Galen on Apodictics

ibidem-Press, Stuttgart

Contents

Foreword

Introduction

Chapter 1 Philosophical basis of Galen’s medical doctrines

1.1 Galen’s perspective on the Hippocratic tradition

1.2 The significance of the doctrines of Plato and Aristotle in shaping Galen’s views

1.3 The doctrine of Homoiomereia as the foundation of Galen’s views on the microstructure of tissue

Chapter 2 Understanding Galen’s clinical experience and apodeixis

2.1 The semiotics of diseases. Theory of pathogenesis as a reflection of the principle of causality

2.2 A comprehensive understanding of philosophical theory and medical practice

2.3 The unity of mind and body in Galen’s medicine and philisophy

Chapter 3 Anatomical dissections as evidence in a philosophical polemic

3.1 Galen’s method of investigation

3.2 The Empiricist school as the opponent of the Hippocratic tradition

3.3 The structure of proof in Galen

3.4 Galen’s understanding of the natural functions of the body as a realisation of the teleological principle

3.5 Galen’s clinical practice and physiological experiments

Conclusion

Bibliography

Foreword

Alexander L. Gungov

The main objective of Dmitry Alekseevich Balalykin’s book, which appears as the seventh volume of Studies in Medical Philosophy at ibidem Verlag, consists in presenting the philosophical grounds for Galen’s integral theoretical and practical system, emphasizing the understanding and application of the apodictic method. The author clearly states that his concept of apodictics in ancient medicine consists in the understanding of “a combination of the use of anatomical dissections, the physiological experiment, the rational doctrine of general pathology and clinical systematization.” As a physician and distinguished historian of medicine, Balalykin is perfectly up to engaging with the medical side of Galen’s works. In terms of philosophy, the most significant part of Galen’s apodictic method is the “rational doctrine of general pathology and clinical systematization”, which is interpreted by Balalykin with appropriate erudition and skills.

Balalykin examines the ontological, epistemological, logical, and natural-philosophical conceptions of Plato, Aristotle, Anaxagoras, Empedocles, Stoicism (in particular works of Chrysippus), and the ancient аtomism as sources of Galen’s philosophical views (or as philosophical ideas that Galen does not accept but opposes), and their decisive influence on his theoretical medical concepts and clinical findings and claims. Balalykin pays special attention to the notions of eidos, lekton, entelechia, and cataleptic impression, as well as to Aristotle’s doctrine of the four types of causes. In regard to the apodictic method, various types of evidence known in antiquity are considered in his book: apodictic, aimed at reaching the truth; dialectical, meant to get to plausible conclusions, which could serve as hypotheses for further quests in the name of truth or for didactic and other practical purposes, including convincing interlocutors; rhetorical, dedicated to persuasion; and sophistic, striving to win a dispute at any cost, even by means of manipulation and deliberate misleading. In connection with the apodictic method, Aristotle’s categorical syllogism is discussed, whereas Stoic hypothetical syllogism is analyzed as a part of the dialectical method.

The author puts at the heart of his study of the transition from philosophical foundations to medical conclusions the ancient natural philosophical teaching of the three tetrads, followed by a number of ancient thinkers: the four elements—earth, fire, air, and water; the four humors—blood, phlegm, and yellow and black biles; and the four substances—hot, cold, dry, and moist. The book analyzes the fundamental philosophical and medical significance of the balance and imbalance between the members of each tetrad. Balance and imbalance are traced as being inseparable from the theory of homoiomereia in view of what in modern medical language would correspond to a certain extent to nosology, etiology, pathogenesis, therapy, and prognosis. Last but not least, the importance of the Platonic concept of the tripartite nature of the human soul for the understanding of causation in medicine, classification of diseases, control exercised by the higher rational and immortal part of the soul on the health and disorder of the body, as well as the unified origin of somatic and psychic disorders are underlined.

Balalykin has succeeded in structuring and conducting his research in view of the decisive influence of the rich array of philosophical ideas from Classical Greece and the Hellenistic period on Galen's medical theory and clinical practice. He is not tempted to interpret the theoretical legacy of the ancient physician only from the point of view of modern medicine or predominantly in the context of the development of ancient medicine per se, whereas putting into brackets such a seemingly distant and lateral area as ancient philosophy. The author reveals the formation of ontology of health and disorder on the basis of the principle of balance and imbalance within the four tetrads, as well as according to the theory of homoiomereia that defines the structure of the macro- and the microcosm. The quantitative idea of health and disease, as well as the presence of degrees of health and disorder, depend on these principles. Homoiomeres define the anatomical structure of the human body, where there are simple homoiomerous structures and tissues and complex non-homoiomerous organs. By carrying out an ontological line of reasoning, Balalykin repeatedly argues that these principles have allowed Galen to outline his concept of general pathology and to classify diseases. The author convincingly demonstrates that Galen's understanding of the causes of diseases starts from the same ontological basis. From the perspective of the ancient physician we cannot speak of the contemporary meaning of etiology, as in Galen’s classification of causes there is a trend of universalization, whereas etiology deals with the specific causes of pathology within a certain nosologic unit. However, Galen's understanding of the causes of diseases allows him to persist in treatment aimed at eliminating the causes of a pathology (today known as “etiological treatment”) and not simply at eliminating the symptoms. At the level of medical causality, the author makes a point of the four types of causes in Aristotle, shows how they have been transformed by Galen and, foremost, discusses the final cause that the ancient physician considers as a teleology of function of an organ or of the body as a whole. The doctrine of teleology, along with and inseparable from the principle of balance of the three tetrads and the principle of homoiomereia, are the main grounds for Galen’s rejection of the explanation of the ancient Methodists regarding the causes of disease. The assertion of the Methodist physicians, who have adopted the ontology of ancient atomism that the general pathology is due to clogged pores in a certain part of the human body, is unacceptable to him. He is a follower of Plato and Aristotle and the mechanics of the atomism does not correspond to the teleology of function, inherent in the body in the states of health and disease alike. Balalykin explains that the principle of teleology should not be confused with the Stoic determinism of physicians from the Empiric school that is set by blind fate and is completely beyond any rational control. Thus, the author unambiguously shows: the philosophical preconditions at the level of ontology preset Galen's position on medical causality. Furthermore, he clarifies that the mechanisms of diseases, pathogenesis, depend on the same ontological arguments.

According to Balalykin the respective central concepts of Plato’s and Aristotle’s ontology and epistemology, eidos and entelechia, become decisive for the formation of the apodictic method in Galen. The creation and functioning of the sensory world after a model of the non-sensory eidos that guarantees realization in the sensory world of certain patterns, perceptible by the human mind, gives Galen the opportunity to follow in the medical theory and practice a method based on a cognizable necessity. The feasibility of apodictic method is reinforced by the Aristotelian entelechia, which justifies teleological changes both in healthy and diseased persons, and also the state of a person between health and disease. The author points out why Empirics, criticized by Galen, following the Stoic view of lekton adhere to the situational understanding of diseases and cannot perceive the apodictic method that yields the necessary conclusions. Instead, they are forced to rely on a dialectical method that provides nothing more than probabilistic conclusions. Stoic lekton has no ontological status of necessity, unlike eidos and entelechia, because it is not material in character, and for the Stoics this is equivalent to a lack of reality. This means that disease observations—diagnosis of the disease, as well as its treatment decisions—are lektons with probabilistic value. The non-acceptance in principle of the theory leads to the underestimation of medical causality and disinterest in the mechanisms of diseases among physicians from the Empiric school. Moreover, these philosophical reasons limit the diagnostic and therapeutic actions of Empirics to addressing pathological symptoms using their own experience gained in similar situations or the experience of their counterparts, applied depending on the available pharmacological and dietary agents that have proven their effects in such symptomatology. Here, the author is a very shrewd observer when he perceives an essential dialectical feature (‘dialectical’ not in the sense of the ancient dialectic, but of Georg Hegel’s speculative dialectic) according to which the Empirics, by denying the possibility of knowing general principles, are not able to apply individualized treatment and are inevitably entangled in repetitive patterns. Balalykin intuitively and completely justifiably perceives that this paradoxical situation expresses the fact of the transformation of one-sided rational statements into their opposites. The Empirics, following dogmatic one-sided constructions of Stoicism and insisting on the significance of only a singular disease situation, allow an insurmountable gulf between the singular and the universal, thus falling into the lifeless generalization of oversimplification. Galen’s approach, based on Plato’s and Aristotelian philosophical views, freely overcomes the rational one-sidedness and rises up to the level of rational speculative dialectic by perceiving the unity between singular, particular, and universal. The singular symptoms of a patient manifest themselves in an inseparable and individualized unity with the universal and indispensable features of the given disease (according to the modern terminology of the “nosological unit”) and thus form the particular type of a specific patient’s disease. The interpretation of schematization during treatment by the Empirics proves that the assumption and knowledge of universal features of diseases and their treatment does not prevent, but on the contrary supports the application of an individual approach to diagnosis and treatment.

In studying Galen’s apodictics, Balalykin addresses a purely logical problem. He points out that Galen holds on to making necessary conclusions through categorical syllogism, which provides true knowledge, while physicians from the Empiric school, in conformity with their understanding of probable and solely plausible knowledge, use hypothetical syllogism. The author is quite right that in both forms of hypothetical syllogism, pure hypothetical syllogism and hypothetical categorical syllogism, there is an element of hypothesis that gives some probability to the conclusion reached. Nevertheless, it should be taken into consideration that the very inferences of these types of syllogism produce necessary conclusions. The two forms of the inference are known as modus ponens and modus tollens, which are accepted as valid both by traditional formal logic and by its modern symbolic version. Furthermore, the categoricalness of the strict categorical syllogism’s premises is not necessarily identical with their truthfulness and leaves room for a certain dose of probability. There is Aristotle’s well-known claim about the middle term of the categorical syllogism being identified by dialectical means of the art of topics. The truthfulness of categorical syllogism (not just logical validity) is borne not only by the formal laws of this type of inference, but by the overall context in which it takes place. Similarly, the probability of a hypothetical syllogism (again, not just logical validity) depends on the context of its application. We should not neglect the practical reliability of the negative modus of the hypothetical categorical syllogism modus tollens in clinical practice. During the differential diagnostics procedure diseases with similar symptoms are excluded in order to determine the real disease(s). The exclusion is done by the modus tollens rule whereby the absence of a necessary symptom or sign leads to an absence of the corresponding disease. In terms of logical validity, this is a completely necessary and correct conclusion. In medical practice, it excels the positive modus ponens, where the inference is driven from the presence of the cause of a disease to the disease itself, because even the presence of the necessary cause of a disease cannot lead to the disease in the case that the sufficient cause is not also present. However, when discussing the necessary validity of the eliminating modus tollens, we should not forget that it is a common situation in diagnostic practice when the absence of a symptom or sign (in the case it is not a pathognomonic symptom or sign) does not guarantee the absence of the disease we are looking for. This means that the decision to reject or affirm the presence of a disease goes beyond logical necessity, but that does not at all mean, as the author clearly demonstrates, that the decision is not subject to the apodictic method.

It would be entirely justified to state that Galen on Apodictics masterfully demonstrates the philosophical impetus in the formation of the apodictic method in Galen’s clinical practice and theoretical treatises and outlines this method as “an expression of a new type of rationality in the field of medicine” during the Roman Empire. No doubt, Balalykin’s book is a significant and valuable contribution to studies in the field of philosophical analysis of Galen’s works on an international scale and deserves excited and committed readers.

Introduction

Modern academic literature generally accept the existence of a unified branch of science—the “history and philosophy of science”. Unfortunately, historians concerned with separate areas of natural science have very little interest in philosophical methodology: they are often concerned with specifics and do not seek to generalise and identify common patterns in the development of the subject under investigation.

The history of medicine is dominated by a tendency for narrowly specialised analysis, which is generally typical for the history of natural sciences. Among medical professionals studying history, priority interest is payed to the events directly influencing the modern image of medical science and practice. There are extensive studies in historiography devoted to the history of surgery, cardiology, immunology, the establishment of medical education, etc.1 By virtue of mental inertia, their chronological framework mainly covers the 19th–20th centuries, and interest in earlier epochs is rare.

The same applies to studies on the philosophy of science. For example, V.S. Stepin considered it obvious that the history of modern science begins from the 17th century, and he masterfully dissertated on the categorical grid which describes the context of events in the 17th–19th centuries.

I presume this conviction has to do with the fact that most scientists came to the philosophy of science from physics and mathematics. They operate with familiar facts from the history of natural science disciplines. However, can data from the history and philosophy of physics be unambiguously extrapolated to the history and philosophy of medicine? Interdisciplinary research, which constitutes part of this work, enables to answer this question negatively.

Obviously the mainstream in historiography often leads to the study of the history of medicine beyond the general context of the development of natural science, global social and cultural processes, which in actuality have had a certain influence on the mindset of scholars and their research program. For example, the subject of substantive discussions becomes the fact itself of referring to the work of ancient and medieval scientists as “scientific”. Researchers who refuse to recognise Hippocrates, Galen or Avicenna as scientists refer to the modern-day definition of the concept of “science”, which involves the use of the experimental method and language of mathematical explanations.

B. Russell defines the concept of “science” as knowledge above all. It is widely accepted that this is knowledge of a special kind, which seeks to find general laws linking multiple separate facts. However, the view of science as knowledge is gradually being sidelined by the view of science as a force which controls nature. A person of science (Russell does not mean everyone, as many people of science are not scientists—he is talking about a person of science as he should be)—is an attentive, careful and consistent person. He only relies on experience in his conclusions and is not prepared to make sweeping generalisations. Such person does not accept theory just because it is elegant, symmetrical and is synthetic in nature, but examines it in detail and in real applications.2

According to André Comte-Sponville, science is a collection of knowledge, theories and hypotheses relating to the same subject or same field (for example, nature, living beings, the Earth, society, etc.). Science not so much states as it constructs this knowledge, in line with historical context, logically organising or proving it (to the extent to which it can be proven), achieving for it, if not universal, at least group recognition from competent minds (this is what distinguishes philosophy from all other sciences because the clash of competent minds is possible in philosophy), finally recognising that all sciences, except mathematics, are empirically falsifiable. Add to this the fact that the scientific approach usually counterposes the so-called common sense (scientific knowledge is not always self evident), and the following simplified definition could be made: science is an organised collection of verifiable paradoxes and corrected errors. An integral part of the essence of science is progress because science develops through “conjectures and refutations”.3

Clearly, the given definitions (there are many such definitions) are fully applicable to the works of scientists from the ancient world. However, it is clear that the physics of Aristotle is different from the physics of Newton or the physics of Einstein.

Today, the so-called standard conception of science is generally accepted. According to this conсeption, science and scientific knowledge are characterised, first of all, by objectivity. The world of natural phenomena is considered factual and objective. The goal of science is the precise description and explanation of objects and phenomena, processes and relationships existing in nature. Secondly, science establishes (this particularly guarantees objectivity) the laws of nature. Thirdly, scientific knowledge is formed in the process of impartial gathering of facts and relationships between them, the establishment of empirical laws based on said gathering of facts and further elaboration of scientific theory based on said laws.

The objectivity of scientific knowledge, in my opinion, is clear for the doctor who draws knowledge from a physiological experiment and clinical practice.

The scientific (even in the modern understanding of medicine or, for example, mathematics) nature of the actions and discourse of great doctors of the past is often so obvious that the term “protoscience” has gained a foothold in professional literature. It is generally used to describe the entire period of development of natural science, when the time before the advent of scientific revolutions is referred to as the “protoscientific” or “prescientific” period. Therefore, on one hand, the value and historical role of the work of scientists in the ancient and medieval ages is recognised, and on the other hand, the dissimilarity between the work of Aristotle or Soranus of Ephesus and the modern type of scientific research is also stated.

Active discussion over the clear definition of the concept of “protoscience” itself continues. I think T. Kuhn’s theory of paradigm shift is key in understanding the structure of scientific revolutions. This theory is also subject to constant review and certain criticism. Against this backdrop, it is often quite difficult to discern ontological and gnosiological links between events and protoscientific methods and the modern-day development of certain disciplines.

When K. Popper’s book titled Conjectures and Refutations: The Growth of Scientific Knowledge4 came out, the term “protoscience” got a somewhat disparaging shade of meaning—“pseudoscience” or “something, which is not real science”. Furthermore, the understanding of the history of natural science before the 17th century as the development of some “not exactly scientific ideas”, taking cue from K. Popper, is typical for many historians working in the second half of the 20th century. This is a part of presentists methodology ‒ to think only modern science is real.

I use the term “protoscience” following another, long-standing historiographical tradition under which certain works of ancient scholars are taken as ideas that are ontologically very close to modern ideas. I argue that they may be considered as partially commensurable with them. Remember, according to the modern conception of science, rationality, objectivity, reproducibility and verifiability, logical rigour, preciseness and logical interrelation of various elements are considered the hallmarks scientific knowledge. These characteristics are sometimes supplemented with utility, which reflects the essence of science as part of culture. These attributes are characterised by the ideals of scientific rigour. The task of science is to reveal patterns and general principles which facilitate not only the observation and stating of facts, but also their explanation. Such an approach defines very stringent requirements for historians and philosophers: the scientist must articulate inferences based on the analysis of sources.

When it comes to the fundamental methodological difference between the modern science and protoscience in the ancient world, two principal points are normally highlighted: the experimental method of studying specific natural phenomena and mathematical processing of the obtained data. The latter involves systematisation and description of observable phenomena using mathematical formulae and equations. But here another question arises: from this perspective, can modern-day medicine be considered science? After all, to this day, mathematical explanation of observable processes has not become part of the everyday practice of the doctor. Furthermore, I can boldly predict that it never will.

A fundamental division of modern science and science of antiquity has become general in historiography (it is considered as a result of the scientific revolution of the 18th and 19th centuries). Brief analysis of the numerous arguments of supporters of this point of view shows that they relate primarily to questions of the methodology of knowledge: in their opinion, it was believed in antiquity that the comprehension of the world around was possible only through notion sciences (philosophy and mathematics)—natural (intrinsic) was contrasted with technical (artificial, created by man)5. In particular, it is suggested that science of antiquity adhere to the “empirical” method of studying nature, in contrast to the “experimental” method inherent in modern science. This thesis is generally illustrated by examples from the history of physics and, sometimes, mathematics.

On the other hand, the judgment of early Ionian physics (6th century BC), as the starting point of nature research nucleation from a rational methodology, also became general in modern historiography. In this case, the rationalism of ancient science means the union of astronomical, biological, etc. phenomena by not mystical, but natural physical causes. The three natural sciences specialties—mathematics, astronomy and medicine—are considered to be the most ancient; its appearance is directly related to the early Ionian physics. As early as the beginning of the 4th century BC we see the existence of an absolutely clear system of mathematical knowledge, an astronomical theory based on practical observations, and medicine of Hippocrates. It is in the context of the analysis of its history in the special literature that the discussion of the problem of the apodictic method of knowledge begins. In the 1960s, G. Lloyd6 for the first time very pointedly and reasonably raised the question of the separation of mystical and occult chiliastic practices from the development of ancient Greek rational medicine. And here it becomes clear that it is precisely the development of medicine that historians and philosophers can judge most reliably in view of the quality of the source base: nothing like Hippocratic Corpus is at the disposal of scientists studying the birth of other disciplines. Thus, it turned out that the historically accurate picture of the history of medicine has the best background. Further, G. Lloyd raised the question of the apodictic method of knowledge in the rational medicine of antiquity. It also dealt with the absolute opposition of a clear, structured logical proof to sophistic tricks. Ideally, the apodictic method in medicine should, according to the degree of evidence of the proof, approach the mathematical method. In this sense, the application of the “apodictic” concept to medicine can be regarded as a rather free extrapolation of the concept from the mathematical science vocabulary. However, the Hippocratic Corpus has already shown obvious evidence, with which to argue is as difficult as with a mathematical formula—an anatomical autopsy has become such. G. Lloyd, in fact, was the first who absolutely clearly defined the dissection as a medical apodictic. In addition, a significant number of arguments by G. Lloyd, based on a thorough analysis of sources, relate to the principles of analysis and reflection on clinical experience.

J. Longrigg asserted the incomprehensible differences, comparing medical schools of antiquity. He linked only very definite theories with later history of medicine. In the last decades of 20th century the concept of “ancient Greek rational medicine”, which denoted precisely this direction, was firmly established in historiography.

It means a clear separation of Alkmeon and Hippocrates medicine, which is based on a completely clear natural-philosophical theory, from temple healing, ritual incubation, invoking spirits and other non-rational chiliastic practices. Apodictic (in the understanding of G. Lloyd) cautiously and not quite consistently begins to recognize the basis of the methodology of rational medicine of antiquity. The reason for this caution, I think, is the difficulty with a clear classification of practical knowledge. However, after J. Jouanna was able to describe the basic principles of the clinical practice of Hippocrates7 these difficulties can be considered overcome. I suggest to use the term “clinical systematics”: this is how we can describe the principle of understanding the whole set of practical knowledge about diseases and its treatment, specific to the Hippocratic school. Its development is underway, Galen only emphasizes the hierarchical, logically built and striving to match the particular and the general (that is, “systematic”) nature of the comprehension of practical experience.

The works of V. Nutton have an outstanding meaning in the development of the study of the history and methods of ancient medicine. Due to decades of hard work of V. Nutton, his co-authors, students and followers, the problem of historically reliable reconstruction of the main events of almost a thousand-year-old history of ancient medicine was, in general, solved.8

The availability of sources that allow making an impression about the development of ancient medicine after Hippocrates leaves much to be desired. It is with this that I associate the fact that in modern scholarly literature there is a tendency to consider hippocratics-rationalists and, for example, doctors-empiricist, equivalent historical phenomena. The connection between clinical practice and philosophical theory in the teachings of various medical schools is often misunderstood, their mutual exclusivity is sometimes underestimated. The main sources containing information about antiquity medicine from the 3rd century BC and later, are the works of Galen: 111 out of more than 500 reached us. However, fewer than half were translated into English, fewer than 30 texts into Russian.