Prognosis and Diagnosis: A Comparison of Ancient and Modern Medicine Author(s): Walter Pagel Reviewed work(s): Source: Journal of the Warburg Institute, Vol. 2, No. 4 (Apr., 1939), pp. 382-398 Published by: The Warburg Institute Stable URL: http://www.jstor.org/stable/750046 . Accessed: 26/03/2012 19:04 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.
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A COMPARISON PROGNOSIS AND DIAGNOSIS: ANCIENT AND MODERN MEDICINE
OF
By Walter Pagel* I of the great variety of concepts developed on the borderline between OutGreek philosophy and biology I shall choose one that seems of
fundamental importance, namely "Physis." Once we have made clear the meaning which the Greeks attached to this word, we can infer some historical and sociological reasons for the characteristic developments of Greek medicine and its specific ideology, and contrast its methods with those of modern medicine of the XVIth and XVIIth centuries. All biological theories enunciated by the philosophers of ancient Greece are solutions to one problem, that of the relation between the One and the Many. What unity is concealed by the multiplicity of phenomena? This unity is nature, and all philosophers before Socrates speculated "On Nature." Thus, the Greek philosopher showed his yearning for enlightenment and science. He differed from his predecessor the theologian, who among other more primitive nations had been in charge of medicine, that is to say, of the practical application of the knowledge of nature. Mystical intuitions such as the identity of man and the world were, as Cawadias says, "rationalized" by the Greeks and converted into the doctrine of the elements, air, water, earth and fire, which build up the human body and the world, the microcosm and the macrocosm.' Convinced of one fundamental principle behind all phenomena, the Greek rejects the idea of a multiplicity of agents, such as gods and daemons, governing nature according to their own independent decisions. The basic principle in nature, which the Greek philosopher seeks, acts according to causal necessity. There is no better illustration of these scientific tendencies of the Greek "Physiologoi" than the Hippocratic treatise on the holy disease, epilepsy. The author says that this disease has been attributed to divine influences because men were so amazed at its peculiar symptoms that they had nothing to offer in the way of natural explanation; that referring natural phenomena to gods and daemons is but concealing one's own ignorance behind dishonest pseudo-knowledge; and that he wishes to show that epilepsy is as natural a disease as any other. This seems so much the more important as the therapy of a disease entirely depends * Papworth Village Settlement, Cambridge. 1 "Gastroenterology and metabolism." Proc. Roy. Soc. Med., XXVI, 1933, p. 43 ff. On the attitude of the Greek physician (Galen) towards magic therapy and incantation compare W. Pagel, "Religious motives in the medical biology of the XVIIth century."
Bullet. Instit. Hist. Med. Johns Hopkins Univ.,
as far as possible by careful analysis and rational explanation of the remedy and its effects on the body. Only in cases of emergency, when scientific therapy has proved inefficient, may the physician resort to magic remedies, i.e. those which are inexplicable in their effects, and to incantations, the use of which was widespread in antiquity.
Baltimore, III, 1935, p. 113 ff. The Greek physician tries to eliminate "occult qualities" 382
PROGNOSIS AND DIAGNOSIS
383
upon what is considered to be its cause. Hitherto therapy had consisted of magic and catharsis. Its object was to purify the body from impurity caused by a god. But in the author's opinion it is inconceivable that the human body could be contaminated by a god, the foul by the clean. Thus, therapy by magic is the result of impiety rather than of true religious feeling. The author tries to give a naturalexplanation of the disease which he believes to be due to an overflow of mucus from its source, the brain, into the arterial channels that supply the brain with air, and to an obstruction of these air passages. Accordingly therapy consists in the regulation of diet in order to "add and to withdraw" something from the organism at the appropriate time. For medicine is the art of "addition and subtraction" adding what is deficient and removing what is present in excess.' It is obvious, then, that life under normal and pathological conditions is understood as a physical process, as the result of the undisturbed or disturbed function of the Physis. "Physis" covers, according to the comprehensive investigations of Heidel :2 (a) the natural process itself and therefore both the physiological and the pathological processes, (b) the material basis or the efficientcause of a process and (c) the result of the process, that is, the external or internal structure of what has been developed by a natural process. The last seems the most significant meaning of the word, because in this sense it comprises what we may call constitution,the constitution of groups, tribes, the cosmos, physical and psychical entities such as talents, the character and skill of the good physician,3 etc., and above all the constitution of the individual, the structure and function of a living being, seen in a prospective and dynamic sense, in a movement towards a destined end. This movement is the result of the inborn order of functions in an organism in contrast with acquired properties and states; it is the independently growing "natura" of a thing, the "physis" derived from "phyein," i.e. "to grow" and nature from "nasci," i.e. "to be born."4 Acquired states, such as the bodily state of an athlete, which is produced by a special diet and not <P1*Etin him, are indicated by the word "diathesis" or "dispositio."
According to Ryle5 we regard "diathesis" to-day as a "variation in the structure or function of tissues which renders them peculiarly liable to react in a certain way to certain extrinsic stimuli." Originally diathesis meant any situation or condition, a meaning which afterwards came to include the morbid condition, the "affectus" which is the result of an alteration I Hippocrates,SacredDisease, 7 in fine, from "J'lad" "peperit" or "genuit." E.g. the On Winds, I ""E'tiw ' larp K) TpdOaiEat four qualities are "Arba tholdoth" and naturalists are called "Chochme hatholdoth" d0V7r0V., a(pp at (EaLYTso-vVnEpfla (Eatso (pat u " " e ev erTVEAAE7TOV'O d cOl AApEns, TvArO,. " (Joh. Buxtorf, Lexic. Chaldaic. Talmudic. 7TPOorOEortso--vE' " â&#x20AC;˘'&v â&#x20AC;˘tp 2 Rabbinic. Ed. B. Fischer. Kal
a
Heidel,
"Peri Physeos." Proc. Amer.
Acad. Arts and Sci., XLV,
1910,
p. 77.
3 Hippocrates, Decorum,4, Loeb edition,
vol. II, p. 282.
4 Similarly in Rabbinic Hebrew (especially in Aben Esra) "quality" or "nature" of a substance is expressed by "Tholeda" derived
Lipsiae, I875, p. 486.) On "Physis and Nature" compare Ch. Singer, Historicalrelationsof religionand science,in: Science,Religionand Reality,edited by Joseph Needham. London 1926, p. 85. 5 The natural history of disease. Oxford, I932,
P. 397.
WALTER PAGEL
384
of the normal condition. Diathesis, in any case, means something which is transitional as opposed to a permanent disposition." Similarly KarTraactg, or "constitutio", means not only a certain state of a thing, inborn or acquired, but also the constellation of non-living entities, such as climate, weather, season. "Physis," however, acquires the meaning of the inborn constitution, and finally it also indicates a normal process in contrast with a pathological one, or even a fixed type of a disease prevalent at any particular time. But this conception of "normal" is not, as nowadays, based on the comparison with the average. It is the expression of what is appropriate to a particular individual's constitution, his complexion and mode of reaction which are different from the reaction and constitution of other persons. "Normal" in this sense is for one person something quite different from what it is for another. It may be normal for me to have a fast pulse and warm hands, and for another to have a slow pulse and cold hands, to endure frost, etc. The meaning of physis as normal in the sense of the average is not the original meaning. It becomes important later when the various types of reaction were more strictly classified (Aristotle), as, e.g., it is, according to Galen, normal for a person with humid and warm complexion not to be able to stay awake all night, or to have defective senses, but to be quick in motion.2 Of course, in Galen's writings we find the term frequently used in the modern sense, e.g. when it is said that evacuation of the stomach by the intestine is the normal physiological way in contrast with an evacuation through the cesophagus in vomiting, etc.3 But there is no need to emphasize this distinction between the normal physiological condition implied by the word physis and the pathological process, because it is one of the characteristic features of Hippocratic medicine that disease is understood as a natural or physiological process, differing only quantitatively from the normal functions. Physis in the sense of the typical behaviour of an object acquires, however, a certain significance when the typical course of a disease is indicated as its "physis," whereby disease is understood as an explicable and therefore natural process dependent upon cause and effect and not of divine origin. It is this physical course of disease, its 1 Galen,
De different. symptomat. i;
Opp.
omn. edited by Kuehn, Lipsiae, vol. VII, I821-33, P- 43. See also Barthol. Castelli, Lexicon medic. Graeco-Latin. Lipsiae, 17I3,
p. 261 and Fernel, Joh. Ambian., Universa medicina, Francof.,
1593,
Morbi
definitio,
p. 2346. Galen, Ars Medica,8; Opp. omn., ed. cit., vol. I, p. 326. As a similar example of type classification from Aristotle may be quoted : De partib. anim. II, 4 (650 b 20), Translat. by A. L. Peck in Loeb edit. I937, p. I37:
"Some of the animals whose blood is watery have a specially subtle intelligence. This is due not to the coldness of their blood, but to its greater thinnessandclarity... and an animal which has the thinner and clearer sort of fluid
in it has also a more mobile faculty of sensation." In the same book the significance of the majority of cases ("the average") and of consistency in Physis is emphasised :III,
2 (663 b 28), Peck's translation, op.cit.,p. 223: "Ad E& v CpVrtV & copELvE Ta o7ToAAa flAE'-
'yap -p7wav-T To l bs-wlâ&#x20AC;˘- woAv oovra cp)vtv EUT1.
KaTaL
"To study nature we have to consider the majority of cases, for it is either in what is universal or what happens in the majority of cases that Nature's ways are to be found." 3 Opp. omn., ed. cit., vol. X, p. 359.
pare W. Pagel,
Com-
"Geschichte des runden
Arch. Geschichted. MeMagengeschwiirs", XXV, diz., I932, p. 334.
PROGNOSIS AND DIAGNOSIS
385
natural history, which the physician must know in order to make a prognosis. So it is said that all the psychical disturbances originate in the brain when it is abnormally hot or cold etc., or suffers any unnatural affection to which it was not accustomed.' But the importance of this meaning of physis is in my opinion not comparable with the association of the physis with the individual. The factors on which the definition of a patient's physis should be based are his habits, regimen and pursuits, his conversation, manners, taciturnity, thoughts, sleep or absence of sleep, sometimes his dreams-what they are and when they occur-his picking and scratching, his tears, his alvine discharges, etc. Hence Galen says with regard to the conception of physis "In an individual case one should not speak of nature in general, but should add : nature of whom and where."'2 It is essential for the physician to know and to study this individual nature so as to be able to order the special diet which will suit the individual case and prevent disturbance of the system. -The emphasis laid on variation of the individual mode of reaction with the case under consideration seems to be deeply connected with the Hippocratic opposition to preconceived ideas and doctrines. In cases of fractures the patient himself will hold the arm to be bandaged in the position indicated by conformity with "physis," that is, the position which is most natural in the special case and for the limb concerned. But a theoretical assumption, e.g. that the position of the arm of an archer is the natural one, must be rejected.3 Many arts might be found in which the natural position of the arms is not the same, but they assume postures in accordance with the tools each man uses and the work he has to execute. Physis is not only the inborn plane of structure and function, but also a force working in the organism like a workman. The physis is something like a demiurge controlling all the needs of the body; it propels and throws, it gives and receives, working entirely unconsciously and untaught -"adidaktos". Above all physis is the natural healing power of the body which capacity it combats the causes Tots vocrEpotsacdros-in -8tLaywcOxopLEV of disease. This natural healing power of the individual is the strongest therapeutical agent in disease. Thus we see a development in the conception of physis. It first means something common to all things, the fundamental principle behind phenomena. At a later date the word indicates the constitution peculiar to the individual distinguishing him from other individuals. The subtle elaboration of this conception and the attention given to the individual mode of reaction seem to be the essence of Hippocratic medicine, and to mark the progress achieved by Greek medicine over 1
7
by Withington, Loeb Class. Lib., vol. III, p. 97. See also Ch. Singer, loc. cit. 4 Galen, Method.medendi,Lib. III, cap. 3 2Methodus medendi, Lib. III, Cap. 3, Opp. Opp. omn., ed. cit., vol. X, p. 174 "O'lov omn., ed. cit., vol. X, p. 174 : "AAA' o3X Ji7Aw-s 8&qtoVpyOsTEKat TEXV77) 9(p"Ut5. 5 Galen, de crisibus,8; â&#x20AC;˘Opp. omn.,ed. cit., ElErEV XP?"pdvtv,AAalpoorOEEvat r'lv v HKaO rrov. vol. IX, p. 735. 3 Hippocrates, On fractures,2, Engl. edit. Hippocrates, "OEp/tdopog pripvo:os." Sacred Disease 18, ed. cit., vol. II, p. 176.
386
WALTER PAGEL
the conceptions of the Presocratic thinkers. On the other hand, the strong influence of the latter on the Hippocratic writings is obvious in the stress laid on speculation and particularly on the doctrines of the humoral and elementary composition of the organism. The individual physis depends upon the mixture of the humours peculiar to the living being under consideration. The governing centre of the organism is something warm and humid. The "Krasis" as a kind of chemical combination opposed to a more physical "Mixis" applies to humours. No doubt, Alcmaion of Kroton must be regarded as one important source of humoral biology and pathology. It is known that he proclaimed the supremacy of the head, a view which is possibly' responsible for the famous theory of catarrh that predominated in pathology until the XVIIth century. According to this theory, most diseases are due to a flow of phlegm from the brain directly through the skull into the lower parts such as the lungs, the joints, the bones, the jaw. Traces of this belief persist even to-day, when we speak of rhumede cerveau,rheumatism etc. In fact, this doctrine formed the nucleus of pathology until by anatomical investigation and physiological argumentation its impossibility was established by J. B. van Helmont; this greatly furthered the abandonment of Greek humoralism and the foundation of modern pathology.2 There are many other traces of the influence of the pre-Socratic writers in the Hippocratic Corpus to which Peck has particularly drawn attention.3 In some of the Hippocratic treatises the controversies of the contemporary philosophical schools are reflected. There is a tendency to belittle the doctrines of the Eleatic school and to accept those of Heracleitos.4 Among the Hippocratic writings there are two, those on "Regimen" and on "Nutriment" which present striking resemblances to the aphorisms of Heracleitos. The significance of Greek medicine, however, does not lie in humoral biology and pathology, although humoralistic doctrines were revived in the middle of the XIXth century and still receive attention, now that the importance of humoral transmission of all nervous and vital impulses has been recognised. In the writer's opinion Greek medicine owes its importance to the foundation of pathology on the concept of physis, the individual 1 It may be objected, however, that the theory of "catarrh" is compatible with the view of the brain as a receptacle for phlegm without sensation (Aristotle, for example De partib.anim. II, 7 (652b), in Peck's edit., p. I52) rather than with that of the brain as "Hegemonikon" (Alcmaion). 2For the history of the doctrine of catarrh
see W. Pagel, J. B. van Helmont. Einfiihrung in die philosophischeMedicin des Barock. Berlin. ff. The decisive part played by I930, p. 48
van Helmont in the abolition of the old doctrine of catarrh is still not sufficiently recognised. In a recent account of the history of rheumatism F. Klinge does not even mention van Helmont and gives the credit
entirely to Conr. Vict. Schneider who by his studies on the mucous membranes ("Schneider's membranes") confirmed the local origin of the phlegm established before by van Helmont. (F. Klinge, "Der Rheumatismus," Ergebn. allgem. Path. u. path. Anat., 1933, 27, I.)
3 See Jones in introd. to the Loeb edit. of Hippocrates, vol. IV, pp. XLIII, XLIX ff.
4 R. O. Moon, Hippocrates and his successors in relation to thephilosophyof their time. London, I923, P- 55, and Gask, G. E., Early medical schools. The cult of Aesculapiusand the origin of Hippocratic medicine.Annals of Med. History 1939, I, p. 128.
PROGNOSISAND DIAGNOSIS
387 constitution and thereby on morbid predisposition.' The doctrine of temper so carefully elaborated in Greek antiquity, implies the doctrine of the internal causes of disease, e.g. the classical description of the individual predisposed to pulmonary tuberculosis may be quoted: Those inclined to this disease are thin people with chests like two boards, shoulder blades like wings and a prominent larynx, who are white and whose chests are tender, spongy or weak. All cold and moist climates are associated with the disease.2 In this description the accent is characteristically laid on the internal predisposition, while only a short reference is made to external auxiliary factors; and it is typical of Hippocrates that a r6le is even ascribed to climate. Another example occurs in the comment that in certain epidemics those who suffered most were generally young people with pale smooth skin, smooth black hair and dark eyes, who were inclined to idleness, people with thin hoarse voices, and those prone to anger.3 Such examples could easily be increased from the classical Hippocratic books on Epidemics. To sum up therefore (i) Physis in the medical sense is the mode of reaction distinguishing the individual from other human beings and governing the course of illness. (2) Hippocratic medicine was based on a study and observation of the nature of the individual, his peculiar mode of response, his physis. (3) The importance of Hippocratic medicine is not found in the pathological doctrines which it developed; it lies rather in the skill of the physician to adapt his opinion on the course of the disease and its cure to the "Physis" of his patient. II Is there any historical or psychological reason to explain the specific character of Hippocratic biology and medicine? Hippocratic medicine chiefly endeavoured to build up prognostication; prognosis rather than diagnosis was its main object.4 It is this that differentiates Greek medicine in general from "modern" scientific medicine which, since the foundation of a new pathology on an anatomical basis during the XVIth and XVIIth centuries, has made diagnosis the corner-stone of medicine and the guide in therapy. It is because of his desire for a correct prognosis that the Hippocratic physician studies the individual and his particular mode of reaction, his temper and complexion, according to which the disease must take its course. There is no such thing as disease; there are individuals who fall ill; and there are different symptoms and complexes derMedizin, 1927, p. I ff., and "On Hippocrates," Bull. See also P. Diepgen, Geschichte Instit. Hist. Med. Johns Hopkins Univers., pp. 56 and 104. 2Aretaeus, De causis et notis diuturnorum Baltimore, II, I934, p. 190 ff. On the signiaffectuum,I, 8 and similarly Hippocrates, ficance of "Prognosis" which, in the Hippocratic sense, covers not only forecasting of Epidemics, III, 14. the future, but also deducing of the past 3 Hippocrates, Epidemics,I, 2. 4 Compare the account of Greek Medicine events, see R. O. Moon, loc. cit., p. 25. in H. E. Sigerist, Antike Heilkunde,Munich, I
Leipzig, vol. I, I913,
388
WALTER PAGEL
of symptoms developed in the various individuals because of their varying individual constitution. The emphasis laid on a correct prognosis explains therefore the development of the study of temper, or complexion, and of morbid predisposition in Greek medicine. But why was prognosis the main subject of Greek medicine? Littr6 and Daremberg, the great pioneers of Hippocratic philology, regarded prognosis as the scientific achievement of Hippocratic medicine. According to Littr6, prognosis enabled the Hippocratic physician to associate disease with the knowledge of the individual and his specific response and to understand disease as a process independent of the organs affected. But was this scientific significance of prognosis the decisive motive of the Greek doctor? This question was raised by Edelstein who was inclined to answer the question in the negative.' Greek medicine possessed a number of pathological theories and could never have admitted a lack of corresponding knowledge. Moreover, the chief treatise devoted to prognostication deals only with acute diseases and leaves the chronic diseases to other parts of the Corpus which are not concerned with prognosis. To the Greek physician prognosis means much more than a scientific guide through the manifold phenomena of disease. It is also a technical instrument by the sovereign application of which he attains certain practical aims. First of all it makes him independent of the patient's own statements as to the history of the disease and his behaviour before the arrival of the doctor. "I hold," says the author of the Prognostic, "that it is an excellent thing for the physician to practice forecasting. For if he discovers and declares unaidedby his patients the present, the past and the future, and fills in the gaps in the account given by the sick, he will be the more entrustthemselves believedto understandthe cases, so that men will confidently to himfor treatment. Furthermore he will carry out the treatment best, if he knows beforehand from the present symptoms what will take place later."12 The doctor, that is to say, knowing things independently of any given information, creates an atmosphere of admiration and thereby inspires confidence in his skill. Great psychological importance, therefore, attaches to correct prognostication. This is achieved by painstaking semiotic observation such as is described in the Prognostikon,the Coic Prognoses,and the Prorrheticon; the same result may also be obtained by taking into account general conditions, such as climate, wind and season, which influence bodily functions in the average individual, as is taught, for instance, in the treatise on the Nature of Man. Finally, prognostication may be made by means of mantic procedures without any observation of the body. But in accordance with the scientific character of Greek medicine, there is strong opposition to mantic prognosis in the Hippocratic writings. 1 "Peri Aeron und die Sammlung der Vol. IV. Berlin, 1931, p. 6o ff. Problemata, 2 Prognostic,I, ed. cit., vol. II, p. 6. Hippokratischen Schriften."
PROGNOSIS AND DIAGNOSIS "'SEv&
aov01
T"oromâ&#x20AC;˘Ta
pEt L UaOUrLvaot, 7t).
389
SE pypâ&#x20AC;˘po"-
"I shall not prophecy this, but I indicate the symptoms."' There is furthermore a prognosis applying to the prescription of the diet appropriate to the individual. In every moment of life the balance of life forces has to be maintained, a balance which is endangered by all the normal and periodical functions, such as digestion, etc. So in the book on Epidemics a kind of prognostication is used for the prescription of the appropriate diet according to known harmful influences of the seasons. But this scientific application of prognosis was rare. The chief importance of prognostication, according to Edelstein, is the impression created by the physician on the patient and his friends and relatives. The Greek doctor is a craftsman. He may settle in a town or wander about, or he may do both alternately. In town he works at home in his workshop or at the bedside. The itinerant doctor opens a stall in the market place. Moreover, there is free access to the medical profession. Anyone may practice, without any qualification, other than his practical attainments and clinical success. On the other hand, the doctor's workshop is the place where friends and sightseers meet to look at his work, to study the beauty of the human body and to make friends. In this environment the doctor has to show what he can do. He has to win the confidence not only of the patient but also of the patient's friends and relatives, and indeed of the whole population of the town in order to increase his reputation and clientdle. Medicine is a re'xv',an art with certain limitations. There are unforeseen accidental factors; there are unknown causes; there are no determined laws or doctrines as to the nature and fate of the patient. Compared with the power of the natural healing forces the power of the physician is very small. He is a craftsman and works like all the other craftsmen. His work is justified only as far as he copies nature, and it is this imitation of nature which unites all kinds of "techne," of craftsmanship. Nature -or, as it is expressed in the Treatiseon Regimenwhich is deeply influenced by Herakleitos, "the minds of the gods"-taught man to copy their own functions. But Nature of herself knows how to do these things, while the doctor has laboriously to endeavour to copy her.2 According to Hippocratic principles therapy itself can only support nature and is never to be allowed to take drastic procedures. It can only attempt to readjust the abnormal conditions to the state suitable for the patient as an individual being with a peculiar mode of reaction and life. The physician, knowing the limitations of his art and the comparatively small range of medical interference, makes prognosis the field of his special interest. We have taken the conception of physis as the basis of the first part of our deductions. Indeed the physis, the peculiar mode the patient, is the centre of the thought and work of the It is the chief object of his studies for scientific purposes and of the right cure; but the study of man, and his individual 1
Prorrheticon,8, 2.
2
of reaction of Greek doctor. for the finding reactions and
On Regimen, I, I2, ed.cit., vol. IV, p. 251 ff.
390
WALTER PAGEL
symptoms, is also important for the winning of the patient's confidence, which guarantees scientific success and practical prosperity, and is best obtained by prognostication. We may say, therefore, that the specific tendency of Greek medicine, the study of "Physis," reflects the sociological character of Greek medicine and its bias towards prognostication. A sociological explanation of the peculiar tendencies in Greek medicine is fascinating. But does it explain everything? Does it explain, or is it reconcilable with the high ethical standard of Greek medicine with its elaborate professional code dating from very ancient times? Besides the sociological reasons for developing prognostication, was there not, as Jones has suggested", a peculiar and specifically Greek desire for knowing the future, to which the importance of the Oracles of divination and augury was due? Moreover, the position of prognosis as the chief aim and character of important treatises such as that on Air, Waters and Places, on which Edelstein's argument was chiefly based, has recently been contested.2
But the fact remains that the paramount r6le played by prognostication in the Hippocratic writings and the comparatively slight emphasis laid on diagnosis and active therapy are established beyond doubt. It is true that the Hippocratic writings also contain theories in apparent contradiction to these facts. They are usually attributed to the Cnidian School, and the latter is regarded as opposed to the School of Cos. According to Cawadias, however, "there has never existed any opposition regarding
the medical principles of Cos and Cnidos . . . The physicians of Cnidos introduced . . . into medicine the classification of morbid phenomena in diseases, but . . . the Cnidians have never taken their diseases as realities . . . they classified their knowledge in terms of
nosography, but they diagnosedand treatedindividuals."3 The present writer cannot in any case agree with the view that the mere existence of trends of thought in Greek medicine opposed to prognostication is in itself evidence against sociological reasons for the favour given to prognosis in Hippocratic medicine in general, although overemphasis on the sociological explanation is open to criticism. It should be borne in mind that the passage quoted above from the Prognosticon4 gives a genuine and vivid expression to the true motives of prognostication and can be hardly regarded as a mere figure of speech. If not sociological, certainly psychological reasons help to explain the special emphasis laid on prognosis. III It is easy to imagine how the subtle medical art of the Hippocratic era became more and more petrified, even in antiquity, and gave place to a 1 Introduction to Vol. II of the Loeb edition of Hippocrates, p. XI. 2 E.g. by Deichgraeber in: "Die Epidemieen und das Corpus Hippocraticum", Abh. Preuss.Akad. Wiss., Phil.-hist. Klasse, 3, Berlin, 1933; and by Diller, in : "Wander-
arzt und Aetiologe," Philologus,Suppl.,XXVI, 3, Leipzig,
I934.
3 GreekMedicine,St. Bartholemew'sHospital Journ., June 1930. 4 Cf. p. 388.
PROGNOSIS AND DIAGNOSIS
391
number of automatically applied dogmatic doctrines such as we find enumeratedin the work of Galen. Medicine, originally an art, adopted more and more the character of a science or, rather, a pseudo-science. It must be recalled,however,that it was the ingeniouspersonalityof Galen which revived a good deal of the medical and psychologicalart of the Hippocraticphysician;and there is no doubt that the same appliesto many a mediaeval doctor-although he had to carry with him the mass of dogmatic theories and doctrines left to the Occident by Galen and put into a scholastic frameworkby the Arabs. The art of the physician is timeless and independentof the age. The art of the Hippocraticphysicianhas survivedand is as up to date as it has ever been throughoutthe ages. But what has changed and had to change is pathology and its offspring, scientific therapy. Indeed, the historyof medicineshows that the rise of modernpathology during the XVIth and XVIIth centuries is deeply connected with the abandoning of Greek and Latin medicine and though this is less clearly recognized,with an oppositionto the pathologicalideas expoundedin the Hippocratic Corpus. There is much talk about anatomy as the science which made modern pathology possible. Yet the anatomical knowledge of Galen was remarkable;and modern anatomy deserves credit for the inspirationit gave to the new view of man and nature and to the study of the anatomicalbasis of diseaseand surgicaltherapy,rather than for any discoveriesmade in the human body. It is true that a fundamentalrevolution in the conception of disease occurred in the XVIth century, but it derived from a source other than scientific anatomy and physiology. It is very significant that it was a religious mode of thought that gave rise to this reformationof medicine, so deeply connected with the abandoning of Greek and mediaeval pathology. As we have seen, Greek medicine was entirely opposed to religious thought. It was an enlightened scientific (or rather, technical) art, based on a high ethical standard. But it had nothing to do with religion. Disease was simply a defect of the body as a machine, a defect which had to be remedied in orderto restoreefficientfunctioning,to avoid crippling and disability, in short, to preserve the harmony of form and function. Medicine is a r'xvq, the doctor a craftsman. Disease was in no way a punishmentor a sign of some violation of the supernaturaland divine order of things, such as "Zoraath"in Judaism,nor was it a sign of grace or trial, leading the individual to eternity, as in Christianity. This, of course, does not detract from the high ethical standard of Greek medicine.' Hippocrates says2: "One must not be anxious about fixing a fee. For I consider such a worry to be harmful to a troubled patient, particularlyif the disease be acute . . ." And furthermore "I to consider urge you not to be too unkind, but or means. Sometimes carefully your patient's superabundance give your services for nothing, calling to mind a previous benefaction or present
1 For u.Jugendbildg.,V,1925, P. I. detail, see Ernst Hoffmann, "Kultur- Jahrb.f. Wissensch. 2 Precepts,4 ff., ed. cit., vol. I, p. 316 iffphilosophischesbei den Vorsokratikern,"Neue
392
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PAGEL
satisfaction. And if there be an opportunity of serving one who is a stranger in financial straits, give full assistance to all such. For there where is love of men there is love of the art." On the other hand, all these solemn instructions do not reveal the ideological motives and aims of Greek medicine. They are rather a part of the professional code in which humanitarian feeling and the yearning for professional reputation are mixed. "The prudent man," it says, "must also be careful of certain moral considerations-not only to be silent but also of a great regularity in life, since thereby his reputation will be greatly enhanced." To sum up, the Greek physician is the servant of the art rather than of the patient, who has to cooperate with the physician in order to combat disease. The same ideas are also evident in the famous Oath of the Asklepiades which is not only the most impressive document of professional ethics, but also a very fine piece of rhetorical art, in that it shows a significant parallelism between the individual sentences and instructions.' The first and the last (ninth) sentences are solemn declarations: "I swear by Apollo the physician," and, "If I carry out this oath, may I gain for ever reputation, if I transgress it, may the opposite befall me." The second and the eighth sentences concern the doctor's gratitude to his teacher in the art and the duty of medical secrecy, i.e. specific professional affairs which concern the physician himself. The third corresponds to the seventh almost verbally and refers to the patient the former asserts: "Treatment must be applied to help the sick but never with a view to injury and wrong doing," and the seventh declares "Into whatsoever house I enter I will enter to help the sick and will abstain from all intentional wrong-doing." The fourth and the sixth sentences apply again to special offences against the professional law, to inducing abortion and to lithotomy. The latter was left to laymen specially practising lithotomy, most probably because, in the majority of cases, this operation caused sterility. Finally the fifth sentence may be regarded as the climax of the whole without counterpart: "But I will keep pure and holy both my life and art." But the conception of piety and charity connected with medicine is not essential in Greek medicine as it is in Christian medicine. There is no mention of suffering or agony in the Hippocratic writings. Medical assistance is expressly refused in hopeless cases. The Christian doctor, however, takes pity on and attends every case and every man in his ailment, whatever the prospect of the disease and the value of his medical help may be. The Greek doctor who would attend hopeless cases might create among his fellow citizens the impression of pretending to be able to cure them and thereby he might break the written and unwritten law of the profession. Paracelsus, however, to whom medicine owes a great reformation of thought, is the prototype of the religious and christian physician. In his opinion it is human suffering that needs and deserves medical help. It is for this purpose that God created the physician as well as the remedies 1 To this Ernst Hoffmann drew attention in I929 (op. cit., p. I8).
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appropriate to each disease in its environment. The god-fearing physician called and chosen by God is able to cure every disease, if God will-even so-called incurable diseases. "He who does not know how to cure leprosy, does not understand the power of medicine. He who does not make a lame leg straight is no physician. He should know that God has not set up the physician to cure cold in the head and headache. They justify their lack of skill by saying: 'The Disease is incurable,' demonstrating nothing but their own stupidity and mendacity, because God never caused a disease for which he has not created a remedy."' To the Greek physician it seems in certain cases impossible to restore function and harmony in life, because to him miracles are impossible, since they transcend the scientifically determined order of nature. To the Greek, nature consists of ever-constant matter in a state of continuous transformation owing to the displacement of the fundamental elements and atoms, to the hatred and love of the material elements, to their attraction and repulsion. There is no conception of creation, and the r6le of the creator (e.g. in the philosophy of Aristotle) is that of a deus ex machina,who is introduced because the philosophical system needs him, although his functions are by no means essential for the course and progress of the world. In the world of Paracelsus, however, everything is the result of a particular plan and the creative work of a living God, who has placed sparks or a kind of seed in living entities.2 These "sparks," seeds, or "archei" really exist; they live and are thereby distinguished from Aristotle's "entelecheia" or "organicon" which are rather philosophical concepts introduced to establish an ontological order of the phenomena observed in nature. According to Paracelsus everything is living in so far as it fulfils certain aims. Even stones and ores live, because they grow, ever producing new substances of the same kind. So things are essentially and qualitatively different according to the difference of the seed placed in them at their creation. But there is no commutation of the atoms and elements; or, if such a thing takes place, it does not in any way explain the particular properties of creatures. Thus the world is monadically constructed out of an innumerable quantity of divine seeds which constitute the cosmos. These seeds cannot be replaced by each other, nor can they be artificially reproduced by a certain constellation of material elements. They contain something like 1
Opus Paramirum, I, 7-8. In the writer's opinion the doctrine of the "seeds" as independent living entities of which the world consists is particularly characteristic of Paracelsus' philosophy and one of the fundamental conceptions which Paracelsus and van Helmont have in common. I give one quotation out of the many which could be given: "Also kompt der grunt in unser wissen und erkantnus,dieweil alle ding ein samen haben und im samen alle ding beschlossen seind." (Paracelsus, Philo2
sophia sagax der grossen und kleinen Welt.
Edition by Sudhoff, XII, p. I76, Munich, vero propinquius investiI1922-33.)-"Ego gando . . . comperi imprimis res omnes in natura constare semine invisibili." (van Helmont, Butler, Op. omn., edit. by M. B. Valentini, Francof., 1707, p. 556.) In both authors the doctrine of "seeds" is bound up with the disapproval of humoral biology and pathology by which the devil deceived mankind.
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a soul which governs their development, the construction of their form and their function. It follows therefore that the functions of living beings are not merely physical processes. Any influence exerted by one thing on another is primarily something spiritual, just as imagination produces physical effects, e.g. when a pregnant woman is frightened by some monstrosity, the sight produces deformity in the child. It is obvious that this doctrine was the outcome of Stoic and Neo-Platonic ideas, such as those enunciated in the works of St. Augustine or in the Cabbalah, and here, as well as in the work of Paracelsus, they are deeply connected with a religious view of the world and of man. This religious attitude towards the world permeates the whole medical philosophy of Paracelsus, and even his pathology. Man is to be regarded as the product of the peculiar development of a particular seed and not, as in Greek pathology, as the result of a certain mixture of humours. These have a minor significance in health and disease. Much more important are the organs and their harmonious cooperation in the organism which may be compared with the constellation of the stars. One example may illustrate the physiological achievements of Paracelsus. Galen referred digestion in the stomach simply to the warmth of this organ producing fermentation of the food. Paracelsus, however, working on chemical lines unknown to the Greek physician, clearly recognized a special chemical principle in the stomach in charge of the fermentation of food, and it was due to his rejection of the old Greek idea that his follower van Helmont discovered acid as the chief digestive principle of the stomach and alkali as that of the intestine.' Even more conspicuous is the influence of the religious ideas of Paracelsus on pathology. In antiquity there were as many diseases as patients. Disease, not diseases, was the central problem of Greek medicine which did not aim at a classification of diseases as special entities. According to Jones this was due to the Greek instinct to put the general before the particular and to the special character of the ailments common in Greek antiquity to the majority of the patients, namely pneumonic fevers and malaria. In the writer's opinion the emphasis laid on the individual "physis," as the chief medical principle on which the variation of the clinical symptoms depended, prevented the Greek physician from forming an ontological theory of diseases as classifiable entities, although attempts in this direction may be found in those treatises of the Corpus which are generally attributed to the Cnidian school of medicine. To Paracelsus there were as many diseases as causes, a view which corresponds with the idea of the "contagium," the divine seeds,2 the "logos," the "sparks" 1 This is another example of the dependJena, I904, p. I86, and Opp. omn., edit. by ence of Helmont's biological doctrines on Sudhoff, ix, 1925, p. 1342 It is those of Paracelsus. Helmont's treatise, noteworthy that Harvey regarded Calorefficienter non digerit,sed tantumexcitative, the semen and its fertilizing action on the in which the digestion in the stomach by egg as that of a "contagium," i.e., a pure means of acid (and not heat) is established, irritant which did not contribute to the is undoubtedly based on Paracelsus' Opus material substance of the embryo. See Paramirum.See Paracelsus, Volumen Paramirum J. Needham, A Historyof Embryology,Camund OpusParamirum,edit. by Franz Strunz, bridge, 1934, p. 125 ff.
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in things, producing their form and governing their function, and imagined to be composed of the finest matter and to have special affinities to special organs. Humoral pathology disregarded the organs and their peculiarities in favour of the whole organism. Paracelsus pointed out that in each disease some particular organ is involved and that local events are of the greatest importance. Hence it is to Paracelsus and his religious view that we owe the new conception of disease in the establishment of three new doctrines, namely:
(i) the external cause is the essence of disease, (2) the organ
involved and the anatomical changes decide the nature of disease, and (3) disease consists of a complicated disturbance of organ metabolism which secondarily reflects on the whole system. Let us take a practical example. The Greek physician tries to find out the dominating elements in the patient's organism, such as the "moistest fire" or the "densest water," and hence deduces his patient's nature (physis), e.g., a moist and warm complexion. He knows that such persons are most liable to illness in spring and least liable to it in autumn, because in spring there is excess of moisture, but in autumn a moderate amount of dryness. Such persons, especially when young, are subject to catarrhs and their regimen should consist of such things as are dry and cool. The Greek physician is therefore mainly concerned with the internal causes of disease represented by the "Physis" which the patient shows in his normal life.' The physician of the "modern era" in medicine would, however, endeavour to find out first of all an external cause of a disease, e.g. the poisonous influence of special vapours inhaled in mines or a special kind of contagium. Secondly he would try to localize disease in a certain organ, e.g. in the lungs or in the heart. He would plan the cure chiefly according to the external cause of the disease and the organ involved. Then he would pay attention to the particular complexion of the patient which might lead to some minor alterations of the cure or influence his prognosis. It is obvious that these principles must cause a new movement in therapy. Whereas in antiquity the Hippocratic physician had to be content with supporting the healing power of nature by mild applications, especially of laxatives, or by ordering a special diet, therapy is now directed towards the removal of the external causes of disease and this is attempted mainly by the administration of strong chemical remedies such as mercury, antimony, etc. It sounds somewhat paradoxical that much of modern scientific medicine should have developed from religious mysticism. But scientific knowledge often develops out of an original unity of faith, mysticism and knowledge. Scientific discoveries are often the after-effects of non-scientific considerations, or experiments. 1 This
Elsewhere
the writer has endeavoured
to show how
does not imply that external causes In epidemics a contamination of the air of disease were unknown to the Greeks. is supposed which is harmful for the whole I have mentioned above (p. 387) the import- population. Galen (de sanitatetuenda,I, i i) ance attached to weather and season as gives warning against the infected air in the pathogenic factors in the Hippocratic corpus. neighbourhood of dung-pits.
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much modern science and medicine owe to religious speculation.' There is good reason to suppose that empiricism and experimental knowledge originated partially in the religious scepticism of the XVIIth century, the many-sided "background to Harvey" of which Sir Walter LangdonBrown has recently given a brilliant account.2 The body of Greek medicine was pressed into the scholastic framework of the doctrines of the Middle Ages. Logical deduction of diagnoses and remedies from tables finally constituted the paramount method of the mediaeval physician. It is this scholastic version of Greek biology to which the realistic mind and above all the religious scepticism of Paracelsus, Agrippa of Nettesheym, van Helmont, Campanella, Comenius, Sir Thomas Browne were opposed. How could human understanding dare to find out the secrets of God's creation by logical deduction? In order to approach God, it was necessary to study His creation and the laws governing it with appropriate methods, the nature of things according to their own principles. It is true that the majority of anatomists, physiologists and physicians of the new era were not particularly religious men, nor men who were led to research by religious motives or adapted their discoveries to a religious view of the world. But on the other hand, the impulses given by religion should not be overlooked. Early chemistry was permeated by religion and was clearly connected with religious thought and feeling. The discovery of "Gas" by van Helmont, for example, must be referred to his tendency to find the divine spark which accounts for the specific differences of the various objects in nature by means of spiritualization and pneumatization of their material part; the existence of Gas van Helmont then demonstrated by experimental methods.3 The greatest chemist and physicist of the XVIIth century, Boyle, often refers to van Helmont's doctrines and discoveries. 1 W. Pagel, "Religious motives in the philosopher or mystic, his scientific and medical biology of the XVIIth century," philosophical achievements are unduly belitBull. Inst. Hist. Med. Johns HopkinsUniversity, tled, and a veryh elpful biography of van Helmont has recently been produced in which his Baltimore, mi, 1935, P- 97-312. See also E. Cassirer, "Individuum und discoveries in science and medicine are not Kosmos in der Philosophie der Renaissance." even mentioned (Paul NMvede Mevergnies, Studiender Bibliothek Warburg,vol. X, Leip- "Jean-Baptiste van Helmont, Philosophe par to Cassirer le Feu," Bibliotheque de la Facultede Philosophie zig, I927, P- 57; according these religious motives of scientific studies et Lettresde l' Univers.de Lidge, Fasc. LXIX, It is obvious that are clearly outlined by Nicolaus Cusanus. Paris, E. Droz, 1935). Science is reading the signs written by God in these attempts at neglecting one part of Helmont's activities which, to an unbiassed the "Book of Nature." 2 "The Background to Harvey," Brit. Med. observation, is as important as the other, are due to hesitation in recognizing their J.,-1936, p. 793. 3 This religious attitude of van Helmont interdependence which is the essential feature and other early religious scientists is usually in van Helmont and many other XVIIth not recognized as the inspiration of their century scientists. There can be no underscientific work. Where van Helmont is duly standing of van Helmont unless the mutual praised as one of the founders of modern influence of the mystic and the scientist science and medicine in the XVIIth century, is fully studied and recognized in this great his religious and metaphysical tendencies are figure. Helmont has this interdependence entirely overlooked or excused as due to the of religious, metaphysical and scientific spirit of his age. Where, on the other hand, elements in common with Paracelsus. For van Helmont is described as a "Hermetic" the work of Paracelsus, cf. F. Strunz, Theo-
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Of course, even in the work of Paracelsus and van Helmont the fundamentals of Greek medicine persist, and in many details the doctrines of both these authors show not only no advance, but even, when compared with the advances of the Greeks, retrogression. According to Galen the chest works like a pair of bellows, i.e., the lungs which are suspended in the airless pleural cavity are expanded by suction when the chest is elevated during inspiration and compressed when the circumference of the chest is diminished during expiration. This conforms precisely with present day physiology. According to van Helmont and his contemporaries, e.g. Harvey, there was, however, no suction in the pleural cavity which made the lung follow the movement of the chest. Van Helmont assumed pores in the marginal parts of the lung, through which the air penetrated into the pleural cavity during inspiration and compressed the lung like a cushion thereby causing expiration. It was through the conclusive experiments carried out by Haller on animals about a century later, that the accuracy of ancient physiology was confirmed in this point.' Nowadays the function of respiration seems to be clearly established on the lines of the experiments of Haller. But, however paradoxical this may seem, it should be added that a grain of truth may be found in the doctrine of the pulmonary pores. We have to recognize that the lung is not absolutely airtight and that air may penetrate in small amounts into the pleural cavity. But there is no doubt that these quantities of air have no significance in the function of respiration, and thus the ancient Greek doctrine remains valid. It is noteworthy that Paracelsus and van Helmont consider themselves as opponents rather of Galen and the Arabs than of Hippocrates. In their opinion Hippocrates is even the divine father of physicians. He was much in advance of his followers by pointing out the dynamic principles governing the organism, and by showing that it was not the various qualities such as cold, heat, acidity, bitterness, etc. that produced disease, but rather that it was cold, hot, acid or bitter substances themselves that were phrastus Paracelsus; Idee und Problem seiner Helmont's work has been definitely proved and expressed as far as the general phiWeltanschauung(Salzburg, I937). According to the account of Helmont's achievements in losophical attitude and biology and medicine chemistry which was recently given by are concerned. The writer has nevertheless J. R. Partington ("Joan Baptista van Hel- definitely pointed out the progress achieved mont." Annalsof Science,1936, vol. I, p. 359), by van Helmont especially in chemistry "the recent attempts to prove the great (pp. Io, 63, 11o of his book), and the passage dependence ofvan Helmont on Paracelsushave quoted by Partington (p. 4I of the writer's gone too far, and are often too vaguely book) in favour of the dependence of Helmont expressed." The present writer has given on Paracelsus was intended to and does above some examples of the agreement of clearly prove the opposite, i.e. differences Paracelsus and van Helmont in general out- between the views of Paracelsusand Helmont. look as well as in scientific detail (p. 393 f.).- The theme of the dependence of Helmont In his book on van Helmont, the account of on Paracelsus deserves attention and the this has been substantiated by a multitude writer hopes to deal with it in a special of quotations from Paracelsus and van paper. 1 For detail compare the writer's I. B. van Helmont (e.g. on pp. I5, I8, 34 if-, 39, 44, Helmont,op. cit., p. 8o ff. 48, 74, 77, 79, 84, 93, I I2, etc.) and thereby the influence of Paracelsus on van
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its causes. Accordingly they formed their own special picture of Hippocrates. The books containing the humoral pathology such as "On the Nature of Man," were in their opinion forged, whereas a book like that "On Winds," which was always regarded as a spurious pseudo-Hippocratic treatise, was the central and genuine book of the Corpus?.' It is this treatise which contains the precept about first finding out the cause of the disease in order to administer the appropriate remedy rather than treating symptoms, which is precisely the central demand in van Helmont's reformation of medicine.2 Our conclusions may therefore be summarised as follows (i) "Physis," the individual mode of reaction, was the centre of Greek medical ideology and knowledge. Accordingly the attention of the Greek physician was focussed on prognosis rather than on diagnosis and the elaboration of strict pathological doctrines. (2) The development of this specific character may also be explained by the sociological and psychological background of Greek medical art and craftsmanship. (3) In the dawn of modern medicine during the XVIth and XVIIth centuries, Greek ideology was abandoned partly owing to a religious scepticism against the formal logical pseudo-science into which the old Greek medicine had been converted in the systems of Galen and the mediaeval physicians. A new concept of disease developed on an anatomical and aetiological basis and diagnosis thereby occupied the central place which in antiquity had been taken by prognosis. Although the reformation of pathology was directed against the ancient doctrines and their mediaeval aspect, the achievements of Hippocratism remained valid also in pathology. It was the elaboration of the "Natural History of Disease" which medicine owes to Hippocratic writings and which in the work of the English Hippocrates, Thomas Sydenham, led to the modern classification and systematization of disease.3 Once again the physis of the individual, but also the physis of the external condition and the physis of climate and locality, were carefully taken into account, and the modern idea developed on the lines of Hippocratism.4 1 See Pagel, "Leibniz, Helmont, Stahl." point between Hippocrate sand Sydenham
Arch. Gesch. Medic., xxIV, I931, p. 57.2 The same opinion as to the genuineness
of the treatise on winds was given by Menon, a pupil of Aristotle, in the well known London papyrus. But as this opinion was absolutely foreign to Hippocratic research at the end of the last century when this document was discovered, the value of the manuscript as a testimonial for the genuineness of certain of the Hippocratic writings was denied. On the great value of Menon's work, see Deichgraeber, op. cit., p. 159. 3 Compare on the difference in the view-
Owsei Temkin, "Die Krankheitsauffassung von Hippokrates und Sydenham in ihren 'Epidemien'." Arch. Gesch. Mediz., xx, 1928, p. 3274 On the revival of Hippocratism in present
day medicine, see A. Castiglioni, L'Orientamentoneo-ippocratico del pensieromedicocontem-
poraneo. Torino, I933, and P. A. Cawadias,
"Neohippokratische Richtungen in der Gegenwartsmedizin." Hippokrates, IV, 1932, p. On Hippocratic medicine as the I88. "Beginning of observation," see Needham, History of Embryology, 1934, p. 13-