De Medicina (1.pr)

Just as agriculture promises nourishment to healthy bodies, so does the Art of Medicine promise health to the sick. Nowhere is this Art wanting, for the most uncivilized nations have had knowledge of herbs, and other things to hand for the aiding of wounds and diseases. This Art, however, has been cultivated among the Greeks much more than in other nations — not, however, even among them from their first beginnings, but only for a few generations before ours. Hence Aesculapius is celebrated as the most ancient authority, and because he cultivated this science, as yet rude and vulgar, with a little more than common refinement, he was numbered among the gods. After him his two sons, Podalirius and Machaon, who followed Agamemnon as leader to the Trojan War, gave no inconsiderable help to their comrades. Homer stated, however, not that they gave any aid in the pestilence or in the various sorts of diseases, but only that they relieved wounds by the knife and by medicaments. Hence it appears that by them those parts only of the Art were attempted, and that they were the oldest.

From the same authority, indeed, it can be learned that diseases were then ascribed to the anger of the immortal gods, and from them help used to be sought; and it is probable that with no aids against bad health, none the less health was generally good because of good habits, which neither indolence nor luxury had vitiated: since it is these two which have afflicted the bodies of men, first in Greece, and later amongst us; and hence this complex Art of Medicine, not needed in former times, nor among other nations even now, scarcely protracts the lives of a few of us to the verge of old age.

Therefore even after these I have mentioned, no distinguished men practised the Art of Medicine until literary studies began to be pursued with more attention, which more than anything else are a necessity for the spirit, but at the same time are bad for the body. At first the science of healing was held to be part of philosophy, so that treatment of disease and contemplation of the nature of things began through the same authorities; clearly because healing was needed especially by those whose bodily strength had been weakened by restless thinking and night-watching. Hence we find that many who professed philosophy became expert in medicine, the most celebrated being Pythagoras, Empedocles and Democritus. But it was, as some believe, a pupil of the last, Hippocrates of Cos, a man first and foremost worthy to be remembered, notable both for professional skill and for eloquence, who separated this branch of learning from the study of philosophy. After him

Diocles of Carystus, next Praxagoras and Chrysippus, then Herophilus and Erasistratus, so practised this art that they made advances even towards various methods of treatment.

During the same times the Art of Medicine was divided into three parts: one being that which cures through diet, another through medicaments, and the third by hand. The Greeks termed the first Διαιτητικήν, the second Φαρμακευτικήν, the third Χειρουργίαν. But of that part which cured diseases by diet those who were by far the most famous authorities, endeavouring to go more deeply into things, claimed for themselves also a knowledge of nature, without which it seemed that the Art of Medicine would be stunted and weak. After them first of all Serapion, declaring that this kind of reasoning method was in no way pertinent to Medicine, based it only upon practice and upon experience. To him followed Apollonius and Glaucias, and somewhat later Heraclides of Tarentum, and other men of no small note, who in accordance with what they professed called themselves Empirici (or Experimentalists). Thus this Art of Medicine which treats by diet was also divided into two parts, some claiming an Art based upon speculation, others on practice alone. But after those mentioned above no one troubled about anything except what tradition had handed down to him until Asclepiades changed in large measure the way of curing. Of his successors, Themison, late in life, diverged from Asclepiades in some respects. And it is through these men in particular that this health-giving profession of ours has grown up.

Since of the divisions of the Art of Medicine, the

one which heals diseases, as it is the most difficult, is also the most famous, we must speak about it first. And because there is a primary difference of opinion, so holding that the sole knowledge necessary is derived from experience, others propounding that practice is not efficient enough except after acquiring a reasoned knowledge of human bodies and of nature, I must indicate which are the principal statements on either side, so that I may the more easily interpose my own opinion also.

They, then, who profess a reasoned theory of medicine propound as requisites, first, a knowledge of hidden causes involving diseases, next, of evident causes, after these of natural actions also, and lastly of the internal parts.

They term hidden, the causes concerning which inquiry is made into the principles composing our bodies, what makes for and what against health. For they believe it impossible for one who is ignorant of the origin of diseases to learn how to treat them suitably. They say that it does not admit of doubt that there is need for differences in treatment, if, as certain of the professors of philosophy have stated, some excess, or some deficiency, among the four elements, creates adverse health; or, if all the fault is in the humours, as was the view of Herophilus; or in the breath, according to Hippocrates; or if blood is transfused into those blood-vessels which are fitted for pneuma, and excites inflammation

which the Greeks term φλεγμόνην, and that inflammation effects such a disturbance as there is in fever, which was taught by Erasistratus; or if little bodies by being brought to a standstill in passing through invisible pores block the passage, as Asclepiades contended — his will be the right way of treatment, who has not failed to see the primary origin of the cause. They do not deny that experience is also necessary; but they say it is impossible to arrive at what should be done unless through some course of reasoning. For the older men, they say, did not cram the sick anyhow, but reasoned out what might be especially suitable, and then put to the test of experience what conjecture of a sort had previously led up to. Again they say that it makes no matter whether by now most remedies have been well explored already . . . if, nevertheless, they started from a reasoned theory; and that in fact this has also been done in many instances. Frequently, too, novel classes of disease occur about which hitherto practice has disclosed nothing, and so it is necessary to consider how such have commenced, without which no one among mortals can possibly find out whether this rather than that remedy should be used; this is the reason why they investigate the occult causes.

But they call evident those causes, concerning which they inquire, as to whether heat or cold, hunger or surfeit, or such like, has brought about the commencement of the disease; for they say that he will be the one to counter the malady who is not ignorant of its origin.

Further, they term natural actions of the body, those by which we draw in and emit breath, take in

and digest food and drink, as also those actions through which food and drink are distributed into every part of the members. Moreover, they also inquire why our blood-vessels now subside, now swell up; what is the explanation of sleep and wakefulness: for without knowledge of these they hold that no one can encounter or remedy the diseases which spring up in connexion with them. Among these natural actions digestion seems of most importance, so they give it their chief attention. Some following Erasistratus hold that in the belly the food is ground up; others, following Plistonicus, a pupil of Praxagoras, that it putrefies; others believe with Hippocrates, that food is cooked up by heat. In addition there are the followers of Asclepiades, who propound that all such notions are vain and superfluous, that there is no concoction at all, but that material is transmitted through the body, crude as swallowed. And on these points there is little agreement indeed among them; but what does follow is that a different food is to be given to patients according as this or that view is true. For if it is ground up inside, that food should be selected which can be ground up the most readily; if it putrefies, that which does so most expeditiously; if heat concocts it, that which most excites heat. But none of these points need be inquired into if there be no concoction but such things be taken which persist most in the state in which they were when swallowed. In the same way, when breathing is laboured, when sleep or wakefulness disturbs, they deem him able to remedy it who had understood beforehand how these same natural actions happen.

Moreover, as pains, and also various kinds of

diseases, arise in the more internal parts, they hold that no one can apply remedies for these who is ignorant about the parts themselves; hence it becomes necessary to lay open the bodies of the dead and to scrutinize their viscera and intestines. They hold that Herophilus did this in the best way by far, when they laid open men whilst alive — criminals received out of prison from the kings — and while these were still breathing, observed parts which beforehand nature had concealed, their position, colour, shape, size, arrangement, hardness, softness, smoothness, relation, processes and depressions of each, and whether any part is inserted into or is received into another. For when pain occurs internally, neither is it possible for one to learn what hurts the patient, unless he had acquainted himself with the position of each organ or intestine; nor can a diseased portion of the body be treated by one who does not know what that portion is. When a man's viscera are exposed in a wound, he who is ignorant of the colour of a part in health may be unable to recognize which part is intact, and which part damaged; thus he cannot even relieve the damaged part. External remedies too can be applied more aptly by one acquainted with the position, shape and size of the internal organs, and like reasonings hold good in all the instances mentioned above. Nor is it, as most people say, cruel that in the execution of criminals, and but a few of them, we should seek remedies for innocent people of all future ages.

On the other hand, those who are called "Empirici" because they have experience, do indeed accept evident causes as necessary; but they contend

that inquiry about obscure causes and natural actions is superfluous, because nature is not to be comprehended. That nature cannot be comprehended is in fact patent, they say, from the disagreement among those who discuss such matters; for on this question there is no agreement, either among professors of philosophy or among actual medical practitioners. Why, then, should anyone believe rather in Hippocrates than in Herophilus, why in him rather than in Asclepiades? If one wants to be guided by reasoning, they go on, the reasoning of all of them can appear not improbable; if by method of treatment, all of them have restored sick folk to health: therefore one ought not to derogate from anyone's credit, either in argument or in authority. Even philosophers would have become the greatest of medical practitioners, if reasoning from theory could have made them so; as it is, they have words in plenty, and no knowledge of healing at all. They also say that the methods of practice differ according to the nature of localities, and that one method is required in Rome, another in Egypt, another in Gaul; but that if the causes which produce diseases whether everywhere the same, the same remedies should be used everywhere; that often, too, the causes are apparent, as, for example, of ophthalmia, or of wounds, yet such causes do not disclose the treatment: that if the evident cause does not supply the knowledge, much less can a cause which is in doubt yield it. Since, therefore, the cause is as uncertain as it is incomprehensible, protection is to be sought rather from the ascertained and explored, as in all the rest of the Arts, that is, from what experience has taught in the actual course of treatment: for even a farmer, or a pilot, is made not by disputation but by practice. That such speculations are not pertinent to the Art of Medicine may be learned from the fact that men may hold different opinions on these matters, yet conduct their patients to recovery all the same. This has happened, not because they deduced lines of healing from obscure causes, nor from the natural actions, concerning which different opinions were held, but from experiences of what had previously succeeded. Even in its beginnings, they add, the Art of Medicine was not deduced from such questionings, but from experience; for of the sick who were without doctors, some in the first days of illness, longing for food, took it forthwith; others, owing to distaste, abstained; and the illness was more alleviated in those who abstained. Again, some partook of food whilst actually under the fever, some a little before, others after its remission, and it went best with those who did so after the fever had ended; and similarly some at the beginning adopted at once a rather full diet, others a scanty one, and those were made worse who had eaten plentifully. When this and the like happened day after day, careful men noted what generally answered the better, and then began to prescribe the same for their patients. Thus sprang up the Art of Medicine, which, from the frequent recovery of some and the death of others, distinguished between the pernicious and the salutary.

It was afterwards, they proceed, when the remedies had already been discovered, that men began to discuss the reasons for them: the Art of Medicine was not a discovery following upon reasoning, but after the discovery of the remedy, the reason for it was

sought out. They ask, too, does reasoning teach the same as experience? If the same, it was needless; if something else, then it was even opposed to it: nevertheless, at first remedies had to be explored with the greatest care; now, however, they have been explored already; there were neither new sorts of diseases to be found out, nor was a novel remedy wanted. For even if there happened nowadays some unknown form of malady, nevertheless the practitioner had not to theorize over obscure matters, but straightway would see to which disease it came nearest, then would make trial of remedies similar to those which have succeeded often in a kindred affection, and so through its similarities find help; that is not to say that a practitioner had no need to take counsel, and that an irrational animal was capable of exhibiting this art, but that these conjectures about concealed matters are of no concern because it does not matter what produces the disease but what relieves it; nor does it matter how digestion takes place, but what is best digested, whether concoction comes about from this cause or that, and whether the process is concoction or merely distribution. We had no need to inquire in what way we breathe, but what relieves laboured breathing; not what may move the blood-vessels, but what the various kinds of movements signify. All this was to be learnt through experiences; and in all theorizing over a subject it is possible to argue on either side, and so cleverness and fluency may get the best of it; it is not, however, by eloquence but by remedies that diseases are treated. A man of few words who learns by practice to discern well, would make an altogether better practitioner than he who, unpractised, over-cultivates his tongue.

Now the matters just referred to they deem to be superfluous; but what remains, cruel as well, to cut into the belly and chest of men whilst still alive, and to impose upon the Art which presides over human safety someone's death, and that too in the most atrocious way. Especially is this true when, of things which are sought for with so much violence, some can be learnt not at all, others can be learnt even without a crime. For when the body had been laid open, colour, smoothness, softness, hardness and all similars would not be such as they were when the body was untouched; because bodies, even when uninjured yet often change in appearance, they note, from fear, pain, want of food, indigestion, weariness and a thousand other mediocre affections; it is much more likely that the more internal parts, which are far softer, and to which the very light is something novel, should under the most severe of woundings, in fact mangling, undergo changes. Nor is anything more foolish, they say, than to suppose that whatever the condition of the part of a man's body in life, it will also be the same when he is dying, nay, when he is already dead; for the belly indeed, which is of less importance, can be laid open with the man still breathing; but as soon as the knife really penetrates to the chest, by cutting through the transverse septum, a sort of membrane which divides the upper from the lower parts (the Greeks call it dia/fragma), the man loses his life at once: so it is only when the man is dead that the chest and any of the viscera come into the view of the medical murderer, and they are necessarily those of a dead, not of a living man. It follows, therefore, that the medical man just plays the cut-throat, not that he learns

what our viscera are like when we are alive. If, however, there be anything to be observed whilst a man is still breathing, chance often presents it to the view of those treating him. For sometimes a gladiator in the arena, or a soldier in battle, or a traveller who has been set upon by robbers, is so wounded that some or other interior part is exposed in one man or another. Thus, they say, an observant practitioner learns to recognize site, position, arrangement, shape and such like, not when slaughtering, but whilst striving for health; and he learns in the course of a work of mercy, what others would come to know by means of dire cruelty. That for these reasons, since most things are altered in the dead, some hold that even the dissection of the dead is unnecessary; although not cruel, it is none the less nasty; but all that is possible to come to know in the living, the actual treatment exhibits.

Since all these questions have been discussed often by practitioners, in many volumes and in large and contentious disputations, and the discussion continues, it remains to add such views as may seem nearest the truth. These are neither wholly in accord with one opinion or another, nor exceedingly at variance with both, but hold a sort of intermediate place between divers sentiments, a thing which may be observed in most controversies when men seek impartially for truth, as in the present case. For as regards the causes which either favour health or excite disease, how breath is drawn in or food distributed, not even philosophers attain to full knowledge, but seek it out by conjecture. But where there is no certain knowledge about a thing, mere opinion about it cannot find a certain remedy.

And it is true that nothing adds more to a really rational treatment than experience. Although, therefore, many things, which are not strictly pertinent to the Arts as such, are yet helpful by stimulating the minds of those who practise them, so also this contemplation of the nature of things, although it does not make a practitioner, yet renders him more apt and perfected in the Art of Medicine. And it is probable that Hippocrates, Erasistratus and certain others, who were not content to busy themselves over fevers and ulcerations, but also to some extent searched into the nature of things, did not by this become practitioners, but by this became better practitioners. But reasoning is necessary to the Art of Medicine, not only when dealing with obscure causes, or natural actions, but often . . . for it is an art based on conjecture. However, in many cases not only does conjecture fail, but experience as well; and at times, neither fever, nor appetite, nor sleep follow their customary course. More rarely, yet now and again, a disease itself is new. That this does not happen is manifestly untrue, for in our time a lady, from whose genitals flesh had prolapsed and become gangrenous, died in the course of a few hours, whilst practitioners of the highest standing found out neither the class of malady nor a remedy. I conclude that they attempted nothing because no one was willing to risk a conjecture of his own in the case of a distinguished personage, for fear that he might seem to have killed, if he did not save her; yet it is probable that something might possibly have been thought of, had no such timidity prevailed, and perchance this might have been successful had one but tried it. In this sort of practice similarity is not always of service, and when it does prove serviceable, nevertheless there has been a process of reasoning, in the theorizing over similar classes of diseases and of remedies, as to which is the best remedy to use. When, therefore, such an incident occurs, the practitioner ought to arrive at something which may answer, even if perhaps not always, yet nevertheless more often than not. He will see, however, every novel plan, not from hidden things, for these are dubious and unascertainable, but from those which can be explored, that is, from evident causes. For what matters is this: whether fatigue or thirst, whether heat or cold, whether wakefulness or hunger, whether abundance in food or wine, whether intemperance in venery, has produced the disease. Nor should there be ignorance of the sick man's temperament; whether his body is rather humid or rather dry, whether his sinews are strong or weak, whether he is frequently or rarely ill; and when ill whether so severely or slightly, for a short or long while; the kind of life he has lived, laborious or quiet, accompanied by luxury or frugality. From such and similar data, one may often deduce a novel mode of treatment.

None the less the foregoing statements ought not to be passed by as if they did not admit of controversy. For Erasistratus himself has affirmed that diseases were not produced by such causes, since other persons, and even the same person at different times, were not rendered feverish by them. Further,

certain practitioners of our time, following, as they would have it appear, the authority of Themison, contend that there is no cause whatever, the knowledge of which has any bearing on treatment: they hold that it is sufficient to observe certain general characteristics of diseases; that of these there are three classes, one a constriction, another a flux, the third a mixture. For the sick at one time excrete too little, at another time too much; again, from one part too little, from another too much; and these classes of diseases are sometimes acute, sometimes chronic, at times on the increase, at times constant, at times diminishing. Once it has been recognized, then, which it is of these, if the body is constricted, it has to be relaxed; if suffering from a flux, that has to be controlled; if a mixed lesion, the more severe malady must be countered first. Moreover, there must be treatment of one kind for acute diseases, another kind for chronic ones, another for increasing, stationary, or for those already tending to recovery. They hold that the Art of Medicine consists of such observations; which they define as a sort of way, which they name μέθοδοσ, and maintain that medicine should examine those characteristics which diseases have in common. They do not want to be classed with reasoners from theory, nor with those who look to experience only; for in so naming themselves Methodici, they dissent from the former because they are unwilling that the Art should consist in conjecture about hidden things, and from the latter because they think that in the observation of experience there is little of an Art of Medicine.

As relates to Erasistratus, in the first place the

actual evidence is against his opinion, because seldom does a disease occur unless following upon one of these; secondly, it does not follow that what has done no harm to one patient, or to that same patient upon one occasion, may not harm another patient, or the same one at another time. For it is possible that there are certain underlying conditions in the body, whether related to infirmity, or to an actual affection of some kind, which either are not present in another person, or were not existent in that patient on another occasion, and which of themselves are not enough to constitute a disease, yet they may render the body more liable to other injurious affections. But if Erasistratus had been sufficiently versed in the study of the nature of things, as those practitioners rashly claim themselves to be, he would have known also that nothing is due to one cause alone, but that which is taken to be the cause is that which seems to have had the most influence. Indeed it is possible that when one cause acts alone, it may not disturb, yet when acting in conjunction with other causes it may produce a very great disturbance. Moreover, even Erasistratus himself, who says that fever is produced by blood transfused into the arteries, and that this happens in an over-replete body, failed to discover why, of two equally replete persons, one should lapse into disease, and the other remain free from anything dangerous; and that clearly happens every day. Hence, however true this transfusion, one can learn that it does not occur of itself when there is bodily fullness, but when there is added something else.

But disciples of Themison, if they hold their

precepts to be of constant validity, are reasoners even more than anybody else; for if a man des not hold all the tenets that another reasoner approves, he does not forthwith have to assume a different name for his art, if (and this is the essential point) he does rely not only on written authority, but also upon reasoning from theory. But if, which is nearer to the truth, the Art of Medicine admits of scarcely any universal precepts, reasoners are in the same position as those who depend upon experience alone, all the more because whether the disease has braced or relaxed is what the most uninstructed can see. But if a remedy which loosens a body braced up, or tightens a loosened body, has been deduced by a reasoning from theory, the practitioner is a reasoner; if (as the man who denies himself to be a reasoner must admit) he acts from experience, he is an Empiric. Thus according to Themison, knowledge of a disease is outside the Art, and medicine is confined to practice; nor has there been added anything to what Empirics profess, but something taken away; for reasoners from theory gaze about over a multiplicity of matters, Empirics look to circumstances the most simple, and nothing more than commonplaces. For in like manner those who treat cattle and horses, since it is impossible to learn from dumb animals particulars of their complaints, depend only upon common characteristics; so also do foreigners as they are ignorant of reasoning subtleties look rather to common characteristics of disease. Again, those who take charge of large hospitals, because they cannot pay full attention to individuals, resort to these common characteristics. I vow, the ancients knew all this, but were not content therewith; therefore even the oldest authority, Hippocrates, said that in healing it was necessary to take note both of common and of particular characteristics. Indeed these very Methodici, even within their professed limitations, cannot be consistent; for there are divers kinds of constricting and relaxing diseases, those in which there is a flux being the more easy to observe. For it is one thing to vomit blood, another bile, another food; it is one thing to suffer from diarrhoea, another from dysentery; one thing to be relaxed through sweating, another to be wasted by consumption. Humour may break out into particular parts, such as the eyes or the ears; from a risk of this kind there is no human member free. No one of these occurrences is treated in the same way as another.

Hence the Art descends straight down from a consideration of the common characteristics of a flux to the particular case. Moreover, because the same remedies do not meet with success in all, even of similar cases, additional knowledge of peculiarities in such a case is often necessary. Although certain things act upon the bowels in most cases, whether as astringents or as laxatives, yet there are to be found some in whom the same thing acts differently than it does in others. In such instances, therefore, investigation of particular characteristics is salutary, that of common characteristics the reverse. Moreover, a reckoning up of the cause often solves the malady. Thus Cassius, the most ingenious practitioner of our generation, recently dead, in a case suffering from fever and great thirst, when he learnt that the man had begun to feel oppressed after intoxication,

administered cold water, by which draught, when by the admixture he had broken the force of the wine, he forthwith dispersed the fever by means of a sleep and a sweat. He, as a practitioner, provided an opportune remedy, not out of consideration whether the man's body was constricted or relaxed, but from what had happened beforehand to cause it. Besides, according to these very authorities there are particulars relating to locality and to season. When they are discussing what should be done by men in health, they prescribe the avoidance of cold, heat, surfeit, fatigue, venery, especially in sickly localities and seasons; in such places and seasons rest is to be taken, particularly when one feels a sense of oppression, and neither the stomach is to be disturbed by an emetic, nor the bowels by a purge. Such generalities are indeed true: none the less they descend from them to certain particular characteristics, unless they would persuade us that climate and season are to be taken into consideration by those in health but not by the sick, the very persons in whom all such observance is by so much the more necessary, the more that their weakness is liable to all attacks. Nay, even in the same patient, the particular characteristics of a disease are very various, and those who have been treated for a time in vain by the ordinary remedies have been often restored by contrary ones. And in the giving food too there are many distinctions to be noted; I will content myself with one instance. For hunger is more easily borne by an adult than by a boy, more easily in a dense than in a thin atmosphere, more easily in winter than in summer, more easily by one accustomed to a single meal than by one used in addition to one at midday, more easily when sedentary than when in active exercise; and often it is necessary to hurry on the meal in the case of one who is intolerant of hunger. Hence I conjecture that he who is not acquainted with the peculiar characteristics has merely to consider the general ones; and he who can become acquainted with peculiarities, whilst insistent upon them, ought not to neglect generalities as well; and consequently, presuming their state to be equal, it is more useful to have in the practitioner a friend rather than a stranger.

Therefore, to return to what I myself propound, I am of opinion that the Art of Medicine ought to be rational, but to draw instruction from evident causes, all obscure ones being rejected from the practice of the Art, although not from the practitioner's study. But to lay open the bodies of men whilst still alive is as cruel as it is needless; that of the dead is a necessity for the learner, who should know positions and relations, which the dead body exhibits better than does a living and wounded man. As for the remainder, which can only be learnt from the living, actual practice will demonstrate it in the course of treating the wounded in a somewhat slower yet much milder way.

With these premises I will first speak of how those in health should act (Book I), than I will pass on to what pertains to diseases (Book II, 1‑8), and to their treatments (Book II, 9‑33).