Ancient Western Medicine Part 2

Just to assuage any doubts, I don't ascribe to the humoral theory of disease.  (I believe in inflammation - everyone should know that!).  However, there is still much to learn from ancient Western medicine.  I think there is an idea that Western medicine is all leeches and lipitor, but in fact there is a long and noble history of careful observation, philosophy, and anatomy.  And like any psychiatrist, I like to know the background and the nitty gritty - it helps establish the basis for what we think and do today.  Western medical thinking has made some missteps - in the past, and recently, and our history helps us understand both our mistakes and our wisdom.  I will focus here, as always, on mental health (with the help of Melancholia and Depression: From Hippocratic Times to Modern Times)

So� Plato and Aristotle and Galen and Hippocrates were not enemies of feeling.  Aristotle recognized that strong passions could contribute to motivation, though he felt passions should be directed in ethical and religious directions.  A group of philosophers known as the Stoics held sway thereafter - and while Aristotle felt passions ought to be controlled, the Stoics thought they should be done away with.  (I am no expert in Eastern philosophy by any means, but this ideal does seem to dovetail with my reading of Siddhartha and the state of wanting nothing).  "One was to avoid whatever might lead to greater tumults of the soul� except in the case of the wise man, they viewed [passions] as perverted judgments.  They sought inner peace as the basic good and thought of the passions as disorders of the soul, disturbing to reason and contrary to nature."

The Stoics also believed in the concept of "pneuma,"  or "spirit."  It was a "most subtle material substance� a life-giving principle in the body that was replenished from the air through the lungs and pores of the skin and from the digestion of food."  In general, spirit and passions were associated with the heart, and the liver was the seat of baser bodily appetites.

With Stoics and Humors and Passions we bring ourselves forward through the Middle Ages and the Renaissance.  In the fourth century we have writers separating the soul into two parts-  rational and irrational.  The irrational part was divided into basic elements of waste disposal and appetites and desire, and the rational part of thoughts and more noble passions (intellect and religion). Interestingly, at this time, the seat of grief was felt to be the stomach.

The Renaissance writers began to be more flexible about the positives of passions - Aquinas felt that rational passions led to the acquisition of knowledge and fulfilling of the potential via the five senses.  Later Renaissance writers devoted more time to passion, spirit, and  affects.  By the 16th century, the head began to replace the heart as the center of feeling (except perhaps on Valentine's Day).

Descartes made some adjustments of the ancient ideas of the 6 non-naturals - he suggested we focus on the six primary passions instead - surprise (astonishment), love, hate, desire, joy, and sorrow.*    He finally felt that passions were felt "by the soul" rather than in the visceral organs.

Later, Hobbes and Spinoza would publish writings describing the baseness of the soul, and how it operated in self-serving interest.

In the end, the "self-serving" meme would come to dominate - and fits in nicely with an evolutionary genetic view.  My one observational addition is that doctors of the early 20th century had some "advantages" in training and physical diagnosis that we no longer enjoy.  At the time, one might see aortic stenosis and be able to diagnosis the late stage via observation and stethoscope - nowadays an echocardiogram and ultrasound would preempt physical diagnosis.

In addition, the fact that the average American is obese also changes physical diagnoses.  In the past, one could readily palpate liver, kidney, aorta, spleen - now an apron of fat is often in the way.  We have to rely on ultrasound and CT scan  - though the million dollar CT scanners are calibrated to 300 pounds or less - larger patients need to be sent to specialized MRI or CT scanners calibrated to greater weights.

Everything has changed very rapidly with the advent of so many medications and so much adiposity.  Medical science has not caught up, having gone the wrong direction with respect to treatment of obesity, and no one knows the consequence of so many medications being recommended all at the same time all at once�we are in a no-man's land of polypharmacy and low-fat living.

Well, I hope we move on from that sooner rather than later.  But I'm an optimist.

*My favorite schema for productive psychotherapy was developed by one of my teachers in residency, and a former wife of another teacher of mine, George Valliant,  Leigh McCullough - her key book is Treating Affect Phobia: A Manual for Short-Term Dynamic Psychotherapy) She advises a combination of cognitive work and focus on intolerable emotions, with the Descartes driving passions being primary, whereas the inhibitory emotions of anxiety, boredom, and frustration lead us backwards and only burning up much needed energy.  

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