Tuesday, June 21, 2011

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.  


  1. Descartes is a personal favorite of mine because of his stance on thinking and the mind. Nice post!

  2. I've read something about changed personalities after larger transplants – changes in both feelings (love, temper) and carvings/food preferences. People talk about having to re-learn to love their spouse.

    I don't think my feelings literally origins from my heart muscle... But I also seriously doubt that they only exist in my brain.

    Food for thought. ;)

  3. I get the feeling that the Amercian medical system may be leading us away from the traditional Western medicine towards over reliance on imaging and tests. When I recently spent two months on a rotation in a San Diego hospital I was shocked at how little history-taking and physical examination we were expected to do. History was limited to a few questions on how the patient spent the night. Examination was a perfunctory pulse checking with the vitals copied down from the nursing log. Every patient was getting daily bloods and x-rays. The attending was so impressed when I was presenting a patient's abdominal signs.
     Here in Australia we are still expected to be able to diagnose aortic stenosis with a stethoscope. Requesting an abdominal CT to diagnose appendicitis is almost an admission of failure to interpret clinical signs. Medical exams are still in the form of "long cases": one hour in a room with a patient to come up with differentials, a list of investigations and a management plan. 
    There is still a lot of value in traditional Western medicine. Maybe one of the reasons why people start to gravitate towards Eastern philosophies is that they feel that our methods are becoming less and less personal. All the more reasons to maintain those skills.

  4. Anastasia - back when I was in med school there was always the bemoaning of the loss of learning the physical exam skills. AS is not the best example as it is an obvious murmur - and certainly *we* were expected to do very thorough histories and exams. We had the good fortune of being at a couple of hospitals with lots of people who showed up straight from their home country with all sorts of classic advanced disease you typically would not see in an every day hospital - but our anatomy class was 4 months long. "Back in the day" our professors would say: "you took anatomy for 4 years."

    Depending on the rotation we were also expected to have our patient's vitals and lab values and medications memorized for presenting during rounds…and during rounds if you did not know your stuff, you would be very readily embarrassed in front of your peers. (Though there were tales of the "good old days" when, if you got an answer wrong during case conference, the head internal medicine doctor would give you a quarter and tell you to go call your mom because you just failed out of med school.) it was not an easy med school, old school even at the time. Which served me well, I think.

    I don't know what things are like now. I teach second year students at Harvard how to do psychiatric interviews. We expect them to be thorough. We do not publicly embarrass them if they don't follow the appropriate lines of questioning or miss major sections - they are just learning, and we critique them kindly. There is also a ton more to know. All the molecular biology and pharmacology and infectious disease details... in the 1940s after med school you had a year of internship then you were good to go, or if you wanted to specialize, sometimes residencies were a few months long! I spent four years after med school learning psychiatry. Most of my class went on to fellowships after that (a year, or two, or three…).

    Anyway… the other day a patient came to me complaining of new memory problems. Of course I did a rather thorough "bedside" cognitive exam - the initial evaluation takes me an hour. It is rare that it takes me less time. She had already seen a neurologist. She told me (I'm assuming she's telling me the truth) that the neurologist spent 5-10 minutes with her, didn't ask her any of the fairly standard cognitive testing questions I did (and I had her copy figures, draw a clock, read, etc.), but the neurologist asked her a bit about her symptoms, told her to lose weight and "get off some of your medications" and ordered an MRI.

    I don't know any neurologists (or psychiatrists) personally who would consider that an acceptable initial evaluation for a cognitive complaint.
    But it does seem to be the equivalent to the lack of rigor you saw in San Diego.

  5. Obviously I'm drawing from my n=1 experience in the States. I understand that it is very doctor-dependent as you say. I'm starting to see though what our old professors refer to as "the lost Art of Medicine". Isn't it why we can now diagnose an absolutely healthy individual with a fictitious disease (hypercholesterolaemia) based on one number on the blood test and then give them drugs to "treat" it? Thank you for your blog. Psychiatry is not my strong suit and I'm enjoying supplementing my education with your articles :)

  6. Late comment:

    I love your blog first off!

    I don't mean to sound synical, but I feel like they are either diagnosing fictitious diseases OR they are ignoring potentially serious disease by saying: Go lose weight...

    I know too many examples of the latter. It's frustrating.


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