Ancient Medicine/Medicina Antiqua::Galen: Commentary on: Hippocarates: On the Nature of Man: De Natura Hominis

Galen
On Hippocrates On the Nature of Man
Part Two

translated by W.J.Lewis, with the assistance of J.A.Beach

This translation
Galen
Part 1

Further Reading

108-109. I have expounded on the book itself On the Nature of Man in the first part of this work. Now I will turn to those things which have been incorrectly attached to it, added while the book was being assembled. For the added work is a single short book, in which the regimen of healthy people is discussed, and it seems to be the writing of Polybus, the student of Hippocrates. In addition, between this and the On the Nature of Man, something else has been compiled, and appended by the one who first joined these two short books into the same one, i.e. the On the Nature of Man of Hippocrates himself and the Regimen of Health of Polybus. For at the time when the Attalid and Ptolemaic kings were vying with each other in the acquisition of books, a recklessness began to arise with respect to the attribution and preparation of books on the part of those who, for money, brought back to the kings the writings of well-known men. For since both of these books are short, the On the Nature of Man and the Regimen of Health, some person, considering each of them to be negligible on account of their shortness, placed them both together in the same book. And perhaps some other person, or perhaps the same person who first joined them, inserted some material between the two, which we will now discuss.

110. "One should know these things about diseases: whatever diseases result from fullness, are cured by draining; the diseases generated by draining, are cured by fullness; the ones arising from exertion, are cured by rest and the ones caused by excessive idleness, are cured by exertion. With the knowledge of all this, the physician must stand in opposition to the constitutions and diseases and forms and seasons and times of life, and should loosen those things which tighten, and make tight those things which are loosened. In this way the sickness may be halted, and this seems to me to be the cure."

110-111. Beside every line of this entire passage, Dioscorides made the mark called the ‘dagger’ (Aristarchus used such a mark for those line of the Poet which he suspected). Dioscorides made this mark, inferring that the present passage was by Hippocrates, the son of Thessalos. For the great Hippocrates had two sons: Thessalos and Drakon, each of whom had a son Hippocrates. These remarks apply to the entire passage. Still, it is appropriate for us to consider this material to some extent, dealing with each phrase separately.

111-113. "Whatever diseases are caused by fullness, are cured by draining."
Saying that the necessary cause of diseases is fullness or draining or any of the other afore-mentioned things is not the same thing as saying that something arises on account of fullness or any of the others. For it is true that some diseases arise through fullness or as a consequence of fullness (for to say one or the other makes no difference), but it is not true that fullness is the necessary cause of the disease. For the disease itself is a certain condition in the body of the creature, which fundamentally harms the function, as is shown in the work, On the Difference of Diseases. But fullness does not fundamentally harm function, as has also been shown a while back in the work On Fullness. Rather, fullness causes harm through some intermediate condition, which Erasistratus has proposed arises in one way, Asclepiades in another way, and those physicians called ‘Pneumatics’ in yet another way. We have written further, how diseases arise from each fullness. For ‘fullness’ has been defined in two ways: the first way with respect to its fundamental property, and the second with respect to the capacity of vessels. Fullness, as it is defined with respect to fundamental property, leads the humors into corruption and sends a stream into the weakest parts in the body. On the other hand, fullness defined by volume causes openings and ruptures of the vessels, and sometimes sudden death, whenever it blocks up the body’s transpirations. The term ‘healing’ may be used in reference to those things causing the diseases, not only to those diseases which have already arisen. If, indeed, someone were to use the proper term with reference to them, he would say that such causes are preconditions of diseases, just as Athenaeus does. And again, these same preconditions, those which he calls ‘previously-completed’ and ‘starting-before’, arise in turn from the following: poor digestion of large amounts of meat, followed by visits to the public baths and gymnasium at unpropitious times, and by all the things which I discussed in the treatise On the Previously-Completed Causes: these become agents of the preconditioning causes of each disease.

113-114. "The diseases caused by draining, are cured by fullness".
The writer of this passage doesn’t seem to have used the term ‘fullness’ correctly here, since not only all physicians, but all the other Greeks as well, are accustomed to assign the term ‘fullness’ to excesses of a well-balanced quantity, and emptiness is not rectified through a corresponding imbalance. Hear next the argument advocating opposing imbalances. Since certain foods are well-balanced depending on one’s constitution, the lack or the abundance within a healthy person will be comprehended by a comparison to these foods. Whoever is emptied, if he is to be restored, will be increased by that amount of well-balanced material which was present there earlier. For if the same amount of food would be brought in now, as was being brought in before the draining, that which was drained would never be restored in full. But it is the mark of a skilled practitioner that the increase of this be made in a balanced way and that what was drained off not be filled at a crisis point, and not suddenly all at once. Some physicians teach that drainings are never the causes of diseases. They say that drainings only cause a weakening of strength, and a wasting away of the outside of the body, and that no disease arises from deficiency. But they haven’t seen those diseases which arise from imbalanced drainings. When this happens, the patients readily become chilled, and quickly feverish again, and are easily overpowered by fatigue and all the external afflictions, so that even those who are healthy are led into illness by sleeplessness and distress and indigestion and temper.

114. "Whatever diseases arise from exertion are cured by rest."
What he calls ‘exertions’ are those exertions arising from ill-balanced motion. And indeed, that motions which treat the body in this way should be halted, is something which all men know, and they act accordingly, without being obliged to consult a physician. And we have shown, that not only men, but even irrational creatures rectify a harmful situation through methods opposite to it.

115. "Whatever diseases arise from excessive idleness are cured by exertion."
Idleness does not cause disease primarily and in itself, but by means of excess. For parts of the body characterized by idleness become weaker and less robust, as each excess comes about due to this idleness. Moreover, an ill-balanced motion does not make the power stronger, but it does empty out the excess liquids which have been collected. For it is quite clear that if there is a slight over-fullness with respect to this abundance of liquids, or a well-balanced motion takes place, a man becomes worn out gently through this, but does not become feverish.

115-116. "With the knowledge of all this, the physician must stand in opposition to the disease: the form and season and time of life..."
He seems to say ‘form’ as equivalent to the nature of the body, the substance of which we have shown to consist of a mixture of four elements. Indeed it has been demonstrated that all diseases are cured by opposition to their fundamental properties, not to their immediate symptoms. And the nature of the body, since it is a mixture, is not entirely corrected through oppositions, just as the seasons and times of life are not. For some people are born well-balanced, as others are born ill-balanced, and the good balance of the former is preserved by similar things and the ill-balance of the latter corrected by opposing things. And these things are defined in the procedure, On Healthy People.

116-117. "...and loosen those things which tighten, and make tight those things which are loosened."
He hasn’t made a proper comparison of the diseases here. For ‘things which loosen’ is normally considered a counterpart to ‘things which tighten’, and ‘things which are tightened’ to ‘things which are loosened.’ For ‘things which tighten’ and ‘things which loosen’ are properly said in reference to the causes of disease, not in reference to the bodies themselves which are being harmed. Contrariwise, ‘things which are tightened’ and ‘things which are loosened’ are said in reference to bodies already being harmed. So ‘things which are tightened’ and ‘things which are loosened’ are terms not for diseases, but for the bodies being tightened or loosened, just as are the terms ‘hard’, ‘soft’, ‘thin’, ‘thick’, concerning which the eighth book of the Epidemics speaks well in this passage: "...softening of hard skin, loosening of skin which is tightened..."

117. For in this book, ‘being compressed’ is spoken of with reference to ‘holding together’, and is the opposite of ‘being made thin’, just as ‘being thickened’ is the opposite. For this, in turn, has the same force as ‘being thickened’, just as ‘having been thickened’ has the same force as ‘having been compressed’.

117. "Some diseases arise from regimen, and some from the air which we inhale as we live."

People sometimes refer to food and drink alone as ‘regimen’, but most often they include activities in this term, and it will be considered as defined in this way here. For diseases arise not only from what we eat and drink, but also public baths and activities at the gymnasium, and sleeplessness, and distress, and anger, and chills, and overheating. And harm often arises "from the air" alone as it is inhaled, such as in those places called ‘the regions of Charon’.

118. "The diagnosis of each disease should be made in this way: when many men are stricken by one disease at the same time, the cause should be assigned to that which is the most common and which we all make use of. And this is that which we breathe. For it is clear, that the regimens of each of us cannot be the cause since the disease has been contracted by everyone in turn, the young and the old, the men and the women, drinkers and non-drinkers, wheat-eaters and bread-eaters, those exerting themselves heavily and those exerting themselves little. So regimen cannot be the cause when men living in so many different ways are stricken with the same disease. But whenever diseases of all types arise at the same time, it is clear that the individual regimens are the cause of each disease."

118-119. He says correctly that diseases common to many have a common cause, just as he is correct about other things in this passage, but he is not correct in assigning the origin of all common diseases to air alone, if indeed, "Those in Ainos eating pulse during a famine became weak in the limbs, while those eating vetch-seeds suffered pains in the knees" (Epidemics 2.4.3.2, also 6.4.11.2). And we know that some people, compelled by famine to eat half-rotten wheat, were stricken by a common disease from a common cause, and we know how an entire encampment using wretched water had a similar illness among all the soldiers. But the rest of the passage is clear.

119-121. "...and the treatment must be carried out in opposition to the cause of the disease, as I have said elsewhere, and there must be a change in regimen. For it is clear that the type of life the man is accustomed to lead is not suitable, either entirely or in most respects, or in some single respect. These things, once they have been discovered, should be changed, and the treatment should be performed based on the observation of the man’s time of life and his body type, and the season of the year, and the kind of disease; sometimes removing, sometimes adding, as I have said before. And it is necessary to make alterations in the medicine and regimen based on each of these: time of life, season of the year, body type and disease. But when the epidemic of a single disease prevails, it is clear that the regimen is not the cause, but rather that which we breathe, and it is clear that it possesses some noxious vapor. And at such a time, this advice should be given to men: not to change their regimen, which is not the cause of the disease, but to look to their body, that it may be as thin and as weak as possible, gradually reducing the food and drink which they are accustomed to consume. For if the regimen should be changed abruptly, there is a risk of some newer danger in the body from this change. But it is necessary that the regimen be followed in such a way that it is clear that there is nothing harming the man. And it is necessary to be mindful of the breath, that the airflow into the body be as slight as possible and as distant as possible, exchanging those places in which the disease prevails for ones of a different type, and reducing the body, for on that account men will need less plentiful breathing and less deep."

121-122. He has written that a cure for common diseases is lacking when they arise from the surroundings. For although certain vapors from marshes or swamps or wetlands often become causes of such diseases, still, sometimes it is the mixture of seasons alone. With reference to the vapors, he has written a therapy correctly, for the most specific quality of the entire matter, rather than for the single quality of those who are suffering bodily afflictions, and he has devised this therapy with two aims, a change of location and the practice of lighter inhalation. However, with reference to people who are stricken because of their quality, there should not only be a treatment of diseases which have already arisen, but also a prevention against them arising at all, by means of opposing qualities; if the body would be harmed by excessive heat, it can be prevented by cooling, if harmed by a chill then prevented by heating, and the same principle for the other qualities, both simple and compound. I have already spoken before concerning the indication of diseases by time of life and seasons and proportions of the body.

122. This "...to make alterations in medicine..." seems to me to have been written here in place of "to apply medicine" to the disease from an opposition. For currently in Asia a man is said to "be altered" in this way: usefully or kindly or suspiciously or harshly.

122-123. "Whatever diseases arise from the strongest parts of the body are the deadliest. For if the disease remains in the place where it began, it is necessarily the case that, as the strongest part suffers, the entire body is disturbed. And if the disease should come to one of the weaker parts from the stronger, it is difficult to expel. But whatever disease goes from the stronger to the weaker, is easily released. For the flux is easily locked out by the strength."

123-128. If someone wished to say either a part or a body was ‘strongest’, he would properly name that one best equipped for strenuous action, the same way that we say that Hercules was born the strongest. But in another way we say that one body or one part is strong with respect to one activity, and another body or part with respect to another activity. For although in general there is strength in the body for each activity, nevertheless for any given activity, one part as opposed to another becomes the strongest. For this is one activity: the movement of a living thing by impulse, such as the movement of something running, or struggling with some living creature, or pulling apart some body, living or dead, or dragging in some way. And there is one other power, and vital activity with respect to this power, according to which the arteries and the heart pulse. With respect to those activities differing from each other in type, some others are distinct, not only in animals, but even in plants, so we call them natural forces: drawing, altering, holding and separating. So, for example, sometimes it happens that the stomach may have the strongest power in one body or another with respect to the activity of either holding or of altering, and then at some time the liver or spleen or one of the others is strongest. Contrariwise, the stomach may have the weakest power in this same body with respect to drawing and separating, and the liver may have the strongest. And the person who wrote this passage concedes that a part seems to be strong in us, to the extent that it does not easily suffer from disease-generating causes. Further, by God, this is added, i.e. a part is strong to the extent that, when some abundance of humors has collected in it, it is able to send this abundance into another part, by means of the separating power. For clearly the sender must be stronger than the receiver. Let there be, for example, some weakest part for each body, and some strongest part, as is certainly agreed on by all physicians and laymen. For they say that the feet are weakest for those with gouty feet, just as the joints are for arthritics, and the head for headache sufferers; just as the spleen is for those splenetic by nature and the eyes for those affected with eye-diseases, and so on for each part. Given that the disease-producing causes are of two kinds (the one external, the other driven by our own selves); with respect to ailments from the outside, some parts of our body are sometimes weak, and with respect to diseases from the inside, other parts are weak, since the powers of the causes themselves are of different kinds. For diseases arise internally through an abundance or wretchedness of humors, while some external causes harm the bodies of living things through making an ill-balance, and others harm by bruising or cutting. To be sure, the suffering of those with dislocations seems to arise from both. For one man, by himself without touching another, suffers a dislocation either by going to his knees or opening his jaws or somehow either exerting or twisting one of the other joints. And before now someone has suffered a fracture without any external causes, from contorted twistings or excessive leaps. For as many as are the kinds of causes, there are just as many kinds of weakness and strength in the parts of the body which suffer easily, or which do not suffer. For the diseases impelled by the humors all arise according to the strength and weakness of the separating powers. So, among similar parts of a creature, the disease-working humors go from the ones most able to reject them into others, and then from those into others, until they settle in some one of the weakest, which has no part weaker than it anywhere into which it might send the offending humor. And if this part has some exit-passage, as the intestines and stomach and bladder and uterus do, the offending cause is poured out through excretion. And if it should be lighter in composition than the passages of that part, then often the draining comes about with the vessel having been greatly torn or opened, as among those bleeding profusely without any trauma. If it is not opened or torn, the heavy, viscous humor descends and makes a mass in the part according to its nature. In this way, there is a certain strength and weakness of the parts of the body for those sufferings which have originated in ourselves. But the parts suffering from external causes seem to suffer generally with respect to being heated and chilled and dried and made wet. For those things leading the bodies of living things into disease by means of bruising or cutting or doing some such thing are rare. Moreover, one is born weak and strong with respect to one and another of these such diseases. For whatever parts are colder by nature, these are affected easily by chilling causes; the hotter ones, by heating; and the some logic applies to those imbalances with respect to wetness and dryness. For it is demonstrated that although some parts suffer readily from heating or chilling or drying or wetting causes, nevertheless there is another stronger part able to efficiently send off its own suffering into these weaker ones.

128. Since ‘stronger’ part and ‘weaker’ part are not spoken and thought of simply, but in many different ways, it is not possible to evaluate this passage nor to know whether it is true or false. But it is possible to say one thing with reference to this passage, and with reference to all the others written about things which are often said and thought ambiguously: that their account is so confused and inarticulate, that no one in the audience is helped by it.

128-130. And indeed there is a strong counter-argument against this passage, where he says "whichever diseases go from the weaker to the stronger are the most easily released. For the flux is easily locked out by the strength." Wherefore, exegetes have written different explanations of ‘apokleizetai’ (is locked out): some taking it as ‘apokleizetai’, some as ‘apokleietai’ (is shut out), and some as ‘apopagiosetai’ (is curdled), expanding the third syllable from the end of the verb ‘apopagiosetai’ with the omega, some with eta and sigma, just as Dioscorides says this verb is taken from ‘pagesesthai’ (to be made solid), instead of ‘apokrouesthai’ (to be beaten away). But the offending humor, driven from the weakest parts to one of the strongest parts, would be repelled in turn and nothing much would happen from this to someone suffering thus. It is better to write the passage in this way: "for the flux is released by the strength,’ that is, having been cooked and altered, it is released. Some, making a false argument, say that the most essential parts are the strongest. For it is best for the offending humors to be moved from the most essential parts to the less essential, not from the less essential to the more. For we often observe, that when humors are carried into the limits and repelled into the joints and feet, if they go into some essential part there is only one hope of saving the dying man, and that is if we should be able to drive the humors back into the limb.

130-132. "The thickest blood vessels are arranged in this way: there are four pairs in the body, and the first of them reaches from the back of the head through the outside of the neck and along the inside of the spine and inside to the loins, and into the upper legs, and then it passes through the lower legs to the ankles on the outside and into the feet. Bloodlettings to treat pains in the back and loins should be made from the hams and the outside of the ankles. The second pair of vessels, having its origin from the head by the ears, through the neck, is called the jugular: they go from the inside of the belly along the spine on either side, and along the loins and into the testicles and into the thighs, and through the hams from the inner part, and then through the lower legs to the inner ankle and into the feet. Bloodlettings against pains in the loins and testicles should be made from the hams and the inner ankles. The third pair goes from the temples through the neck under the shoulder blades; then they are carried to the lungs and one reaches from the right to the left and the other from the left to the right. And the right-hand one goes from the lungs below the breast and into the spleen and the kidney, while the one from the left goes into the right-hand side through the lungs below the breast and into the liver and the kidney, and they both end in the anus. The fourth pair goes from the front of the head and eyes under the neck and collar bones, and then from the upper side of the upper arms into the elbows and then through the fore-arms into the wrists and fingers, then from the fingers back through the hands and upper side of the fore-arms into the elbows and through the lower side of the upper arms into the armpits and from the upper ribs one reaches the spleen and the other reaches the liver, and then they both end by going over the stomach into the genitals. And this is how the major vessels are. And there are also vessels from the belly, of many sorts and in many places all over the body, through which nourishment comes to the body."

132-134. Of matters in dispute based on skill, observation decides some, and reasoning decides others. Things decided by observation, therefore, require a finely discerning observation, and those decided by reasoning require a well-trained argumentation. Concerning the digestion of foods in the stomach, and after that, the generation of humors and the distribution and nourishing, and with respect to other such things, we lack an argumentation to determine the opinions written by the ancients. To know whether ruminants have four stomachs and sheep have one, observation is required, not reasoning. On the other hand, both matters decided by observation and those decided by reason possess a way of testing what is untrue. For although matters decided by observation bring the readiest decision to those disagreeing with each other, based on the evidence from dissections, nevertheless those decided by reasoning can be decided from written arguments without dissection. So, if someone is compelled to use written works to argue against people who boldly assert the most shameless and uneducated things concerning some anatomical theory which should be decided by observation, those who are not familiar with the evidence from dissection are unable to distinguish what is false from what is true. For, just as if someone were to say that Crete is not an island, he would be scorned by all of those listening, since they would know it is an island, so too if someone were to say that dogs have four stomachs, but ruminants have one, he would be laughed at in the presence of those who have seen the four stomachs in ruminants and the single one in dogs. And it is the same thing with the dissection of blood vessels. For the decision requires observation, not reasoning. And until those who differ in opinion from the passage above write their own works, just as they wish, the truth will continue to be unclear to those who have not performed dissection.

134-138. We, who have reached such a different opinion from those who dare to say in this present account that four pairs of vessels reach from the head into the body, are unable to give a strong argument from written sources to those people who are ignorant of matters with respect to dissection, because this decision requires knowledge from observation alone, not from logical reasoning entirely -- we are unable to give a strong argument, that is, unless someone selects those writings concerning the investigation of judgment by other physicians and philosophers (not the least of whom are the Empiricists), and is willing for the judgment to be made according to these writings he has selected. For I do not avoid other such tests and consensus of investigators, especially if they are experienced in the matter being investigated, such as Eudemus, and Herophilus the dissector, and Crateuas and Dioscorides of pharmaceutical metals. For if someone shuns this sort of judging, not only will they be unable to demonstrate that there are eight vessels coming from the head, but not even that there are three or two. For there is a single greatest vessel, which they call ‘koilic’, stretched through the lobes of the liver along the length of the living creature, clearly passing through the diaphragm region of the creature below and above. This same ‘koilic’ vessel is carried up through the diaphragm region to the heart, and also down to the spine, entering in against the lobe of the liver, and then all of the vessels of the upper diaphragm are clearly seen springing from the vessel carried up as if from a tree trunk, while those of the lower diaphragm spring from the vessel curved against the spine. These things have even been written by Hippocrates in the second book of the Epidemics: he called the ‘koilic’ vessel the ‘hepatic’ and it is written in this way by all the anatomists. For no other physician says there are eight vessels leading from the head down into the body, not among those performing dissections less carefully and not among those performing them very carefully, neither Diocles, nor Praxogoras, nor Erasistratus, nor Pleistonicus, nor Philotimus, nor Mnesitheus, nor Dieuches, nor Chrysippus, nor Aristogenes, nor Medeius, nor Euryphon nor any other of the ancient physicians. And what is there yet to say concerning those who have added to the anatomical theory after them, like Herophilus and Eudemus, to whom no one has yet added anything in methodology, up to Marinus and Nomisianus, not even Heracleianus, who was my contemporary, but not my colleague, in Alexandria. For there are many students of these men, and others, the most distinguished being my teacher Pelops (student of Nomisianus), and Quintus, student of Marinus. But although Quintus wrote no book on anatomy or anything else, nevertheless we do have not a few books of anatomy by all the others. And there are anatomical writings by the students of Quintus, such as Satyrus, and our teacher, and Lykus. So, of all of these, and of the many anatomical writers besides them, no one recognizes four pairs of vessels leading from the head. For this is like saying there are eight Acropolis’ in the city of Athens when there is only one. Indeed, it is possible for someone to say that there are eight inhabited hills in Rome, just as someone may say there are six. For each of them is off by one. But if someone were to say that there is one inhabited hill, instead of seven, or on the other hand, that there are eight Acropolis’ in Athens instead of one, they would differ from someone telling the truth by much more than one. Thus, since there is one single vessel carried up from the lobes of the liver into the upper body (or if someone starts the dissection from above, it is said to be carried down rather than carried up, but still one single vessel is observed), someone saying that eight vessels are carried down from above would be most ridiculous. For whether you wish to say that the ‘hepatic’ or the ‘koilic’ vessel is carried below from above, or carried above from below, it is still the same single one stretched through the lobes of the liver. So if some anatomy book by someone else has been found having such an opinion, no one has taken the opinion further, nor dared to acknowledge it step by step. Rather, upon hearing this one proposal, that there are four pairs of vessel in the body, anyone would condemn it as if stunned, and immediately withdraw from the proposition. But since someone has added this writing to the treatise of Hippocrates, we have been forced to allow this much time to be lost, as we are still spending arguing against this opinion, and have spent before now, inasmuch as we recognize that these things are wretchedly written.

138-142. He says that a pair of blood vessels starts from the back of the head, and is carried through the neck, and then, traveling from the outer parts along the spine to the loins, from there goes through the leg into the outside of the ankle. And he says that another, second pair arises from the places near the ear, and goes through the throat, being known as the jugular veins, and then, like the first pair, from the outer parts along the spine, so it then goes from there inside to the testicles and thighs, and then reaches through the knees and to the ankles on the inside. Who, having seen the dissection of animals, on hearing these things would admit them for even one day? For although there are many poorly explained observations in dissections, concerning which it is reasonable that someone might make a mistake since they have not completely thrashed it out in practice, and for this reason disagreements concerning them have arisen, still the sight of the greatest blood vessel is so clear, that no one who has been able to learn anything from dissection would be able to overlook it. This is agreed on by everyone to such an extent that even the poets know it. Indeed, Homer says (Il. 13.546-547): "He cut away that entire blood vessel which, placed at the top of the back, reaches entirely through the neck." Therefore he knew there is one single vessel, as in fact there is, not four vessels with two from the outside of the spine, and two more at the same spot stretching alongside them on either side of the spine. But no creature possesses four vessels as the fabricator of the anatomy described here has written. Instead, the blood supply for whatever is between the limits of the back comes from the single great blood vessel, as Hippocrates wrote in the second book of the Epidemics: "The upper limit of it against the collarbones, and the lower limit against the eighth vertebra" and the upper splits into the jugular veins, and the lower into the vessels carried into the legs. For how could the one who wrote about this second pair suppose that the two jugular veins, persevering, are carried along the spine out from the inner parts to the legs? How could they reach the ankles? For, since there is one single large vessel leading into each of the legs, it is not the case that the vessels of the inside of the ankles come from one vessel, and those of the outside of the ankle from another; but rather they are all offshoots of this very vessel. Even more laughable than these is the third pair, which he says originates in the temples and is carried through the neck beyond the shoulder-blades into the lungs and then from there the two members of the pair exchange the straightforwardness of their direction, and are turned to the side, the one from the right-hand parts going to the left, and then reaching below the breast to the spleen and the left kidney, while the one from the left-hand parts goes to the right, then under the breast to the liver and right kidney. And both end in the anus. But the anus, my brilliant friend, as someone arguing against the writer of these things would be likely to say, receives a bloodstream from the entrails in this spot at the loins, whence it happens that the bloodstreams of the belly in each part are carried into the legs like some great conduits. Moreover, what physician, what butcher even, is unaware that blood is carried from the heart to the lungs through a single vessel. But the inventor of this third pair makes no mention of the heart anywhere in his account. Rather the present treatise assumes that the heart, which some dissectors say is the source of all the blood vessels in the body, possesses not one blood vessel. For he has said that the fourth pair originates from the front of the head and the eyes, and goes past the neck pressed against the collar bones, to the arms, namely to each individual hand, and then from the upper parts becomes entangled in the fingers, and is carried back through the entire hand and arm to the armpit, and from there goes through the ribs, one to the liver, the other to the spleen, and then, carried from the stomach, they both end in the genitals, so that they give no share whatever to the heart. How, finally, could the one fabricating these things like a young Prometheus have overlooked such an important organ as the heart? Indeed, he made no mention of the brains. For clearly this is less noble than the ankles! And beyond all this even is the blindness with respect to the kidneys, to which great vessels are carried from the belly; overlooking these, he has imagined that some vessels are carried from the lungs to the kidneys. So it is clear from all these things that he has not merely mis-observed, as some dissectors have mis-observed some things, but that he has observed nothing at all. For someone who does not observe the most important things is truly not described as mis-observing, but as not observing at all.

142-144. No one who has set to work at all observing something at dissections would be unaware that his theory about vessels being carried down from the head into the whole body is like a drunken hallucination. For although it is likely that dissectors may mis-observe some small blood vessels, someone would certainly not write another, entirely different account, nor leave out things which can be distinguished by blind men, as it were, using their fingers to touch. In truth, there is one vessel, through which blood is carried from the liver into the entire body, with small vessels branching off from the liver like many shoots from a trunk, which carry the blood to all the parts of the creature. And if you compare the blood in the belly to a river, and compare that which is carried from it into the parts of the body to a pipe, you will not be mistaken in this image. But if someone were to say that the large blood vessel is like a river or tree trunk, every physician would agree that this is a single vessel, except for the one who has audaciously added four pairs of vessels in this book. For in contrast to the others, just as he has allowed the heart to be overlooked, so also he ignores the ‘koilic’ vessel, although he does remember the jugulars, into which it is split at the upper neck. For the large vessel dominates whatever is between this place and the limits of the spine, having offshooting vessels on either side. It is split in two at each of the limits of its parts: at the top, large vessels are carried through the throat, called jugular, and at the bottom, as has been said, one single large vessel is carried to each leg. But when he made note of the vessels carried through the throat, the jugulars, in the second pair, this young Prometheus showed great ignorance and boldness by nowhere noting the ‘koilic’ vessel as it splits, from which these jugulars arise. For if he had seen the smallest thing in dissections, he would have had to say that the jugulars, going towards each other, end in this one vessel, the ‘hepatic’ vessel, or ‘koilic’ vessel, or whatever else someone may want to call it. But the argument was written by someone saying that two vessels. perservering, are carried through the inner parts along the spine to the insides of the ankles.

144-146. Why, then, would anyone make note of the vessels which he has written about after the four pairs? He claims that these carry nourishment from the belly into the entire body, as if the afore-mentioned four pairs were generated for some other function by nature, and did not have the single function common to all blood vessels: to carry blood from the liver to all the parts of the creature. For not one of those distributing the juices from food, from the belly and intestines into the liver, goes further than the liver. But they do not seem to be at many places in the liver, although they are great in number, attending to the stomach and other intestinal organs. Rather, they all reach to one spot, which is called the ‘portals’ of the liver: the one who first assigned the term ‘portals’ to this place was comparing the liver to a city or to some great dwelling, and the intestinal organs to the fields from which the food is carried into the gates of the city or dwelling as if through many roads, the blood vessels. But the young Prometheus is foolish in this creature which he has concocted according to his own theory. For someone would not make up a creature with these attributes, a creature in which the vessels carry nourishment from the intestinal organs directly into the body. For in fact they all reach into one spot, the portals of the liver, and from there the vessels receive the nourishment prepared in this organ, and go out again to the ‘koilic’ vessel from which, as I said a little above, the blood is distributed into the entire body

146. "They also carry from the thick vessels into the belly and into the rest of the body from the outside and from the inside, and they give to each other; from the inside to the outside and from the outside to the inside."

146-148. Four pairs of vessels are enough for the young Prometheus, but he is not satisfied, and from greediness he has disgraced himself by adding to these the vessels carrying nourishment from the belly into the body. Now he has added to the argument a colophon about the common features of blood vessels, saying nothing true. For not one of these vessels flowing from the koilic vessel, which he terms ‘thick’, seems to be distributed into another pair flowing in the belly or internal parts. But just as the fabricator of these things had said nothing true in the anatomy which he proposed, neither entirely, nor in even one passage, so Hippocrates says nothing untrue at all in the second book of the Epidemics. But those who attempt to make an exegesis of the books of Hippocrates, not grasping even the outline of anatomy, are out of their minds, and especially those calling themselves Hipppocratics, who suppose that all this nonsense on the anatomy of blood vessels, and the second book of the Epidemics, were both written by the same man. If indeed something additional were to be theorized concerning the second of these, it is possible that the same man, with the passage of time, becoming more skilled with respect to what he had written first, would judiciously set out a second work. But then Hippocrates himself would seem to have described meticulously not only those things clearly visible to all, but also to have mis-observed things which even someone performing a dissection without sight should discover by touch -- how is it possible for the same man to have written both of these? By what logic would someone, having written an argument concerning the elements of man, tack on to it in turn a discussion about blood vessels? For either one should write about anatomy in its entirety, or not write about blood vessels. Although such a variety of theory is acceptable in outlines which we write for our own recollection, nevertheless in a treatise it is not at all acceptable for some part of a second teaching to be added to the first after it has been completed, and then, a little later, to write the remainder about something a bit different, or entirely different, as is the case with these things attached to the book On the Nature of Man.

148. "Bloodlettings should be performed according to these principles."

149. He has already said these things clearly about the first pair of vessels, having set this down at the end in this sentence: "Bloodlettings for pains in the back and loins should be made from the hams and from the outside of the ankles," and adding this to the second pair of vessels: "Bloodlettings for pain in the genitals and testicles should be made from the hams and the inside of the ankles." He does not say anything about bloodletting with reference to the third and fourth pairs, in the same way as he constructed a defective account about these things, omitting many parts of the body in which he ought to have said there are vessels to be opened. But just as he has written detaching some small piece of the entire subject of anatomy, so also he detached the accounts concerning bloodletting.

149-150. "One must be careful to make the cuttings of the vessels as far as possible from the places where the pains have been discovered to originate, and the blood to collect. In this way the change will be the least far-reaching and sudden, and you will change the habitual course, so that the blood will no longer collect in the same spot."

150. The exegetes have understood correctly, that he says ‘cuttings’ in reference to what we describe with the compound word ‘bloodlettings’. And they all agree on this: that he has not further differentiated whether he approves of opposition to flowing humors starting when the parts of the body are already in pain, or starting in a period of health. And for this someone might blame him. But it seems to me that he is speaking about healthy people, and assuming that the excessive humors are carried into other parts.

150-152. "The ones who spit up a great deal of pus without there being a fever, and the ones who have a great deal of pus standing in their urine, without pain, and the ones with bloody evacuations, just as among those with dysentery, with this persisting for a long time, and they being thirty-five or older -- to all of these a spontaneous disease has arisen. For it must be the case that they were hardworking, exerting their body, and diligent when they were young, and then later, removed from their toils, they became fleshy with a soft flesh very different from before, and their body is quite changed, from the earlier one to the one which it has become, so that there is no correspondence. So, when some disease strikes men in this condition, they escape to begin with, but later, after the disease, their body wastes away in time, and ichor-like material flows through the vessels where they happen to be the broadest. If it presses on to the lower belly, then the fecal matter becomes like the matter which is inside the body, for since the path goes down, this material does not stand long in the bowel. For those into whose chest it flows, suppuration arises. For since the exit is going upwards, it sits for a long time in the chest and becomes pus-like. For those in whom it empties into the bladder, it becomes white due to the heat of that place, and separates, and the lightest goes up and the heaviest goes down and is called ‘pus’".

152-153. All the things said in this passage are clear and should be paid attention to, without an exegete interpreting. And if they are all true, they should be put to the test of observation and the test of logic. As for the test of observation: it is to see if some people without fever are observed either coughing up pus or excreting something in their urine, and in addition to this, if they were hardworking in their earlier life, but now have ceased working for some time, and if when they were sick they survived, but later these afore-mentioned pus-like excretions afflicted them. By logic, it can be decided whether the cause from which the writer says these things have occurred is true or false. It is clear to those experienced in the explanatory method that the things said by this author are not so by necessity. For if this account had a persuasiveness, then each person would see it for himself. Concerning the observations of experience, I may say this to you that I have seen bloody excretions from the stomach occur not infrequently in those who have put an end to the habit of strenuous exercise, but never pus-like excretions. I have often seen mucus-like excretions from the stomachs of these men, in both wasted and healthy periods, as also the material coughed up has been putrefied, but it is not pus-like.

153. "Stones occur in children because of the heat of that place and of the entire body."

154. "Of that place", clearly meaning "of the bladder", concerning which he wrote thus at the end of the first passage: "For those into whose bladder it flows, it becomes white due to the heat of that place." So he says that stones occur in children because of the heat of the bladder and of the entire body, and then he speaks next about the heat of children.

"For one must know well, that man is hottest on his own account at the beginning of his life, and coldest at the end."

154-155. The account of those who say simply without qualification that man is hottest at the beginning of his life is not true, but with a qualification it is true. For he is hottest, if it is derived from an ‘innate quality’. And this is the case with most children. The writer of this present passage has misunderstood the most crucial thing in this account, as will be clear from the following passage. For he has not realized, as Hippocrates said, that "those things growing the most possess a hot innate quality", and Hippocrates himself understands it so, but without this term "innate quality", he would have simply thought that growing things were hot.

155. "For it is necessarily the case that the body which is growing and spreading is hot due to the life-force."

155-156. Although Hippocrates says "those things growing most possess a hot innate quality", this person seems to have understood simply that for things which are growing the body is hot, without the term "innate quality" being added to the account. For he says that this very ‘spreading’ comes about due to the "hot life-force". And he wants to explain such a spreading due to life-force in this way: it seems to him that growth is some vigorous and vital action, and further, that just as other vigorous actions heat the one performing them, so growth does as well. But, on the contrary, he should have said that children grow due to the hot innate quality, not that they become hot due to the growth. For the hot innate quality is not only well-balanced with respect to heat, but also with respect to wetness. Thus such bodies, grown naturally for things which are extending in three dimensions, as if dispersing, take the increase in all these dimensions. Nature, therefore, extends these dimensions in every organ innately suited for this, using the heat. For it is readily extended by means of wetness. Indeed, many children, when they eat large amounts, concentrate the humor specifically termed ‘raw’, from which stones easily arise, since, although this humor from which the stone is formed possesses a name taken from its material, nevertheless, the productive cause is from heat.

156. "But when the body begins to waste away, running down easily, it becomes colder."

156-157. Here again, when the body no longer grows for those past their prime, he says that it becomes colder due to idleness. But, on the contrary, there is a better explanation of the cause. For as the hot innate quality becomes less in the body, the growth ceases. The author of these things has made his own opinion clearer in the following passage:

157. "And according to this account, inasmuch as a man grows the most at the beginning of his life, so he becomes hottest then, and at the end of his life, inasmuch as he wastes away, so he necessarily is coldest."

We have correctly explained the passage in which he said "...for it is necessarily the case that a body which is growing and spreading is hot due to the life-force." For, on the contrary, he ought to have said that the growing thing grows due to the hot innate quality, not that it becomes hot due to growth. It is analogous to this for someone past their prime, when they are no longer growing: he thinks that the coldness arises due to a resting from the earlier action of growth which has now ceased.

158. "People in this condition become healthy spontaneously; most of them doing so in a space of forty-five days after they began to ail, but whichever ones exceed this period of time, will spontaneously become healthy in one year, if the patient is not attacked in some other way."

158-160. Who are the ones he says are "in this condition"? He clearly refers to those who, having stopped exercising due to idleness, cough up and urinate pus, and are afflicted with dysentery. Although I have said that I have seen many who have exchanged their earlier life of exertion and toil for a sedentary one, afflicted with bloody dysentery, yet I have not seen any of these coughing up or urinating pus. But he seems to me to be saying that the humor termed ‘raw’, when it has undergone coction, is pus. Why is this to be marveled at, when even Erasistrates supposes that the sediments in urine are not this humor, but pus, not knowing that such matter often settles out for the heavy eaters among healthy people. Indeed, over the course of time, we have seen a variety of matter resembling that which is called mucus excreted in the urine, in various kinds of men leading idle lives. And for some of these people, the excreted matter, having made a slow passage, seems to resemble pus, just as for those who bring up pus when they breathe, because such matter, being retained for a long time, undergoes coction. He gave the cause of this earlier, saying that, for dysentery, the downward passage is the cause of the quick exit of the excessive matter. On the other hand, for those coughing up matter, the upward direction of this passage is the cause of the slow exit, and for those with matter in their urine, the cause is the heat of that place. If someone does not agree that there is a difference between pus and the ‘raw’ humor in urine or coughed-up matter or in evacuated matter, this person is in one or the other of two situations. For either he is willingly playing the villain opposed to this teaching, like Erasistratus, claiming that all fevers arise in phlegmatia, or he is a sophist who is unacquainted with the works of this art, whom the ancients correctly termed a ‘logiatros’ (i.e. ‘doctor in word only’). For pus differs from the ‘raw’ humor in color, substance, and smell. And an excretion of the raw humor occurs from the nose and mouth in periods of good and bad health, but the author of this passage above does not bear this in mind.

160-161. He probably said that people in this condition recover "spontaneously", as meaning "without our doing anything." For nature will purify them independently. It sets a day for them which is assigned in two ways: one time according to the time of year in which the afore-mentioned excretion happened to start, and the other time extending for one year, but also the short time reaching to forty-five days. Some do not write forty-five, but forty. But I, who have seen many people cleared by nature in this way, know that there are not merely two times for emptying, but a great many. One person is cleansed finally on one assigned day, and another on another, some on the fortieth day, and some extend to an unequal number of months, but there are those who have this persisting throughout the whole year.

161. "Whatever diseases arise suddenly and whose causes are well-known are clearest to prognosticate about. It is necessary that their cure be accomplished by someone opposing the cause of the disease. For in this way the thing in the body which is allowing the disease may be released."

161-162. In this passage he seems to disagree with what is said in the Aphorisms (2.19): "The prognoses of severe diseases are not entirely clear, whether of recovery or of death." And Sabinus himself, when he attempted to resolve this, chattered on, but said nothing reliable. And so did many others who were making an exegesis of this book. And it seems to me that they do not understand what ‘suddenly’ means. Indeed, they think the term is used for severe diseases which last a short time. But it is not appropriate to use this term in reference to these, but rather, for those diseases having an origin from clear causes, it should refer to one which has arisen in a brief interval of time, as opposed to a longer interval. In these cases, the prediction of what will happen is quite easy, because it is well known what sort of cause there is and how great it is. Those diseases which arise suddenly after a long period of time possess no clear cause of origin, and in the same way their prognosis is not clear. And the immediate causes of diseases are: overheating, chills, sleeplessness, distress, worries, indigestion, sleeping on a hard bed, toil, drunkenness and other such things. For this reason, therefore, he says that "the cure of such things is accomplished" by what is opposite to the "cause" of the disease, such as cooling if one has been overheated, heating if one has been chilled, resting if weary, exercising more if habitually idle, draining if overfilled, filling if drained, just as he said in the earlier passage which began "whatever diseases arise from fullness are cured by draining."

163. "In the case of those in whose urine there is sand-like material or chalk as sediment, a swollen mass arises at first in the thickest vessel, and it suppurates. Then, as these masses do not quickly break out, chalk grows out of the pus, and is shed through the vessel into the bladder with urine."

If this sort of urine occurred for the reason which he assigns, it would occur when the kidney itself is similarly afflicted, without the large blood vessel being involved. For the excretions in the urine which are so described often occur without swollen masses, when a sufficiently thick or viscous humor, making a slow exit-passage, is dried by the heat of that place and congeals.

"In the case of those whose urinations are merely bloody, the blood vessels have suffered."

164. It is not clear what this "have suffered" is said in reference to. For it is possible that it means "to be worn out", as these vessels have become weak, and the blood half-cooked, and it allows this to flow easily because of looseness. Or, to judge in another way, it is possible to explain it as "suffering", as apart from "being worn out"; with the kidneys themselves suffering nothing, but the condition existing in the blood vessels alone. Indeed, from such an exegesis it is not clear what sort of condition it is. But it is quite clear that neither Hippocrates nor Polybus would have said ‘urinations’ (ouremata), being able instead to say "in the case of those whose urines (oura) are bloody." For Hippocrates, although he certainly often writes the word ‘urines’ (oura), uses ‘urinations’ (ourema) in no expression. And many other added writings are shown clearly to belong neither to Hippocrates nor to Polybus.

164-165. "In the case of those who have small filaments of flesh in their urinations, which are thick, it must be known that these are from the kidneys."

165. Here he rephrases the Aphorism: "in the case of those who have small pieces of flesh, like hair, pass in their urine, this is being excreted from their kidneys."

"In the case of those with clear urine, who now and again have something like bran carried in the urination, their bladder is flaking."

Again he is rephrasing this Aphorism: "in the case of those having something bran-like passing in their urine, which is thick, their bladder is flaking."

166. "Most fevers arise from bile, and there are four specific ones, apart from those arising in separately distinguished ailments. Their names are: the continuous, the quotidian, the tertian, and the quartan. The one called continuous arises from the most abundant and purest bile and it reaches the sharpest crisis, after the shortest period of time. For the body has no time to cool inasmuch as it is heated by great heat. The quotidian, after the continuous, is from the most abundant bile, and finishes more quickly than the others. But it is longer than the continuous, because it arises from less bile and because the body has a rest, while in the continuous fever it rests at no time. The tertian fever is longer than the quotidian and arises from less bile. By however much more time the body rests in the tertian compared to the quotidian -- by the same amount is this fever longer lasting than the quotidian. The quartan fevers relate to the others following the same reasoning; they are more long-lasting than the tertian, to the extent that they have a smaller share of the bile which produces heat, and the body takes part in more cooling. This excessive length and tenacity arises for them from black bile. For, of the humors in the body, black bile is the most viscous, and holds its place for the longest space of time. And you will know by this that the quartan fevers have a share in black bile. For men of an age between twenty-five and forty-five are most likely to be afflicted by quartans, and most likely to be afflicted in the autumn. And of all the times of life, this is the one most governed by black bile, and of the seasons, autumn is the most governed. The ones who are afflicted by quartan outside this season and this time of life -- it should be known well that their fever will not be lengthy, as long as the man is not suffering from anything else."

167-169. Many of the exegetes, Sabinus among them, seem to me to be affected in a similar way as when a man was ailing with dropsy, and the physician Philotimon thought it appropriate to treat him for hangnail. For it is one of two things: either he does not see how completely ill the patient is, or he does not suppose that treatment is necessary. And thus one must consider that the exegetes either blot out the eye of the mind, or that they suppose that minor complaints require some treatment, but that serious ones do not require assistance. As if wakened from a deep sleep, they perceive the disagreement with Hippocrates made in this passage here, which claims that the ‘quotidian’ fever lasts less time than the ‘tertian’, while Hippocrates has clearly said in the first book of the Epidemics and in the Aphorisms "the tertian fever comes to crisis the most quickly." So they have said that this is not a Hippocratic text, since it clearly says things which are untrue and since it differs from what is written elsewhere by Hippocrates. For in this place alone they understand that the writing which has been appended is false, and disagrees with writings of Hippocrates elsewhere. And if it is in this section alone that they notice that the appended writing is false and disagrees with Hippocrates, then they resemble someone seeing a hangnail and not seeing that the entire body is in a most serious condition.

169-170. Someone who is unaware that the ‘quotidian’ fever is longer lasting than the ‘tertian’ fever shows that, on the one hand, he is not skilled in medical works, and, on the other, that he has not constructed a lie due to the madness of someone shameless, but that he was roused by a trusted account, and especially since it seemed to some of the ancients, including Plato, that constant fevers arise from an excess of fire, quotidian from an excess of air, tertian from an excess of water, and quartan from an excess of earth. For a passage from Plato has these very words (Timaeus 86a3): "The body suffering from an excess of fire ends up with constant inflammations and fevers; the one suffering from an excess of air, with quotidian fevers; tertian fevers afflict one suffering from an excess of water, on account of it being more sluggish than air and fire; and an excess of earth, the fourth, most sluggish element of all, which, having been purged, hardly ceases in a fourfold period of time, causes quartan fevers." So if Plato says the most sluggish element, as it is the most settled and least mobile, is cleansed out in a four-fold period of time, it also seemed convincing to differentiate the others from each other by the same analogy, so that it would happen for the next earth-like element, which would be water, that it would be associated with the next closest to a four-fold period, and that the next element again (which is air), would cause the quotidian, and the quickest (which is clearly fire) would cause the continuous fever.

170-171. But more reasonable than this is the account which assigns the reason for the origin of the fevers to the hot element of nature, that is, fire. For it is not good reasoning for the hottest condition to come about from an excess of the cold element in the body. In fact, if it is reasonable that the hot condition comes about through an excess of the hot element, then the fevers differ from each other by differences which should be ascribed to the amount of the cause (i.e. the hot element). And if, indeed, we concede this: that the most constant and hottest fever arises from the most fire, and the next hottest has the second place in amount of fire, and the tertian fever the third place, and quartan fever the fourth, then the dissolution of these fevers will be dependent on the causes: the quickest dissolutions from the hottest fire, the second quickest from the quotidian, the third from the tertian and the fourth from the quartan. So, to the extent of plausibility, these are well said, but the result of the investigation of actual practice disproves the account. And, having nothing reliable to say in his added writing on the anatomy of blood vessels, the one who has fabricated this seems to have been lying not once or twice or three times, but many times entirely, and, in addition, not saying one true thing among these, even by chance.

171-173. It is to be marveled at, with reference to these exegetes, how they object to nothing by the one who wrote all the text after the On the Nature of Man up to this point, but now they do object and on this account it seems to them that the entire book is not Hippocratic. Someone may marvel further at Sabinus and most of the exegetes, that they were always praising all these added writings: this thing was written amazingly, according to one man, and that thing miraculously according to another; and another thing divinely according to yet another. And now, suddenly they have forgotten all this, and because of a single conflicting opinion, the book seems to them not to be Hippocratic. But they shift it to Polybus, since they are acquainted with the Aphorisms and the first book of the Epidemics, but Polybus was not. Polybus, as the student of Hippocrates, must have heard from him many times concerning the differences of fevers, and not a few times must have been acquainted with his writings along with this, and have seen that in illnesses the tertian fever is the quickest to reach a crisis and the quotidian the slowest. For Polybus was not one of those who expounded at Alexandria; not one of those who, having observed nothing yet, afflict the sick person with their skill at guessing, saying nothing sound, and nothing about those things which skillful ones see clearly revealed in illnesses. So the one who has written these things was either such a sophist, or a quack, as seems likely, having appended this lie so that blame might be inflicted on the ancient author. The term, ‘continuous’ (sunokhos) is proof that the added writings are more recent. For in no place does Hippocrates, nor any other ancient writer, call the ‘constant’ (sunekhos) fever ‘continuous’ (sunokhos), just as he does not call ‘urines’ (oura), ‘urinations’ (ouremata), but these are terms of more recent physicians who were ignorant of the ancient wording.

173. Now, leaving these added writings behind, we turn to the On the Regimen of Good Health, which they say is a work of Polybus.

Posted 2/1/98; © 1998; last revised 2/1/98. Send suggestions and comments to Lee T. Pearcy, lpearcy@ea.pvt.k12.pa.us.