The Greatest Benefit to Mankind: A Medical History of Humanity. Roy Porter

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СКАЧАТЬ times of the year. In each season, one humour was thought to predominate. Bodily phlegm increased during the winter because, being cold and wet, it was akin to the chilly and rainy weather of a Mediterranean winter; colds, bronchitis and pneumonia were then more prevalent. When spring came, blood increased in quantity, and diseases would follow from a plethora of blood, including spring fever outbreaks (primarily benign tertian malaria), dysentery and nose-bleeds. By summer, the weather was hotter and drier, yellow bile (hot and dry) increased, and so the diseases resulting from yellow bile would multiply, that is severe fevers (falciparum malaria). With the cooler weather at the end of summer, fevers waned, but many would display the consequences of repeated fever attacks, their skins showing a dirty yellowish tinge and their spleens enlarged. The autumnal decline of fevers indicated to the Hippocratic physician that yellow bile had diminished while black bile was increasing. Seemingly the most problematic humour, black bile makes good sense in the light of awareness of the effects of malarial fevers. Philiscus, whose evidently malarial condition was described in Epidemics I, suffered from black urine and his ‘spleen stuck out’; the spleen was considered the seat of black bile. Faced with fevers, Hippocratic doctors predictably did not attempt anything heroic. Valuing regimen and diet, they gave barley water, hydromel (honey and water) or oxymel (honey and vinegar) – a ‘low’ diet with adequate fluids.

      The doctor should therefore observe sickness, attending the patient and identifying symptom clusters and their rhythms. Airs, Waters, Places took it as axiomatic that understanding of locales would enable the healer on arrival in a faraway town to grasp the local diseases, so that he could ‘achieve the greatest triumphs in the practice of his art’, something important in a competitive market.

      The art of diagnosis involved creating a profile of the patient’s way of life, habitation, work and dietary habits. This was achieved partly by asking questions, and partly by the use of trained senses:

      When you examine the patient, inquire into all particulars; first how the head is … then examine if the hypochondrium and sides be free of pain, for … if there be pain in the side, and along with the pain either cough, tormina or bellyache, the bowels should be opened with clysters … The Physician should ascertain whether the patient be apt to faint when he is raised up, and whether his breathing is free.

      Hippocratics prided themselves on their clinical acuity, being quick to pick up telltale symptoms, as with the facies hippocratica, the facial look of the dying: ‘a protrusive nose, hollow eyes, sunken temples, cold ears that are drawn in with the lobes turned outward, the forehead’s skin rough and tense like parchment, and the whole face greenish or black or blue-grey or leaden’. Experience was condensed into aphorisms; for instance, ‘when sleep puts an end to delirium, it is a good sign.’

      Hippocratic doctors cultivated diagnostic skills, but the technique they really prized was prognosis – a secular version of the prognostications of earlier medicine:

      It appears to me a most excellent thing for the physician to cultivate Prognosis; for by foreseeing and foretelling, in the presence of the sick, the present, the past, and the future, and explaining the omissions which patients have been guilty of, he will be the more readily believed to be acquainted with the circumstances of the sick; so that men will have confidence to intrust themselves to such a physician.

      This skill had a social function: prognostic flair created a favourable impression, setting the gifted healer above quacks and diviners. To be able to tell a patient’s medical history and prospects displayed acuity. And by declaring, if need be, that death was impending, a healer escaped blame for apparent failure.

      Hippocratics made no pretence to miracle cures, but they did undertake that they would first and foremost do no harm (primum non nocere) and presented themselves as the friends of the sick. This philanthropic disposition attested the physician’s love of his art – above fame and fortune – and reassured anxious patients and their relatives. Such concerns are addressed in the Hippocratic Oath (see box, opposite).

      For all its later prominence, little is known about the Oath’s origins, except that it dates from between the fifth and third centuries BC. It certainly did not set general standards of conduct, for the sanctity it accords to human life is anomalous to classical moral thought and practice, abortion and infanticide being familiar practices, condoned by Plato and Aristotle. The fact that it prohibits prescribing a ‘destructive pessary’ suggests a Pythagorean influence, with their belief in the transmigration of souls.

      The Oath foreshadowed the western paradigm of a profession (one who professes an oath) as a morally self-regulating discipline among those sharing craft knowledge and committed to serving others. But it was equally an agreement between apprentice and teacher. As it makes clear, Hippocratic medicine was a male monopoly, although male physicians might cooperate with midwives and nurses.

      Hippocratic medicine had its weaknesses – it knew little of the inner workings of the body – but its striking innovation lay in perceiving sickness as a disturbance in the health of the individual, who would then be accorded devoted personal attention. ‘Life is short, the art long, opportunity fleeting, experience fallacious, judgment difficult,’ proclaims the first of the Hippocratic aphorisms, outlining the arduous but honourable labour of the physician.

      The significance of Hippocratic medicine was twofold: it carved out a lofty role for the selfless physician which would serve as a lasting model for professional identity and conduct, and it taught that understanding of sickness required understanding of nature.

      MEDICINE AND PHILOSOPHY

      With Greek philosophers praising health as one of the greatest blessings of life, medicine became implicated in wider debates about human nature and the status of the body. The earliest writer to mention Hippocrates and his theories, Plato (427–437 BC) developed a series of analogies to divide human nature into three functions – reason, spirit, and appetites – located respectively within the brain, the heart and the liver, and all potentially in conflict. Only in the philosopher would reason, aided by spirit, triumph over sordid desires. The Republic’s distinctions between reason and appetite, mind and body, was of utmost philosophical and psychological significance. Plato’s place in later medical thinking, however, rests on the Timaeus (c. 375 BC). This pictured the body as built up from transcendental geometrical shapes. The human frame was constructed by the Creator with specific purposes in mind; hence medicine had a discernible teleology. Somatic in orientation, the Timaeus taught that morality was not simply a matter of education; behaviour might also be determined by organic constituents, by excesses or deficiencies in the spinal marrow which affected the sensations of pleasure and pain; madness might thus have a physiological cause, to be treated by medical means. Because the mind was influenced by the body, the doctor had a part to play in teaching virtue. Advancing a physiology compatible with Hippocratic medicine, the Timaeus became a highly influential text, linking medicine and philosophy, health and politics.

      THE OATH

      I swear by Apollo the healer, by Aesculapius, by Health and all the powers of healing, and call to witness all the gods and goddesses that I may keep this Oath and Promise to the best of my ability and judgment.

      I will pay the same respect to my master in the Science as to my parents and share my life with him and pay all my debts to him. I will regard his sons as my brothers and teach them the Science, if they desire to learn it, without fee or contract. I will hand on precepts, lectures and all other learning to my sons, to those of my master and to those pupils duly apprenticed and sworn, and to none other.

      I will use my power to help the sick to the best of my ability and judgment; I will abstain from harming or wronging any man by it.

      I will not give a fatal draught to anyone if I СКАЧАТЬ