compared to physics, for instance.

1.2 The significance of the doctrines of Plato and Aristotle in shaping Galen’s views

The medicine of the authors of the Hippocratic Corpus was already a sufficiently mature discipline which offered skills for critical thinking and systematisation of empirical experience. However, the system of Hippocrates’ views was far from dominant—it had plenty of opponents among physicians of the civilised oecumene. The shortcomings of his system were obvious and were defined by the lack of a theory of natural philosophy, which could have offered a global world view and methods of obtaining knowledge about it, which could match the tasks of medicine. This world view was supposed to meet a variety of explanatory tasks—from questions about the origin of matter in general to the specific physics of the human body.

The critical components of this system of natural philosophy, which formed an adequate world view of medical researchers, were proposed by Plato and Aristotle It is particularly through the merging of the doctrines of two of his great predecessors that Galen created medicine as an integral scientific-practical system. It is no mere chance that one of the principal treatises of Galen is titled “On the Doctrines of Hippocrates and Plato”.

Plato’s legacy is the great phenomenon in the history of civilisation. A lot has been written about it. The same applies to Aristotle (probably even to a greater extent). In a concise way, I will try to demonstrate the significance of the Academy and the Lyceum in the formation of a proper world view and the type of rationalism typical for a physician in the Hippocratic tradition.

Plato learnt medicine from Philistion, with whom he got acquainted on his way to Magna Graecia. Philistion was born and raised in the Southern Italian town of Locri. He built a remarkable career and by the time he met Plato, he was the personal physician of the tyrant of Syracuse Dionysius II. Living in Sicily, he was of course influenced by Empedocles’ doctrine of the primary element, which had a determining influence on his views about general pathology. Philistion had a reputation as a staunch anti-Hippocratic, although the essence of his dispute with the famous physician from Kos is unclear based on surviving sources. We can only indirectly make judgements about it based on fragments of texts from the Hippocratic Corpus where disagreements with the ideas of Empedocles are expressed.

Plato’s views on the problem of medicine are primarily laid out in Timaeus and pertain to a wide range of issues—from anatomy and physiology to the problem of the unity of the corporeal and the spiritual. Among other things, Plato offers his classification of diseases, clearly defined under the strong influence of the ideas of Philistion. Plato suggests that there are three types of diseases. The first group is defined by the disruption of the equilibrium of the four primary elements—earth, air, fire and water. Excess or deficiency of any of the elements in the body gives rise to processes leading to the decay of health.24 Plato associates the second group of diseases with disturbances in the nourishment of parts of the body. Based on the assumption that blood is directly formed in the liver from digested food, Plato reaches the conclusion that blood contains all substances necessary for the body. Sinews are formed from fibrins and other substances of clotted blood. With normal blood supply, flesh produces a certain viscous fluid which attaches it to the bone and nourishes bone matter and bone marrow. Unless the structure of nutrition is disrupted, the blood always has enough of the necessary “building” material to form and restore various tissue. The disturbance of nutrition causes disease—flesh decomposes, releasing products of decay into the blood. Blood changes colour, becomes bitter, acidic and saline. Decay products destroy it and, spreading through veins, disrupt the nourishment of flesh. Decay and decomposition processes spread.25 Diseases of the third group are associated with the imbalance of humors and primarily arise from the disturbance of the breathing process. The aim of breathing is to cool the inherent heat generated by the body. Breathing may occur through the lungs and special pores in the skin. If the work of the lungs is impeded by excess humor (for example, phlegm), the breathing process occurs in a different way and to a greater extent than naturally. As a result, natural metabolic processes are distorted, and decay processes arise in those parts of the body with respect to which respiratory functions are not properly occurring. A characteristic feature of such diseases is excessive perspiration caused by excess heat in the body.26

This classification reflects the considerable influence of the views of Empedocles and Philistion. According to Empedocles’ theory of digestion, food is broken down into small particles in the mouth, then under the effect of internal heat it is digested in the stomach, broken down into its constituent elements, which are then carried into the liver where they turn into blood. Therefore blood contains all substances necessary for the vital functions of the body. These substances move in the human body with the flow of blood and are absorbed by tissue according to the “like attracts like” principle. If, for example, the primary element of “fire” is dominant in the bones (after all they are dry and hard), then this primary element comes from the blood and most of all enters the bones in particular, etc. Plato also follows in the tracks of Empedocles when it comes to ideas about flesh as a secondary formation which originates from blood. However, the definitive articulation of the theory of disease can be considered Plato’s own discovery.27 Thanks to Plato, the theory of the four primary elements, which was subsequently supported by the peripatetics, held a dominant position in science for centuries. Equally important for the development of rational medicine is Plato’s cutting loose of all elements of mysticism and deification of the primary elements, associated with the idea that they are constantly undergoing a process of morphogenesis. In his system, the four primary elements become simply physical phenomena, clearly associated with empirical practice and taking their place in the global world view created by Demiurge God based on defined laws. Here Plato’s natural philosophy aligns with the views of Hippocrates who intuitively, based on practice, arrived at the perception of the profound functional purposefulness of the human body. They have a common enemy—sophists and mystics, who misinterpreted Empedocles and claimed that nature is a blind and irrational force. Plato understands very well the universal nature of the matter under consideration, which is why in Timaeus he considers it necessary to clearly define the place of the primary elements in the general system of natural philosophy. Here the significance of primary elements is reduced from the sources (as is the case with Empedocles28) to some kind of building material: like an architect, the Demiurge builds the world in general and human body, in particularly, according to a certain design using the necessary components.

Note two critical components of Platonic physics: first, the primary elements can be transformed into each other, changing their intrinsic properties; secondly, the description of these properties is given in the language of mathematics. The foundation of Plato’s idea about the vital functions of the body becomes the teleological principle—the purposiveness of function and, consequently, anatomy. The ontological foundation of the human body is an Act of Divine creation of ordered matter which functions according to defined laws incorporated in it. The theory of the primary elements becomes a critical part of the description of this structure. However, there was need for a systematic, consistent description of the movement of primary elements in the human body. After all, it is clear that the human being grows and develops, ages and dies; certain metabolic processes occur in his body, and this indicates the presence of changes. The Aristotelian system (with the exception of the doctrine of the creation of the world, of course) was subsequently built on this assessment and the description of the body in the categories of the laws of motion of matter.

Plato solves the task of describing this dynamic using mathematical analogies—this reflects the clear influence of Pythagoreans. Plato also needs mathematical analogies to describe the act of the creation of the universe by the Demiurge.29 The subordinate, secondary nature of the primary elements in Plato’s cosmology is emphasised from the outset: the Demiurge brings them to a certain order described by geometrical shapes and numbers. The universe in Plato’s cosmology is described by a three-dimensional coordinate system. Therefore particles of each building element must be formed by Supreme Intelligence in a defined mathematical form, exist in an ordered physical world, change and interact with each other purposefully—in accordance with the laws of the functioning of natural bodies set as the foundation of creation by God. Here Plato challenges the basic principle of atomism, so well-liked by many sophists—the mechanically random nature of the motion atoms. The theory of possible transformation of primary elements is extremely important for the history of medicine. It exactly enables to view the human body as a dynamic system. In the final part of Timaeus, Plato transitions from the macrocosm to the microcosm, i.e., the structure and functioning of the human body, which he describes using the same teleological, axiological and physical principles. Here Plato is decisively at variance with Empedocles in substance: he places the centre of rational activity, higher control of the functions of the body in the brain. According to Empedocles, this centre is located in the area of the heart, which goes together with the great significance of blood and blood supply in his system.

The geometric analogies Plato uses to explain the motion of particles of primary elements are of exceptional interest. Organs consisting of smaller particles are impermeable for larger particles. Anatomical structures consisting of larger particles are permeable for smaller particles.30 Plato even explains functional processes in the body in the language of geometrical shapes. He presents primary elements in the form of various geometrical shapes: fire as a tetrahedron, water as an icosahedron, air as an octahedron and earth as a cube. For example, the element of fire exists in the form of the smallest, all-permeating particles, which as it were “cuts” with its “tetrahedron” the links between the primary elements into which broken down food in the stomach disintegrates. Plato illustrates this penetrating power of fire and air, created by God to carry out fundamental physiological processes, using a “fish-trap”—a peculiar model of the human body.

Similarly, in the language of mathematics, Plato attempts to explain the processes of growth and aging of the human body. A baby is conceived when the male and female seeds of the parents are fused. The triangles of the elements constituting the body of the baby or young person are free of foreign inclusions, some kind of “stuck dirt” and are tightly attached to each other. Damaging factors in the form of the flow of elements from the outside (including those coming from food) are structurally weaker than those constituting the inner core of the body tissue of a young person. Plato interprets the aging process as the “slackening of the roots of the triangles of the elements”, leading to the loss of structural solidity of the tissue. They are therefore easy to separate. They lose their ability to withstand external effects. The body is damaged and ages.

I see a lot in common between the interpretation of the principles of general pathology by the authors of the Hippocratic Corpus and Plato’s reasoning. First of all, this pertains to regarding disease as a quantitative category, when a healthy body and a sick body have the same components, but with excess or deficit of some of the components. Secondly, this is the interpretation of the state of “good mixture” of elements (“crasis”), which accompanies health, and disruption of their mixture (“dyscrasia”). The most striking similarity of the thought process of Hippocrates and Plato is seen when analysing the third class of disease caused by the imbalance of the liquids: Plato describes the origin and properties of phlegm and both types of bile, enough to understand their pathological influence on the functioning of the human body.

A critical component of Plato’s philosophy is the concept of the mutual influence of the spiritual and the corporeal (in the modern sense this is called the psychosomatic integrity of the human body). Diseases of the soul, according to Plato, do not have a divine origin and are explained by a defective inherited constitution or bad upbringing. Psychosomatic integrity in his system has a physical explanation: parts of the soul located in corresponding parts of the body are associated with them. Hence the processes of aging and disease of the flesh also affect the spiritual life of the human being. As a result, inflammation of brain tissue, which is the cause of fatal diseases, is so dangerous, particularly because in this case the bonds between the substance of the superior, immortal part of the tripartite human soul and its repository—the brain—weaken. Therefore, since death arrives the moment the immortal part of the soul separates from the body, any local damage to the brain in which the Demiurge placed the immortal soul means an unfavourable prognosis of disease in general. Sacredness in this case is determined by the significance of the phenomenon—after all bodily death indicates the act of final separation of the immortal part of the soul and the body. Inferior parts of the soul also die with flesh, and the habits of the human being vanish with them too. It is interesting that we see these ideas of Plato developed by Galen: he views the inferior parts of the soul as substantially similar to the structure of those organs in which they are located.31

There was a tradition in European historiography to criticize these ideas of Plato as rudimentary and incoherent compared to the Hippocratic Corpus.32 It is impossible to agree with this criticism: I see considerable congruence between the views of Plato and those of the authors of the Hippocratic Corpus. Furthermore, this congruence does not surprise us, even considering Philistion’s reputation as an obvious anti-Hippocratic. How exactly was the disagreement between Philistion and Hippocrates supposed to manifest? It is usually regarded that medicine at this time was dominated by two opposing schools—dogmatists and empiricists. Summarising the characteristics of these schools, we may get the following: empiricists rejected the value of theory and the resulting principles of studying anatomy and physiology, extolling the significance of everyday medical practice; dogmatists in turn advocated for the need for a systematic approach to diagnosis and treatment of diseases. Of course, it reflects a longer historical perspective: this is a conflict between “theoreticians” and “practicians”. But how this contradiction could look like in the past? However, does this mean that, for instance, Philistion rejected Empedocles’ system and Alcmaeon’s views, regarding them as theoretical or denied the treatment of the opposite with the opposite, believing that Hippocrates did not substantiate it theoretically enough? The negative answer to this question is obvious considering the observations made earlier. Furthermore, remember that by all accounts, the Hippocratic system was characterised by priority attention to the results of the practical work of the physician and the rejection of abstract sophist theories. So, what is the difference?

In my opinion the right answer lies in treating medicine as a theoretical-practical system which progresses along the path of accumulation of knowledge and its generalisation. This in turn determined the need to turn to anatomical dissections (we see some of their descriptions as early as the Hippocratic Corpus). We see the further conceptualisation of rationalist dogmatists through the excellent examples of Herophilos and Galen.

Sometimes Galen’s philosophical views are called “eclectic”. However “eclecticism”, “eclectic system” basically means the mismatch between the philosophy of a thinker who proposes a new global theory with taxonomic ranks more developed with respect to his predecessors and not-every-successful contemporaries. The medical ideas of Plato may also seem “eclectic” because they combine elements of the ideas of Empedocles, Diogenes of Apollonia, Alcmaeon, etc. One can certainly speak of the incompleteness of Plato’s medical theory—it does not encompass all problems associated with solving tasks facing the doctor. Nevertheless, it is clear that Plato proposed fundamental principles which shaped the foundation of the theory of ancient rational medicine. The idea of a tripartite human soul and the placement of its superior, immortal part in the brain turned out to be particularly fruitful. This idea particularly defined further anatomical and physiological studies and subsequently enabled Galen to outline basic methodological categories in his medical system.33

In his commentary to Timaeus, Galen pays considerable attention to the functional explanation of the model proposed by Plato:

It may be recalled that, according to Plato, we need to imagine that the whole of the greater weel is the outer covering of the body, which constantly interacts with the outside air. Within it, it contains two air-filled vessels akin to smaller weels. One of these is located in the abdominal cavity, and the other in the chest. The whole space between the greater weel and the lesser ones is filled with rays of fire running along the arteries and veins, while the cavities themselves assist in movement from the inside outwards, and from the outside inwards. Accordingly, Plato says that there are two opposite movements in the two smaller weels. One is directed towards the outside air, and the other, correspondingly, from the outside air inwards. Next, Plato explains to us how these movements take place, and why they do not stop for as long as the body is alive. Summing up his ideas, he says that this double movement creates a double process of respiration and a double process of nutriment distribution. I, however, call respiration a function consisting of inspiration and expiration, and in this I agree with all physicians, that there are three states: the first is movement inwards, the second is movement outwards, and the third is the result of these movements. Hence, the first form of movement is ‘inspiration’, the second is ‘expiration’, and respiration itself is the result of these movements. Plato calls breathing in respiration and says that air passes through the trachea and, evidently, enters the abdominal cavity. He believes that the movement of air outwards and inwards takes place in the cavity within the greater weel and the lesser weels there. When food and drink enter, they are crushed and broken up into particles, after which they are dispersed throughout the body as heat and pneuma with the help of the network [of the vessels]. Physicians call this process the distribution through the body of nutriment, which reaches every part of the body via the arteries and veins. Plato then states that this is the reason for the double movement of pneuma and heat. (Comm. Tim. 78d2-79a4)34

The above-mentioned “fish-trap” as a mechanical model of human body consists of two inner chambers placed one on the other. The Demiurge creates the outer, first mesh from the element of air and the inner one from fire. There is not one, but two funnels at the entrance of the fish-trap, one of said funnels being bifurcated. This indicates the openings through which air and food enter the body. The bifurcated respiratory funnel corresponds to the entrance of air through the nose and the mouth—otherwise it would be impossible to breath while eating. The extension of the lower parts of the two upper funnels signifies the formation of the oesophagus and the trachea with bronchi. Inside the large fish-trap there are smaller ones, which can be entered through funnels—one small fish-trap corresponds to the the lungs, and it can be entered via the trachea and the bronchi, and the other through the stomach, or more precisely the digestive system. The space between the large and small fish-traps is the flesh—muscle tissue penetrated by blood vessels.

Galen explains that the inner “fire” (or inner heat) is the primary source of energy of physiological processes. Even the red colour of blood is a result of this “fire”. The need for constant nourishment of tissues and organs of the human body is due to the loss of nutrients in the life process. This loss is also the result of external attacks of streams of elements existing outside the human body. We take note of Galen’s remark on “double breath” and remind that skin metabolism is of great significance in modern physiology, and the expression “cutaneous respiration” sounds quite scientific from the perspective of modern medicine. Galen’s commentary provides a clearer understanding of the concept of “fish-trap” laid out in Timaeus particularly as part of medical theory. Galen advanced Plato’s fundamental ideas about medicine the furthest and laid them bare from a practical point of view. It is particularly Galen’s train of thought that helps us unravel the gnoseological meaning of Plato’s ideas.

The breathing process constantly sustains the unstable energy of the inner “fire”, which in turn provides the energy of the digestion process. Food is digested in the stomach under the effect of inner heat—the physics of this process become fully clear if the process is considered a combination of the stimulating effect of inner heat and mechanical movement of the smallest particles of fire. The same energy facilitates the movement of blood formed from food particles through the veins. The respiratory function is realised according to the “circular thrust” principle, when, under exit pressure, surrounding air is moved, and successively, by transferring this forced action, generates circular movement, also entering the body through pores in the flesh. Plato argued that breathing has a special purpose, regulating the intensity of internal heat (element of fire). Although he never explained how he sees anatomical interconnections of the two fish-traps with respect to the circulation of blood, which contains elements for nourishing tissues, through the veins. Plato argues that lungs were meant to cool the heart, and air enters the lungs cold and is subsequently heated. It is assumed that the air also comes out through the pores heated by the inner “fire”. Galen rightfully observes that breathing is the exchange of air with the environment in the form of a series of half-turns in opposite directions, in accordance with rhythmic changes in air flow. He explains that the inner “fire” (or inner heat) is the primary source of energy of physiological processes. The need for constant nourishment of tissues and organs of the human body is due to the loss of nutrients in the life process. This loss is the result of external attacks of streams of elements existing outside the human body. All of this depend upon circulation and activity of “fire” element.

Plato describes the topography of the human body, which consists of cavities which accommodate organs according to their importance (due to the locations of various parts of the soul), which enables to determine the peculiarity of each and identify the laws of their interaction as a whole.35 He illustrates the duality of the structure of the human body, which manifests in the functional peculiarities of its organs, which are in constant motion: on one hand, necessary functioning, i.e., striving for health, and on the other hand—constant threat of “disorder” (disease). The duality of the structure of the human body is also exhibited in the movements of elements inside the complex system of the fish-trap in the form of the combination of flow and counterflow (i.e., movement in opposite directions) (Comm. Tim. K78d2-79a4).36

Plato’s doctrine on human nature is based on the idea of of the tripartite nature of the human soul. The primary function of the superior, rational part of the soul is intellect and control of voluntary movements of the human body, similar to the movements of intellect and influencing the preservation of the order of elements, and, as a result, the preservation of health. The property of the rational part of the soul is its immortality. Therefore the state of the physical death of the human being is described through the separation of the immortal part of the soul and the body, which ends with death, which is definitively understood as agony, the separation of the superior, immortal part of the soul from flesh. Taking cue from Plato, Galen argues that:

Reason resides in the brain, from which it controls the nerves and movements, as well as the five senses. The appetitive part of the soul is located in the liver and is responsible for the blood, veins, and also has the ability to differentiate substances necessary for the nourishment of the body. The spirited source, which is located in the heart, monitors the arteries, the natural temperature, pulsation of the blood, as well as the animal part of the soul. (Comm. Tim. 76е7-77с5)37

Plato’s idea of the tripartite nature of the human soul turned out to be exceptionally productive for the development of medicine. The names of two lower parts that have been established in historiography are—“animal” and “vegetative” (as synonyms of the terms “spirited” and “appetitive”)—are not random. Plato points (and in his commentary, Galen stresses the same point) to the unity of the creation of the living: animals and plants have corresponding inferior parts of the soul, which the great philosopher considers mortal. Animals have two—spirited and appetitive—parts of the soul, and plants have only one, inferior part. The presence of two parts of the soul explains their similarity to man: the substance of their structure is made from the same primary elements and is animate. Plato’s system therefore solves the task of the demarcation of what in contemporary science is referred to as organic and inorganic structures. This is confirmed empirically: the entire physical world consists of the same primary elements, but the human being cannot feed38 on, for example, fragments of volcanic lava or sand, but can eat animal meat and plants. This question can be resolved through Plato’s theory, which endows animals and plants with inferior parts of the soul, which allows for the use of similar substances for the nourishment of human body tissue. Commenting on Plato, Galen notes that his predecessor “pointed out that desiring capacity of the soul is equally inherent in all living beings and plants” (Comm. Tim. 76е7-77с5).39 The key to this dilemma, to my point of view, is exactly the physiological role of the parts of the soul—the influence of different sorts of pneuma makes the elements to become part of metabolism.

The idea of the unity of creation and the functioning of all living organisms, which is typical for Plato’s system, is significant for medicine. These ideas subsequently shaped Galen’s views on the relationship between the spiritual and the corporeal in the context of understanding their unity in health and disease. The ideal of this unity is harmony and balance of the physical state of the body (variable in nature and ultimately mortal) and the soul, which, in its superior part, is immortal and immaterial. The unity of the spiritual and the corporeal cannot be formal; it should be substantial, essential in nature, which Galen pointed out in his commentary:

What only remains is to point out to those who consider that our soul has one essence, which holds in itself three potential facilities—rational, spirited (θῡμοειδής) and desiring (ἐπιθῡμητικόν). It would be reasonable to argue that the three parts of the soul are in fact one essence. Plato points to the difference between the rational soul and unconscious spiritual phenomena; therefore reason is in a state of battle with the desiring and spirited parts of the soul. Furthermore, the rational part of the soul sometimes seeks the help of the spirited part in order to resist the desiring facility. Plato only points to these types of soul, but does not speak about them as one essence. Even if the essences of the soul were different, they would still be present in all internal organs, and so any one of us can claim that we have not three souls, but three properties of one soul. (Comm. Tim. 76е7-77с5)40

The historical evolution of Plato’s idea of the mutual influence of the spiritual and the corporeal formed Galen’s concept of unity of soul and body, and, further, led to the emergence of the modern concept of the psychosomatic integrity of the human being. In light of this detailed description of Plato’s views on the anatomy and physiology, the three groups of the development of disease he proposes become clear. Psychosomatic integrity has its physical explanation: parts of the soul located in corresponding organs are closely associated with them. Hence the processes of aging and degradation of flesh also affect the spiritual life of the human being. Inflammation of brain tissue, which is the cause of diseases which threaten human life, is dangerous particularly because in this case the bonds between the substance of the superior, immortal part of the tripartite human soul and its repository—the brain—weaken. Plato does not consider epilepsy something supernatural and shares Hippocrates’ view on this matter, mocking the name “sacred disease”, pointing out its appropriateness only to the extent to which sacred substance is the brain matter it afflicts. Sacredness in this case is determined by the significance of the phenomenon, after all bodily death indicates the act of final separation of the immortal part of the soul and the body. The death of the inferior parts of the soul (spirited and sensuous) along with flesh is clearly defined here. Again, it is interesting how Galen further develops these ideas of Plato: he sees the inferior parts of the soul as substantially similar to the structure of those organs in which they are located.