WEBVTT

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Prof: Without more ado,
then, we'll turn to our topic

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of the morning,
which is about the first

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embodiment of a rational
scientific medicine,

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which is rather an
extraordinary one because it

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lasts from the fifth century
B.C.

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down to the nineteenth century
as a dominant--not

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exclusive--but a dominant
medical scientific paradigm.

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It was associated with this
idea of the first form of a

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rational,
secular, naturalistic form of

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medicine,
with ancient Greece in the

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fifth century,
and in particular with the

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so-called father of medicine,
Hippocrates,

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who lived from about 460 to 377
B.C.

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Now, there's some debate about
whether he was one person or a

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school, a group,
of people.

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There is a corpus of
Hippocratic writings that

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consists of about sixty works,
perhaps by multiple hands.

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But that issue won't really
concern us.

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We're concerned with
Hippocrates as either this

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composite or single figure,
and with the various schools

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that followed in his name.

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The sixty works,
some of them are very famous to

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you already.

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You know about the Hippocratic
Oath.

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We'll be talking about such
other works as On the Sacred

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Disease, On Human
Nature, Epidemics,

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On Airs, Waters,
Places;

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and he also had a collection of
aphorisms.

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One would note the variety of
the Hippocratic corpus.

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It consists of a whole series
of things.

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He/they invented case
histories, and they're included.

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There are lecture notes.

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There are memoranda of all
sorts;

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writings on every form of
medical practice at the time:

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surgery, obstetrics,
diet, the environment,

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therapeutics.

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All of that forms part of the
Hippocratic corpus.

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So, enormous variety.

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In terms of what Hippocrates
accomplished,

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I'd like to make a contrast,
and that is with the

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supernatural view of disease.

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And the first form we could
think of that,

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in drawing our contrast--the
contrast to what Hippocrates

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accomplished--
we can see it in terms of the

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breakthrough from something that
preceded it and went alongside

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it,
down to our own day,

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and this would be first of all
the supernatural view of

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disease;
that epidemics and pestilence

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are divine punishment sent by an
angry god for sin and

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disobedience.

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You can see this in many parts
of our culture.

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It's embodied in the Bible,
for example.

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In Genesis, you know that Adam
and Eve lived happily and

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enjoyed eternal life in the
Garden of Eden,

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until they committed the sin of
eating of the forbidden tree of

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the fruit of knowledge of good
and evil,

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and as a result this was
original sin and they were

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kicked out of the Garden of
Eden.

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From then on for things they
had to work.

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They also became subject to
disease and to death.

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They were immortal until that
time.

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So, we see in Genesis the
embodiment of this idea that

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diseases are a punishment of
sin.

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This was also clear--you can
read further in the Bible,

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in the book of Exodus,
where you learn about the

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bondage of the Israelites in
Egypt and God asking for Moses

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and Aaron for the Pharaoh to
release his chosen people.

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But the Pharaoh's heart was
hardened and so the Egyptians

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were punished with this series
of terrible plagues that are all

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in Exodus.

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Another way of embodiment of
this was in Psalm 91,

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and this is of particular
importance to us--let's move to

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share this with you.

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This is the text of Psalm 91.

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This is particularly important
because it embodies the idea of

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plague and pestilence as a
punishment by God.

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But also in terms of our
historical experience,

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as you're reading Daniel Defoe,
you'll realize that it's Psalm

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91 that was read out from the
Christian churches during times

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of epidemic.

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This was the great plague psalm.

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It embodies hope and an
interpretation of what the

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experience of plague was all
about.

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Let me read part of it here.

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"Thou shalt not be afraid
for the terror by night,

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nor for the arrow that flieth
by day,

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nor for the pestilence that
walketh in darkness,

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nor for the destruction that
wasteth at noonday.

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A thousand shall fall at thy
side, and ten thousand at thy

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right hand, but it shall not
come nigh thee.

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Only with thine eyes shall thou
behold and see the reward of the

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wicked.

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Because thou hast made the
Lord, which is my refuge,

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even the most high by
habitation.

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There shall no evil befall thee;
neither shall any plague come

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nigh thy dwelling."

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So, if you renounce sin,
the pestilence won't come near

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you.

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Let me turn also to another
embodiment in culture,

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our Western culture,
and this is the opening scene

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of Homer's Iliad,
which as you know is all about

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the Trojan War,
and it begins just before this

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scene with Achilles' anger.

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That is to say,
Achilles was the greatest of

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the Greek warriors,
but the Greek King Agamemnon

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had taken his concubine for his
own,

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and as a result,
enraged, Achilles withdrew from

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combat and sulked in his tent.

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Now, he had a friend who was a
priest of the god Apollo,

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and this friend tried to
intervene and beseeched

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Agamemnon to write the wrong and
return the woman.

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But Agamemnon rebuffed Apollo's
priest;

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or as we might say,
he dissed him.

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And, so, what we have here is
this tremendous and terrifying

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scene at the beginning of the
Iliad.

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Let me just quote from the
beginning then.

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"Over and over the old man
prayed as he walked in solitude

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to King Apollo.

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'Hear me Lord of the silver bow;
bring to pass this wish I pray

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for.

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Let your arrows make the
Danaans pay for my tears shed.'

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So he spoke in prayer,
and Phoebus Apollo heard him,

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and strode down along the
pinnacles of Olympus,

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angered in his heart,
carrying across his shoulders

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the bow and the hooded quiver,
and the shafts clashed on the

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shoulders of the god,
walking angrily.

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He came as night comes down,
and knelt then apart and

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opposite the ships,
and let go an arrow.

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Terrible was the clash from the
bow of silver.

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First he went after the mules
and the circling hounds,

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then let go a tearing arrow
against the men themselves and

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struck them.

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The corpse fires burned
everywhere and did not stop

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burning."

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So, that was Apollo punishing
the Greeks on behalf of his

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priest.

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Or let me also mention
something, an example,

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that's more recent and closer
to home;

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that is, I want to talk for a
minute about a Yalie.

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And this is our friend here
John Humphrey Noyes of the

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nineteenth century,
who was at the Yale Divinity

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School,
and he read the pieces we've

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just talked about,
and thought about disease as a

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punishment for sin,
and decided well there was a

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remedy.

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And, so, in all modesty he and
a group of his friends decided

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that they were going to renounce
sin all together,

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and they called themselves The
Perfectionists.

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And they founded an ideal
community,

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first in Putney,
Vermont, and then in Oneida in

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New York State--
it's part of the history of

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American utopian communities--
in which they renounced sin and

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were going to live together in
harmony and peace,

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forever, as eternal people.

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And every morning began with a
mutual criticism in which they

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pointed out each other's
faults--

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this must have been a lot of
fun--in order that they not fall

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by the wayside and lapse once
again into sin.

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Well, I'm sorry to tell
you--this was the 1840s--

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by the 1890s the ideal
community had become instead a

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joint stock company,
and you still have Oneida

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pottery and silverware.

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And I'm very sorry to report
that all of the members of the

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community have been buried.

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I don't know if that was
because they couldn't stick the

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pace, or if the concept was
wrong from the outset.

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In any case,
this was an embodiment,

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then, of the idea of disease as
a punishment for sin.

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But if we view this view of
pestilence as divine punishment,

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it does at least imply a
law-governed cosmos.

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Disease exists for an
intelligible reason,

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and it implies a rational
therapeutics,

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which is repentance:
propitiation of God,

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amendment of conduct,
and renewed obedience to the

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laws.

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There's another variation of a
supernatural view,

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which is more capricious,
and let's call that the demonic

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theory of disease.

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This postulates that the world
is populated by powerful

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arbitrary and evil spirits who
cause disease through their

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malign influence.

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These may be evil persons,
such as witches or poisoners,

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the disembodied spirits of the
dead, superhuman beings,

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or the devil himself.

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We'll see this view throughout
the course, the idea that

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epidemic diseases are diabolical
plots, not natural events.

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There's some occult secret
crime caused by the poisoning of

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witches or scapegoats,
and this gives rise to

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witch-hunts,
to hunt down and punish the

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guilty.

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We know this famously in the
seventeenth century and in our

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own country at Salem.

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But the idea was clearly
expressed in Europe by Martin

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Luther who declared,
"I would have no pity on

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the witches.

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I would burn them all."

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Alternatively--that was a good
therapeutic idea--

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alternatively a person could be
deemed to be inhabited or

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possessed by an evil spirit,
and in that case the cure was

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to cast out the devil through
exorcism.

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And this cosmology survives in
our own language when we talk

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today about someone acting
"like someone

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possessed,"
or "out of his mind."

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And healers pursuing these
sorts of ideas would invoke

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magic, or have incantations.

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They'd prescribe special
concoctions, chants,

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sacred rites and spells.

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And in European history,
a relatively recent

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illustration of that idea was
the idea of the healing power of

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the royal touch.

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Charles II of England,
for example,

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administered this treatment in
the seventeenth century to about

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100,000 people.

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So, healers could do that.

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They could also recommend magic
practices, offerings and

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sacrifices;
magic charms to ward off the

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evil spell;
or they could recommend

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escaping by taking flight;
or invoking the power of a

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powerful ally,
as in the Christian cult of

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saints that we'll be talking
about later.

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So, if you hold that up--those
two views,

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then, of supernatural
interpretations of disease--

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then you can understand the
breakthrough that was made in

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fifth century Greece.

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This was in contrast to the
supernatural divine and demonic

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theories, and it's in contrast
to them that we can see the

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importance of a new idea;
the idea that disease instead

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is a naturalistic event that can
be understood by natural causes.

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Examples of this new,
naturalistic,

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secular view abounded in the
fifth century.

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You can see it in Thucydides,
in his account of the

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Peloponnesian War,
the famous Plague of Athens

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that may have been typhus,
or more recently it was thought

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to have been typhoid.

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But in any case it was a
natural event,

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and is described as such by
Thucydides, with no reference to

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the occult or the supernatural.

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You can see it in Hippocrates'
discussion on epidemics in which

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diseases, epidemic diseases,
are caused by a corruption of

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the air.

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But let me talk about this very
famous example,

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and dramatic one,
of Hippocrates,

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On the Sacred Disease.

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By the sacred disease he meant
epilepsy, and it looks--I guess

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if you wanted any disease--it
looks like a possession by a

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demon.

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It is epilepsy.

15:25.379 --> 15:29.069
And Hippocrates wants to tell
us that this is not a

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supernatural event,
or a possession.

15:31.879 --> 15:35.589
He says instead something
extremely different.

15:35.590 --> 15:42.400
What he tells us is that:
"It is thus with regard to

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the disease called sacred.

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It appears to me to be no wise
more divine or sacred than other

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diseases, but has a natural
cause, like other afflictions.

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Men regard its nature and cause
as divine, from ignorance and

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wonder.

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And this notion of its divinity
is kept up by their inability to

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comprehend it.

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Neither truly do I count it as
a worthy opinion to hold that

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the body of man is polluted by
God;

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the most impure by the most
holy.

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For were the body defiled,
it would be likely to be

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purified and sanctified,
rather than polluted.

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Those who first referred this
malady to the gods appear to me

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to have been just such persons
as the conjurers,

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mountebanks and charlatans are.

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Such persons then,
using the divinity as a pretext

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and screen for their own
inability to afford assistance,

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have given out that the disease
is sacred."

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This was a very major
breakthrough conceptually,

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the beginning of the foundation
of a scientific medicine.

17:01.139 --> 17:07.209
So, therapeutics then got rid,
in a naturalistic view,

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of chance, potions,
spells and sacrifices;

17:12.250 --> 17:15.830
and exorcism,
appeasement of the gods.

17:15.828 --> 17:19.388
The importance of this
momentous step in human

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consciousness was expressed by a
Yale professor of epidemiology

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in the 1940s,
Charles-Edward Winslow,

17:27.488 --> 17:31.768
who wrote--and let me quote a
sentence or two from him.

17:31.769 --> 17:35.889
"If disease is postulated
as caused by gods,

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daemons or demons,
scientific progress is

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impossible.

17:40.608 --> 17:44.078
If it is attributed to
hypothetical humors,

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the theory can be tested and
improved.

17:47.390 --> 17:52.210
The conception of natural
causation was the essential

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first step.

17:53.420 --> 17:57.530
It marks incomparably the most
epochal advance in the

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intellectual history of
mankind."

18:00.690 --> 18:03.520
That perhaps is putting it a
little strongly,

18:03.520 --> 18:05.710
but you certainly get the
point.

18:05.710 --> 18:11.040
Now, why perhaps was there a
rational scientific medicine in

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fifth century Greece?

18:13.118 --> 18:17.008
Here I think the main part of
the answer has to be

18:17.008 --> 18:21.608
imponderable factors such as the
inspiration of Hippocrates

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himself, and his associates.

18:24.150 --> 18:28.200
But there were influences we
could point to as important:

18:28.203 --> 18:32.193
The absence of a priestly
bureaucracy, with the power to

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sanction heretics;
the centralized city states;

18:36.298 --> 18:41.928
the legacy of Greek natural
philosophy, the work of Plato

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and Aristotle in particular;
a culture of individualism.

18:47.410 --> 18:51.750
And I think we also need to
remember the Hippocratics'

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positions.

18:52.730 --> 18:57.000
Although they were known to
treat the poor and slaves,

18:56.998 --> 19:01.668
their care was not by and large
available to the masses.

19:01.670 --> 19:06.770
The primary clientele consisted
of educated, prosperous elites

19:06.769 --> 19:11.529
in ancient Greece and ancient
Rome, and this was a medical

19:11.534 --> 19:14.214
philosophy that suited them.

19:14.210 --> 19:18.520
The educated doctor and the
educated patient spoke the same

19:18.518 --> 19:20.998
language,
and the therapies that the

19:20.997 --> 19:24.887
physician proposed,
such as a special diet or rest,

19:24.885 --> 19:28.245
were remedies the wealthy could
afford.

19:28.250 --> 19:33.690
We should say that Hippocratic
medicine is still with us.

19:33.690 --> 19:38.190
We can see it in the return to
holistic medicine.

19:38.190 --> 19:41.630
We can see it also in the
Muslim world,

19:41.625 --> 19:47.225
and you can still be treated in
Unani medicine by a Hippocratic

19:47.231 --> 19:48.951
style medicine.

19:48.950 --> 19:53.260
And you can see it in certain
popular cultural precepts,

19:53.262 --> 19:57.422
such as "feed a cold and
starve a fever."

19:57.420 --> 20:01.270
Well, if that's its importance,
let's look at its content.

20:01.269 --> 20:06.459
What was the content of this
first embodiment of scientific

20:06.455 --> 20:07.435
medicine?

20:07.440 --> 20:09.330
And it was humoralism.

20:09.328 --> 20:13.968
Here let's talk about what that
is.

20:13.970 --> 20:18.960
The fundamental assumption was
that there's a correspondence

20:18.959 --> 20:23.779
between the macrocosm of the
universe and the microcosm of

20:23.779 --> 20:25.809
the individual body.

20:25.808 --> 20:30.928
Both are composed of the same
materials, subject to the same

20:30.932 --> 20:36.232
laws, and disorder can occur in
one and be followed by disease

20:36.230 --> 20:37.620
in the body.

20:37.618 --> 20:42.518
According to Aristotle and
natural philosophy,

20:42.519 --> 20:49.599
the macrocosm consisted of four
elements that you can see here.

20:49.598 --> 20:56.768
They were earth,
water, air and fire.

20:56.769 --> 21:01.769
And each of the elements is
associated with four qualities,

21:01.769 --> 21:04.959
which can be dry and hot like
fire;

21:04.960 --> 21:08.320
or dry and cold;
or cold and wet;

21:08.319 --> 21:09.859
or wet and hot.

21:09.858 --> 21:13.778
So, the elements embody also
four qualities,

21:13.777 --> 21:17.237
in different proportions,
of course.

21:17.240 --> 21:21.580
And this went on over the
centuries, and there were four

21:21.576 --> 21:25.436
seasons, four winds,
later on four evangelists.

21:25.440 --> 21:28.480
The point for us is there was
also a microcosm,

21:28.480 --> 21:33.310
and one can see the theory
expounded on human nature in

21:33.314 --> 21:39.184
which there are four humors,
which are phlegm,

21:39.184 --> 21:45.564
black bile, yellow bile and
blood.

21:45.558 --> 21:52.148
And each of those--also the
body is composed of these--and

21:52.150 --> 21:57.120
each has qualities of as being
wet and cold,

21:57.123 --> 21:59.323
or hot and dry.

21:59.318 --> 22:03.788
This also determines--the
balance of these humors in the

22:03.787 --> 22:08.247
body--the four temperaments:
whether you're melancholic,

22:08.253 --> 22:11.263
phlegmatic, choleric or
sanguine.

22:11.259 --> 22:13.259
Those words survive in our
culture.

22:13.259 --> 22:16.849
There are four ages of man,
four principal organs of the

22:16.845 --> 22:20.165
body: the spleen,
the brain, the liver and heart.

22:20.170 --> 22:21.890
You see the importance of four.

22:21.890 --> 22:25.010
And the system is axiomatic.

22:25.009 --> 22:29.899
It's based on deductive
reasoning from first principles.

22:29.900 --> 22:33.470
Central, of course,
to all of it was the climate of

22:33.472 --> 22:37.052
Greece, with its seasonal
patterns and its specific

22:37.046 --> 22:38.686
patient population.

22:38.690 --> 22:44.520
Many were malarial victims with
the complications of pneumonia.

22:44.519 --> 22:48.059
And Hippocrates,
indeed, was the world's first

22:48.059 --> 22:49.319
malariologist.

22:49.318 --> 22:52.748
Now, health consisted--was
called eucrasia,

22:52.747 --> 22:56.827
which meant a balance or
equilibrium of the humors,

22:56.827 --> 22:59.437
and therefore the qualities.

22:59.440 --> 23:04.050
And variations are possible,
up to a certain threshold,

23:04.048 --> 23:07.378
and at various times in your
life--or from one person to

23:07.375 --> 23:10.065
another--
the balance among the four

23:10.067 --> 23:11.547
humors can change.

23:11.548 --> 23:15.078
But once you cross a certain
threshold in variation--

23:15.078 --> 23:19.058
that is, one humor becomes
overly dominant,

23:19.058 --> 23:23.658
or one humor is lacking in
sufficient supply--

23:23.660 --> 23:24.700
that's an imbalance.

23:24.700 --> 23:29.340
That's dyscrasia;
an excess or deficiency of one

23:29.337 --> 23:32.297
of the humors,
and that is disease.

23:32.298 --> 23:35.468
So, we know what disease is
then.

23:35.470 --> 23:38.670
It's an imbalance of the humors.

23:38.670 --> 23:43.240
Note that there is no
single--that is to say there

23:43.243 --> 23:48.943
aren't discrete individual
diseases, as in modern medicine;

23:48.940 --> 23:52.640
that is, disease is classified
as typhoid, cancer,

23:52.635 --> 23:54.895
pneumonia, and all the rest.

23:54.900 --> 24:00.260
Disease instead was a holistic
phenomenon of body equilibrium.

24:00.259 --> 24:04.699
There was, in a sense,
only one disease.

24:04.700 --> 24:06.380
Now, what were the causes?

24:06.380 --> 24:11.240
The causes were said to be,
what we might call in modern

24:11.240 --> 24:16.700
jargon, environmental insults;
that Galen later on was to

24:16.701 --> 24:19.941
codify as the six non-naturals.

24:19.940 --> 24:24.730
The human body and constitution
then had contact with the air,

24:24.730 --> 24:27.800
which might be corrupted,
or "miasmatic,"

24:27.796 --> 24:29.326
as it was called later.

24:29.328 --> 24:34.648
Motion, or what we might call
exercise, was the second--or its

24:34.645 --> 24:36.385
lack--non-natural.

24:36.390 --> 24:40.770
Sleep or wakefulness;
excretion or retention of

24:40.767 --> 24:45.717
whatever was ingested;
and the passions of the soul,

24:45.715 --> 24:51.485
these were the non-naturals
that could tip the body into

24:51.493 --> 24:52.653
disease.

24:52.650 --> 24:57.620
Restoring health was based in
part on nature itself;

24:57.618 --> 25:00.768
that is to say,
there's a teleology of the

25:00.768 --> 25:04.758
body, embodied in the phrase
vis medicatrix

25:04.760 --> 25:08.170
naturae;
which is the healing power of

25:08.167 --> 25:08.767
nature.

25:08.769 --> 25:11.969
And the means to restore--the
body,

25:11.970 --> 25:15.610
in other words,
strives to restore equilibrium,

25:15.608 --> 25:19.898
through its innate heat or
through the elimination of

25:19.904 --> 25:22.664
excess humors,
when you sweat,

25:22.660 --> 25:27.330
you sneeze or you vomit;
for all of that is your body's

25:27.328 --> 25:32.248
attempt to get rid of the humor
that's making you sick because

25:32.248 --> 25:33.618
of its excess.

25:33.618 --> 25:38.328
So, this led then to humoral
therapeutics.

25:38.329 --> 25:40.689
And let's talk about that.

25:40.690 --> 25:46.070
The basis of medical strategy
was that the physician was the

25:46.068 --> 25:49.168
ally of nature,
and of the body.

25:49.170 --> 25:52.960
The body was trying to restore
itself to health,

25:52.959 --> 25:58.279
and the physician would join it
in doing battle against disease.

25:58.279 --> 26:03.159
He would read the signs to
decipher the underlying process;

26:03.160 --> 26:06.580
would take a case history;
would practice close

26:06.576 --> 26:11.316
observation, taking the pulse,
listening to the body;

26:11.318 --> 26:16.268
and would examine the urine,
its color, its density.

26:16.269 --> 26:21.469
He would smell it and taste it,
and see whether it contained

26:21.470 --> 26:25.790
blood or was frothy,
as all of those were worrying

26:25.788 --> 26:27.638
prognostic signs.

26:27.640 --> 26:30.970
It was a holistic treatment
where you didn't treat

26:30.974 --> 26:34.384
individual symptoms,
but the whole constitution.

26:34.380 --> 26:38.360
And it also had an idea of the
individualism of the patient.

26:38.358 --> 26:42.118
Treatment should be tailored to
the constitution of the

26:42.123 --> 26:43.033
individual.

26:43.029 --> 26:48.529
There are no disease entities,
because disease is not a thing

26:48.531 --> 26:50.001
but a process.

26:50.000 --> 26:56.030
This was a medicine that was
rather indifferent to diagnosis

26:56.034 --> 26:58.084
or classification.

26:58.078 --> 27:02.098
What it stressed instead was
the answer to the patient's

27:02.102 --> 27:05.252
eternal question,
"Am I going to be all

27:05.247 --> 27:06.707
right doc?"

27:06.710 --> 27:12.130
Prognosis was what really
mattered to the Hippocratic

27:12.128 --> 27:13.378
physician.

27:13.380 --> 27:17.930
The therapeutic principle was
that opposites treat opposites.

27:17.930 --> 27:22.330
So, if you have an excess of a
dry and cold humor,

27:22.328 --> 27:27.508
like a black bile,
if that's the humor that's

27:27.511 --> 27:33.411
causing your illness,
then you would like perhaps to

27:33.409 --> 27:38.929
give the patient a food to
ingest that would be wet and

27:38.932 --> 27:41.102
hot;
and hot in this case,

27:41.101 --> 27:43.661
think of it not simply as the
touch.

27:43.660 --> 27:47.660
We think of it when we talk
about spicy food as being hot.

27:47.660 --> 27:51.740
All the elements that you have
also have qualities,

27:51.741 --> 27:56.071
and so diet is very important
to this therapeutics.

27:56.068 --> 27:58.728
The tools available to the
physician, then,

27:58.730 --> 28:00.250
are first of all diet.

28:00.250 --> 28:04.920
In some sense the Hippocratic
physicians thought we are what

28:04.917 --> 28:08.207
we eat,
and all foodstuffs had

28:08.213 --> 28:11.383
qualities--hot,
cold, moist,

28:11.375 --> 28:17.095
dry--to balance an opposite
defect or excess in the human

28:17.102 --> 28:17.922
body.

28:17.920 --> 28:20.380
Exercise was also important.

28:20.380 --> 28:23.510
A change of environment;
in modern terms,

28:23.506 --> 28:26.196
going to a spa or a sanatorium.

28:26.200 --> 28:32.060
Moderation in the emotions,
moderation in sex.

28:32.058 --> 28:36.568
And medication was important,
because they did practice,

28:36.570 --> 28:40.180
Hippocratic physicians,
internal medicine.

28:40.180 --> 28:45.530
Examples were to promote
evacuation by providing emetics,

28:45.529 --> 28:49.159
sudorifics, purgatives or
diuretics.

28:49.160 --> 28:54.920
And most important perhaps was
a primacy of venesection--

28:54.920 --> 28:58.500
by which I mean bloodletting or
phlebotomy--

28:58.500 --> 29:02.640
that became the hallmark of the
orthodox physician.

29:02.640 --> 29:07.060
Medicine, in other words,
was conceived as a process of

29:07.057 --> 29:11.227
addition and subtraction,
adding what is wanting and

29:11.228 --> 29:14.008
subtracting what is in excess.

29:14.009 --> 29:17.839
Now, you may have your doubts
about venesection.

29:17.838 --> 29:22.568
Let me just mention some of its
advantages in the eyes of

29:22.567 --> 29:24.677
Hippocratic physicians.

29:24.680 --> 29:28.330
It was systematic,
like disease itself.

29:28.328 --> 29:32.358
Its effects were immediate and
you could control them.

29:32.359 --> 29:34.099
It was speedy.

29:34.098 --> 29:38.188
Its limits were also
self-evident to the experienced

29:38.188 --> 29:38.908
doctor.

29:38.910 --> 29:42.470
Perhaps the patient fainted,
the pulse disappeared,

29:42.472 --> 29:45.042
or the color of the blood
altered.

29:45.038 --> 29:48.818
There were however,
of course, contraindications to

29:48.819 --> 29:51.689
bloodletting:
old age and efficiency of

29:51.692 --> 29:53.852
blood;
the summer heat;

29:53.848 --> 29:57.548
evacuation already occurring by
other means;

29:57.549 --> 29:59.529
or extreme cold.

29:59.529 --> 30:03.099
So, the lancet,
the instrument for

30:03.098 --> 30:06.548
bloodletting--
there we have real

30:06.548 --> 30:11.798
lancets--became the symbol of
the orthodox physician,

30:11.798 --> 30:14.338
down through the nineteenth
century.

30:14.338 --> 30:18.438
Now, note that there is no real
humoral physiology,

30:18.436 --> 30:21.876
no idea of the circulation of
the blood.

30:21.880 --> 30:27.080
The heart is not a pump but a
furnace, drawing air from the

30:27.080 --> 30:31.650
lungs, heating it and
distributing it as innate heat

30:31.654 --> 30:33.094
in the body.

30:33.088 --> 30:36.938
So, this was the first
embodiment of scientific

30:36.939 --> 30:37.859
medicine.

30:37.858 --> 30:41.838
I want to talk about an
alteration that it went through,

30:41.836 --> 30:44.726
through the second father of
medicine.

30:44.730 --> 30:49.410
And this is another Greek
physician, who lived however in

30:49.409 --> 30:52.249
ancient Rome,
and that is Galen.

30:52.250 --> 30:56.210
And that's a picture.

30:56.210 --> 31:00.940
Now, his personal--he lived in
the second century A.D.,

31:00.939 --> 31:05.489
from 130 to about 201,
with his formative years being

31:05.492 --> 31:07.422
lived out in Rome.

31:07.420 --> 31:09.830
His personal qualities are
important.

31:09.828 --> 31:12.368
He was very different from
Hippocrates.

31:12.368 --> 31:16.968
Hippocrates was a great
observer, an empiricist.

31:16.970 --> 31:22.760
Galen instead prided himself
above all on his knowledge of

31:22.758 --> 31:25.498
the texts of Hippocrates.

31:25.500 --> 31:29.530
He almost worshipped
Hippocrates, but regarded

31:29.529 --> 31:34.099
himself as the authorized
interpreter of Hippocratic

31:34.096 --> 31:37.676
works, which he turned into a
dogma.

31:37.680 --> 31:41.520
Now, in Rome,
Galen was physician to the

31:41.519 --> 31:42.799
gladiators.

31:42.798 --> 31:47.658
His personal position helps
explain his influence.

31:47.660 --> 31:50.930
He then became private doctor
to the emperor.

31:50.930 --> 31:54.860
And he regarded himself as the
ideal physician,

31:54.857 --> 31:57.247
philosopher and scientist.

31:57.250 --> 32:00.780
He was a man of over-weaning
self-confidence,

32:00.778 --> 32:04.148
who had nothing but withering
scorn for his opponents and

32:04.146 --> 32:06.776
colleagues,
whom he called "murderers,

32:06.778 --> 32:11.048
amateurs, unversed in
Hippocratic wisdom."

32:11.048 --> 32:14.618
He called them "more
ignorant than animals."

32:14.618 --> 32:19.828
It was true also that Galen had
an encyclopedic knowledge,

32:19.828 --> 32:24.098
and we can only understand his
influence if we remember that he

32:24.104 --> 32:28.314
was a man of immense knowledge
of all branches of the medicine

32:28.309 --> 32:30.309
that existed at his time.

32:30.308 --> 32:33.698
And only half of his written
works survive,

32:33.695 --> 32:37.965
but they alone fill twelve
volumes of about a thousand

32:37.970 --> 32:39.180
pages each.

32:39.180 --> 32:42.100
In other words,
he was extraordinary in his

32:42.095 --> 32:44.935
productivity,
and that too is important on

32:44.940 --> 32:46.190
his influence.

32:46.190 --> 32:51.390
Now, Galen had a view that was
foreign to us of the meaning of

32:51.385 --> 32:53.255
scientific progress.

32:53.259 --> 32:57.519
To him Hippocrates was the
permanent foundation of medical

32:57.519 --> 33:01.859
science, and the main tenets of
that science could never be

33:01.855 --> 33:03.795
overturned or revised.

33:03.798 --> 33:08.798
Instead, there was no room in
his thinking for scientific

33:08.798 --> 33:10.048
revolutions.

33:10.048 --> 33:13.978
The writings of Hippocrates
were valid forever.

33:13.980 --> 33:17.380
They could only be completed
and perfected.

33:17.380 --> 33:20.360
And, in fact,
that was Galen's view of

33:20.363 --> 33:21.173
himself.

33:21.170 --> 33:25.860
He was the person who perfected
Hippocratic ideas.

33:25.858 --> 33:29.478
So, in fact,
further progress was probably

33:29.476 --> 33:32.736
unnecessary and perhaps
impossible.

33:32.740 --> 33:38.080
So, Galen became the
authoritative interpreter of

33:38.080 --> 33:39.640
Hippocrates.

33:39.640 --> 33:43.210
This is what we might call
Galenism.

33:43.210 --> 33:47.050
And in his hands,
Hippocrates became a cult

33:47.047 --> 33:51.887
figure, an object of veneration
and almost worship.

33:51.890 --> 33:55.320
Hippocrates,
about whom so little was known

33:55.323 --> 33:59.573
in his personal life,
was now endowed with all manner

33:59.574 --> 34:01.704
of apocryphal virtues.

34:01.700 --> 34:06.720
He was idealized as a model of
wisdom, courage,

34:06.720 --> 34:10.540
temperance, humanity and
honesty.

34:10.539 --> 34:14.179
Mythologies developed about his
religious piety,

34:14.175 --> 34:16.645
his heroism and his hard work.

34:16.650 --> 34:21.400
There was a legend that he was
descended, on his father's side,

34:21.400 --> 34:25.380
from the god Asclepius,
and on the maternal side from

34:25.384 --> 34:26.384
Hercules.

34:26.380 --> 34:30.700
He was said to be a great
patriot who saved Athens from

34:30.704 --> 34:35.594
the plague, a man who scorned
money and was perfectly wise and

34:35.588 --> 34:37.108
perfectly just.

34:37.110 --> 34:41.410
So, he became one of the
greatest cultural figures of

34:41.409 --> 34:45.049
antiquity, an equivalent,
in a different way,

34:45.048 --> 34:48.108
of Socrates,
Plato and Aristotle.

34:48.110 --> 34:52.220
Now, probably some of you are
wondering--

34:52.219 --> 34:56.149
we've talked about humoralism
and its advocates,

34:56.150 --> 34:57.890
and you want to know,
"well,

34:57.889 --> 35:01.559
that's all very fine;
did it work?"

35:01.559 --> 35:06.469
I'd like to say that humoralism
had a number of strengths.

35:06.469 --> 35:12.409
It was a quantum leap from
magical thinking to naturalistic

35:12.407 --> 35:15.067
explanations of disease.

35:15.070 --> 35:19.780
It appealed because it was
accessible to educated laymen.

35:19.780 --> 35:23.710
Contemporaries with an
education understood everything

35:23.706 --> 35:28.076
that Hippocratic and Galenic
doctors said and prescribed.

35:28.079 --> 35:31.749
It was consonant with
contemporary understandings.

35:31.750 --> 35:36.150
We also need to know that
Hippocratic and Galenic

35:36.154 --> 35:40.104
physicians practiced therapeutic
modesty.

35:40.099 --> 35:43.719
They did not participate in
surgery except,

35:43.722 --> 35:46.312
for example,
for setting bones,

35:46.311 --> 35:50.541
lancing abscesses and
practicing venesection;

35:50.539 --> 35:54.979
but the internal cavities of
the body they knew were off

35:54.981 --> 35:55.711
limits.

35:55.710 --> 35:57.850
It was based on observation.

35:57.849 --> 36:00.319
They took case histories.

36:00.320 --> 36:03.620
And we ought to remember,
in terms of medical

36:03.615 --> 36:05.975
effectiveness,
that--my wife,

36:05.976 --> 36:08.536
for example,
who is a primary care

36:08.541 --> 36:11.911
physician,
says that about seventy-five

36:11.905 --> 36:16.615
percent of patients who present
themselves in a clinic have

36:16.623 --> 36:20.543
self-limiting illnesses,
or psychosomatic ones,

36:20.539 --> 36:24.569
and mostly need reassurance
that everything will be all

36:24.568 --> 36:25.238
right.

36:25.239 --> 36:30.459
So, the point about Hippocratic
medicine was that experienced

36:30.460 --> 36:33.390
physicians,
accustomed to seeing ill

36:33.387 --> 36:37.587
people, would be pretty good at
prognosis and reassurance.

36:37.590 --> 36:41.390
They would refuse to treat
cases they regarded as hopeless,

36:41.389 --> 36:44.719
and hopeless cases,
they also had a referral

36:44.724 --> 36:46.884
system--
we'll refer to in a

36:46.884 --> 36:49.074
minute--which was to temples.

36:49.070 --> 36:51.400
I'll come back to that in just
a second.

36:51.400 --> 36:54.740
There were, however,
a number of weaknesses.

36:54.739 --> 36:58.179
So, Hippocratic/Galenic
medicine had a number of

36:58.175 --> 36:59.705
powerful strengths.

36:59.710 --> 37:03.910
It provided a lot in terms of
reassurance and prognosis,

37:03.909 --> 37:06.349
and the answer to that eternal
question,

37:06.349 --> 37:08.089
"Will I be all right
doc?"

37:08.090 --> 37:10.960
and the other question,
"What can I do to help

37:10.958 --> 37:11.818
myself?"

37:11.820 --> 37:14.490
There were a number of
weaknesses.

37:14.489 --> 37:16.029
It was a closed system.

37:16.030 --> 37:20.800
It was based on deductive
reasoning, and came to be bound

37:20.795 --> 37:25.725
up in the authority of the
ancients, with empiricism fading

37:25.733 --> 37:28.523
away;
and indeed in later centuries

37:28.518 --> 37:32.138
it comes to be called
"library medicine."

37:32.139 --> 37:35.309
It was anchored in a cult of
personality--

37:35.309 --> 37:37.859
the cult of Galen,
and through him of

37:37.858 --> 37:40.878
Hippocrates--
and practiced a cult of

37:40.876 --> 37:45.886
antiquity, with knowledge almost
becoming a form of revealed

37:45.893 --> 37:46.663
truth.

37:46.659 --> 37:50.589
So, Galenism involved authority
and tradition,

37:50.590 --> 37:54.590
an elite medicine of
university-trained physicians

37:54.594 --> 37:58.664
who were involved,
particularly in their training,

37:58.664 --> 38:00.644
in studying the classics.

38:00.639 --> 38:02.479
How do you train a physician?

38:02.480 --> 38:07.450
You have them read Hippocrates
and Galen, in the original

38:07.454 --> 38:08.524
languages.

38:08.518 --> 38:11.958
I don't want to say,
however, that there were no

38:11.958 --> 38:12.908
challenges.

38:12.909 --> 38:16.299
It's extraordinary to reflect
that humoralism,

38:16.295 --> 38:20.055
as a dominant medical
philosophy, persists into the

38:20.059 --> 38:21.789
nineteenth century.

38:21.789 --> 38:24.829
But I don't want to think that
it was unchallenged.

38:24.829 --> 38:29.379
We know there were demonic and
religious views that ran

38:29.378 --> 38:30.388
alongside.

38:30.389 --> 38:33.379
But in addition,
there were a series of

38:33.376 --> 38:37.696
scientific challenges that
occurred in a number of major

38:37.702 --> 38:42.662
shocks to the system that slowly
weakened its hold and gave rise

38:42.655 --> 38:45.765
to doubters,
but did not thoroughly

38:45.768 --> 38:49.888
dismantle humoralism until the
late nineteenth century;

38:49.889 --> 38:54.699
and even then it persists in
popular culture and some forms

38:54.695 --> 38:56.845
of alternative medicine.

38:56.849 --> 38:58.759
What were some of these
challenges?

38:58.760 --> 39:02.000
I don't expect you to remember
these at this point;

39:02.000 --> 39:04.700
we'll come back to them later
in the course.

39:04.699 --> 39:07.939
But just so that you'll
understand that it wasn't as

39:07.940 --> 39:10.610
though this system never had
challenges.

39:10.610 --> 39:16.130
Protestantism was a challenge,
with a challenge to authority

39:16.132 --> 39:18.382
and established texts.

39:18.380 --> 39:21.850
And Paracelsus,
whose dates are on your

39:21.846 --> 39:25.186
handout,
was called the Martin Luther of

39:25.188 --> 39:28.288
medicine,
who rejected Galenic and

39:28.289 --> 39:31.599
Hippocratic medicine all
together.

39:31.599 --> 39:37.459
William Harvey discovered the
circulation of the blood,

39:37.460 --> 39:40.930
which overthrew or challenged
Galen's anatomy and his

39:40.934 --> 39:44.344
physiology,
which were proved not to

39:44.342 --> 39:49.602
correspond to the observed
results of dissection and

39:49.599 --> 39:50.939
pathology.

39:50.940 --> 39:54.470
So, the discovery of the
circulation of the blood was a

39:54.469 --> 39:58.029
major blow;
although, oddly enough Harvey

39:58.032 --> 40:02.622
himself never rejected
humoralism, Hippocrates and

40:02.617 --> 40:03.457
Galen.

40:03.460 --> 40:05.830
Then there was the scientific
revolution.

40:05.829 --> 40:10.069
And in particular one can think
of the chemical revolution

40:10.067 --> 40:14.897
associated with men like Joseph
Priestly and Antoine Lavoisier.

40:14.900 --> 40:20.170
They destroyed the Aristotelian
notion of elements.

40:20.170 --> 40:22.050
Earth and air,
for example,

40:22.045 --> 40:26.075
were found themselves to be
composed of a great number of

40:26.083 --> 40:30.553
modern elements that go to make
up what we know as the periodic

40:30.554 --> 40:31.424
table.

40:31.420 --> 40:35.060
And more generally,
the scientific revolution

40:35.056 --> 40:40.426
marked a democratic turn from
authority to empirical evidence,

40:40.429 --> 40:44.789
and it envisioned scientific
and medical knowledge as

40:44.793 --> 40:49.243
infinitely expandable and not
bounded by set texts.

40:49.239 --> 40:51.949
And then, from the point of
view of our course,

40:51.949 --> 40:54.379
the experience of epidemic
disease,

40:54.380 --> 40:57.640
as we'll see,
made the idea of dyscrasia

40:57.639 --> 41:02.989
improbable as a mechanism needed
to explain epidemic disease,

41:02.989 --> 41:07.989
because it's fairly flimsy as a
basis for explaining why so many

41:07.994 --> 41:10.124
people,
in a single place,

41:10.117 --> 41:14.527
at a single moment of time,
had their equilibria all

41:14.532 --> 41:17.472
unbalanced at the same moment.

41:17.469 --> 41:21.469
So, the experience of epidemic
disease is important,

41:21.469 --> 41:24.909
and we'll see the physician,
Fracastoro,

41:24.909 --> 41:29.409
came up with the idea of
contagionism many centuries ago.

41:29.409 --> 41:33.759
In the nineteenth century we'll
see also, with the development

41:33.757 --> 41:36.037
of pathology,
the idea of disease

41:36.039 --> 41:38.939
specificity;
and finally in the late

41:38.940 --> 41:42.380
nineteenth century the germ
theory of disease,

41:42.384 --> 41:46.904
which offers an entirely
different paradigm for disease.

41:46.900 --> 41:49.700
So, that's the journey we'll be
taking,

41:49.699 --> 41:52.999
to the time when humoralism is
replaced,

41:53.000 --> 41:57.030
and we'll look at various
embodiments along the way of

41:57.030 --> 42:00.910
what people considered to be
scientific medicine.

42:00.909 --> 42:05.619
But here a number of you will
be thinking that I've involved

42:05.623 --> 42:08.823
myself in an important
contradiction,

42:08.820 --> 42:14.800
and you'll be thinking about
Asclepius and the fact that I

42:14.797 --> 42:18.257
talked about temples and a god.

42:18.260 --> 42:26.590
And in particular let's look
at--that's the god Asclepius,

42:26.592 --> 42:33.172
and this is the--I'll talk
about who he is.

42:33.170 --> 42:37.580
Hippocrates and Galen were both
pious and devout;

42:37.579 --> 42:40.509
that is to say,
although they believed in a

42:40.512 --> 42:44.852
naturalistic medicine,
it wasn't that they didn't also

42:44.851 --> 42:49.041
believe in the gods,
and through the gods they found

42:49.043 --> 42:53.833
in temple medicine what we might
call the world's first referral

42:53.829 --> 42:54.589
system.

42:54.590 --> 42:57.030
Asclepius, who was he?

42:57.030 --> 43:02.310
He was first a moral hero who
became half human and half

43:02.313 --> 43:05.583
divine, and then entirely a god.

43:05.579 --> 43:08.809
He was thought to be the
kindest of the gods;

43:08.809 --> 43:13.649
the one who loved humanity
enough to sacrifice himself for

43:13.646 --> 43:14.746
their sake.

43:14.750 --> 43:17.630
His father was the god Apollo.

43:17.630 --> 43:21.820
His daughters were
interestingly named the

43:21.824 --> 43:25.104
goddesses Panacea and Hygieia.

43:25.099 --> 43:29.529
And physicians in the ancient
world might call themselves

43:29.528 --> 43:34.278
Asclepiads, meaning the sons of
Asclepius, who regarded their

43:34.275 --> 43:36.565
father as a patron saint.

43:36.570 --> 43:41.540
By the time of Alexander the
Great, Greece possessed three to

43:41.539 --> 43:45.349
four hundred temples dedicated
to Asclepius.

43:45.349 --> 43:50.499
Asclepius was said to have been
killed by Zeus because he taught

43:50.501 --> 43:55.411
mortals the art of healing and
Zeus feared that men and women

43:55.407 --> 44:00.557
would compete with him in no
longer being subject to death.

44:00.559 --> 44:04.209
But Asclepius never practiced
magic.

44:04.210 --> 44:08.240
He was merely the most skilled
of physicians,

44:08.240 --> 44:13.920
using the same principles that
Asclepiads, like Hippocrates and

44:13.922 --> 44:16.582
Galen, would use as well.

44:16.579 --> 44:19.789
Note, of course,
there are similarities to the

44:19.793 --> 44:23.383
story of Christ,
and Asclepius was in fact a

44:23.378 --> 44:27.428
major competitor with
Christianity for a number of

44:27.425 --> 44:28.495
centuries.

44:28.500 --> 44:32.170
And like Christ,
after death he was said to have

44:32.172 --> 44:36.162
risen and to be present
eternally in the temples.

44:36.159 --> 44:40.879
So, the temples were shrines to
Asclepius, at places like

44:40.880 --> 44:41.640
Athens.

44:41.639 --> 44:44.569
I'll show you,
I hope, a couple of examples.

44:44.570 --> 44:49.250
That's Chios,
where Hippocrates was from,

44:49.250 --> 44:53.580
and this is the temple at
Pergamon.

44:53.579 --> 44:56.949
I just want to--there,
it's a whole--this is more than

44:56.951 --> 44:59.561
just a temple,
although it is a temple.

44:59.559 --> 45:02.529
It's almost a compound.

45:02.530 --> 45:06.370
Now, the usefulness of
identifying yourself with

45:06.373 --> 45:11.613
Asclepius was that there was--it
provided physicians with a badge

45:11.608 --> 45:14.798
of identity, a source of
authority.

45:14.800 --> 45:19.030
They were wandering peripatetic
healers, but now they're

45:19.032 --> 45:22.422
recognizable as members of the
same guild.

45:22.420 --> 45:26.180
This gave them a collective
presence and authority,

45:26.181 --> 45:30.321
and Asclepius also vouched for
their ethical conduct.

45:30.320 --> 45:33.980
Remember, these are peripatetic
physicians whom you invite into

45:33.981 --> 45:34.691
your home.

45:34.690 --> 45:38.630
And, so, they needed to have
someone vouch for them,

45:38.630 --> 45:42.840
and he vouches that they're
good doctors and that they have

45:42.835 --> 45:46.165
special care for the poor who
can't pay him.

45:46.170 --> 45:50.430
But again, there is no
contradiction with naturalistic

45:50.434 --> 45:51.324
medicine.

45:51.320 --> 45:56.480
The temples were precursors,
in a way, to health spas,

45:56.483 --> 45:58.923
sanatoria or hospitals.

45:58.920 --> 46:03.660
There they provided care for
the poor and the seriously ill.

46:03.659 --> 46:07.489
Patients could enter them,
the precincts of these

46:07.489 --> 46:11.719
compounds, after a period of
preparation in which they

46:11.719 --> 46:15.629
bathed, fasted,
prayed and offered sacrifice.

46:15.630 --> 46:19.180
But the therapeutic strategy
comes to them in a particular

46:19.184 --> 46:22.244
way, which is called an
"incubation";

46:22.239 --> 46:26.979
which is to say that at night,
after you've prepared yourself

46:26.981 --> 46:29.781
carefully,
in the way I just mentioned,

46:29.782 --> 46:32.382
when you--
then the priest will help

46:32.382 --> 46:36.952
you--and when you fall asleep at
night you'll have a dream.

46:36.949 --> 46:41.489
This is the incubation,
and the god Asclepius will

46:41.489 --> 46:46.959
appear to you and tell you the
strategy you should pursue in

46:46.956 --> 46:49.826
order to become well again.

46:49.829 --> 46:54.699
But the strategy was nothing
other than what a skilled

46:54.702 --> 47:00.312
physician would have prescribed,
had he been skillful and wise

47:00.311 --> 47:02.611
enough to have known.

47:02.610 --> 47:06.720
There was never a treatment
prescribed by Asclepius by

47:06.722 --> 47:10.912
magical means or miracles,
or by practices that weren't

47:10.911 --> 47:13.861
accessible to the ordinary
doctor.

47:13.860 --> 47:18.260
So, this is humoral medicine,
the first embodiment of

47:18.264 --> 47:20.134
scientific medicine.

47:20.130 --> 47:24.270
And I want us to look,
for the next several sessions,

47:24.268 --> 47:30.238
at the way in which it was used
as a lens to view the experience

47:30.239 --> 47:33.649
of terrible epidemic
catastrophes.

47:33.650 --> 47:38.340
And we'll look also at the way
in which the experience of

47:38.342 --> 47:42.872
bubonic plague and other
epidemics challenged or raised

47:42.869 --> 47:46.389
major questions about humoral
theory,

47:46.389 --> 47:50.909
and helped propel the
scientific medical elite towards

47:50.907 --> 47:54.827
a different view of disease and
what it was.

47:54.829 --> 47:58.489
So, we'll see epidemics,
beginning next time,

47:58.490 --> 47:59.740
as a process.

47:59.739 --> 48:04.789
And we'll also want then to
explain it, and we'll look at

48:04.793 --> 48:09.853
bubonic plague as the first of
our major epidemics in our

48:09.847 --> 48:10.837
course.

48:10.840 --> 48:16.000