Heroes Not Zombies

I’ve just read Passions and Tempers, by Noga Arikha (ISBN 978-0-06-073116-8)

I expect you’re familiar with the four terms, melancholic, choleric, phlegmatic and sanguine. They might not be everyday words any more but they’re certainly still common enough currency for most people to have at least some idea what they mean. They are, of course, the four temperaments, each of which is expressive of one of the four humours. Noga Arikha is a historian and this book is astonishing in its range. She begins way back in the sixth century BC and traces the idea of these humours from then right up into present time. I found the book totally absorbing and convincing, not just because of the fascinating story of both the persistence and the development of this ancient idea, but because of the meta-narratives……what this particular history tells us about what it is to be human, what it is to be a physician, and how strong ideas can evolve with the expansion of human knowledge rather than be destroyed by that process.
The book is divided into seven main sections (and given Noga’s deep familiarity with cultural rhythms and divisions, I wouldn’t be surprised if this very structure wasn’t a nod towards the seven ages of Man!). Each section describes the humours in a period of history from antiquity right up to the end of twentieth century. Before I read this book I thought the humours were an interesting extinct idea, and it was the invention of the thermometer in the 17th century which did for them. I understood that when the body temperature of a choleric was compared to that of a phlegmatic type and found to be the same, that the theory was discredited. I now know that analysis was not only simplistic, it was wrong! I also thought that the autopsies performed in the great 16th and 17th century Parisian Public hospitals made the morbid anatomist the great medical authorities and turned illness from being a holistic imbalance, to being a physical disease which could be seen, touched and measured in the body (see The Anatomy Lesson of Dr Tulp) That too turns out to be way too simplistic an understanding.
Humoural theory was indeed a holistic one where the proportions and flows of the humours within a person were thought to be connected to, or influenced by, the environment in which that person lived, which was, in turn, intimately connected with the movements of the Cosmos. The humours themselves were invisible but there were plenty of theories created to explain their behaviour and significance. Dissections and, horrifically, vivisections performed back in third century BC not only developed our understanding of anatomy, but by both failing to show any humours, and by providing alternative, observable explanations for illness, began a train of thought which was indeed to take off in the 17th century with Descartes’ separation of the body from the mind, and in the 18th century with Julien-Offray de la Metrie’s description of Man as a Machine (L’homme-machine) becoming the dominant mode of thought in scientific medicine right up to the present day.
However, as Noga Arikha shows so clearly, the humours as a concept, (as opposed to humours as material entities), still help us to understand the body and the mind as one, not two, and to seek to explain the links between the various parts of the body and the mind. The fact that such modern ideas, as described by researchers in “psychoneuroimmunology”, and philosophers and neuroscientists who discuss the embodied nature of the mind, has such ancient roots is quite breath-taking.
As she says in the introduction…..

….there was a continuum between passions and cognition, physiology and psychology, individual and environment.

Even in Hippocratic writings we read…

every part of the body, on becoming ill, immediately produces disease in some other part.

and

Men do not understand how to observe the invisible through the visible.

Let me just share with you two features of ancient practice which I found highly thought provoking and relevant to current medical practice.
From the sixth to the second centuries BC Asklepieia were the temples of the healer who became a god, Asklepios. One particulary famous one was in his birthplace, Epidaurus. A sick person would have a stay in one of these Asklepieia (which were healing centres, or spas). On admission they would have a ritual bath, then settle to sleep in an area known as the “abaton”. Every morning they would discuss their dreams with the priests, and they would receive water treatments, herbs and even, if necessary, surgery. The lucky ones would be visited in their dreams by the “drakon”, a healing snake which would cure their wounds with its tongue. The patients were encouraged to write down their experiences and their case records became the basis of medical learning which the priest/healers used to develop their treatments.
I find many aspects of this quite fascinating. Don’t we still need such places of healing, where patients can be cared for (maybe we don’t use water treatments and bathing enough these days!), and where, not only can they share their dreams, but are encouraged to record their experiences of care so that health care professionals, and other patients, can learn from them? What strikes me about this story is how the focus was on health, not disease, and how the individual’s subjective experience was central to the care.
The second story which similarly provoked my thinking was captured in these two passages –

A learned doctor was one who had primarily read many books, rather than treated many patients.

Doctors could treat only symptoms that corresponded to cases which records or histories existed already.

The dominant current model is medicine is called “Evidence Based Medicine” and “evidence” is primarily published research. It stuck me as I read the first of those two sentences, that nowadays, those who claim authority in medicine are typically those who have read many articles, rather than treated many patients! Indeed I am often amazed at the pronouncements of professors who claim to know the best way to treat patients but who are not clinically active with real patients.
The second sentence stimulated two thoughts in my mind. The first was recalling what Dr Harry Burns, Chief Medical Officer of Scotland once said about his concern with the way “Evidence Based Medicine” was being used, and that was where was all the innovation to come from, if we only allowed the practice of what we already knew? The second was how difficult it is for many doctors to accept the reality of illnesses which don’t fit the models already described – chronic fatigue syndrome, and, fibromyalgia, being just two of the obvious ones.
So, I found this book stimulating and enlightening. It is a GOOD read and I think it has the potential to deepen any health care professional’s understanding of health and healing.