Schools of Medical Thought:
Dogmatism, Empiricism, Methodism
The texts we have considered illustrate some of the tensions between the dogmatic and the tentative, the speculative and the self-restrained, in post-Aristotelian natural philosophy. But in Hellenistic medicine, varieties of dogmatism and scepticism or anti-dogmatism are elevated into self-conscious methodologies. The so-called Dogmatic medical school
century B.C. ) and of Thessalus (first century A.D. )[201] —set themselves apart from those of their predecessors and contemporaries whom they represented as having certain methodological principles in common.
The evidence we have to rely on is in many cases indirect and much of it comes from critical or hostile sources. Empiricism, especially, is poorly represented by original texts,[202] and so too is Methodism until we come to Soranus in the second century A.D. Neither Celsus nor, more obviously, Galen is an impartial witness, and aspects of their reports are suspect as historical accounts.[203] On the other hand, both are, obviously, evidence for the currency of certain ideas at the time they wrote,[204] and we can analyse their interpretations of the debate even if we have to bear in mind that they are their interpretations and even if the evidence to confirm or refute what they attribute to some of the contending parties is often not available.
Celsus presents a particularly full picture of the alternatives as he saw them in the proem to the first book of his De medicina .[205] The chief issues, as he reports them, relate to the aims, limits, and methods of the medical art. Those grouped together as Dogmatists are represented as holding that medicine should investigate not only (1) the so-called evident causes (such as heat and cold considered as causes), but also (2) hidden or obscure ones, as well as (3) natural actions (such as breathing and digestion, in other words, physiology) and, finally, (4) internal anatomy.[206]
Of these four inquiries the Empiricists are said to accept only the first, that into evident causes, alone. The other three are not just superfluous but impossible, since "nature cannot be comprehended"; the
[201] Whether Themison and Thessalus are to be considered the founders or the forerunners of Methodism is disputed: see, for example, Edelstein 1935/1967a.
[202] The evidence is collected in Deichgräber 1930/1965.
[203] The point is given particular emphasis in Rubinstein 1985.
[204] Celsus wrote in the first century A.D. , Galen in the second.
[205] Med. 1 pr. 12ff., CML 1.19.4ff. Celsus sets out his own position in the dispute at 1 pr. 45ff., CML 1.24.24ff.; see Mudry 1982.
[206] Med. 1 pr. 13, CML 1.19.11ff.
doctor's task is to treat individual cases and for this purpose he must be guided by the manifest symptoms of the patient alone. Against the Dogmatists, the Empiricists rejected "reasoning" and accepted "experience" alone as the criterion. It is this that has suggested cures; it is from experience that medicine has been built up and on which it must continue to rely. It is not a discovery made following reasoning; rather, the discovery came first and the reason for it was sought afterwards. Moreover, where reasoning teaches the same as experience, it is unnecessary, and where different, it is opposed to experience and should be rejected.[207]
As Celsus makes the Empiricist argue:
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 digestion.[208] We have no need to inquire in what way we breathe, but what relieves laboured breathing; nor what may move the blood-vessels, but what the various kinds of movements signify. All this is to be learnt through experiences. In all theorising over a subject it is possible to argue on either side, and so cleverness and fluency may get the best of it. However it is not 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, overcultivates his tongue.[209]
[207] Med. 1 pr. 27f., 36, CML 1.22.1ff., 23.4ff. According to Celsus, the Empiricist response to the possibility, entertained by the Dogmatists, that new diseases may arise was still to insist that the practitioner should not attempt to theorise about causes, but see to which existing disease the condition is similar and try out remedies that had proved successful in such other similar cases.
[208] This appears to allude to the long-standing debate on the nature of digestion, where Herophilus, following Aristotle, argues that it involves "concoction," while Erasistratus and the Erasistrateans explain the process in purely mechanical terms, as the result of the trituration or pounding that the food is subjected to in the stomach before being absorbed, as chyle, into the blood-vessels communicating with the liver.
[209] Med. 1 pr. 38–39, CML 1.23.16–27: sed has latentium rerum coniecturas ad rem non pertinere, quia non intersit, quid morbum faciat, sed quid tollat; neque ad rem pertineat, quomodo, sed quid optime digeratur, siue hacde causa concoctio incidat siue illa, et siue concoctio sit illa siue tantum digestio. Neque quaerendum esse quomodo spiremus, sed quid grauem et tardum spiritum expediat; neque quid uenas moueat, sed quid quaeque motus genera significent. Haec autem cognosci experimentis. Et in omnibus eiusmodi cogitationibus utramque partem disseri posse; itaque ingenium et facundiam uincere, morbos autem non eloquentia sed remediis curari. Quae si quis elinguis usu discreta bene norit, hunc aliquanto maiorem medicum futurum, quam si sine usu linguam suam excoluerit .
Again, "even students of philosophy would have become the greatest medical practitioners, if reasoning could have made them so. But as it is, they have words in plenty, but no knowledge of healing at all."[210]
The third main medical group, the Methodists, had their own subtle and often rather maligned ideas about treatment,[211] but on the essential topic we are concerned with here they are represented by both Celsus and Galen as agreeing with many of the criticisms that the Empiricists brought against the Dogmatists, for example, about their theorising about hidden causes.[212] While Celsus reports the Empiricists as asserting that nature cannot be comprehended,[213] Sextus makes it
[210] Med. 1 pr. 29, CML 1.22.11–13: Etiam sapientiae studiosos maximos medicos esse, si ratiocinatio hoc faceret: nunc illis uerba superesse, deesse medendi scientiam . The rejection of the idea that medicine can be learnt from books has a long history. The Hippocratic surgical treatise Art . 33 (L) 4.148.13ff. refers to the difficulties of explaining surgical procedures, in particular, in writing, and cf. Plato Phdr. 268c, Aristotle EN 1181b2ff.
[211] The Methodist idea of the three common conditions, the constricted, the lax, and the mixed, came under particular attack. To the chagrin of Galen, especially, (e.g., Sect.Intr. 6, Scr.Min. [H] 3.15.2ff., [K] 1.83.1ff.), the Methodists were reputed to have claimed that medicine could be learnt in six months: cf. M. Frede 1982. The three common conditions were neither themselves disease entities nor causes of diseases, but generalisations about the state of the body that guided the practitioner in deciding upon treatment (seen as a matter of counteracting the lax with the constricted and vice versa). As we can see from Soranus (see G. E. R. Lloyd 1983a, pp. 182ff.) and from Caelius Aurelianus, not only in principle but also in practice Methodist pathology and therapeutics stayed a good deal closer to what was directly observable than rival theories and were a good deal simpler than they were.
[212] See Celsus Med. 1 pr. 57, CML 1.26.27f., cf. Galen Sect.Intr. 6, Scr.Min. (H) 3.13.21ff., 7.17.3ff., 18.1ff., (K) 1.81.6ff., 85.14ff., 86.17ff.
[213] Med. 1 pr. 27, CML 1.22.4, where Celsus makes this the grounds, for the Empiricists, of the claim that such an inquiry is superfluous (superuacuam ); cf. Sextus P. 1.236.
appear that the Methodists withheld judgement on that issue.[214] The inquiry into the obscure is to be rejected because it is useless, rather than (as the Empiricists are said to have held) impossible.[215] If that is correct, then the distinction between these two medical groups would in certain respects be analogous to that between some of the Academic sceptics and such Pyrrhonian sceptics as Sextus Empiricus himself, in that the former asserted that the nonevident cannot be grasped (and so in that respect were negative Dogmatists) while the latter withheld judgement on that issue.[216]
Both Empiricists and Methodists thus appear to have combined in a withering attack on the speculative tendencies that had, in fact, been highly developed in Greek medicine from the first—even while other early texts, as we saw, emphasised the difficulty and tentativeness of medicine, resisting the ambition to treat it as an exact science and representing it as a conjectural or stochastic art.[217] But faced with the inordinate array of pathological theories, based on humours, opposites, elements, the supposed disorders of the pneuma, the supposed blocking of the pores in the body, and so on,[218] both Empiricists and Methodists may have agreed in concentrating on the practical aims of medicine. The great strength of their positions, as these are reported, lay in
[215] See Galen Sect.Intr. 6, Scr.Min. (H) 3.14.14ff., (K) 1.82.6ff., and cf. Celsus Med. 1 pr. 57, CML 1.26.26ff.
[216] Cf. Edelstein 1935/1967a, pp. 186f. The interpretation of the position of the Academic sceptics is, however, much disputed: see, for example, Couissin 1929/1983, Striker 1974, 1980, Sedley 1983b, Burnyeat 1984.
[218] The disputes between rival positive pathological theories begun by the Hippocratic writers continue with Herophilus, Erasistratus, and Asclepiades, among many others. For Herophilus, see von Staden forthcoming; for Erasistratus, see especially Lonie 1964 and cf. Longrigg 1981. My colleague John Vallance is preparing a comprehensive edition of Asclepiades.
both cases in the focus on what had proved to be successful in experience, even though our secondary sources press the difficulties of the rejection of "reasoning"[219] and even though, no doubt, the interpretation of experience itself, and of the "appearances" to be relied on, may well have been more problematic than either group allowed.
Yet if the anti-dogmatic and anti-speculative tendencies in Greek medicine thereby reach their apotheosis, there was a price to pay. Both Empiricists and Methodists are said to have ruled out dissection and vivisection. In the latter case, human vivisection, as practised, according to Celsus,[220] by Herophilus and Erasistratus on criminals "received out of prison from the kings," was repudiated by most people, including Celsus, with disgust[221] —though Celsus mentions a Dogmatist justification in terms of the balance of advantage: the benefits accruing to "multitudes of innocent men of all future ages" justified the sacrifice of
[219] M. Frede 1982 has, however, recently argued strongly for the possibility, within Methodism, of the deployment of reason and even of theoretical beliefs, provided these are recognised as speculative.
[220] Med. 1 pr. 23–24, CML 1.21.15–21, which reports a Dogmatist view: longeque optime fecisse Herophilum et Erasistratum, qui nocentes homines a regibus ex carcere acceptos uiuos inciderint, considerarintque etiamnum spiritu remanente ea, quae natura ante clausisset, eorumque positum, colorem, figuram, magnitudinem, ordinem, duritiem, mollitiem, leuorem, contactum, processus deinde singulorum et recessus, et siue quid inseritur alteri, siue quid partem alterius in se recipit .
("Herophilus and Erasistratus proceeded in by far the best way: they cut open living men—criminals they obtained out of prison from the kings—and they observed, while their subjects still breathed, parts that nature had previously hidden, their position, colour, shape, size, arrangement, hardness, softness, smoothness, points of contact, and finally the processes and recesses of each and whether any part is inserted into another or receives the part of another into itself.")
[221] This is clear from Med. 1 pr. 26, CML 1.21.29f., where "most people" are said to hold human vivisection to be cruel (see next note), as well as from Celsus' own rejection at pr. 74f., CML 1.29.17–22, of vivisection: "to cut open the bodies of living men is both cruel and superfluous; to cut open the bodies of the dead is necessary for medical students. For they ought to know the position and arrangement of parts—which the dead body exhibits better than a wounded living subject. As for the rest, which can only be learnt from the living, experience will itself demonstrate it rather more slowly, but much more mildly, in the course of treating the wounded."
"only a small number of criminals."[222] But the Empiricists and Methodists are reported as rejecting human post mortem dissection as well, partly on the grounds that it is, if not cruel, at least nasty ( foedus ),[223] but partly also on the basis of the argument that what is observed in the dead is not relevant to the living, since on death the body is changed.[224]
The obscure not just in the sense of the theoretical or the speculative, but in the sense of what is literally hidden, cannot or need not be inquired into. So far as anatomy went, Celsus has this to add about the Empiricist position:
If, however, there be anything to be observed while 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 recognise site, position, arrangement, shape, and such-like, not when slaughtering, but while striving for health.[225]
Moreover, to judge from Soranus, the Methodists too showed a certain ambivalence on the question. Dissection is useless, Soranus says in the Gynaecology , but it is studied for the sake of "profound learning,"
[222] Med. 1 pr. 26, CML 1.21.29–32: Neque esse crudele, sicut plerique proponunt, hominum nocentium et horum quoque paucorum suppliciis remedia populis innocentibus saeculorum omnium quaeri . ("Nor is it cruel, as most people state, to seek remedies for multitudes of innocent men of all future ages by means of the sacrifice of only a small number of criminals.")
[223] Med. 1 pr. 44, CML 1.24.21f.
[224] On the ancient disputes over dissection, see further Manuli and Vegetti 1977, Vegetti 1979.
[225] Med. 1 pr. 43, CML 1.24.14–19: Si quid tamen sit, quod adhuc spirante homine conspectu subiciatur, id saepe casum offerre curantibus. Interdum enim gladiatorem in harena uel militem in acie uel uiatorem a latronibus exceptum sic uulnerari, ut eius interior aliqua pars aperiatur, et in alio alia; ita sedem, positum, ordinem, figuram, similiaque alia cognoscere prudentem medicum, non caedem sed sanitatem molientem .
it. "For we shall easily be believed when we say that dissection is useless, if we are first found to be acquainted with it, and we shall not arouse suspicion that we reject through ignorance something which is accepted as useful."[227]
Both Empiricists and Methodists thus went some way towards accommodating the findings of dissection. But both probably stopped well short of advocating the continued practice of the method. Here the rejection of dogmatism and speculation was also a rejection of new research. It was left to such a writer as Galen (who, even if he would himself have resisted the label, would certainly have been classed as a Dogmatist by his opponents)[228] to recommend the method. This he does in texts whose very eloquence and passion testify not just to Galen's personal commitment to the method but also to his sense of the need to come to its support against its detractors. In On Anatomical Procedures he sets out no fewer than four kinds of reasons for studying anatomy:
Anatomical study has one use for the natural scientist who loves knowledge for its own sake, another for him who values it not for its own sake but, rather, to demonstrate that nature does nothing without an aim, a third for one who provides himself from anatomy with data for inves-
[228] Cf. M. Frede 1981. It may, however, be noted that while Galen does not often admit making mistakes, he does sometimes do so. Thus in AA 14.7.214 Duckworth, he does so with regard to operations attempting to reveal the courses of certain nerves. There and elsewhere, when he acknowledges that he was at first unsuccessful in a surgical or anatomical operation, it is often to emphasise the need for practice and experience: cf. AA 7.10 (K) 2.621.12ff. (cf. also 3.2 [K] 2.348.14ff., 8.4 [K] 2.674.6ff.). On occasion, too, he admits to some hesitation on points of detail, for instance concerning the nerves of the brachial plexus at AA 15.6.254 (D.).
tigating a function, physical or mental, and yet another for the practitioner who has to remove splinters and missiles efficiently, to excise parts properly, or to treat ulcers, fistulae, and abscesses.[229]
Of these four, it is the last, the practical applications of dissection, that Galen chooses to emphasise here particularly, conducting, at this point, a war on two fronts. First he criticises many of those who practised dissection for concentrating on "that part of anatomy that is completely useless for physicians or that which gives them little or only occasional help," instancing the study of the heart and the bloodvessels communicating with it.[230]
The most useful part of the science of anatomy lies in just that exact study neglected by the professed experts. It would have been better to be ignorant of how many valves there are at each orifice of the heart, or how many vessels minister to it, or how or whence they come, or how the paired cranial nerves reach the brain, than [not to know] what muscles extend and flex the upper and lower arm and wrist, or thigh, leg and foot, or what muscles turn each of these laterally, . . . or where a great or a small vein or artery underlies them.[231]
Even the Empiricists, he proceeds, who "wrote whole books against anatomy," have to admit that such knowledge is necessary for physicians, but against the Empiricists in turn Galen pours out his critical scorn.[232] Castigating the Empiricist claim that the doctor can learn all the anatomy he needs from the inspection of external lesions he writes: "One might well wonder at their temerity, for since even those who have devoted much time to anatomy have failed to bring the study to perfection, one could scarcely learn it from the contemplation of wounds. Perched high on a throne, a man can say these things to his pupils without being able to instruct them in the actual practice of the art."[233] What is needed, he insists, is constant practice on many bodies, aided by the instruction he himself provides in his book.[234] The chief motivation for this study and the book itself is clear: "What could be more useful to the physician for the treatment of war-wounds, the extraction of weapons, the excision of bones . . . than to know accurately all the parts of the arms and legs. . . . If a man is ignorant of the position of a vital nerve, muscle, or important artery or vein, he is more likely to be responsible for the death, than for the saving, of his patients."[235]