A Treatise on Treatises: On the Movement of the Heart and Blood (Part 1)

To be perfectly honest, this started out as one of my lecturers' many "fun" assignments. Very subjective word because in my world that usually entails playing games, reading manhwa, a novel or my slew of hobbies — touched and untouched. Your run-of-the-mill nerd stuff. Hell, it's not exactly fun to work on something when all you're thinking about is how else you could be spending your birthday but well, such are the wiles of life. Anyway, now that I've eased up with that diatribe and you've shared in my suffering (how compassionate you are), let's get to the heart of the issue at hand... Fine. I get it. No puns. I guess you don't like my humour. HA! I lied. And yes, I know it was a cheap shot. It's about to make sense too.

Allow me leave to put you in a frame of mind. If you've read Homer's Odyssey and Iliad, you'd soon think "Wow, these people are raging alcoholics." I mean you'd get a whole paragraph describing a krater (wine mixing bowl for the uninitiated) with such tactile detail and these people would wake up to bread and watered-down wine. That doesn't make sense until you realise that they lived in a time where safe drinking water was rare as sighting the odd red Ferrari in Bulawayo's streets on a Tuesday afternoon. They were as observant as you or I today, enough to note that if you drank water you were very likely to fall sick but they as well noticed that if you mixed it with a little wine it'd be very safe for the natural organic acids and tannins and such chemicals that served an antimicrobial effect (well, they didn't know about the chems, just that it worked). Besides, it made the water a little less insulting to the palate plus who'd say no to a mellow buzz, huh? All this to say we're looking at a society where their health was grossly held up by alcohol, enough that they had to attribute its existence to a god. Enough that the krater, the mixing bowl, would be used extensively as a metaphor by Galen in his medical exploits.

The ⁠Sarpedon Krater, also known as the Euphronios Krater, is a renowned ancient Greek red-figure terracotta calyx-krater created around 515 BC and used as a bowl for mixing wine with water

You see, Galen was such a man brought up in a world where the answers were laid up to gods, metaphysics and a very hazy understanding of the complex workings of the body. He grew up a study of philosophy intended for a statesman as was fashionable at the zenith of the Roman Empire until his father had a dream where he claims Asclepius, the patron god of health, revealed to him that his son must be steered on the path of medicine. Just this should show you that since antiquity, philosophy and belief cannot be removed from the medicine man or the magician as Carl Jung would put it. We will revisit this point later. Galen at 16 would go on to study medicine at the Asclepieion of Pergamon (modern-day Bergama in Turkey). Following his father's death and with the new fortune, he travelled the world as many of us hope to do someday, and furthered his studies in medicine specifically in Smyrna, Corinth and Alexandrian Egypt.

He returned at 28, to the dark recesses of the Roman Colosseum as a trauma surgeon where he made many observations and reforms that saw only five gladiators die from wounds over 4 years where his predecessors would have dozens (plural) perish from wound-related deaths annually. With this portfolio the man went on to test his ability against rival physicians of his time which saw him do public anatomical demonstrations with animals considering the taboo nature of handling human corpses, something even the great hero Achilles was spited for. I mean try reading a Wilbur Smith novel and attempting to answer a test on Southern African history. You're not getting a passing mark mate. These are the moral nekros law limitations Galen was working with. He couldn't study humans to heal humans, he had to map what he saw in animals onto the manimal and come up with answers on how man worked. His fame brought him into the sights of the Roman elite and boom, he landed a job as the emperor's personal physician. Marcus Aurelius' royal physician. Yes, him. Meditations Marcus. In any case, Galen of Pergamon would go on to live into his 70s writing many treatises and transforming Western society's understanding of the heart, blood circulation and therefore the gross medical understanding of health for 1500 years to come.

A map of Galen's triapses throughout the Roman Imperium in the pursuit of knowledge

Alright. Big breath and onto the proponents of Galen's theories and contributions (miscontributions if you are less forgiving. Shame on ye). Galen built upon Aristotle's, Plato's and Hippocrates' understandings to coalesce a system that would turn into tradition. He developed a tripartite system (a system hinged on three parts), with the brain, heart and liver being the three centres of life. The liver made blood from the food, described as chyle, we ate full of natural spirits which would be sent through veins to the heart for refinement. The heart, thought of as a blazing furnace heated the blood and like in a blacksmith's forge it was quenched/cooled with pneuma from the lungs to become vital spirits before being sent to the brain via arteries. Further cooling refinement into animal spirits occurred in the brain at the rete mirabile, a vascular network at the base of the brain in sheep or bulls but not humans (remember the nekros taboo). These animal spirits drove higher cognition, voluntary muscle control and sensation through hollow nerves. Spirits in this sense were thought of as pneuma, an invisible breath/air that animated or gave life. Much like how we would artistically think of God giving Adam life-breath to animate the clay-man He had made.

Now blood instead of circulating as almost every other non-Western culture thought, was theorised to flow centrifugally (away from the source "centre-fugitive") from the liver to nourish and form the flesh of the body. How it did that was through a particular philosophy rooted system of balancing the four elements. Water. Earth. Fire. Air. Long ago, the four nations lived together in harmony. Then, everything changed when the Fire Nation attacked. Kidding. So, these elements mapped onto fluids they witnessed in the body known as the four humours:

1. Air being Blood. Hot and moist. The sanguine that controlled the character of optimism, socialising and being energetic.
2. Fire as Yellow Bile (Choler). Hot and dry being the choleric energy for ambition, passion and anger.
3. Earth through Black Bile (Melancholia). The cold and dry quality of the analytical pragmatist, quiet and prone to sadness. Sadly enough this actually corresponds to what we see as melena from peptic ulcer bleeding in the digestive tract showing up as black, foul-smelling and tarry stools. That or digested blood in coffee-ground emesis (vomiting). Just to paint a picture of how terribly common disease was that they thought it was a natural part of health.
4. Lastly, Water incarnated in Phlegm as cold and moist. This being saliva and any other clear, whitish, watery or thick secretions like mucus, tears, sweat, lymph and synovial fluid or even blood serum. This pillar controlled the calm, steady, and unemotional temperament.

The Humours: A system conceptualised by Hippocrates and later assimilated by Galen

The flesh of our bodies was made up of these 4 humours in their varying proportions relevant to each organ. Say for your right hand, the body would mix the humours into the master substance, blood, which contained them all and the blood would be cooled by melancholia/black bile (earth) to form bone as per cool and dry qualities. Tendons are formed from an earth-water (black bile-phlegm) mixture for the tough but flexible characteristics. The muscles would be formed of blood (air) for they require vitality, heat and soft moist volume to have mass. For the hand to actually move, sense touch and have life, it needs the active force of fire (yellow bile) to introduce hot and dry energy to animate the hand transported by the spirited blood of the arteries. This system also corresponded to what they'd note from blood that is allowed to sit long enough to separate into partitions like modern-day centrifuged blood. The partitions mapped directly in this system. Serum layer for Yellow Bile. The white buffy coat as Phlegm. The upper sediment layer of oxygenated Red Blood Cells (RBCs) as Blood and the bottom sediment layer with deoxygenated and discoloured RBCs as Black Bile. You can see how this explanation would have you nodding in understanding. The body was made up of a careful mixture (krasis) of these different humours/liquids. You could think of the body as a kind of krater. Yes, he, not me, said you are a mixing bowl. He was describing the world in the terms available to him in his era. That's a little callback to Vygotsky.

A simplified view into what the tripartite system looked like. Note the open ended system, lack of atria, interventricular pores and the pneuma only pulmonary vein

Blood, the 'avatar' substance, would travel to a limb and be used up as nourishment like the wood Gogo wants chopped for cooking and the organ would disperse the remainder into the atmosphere as heat and invisible fuliginous vapours. It was an open-ended system. Hunger states were explained as a reverse process of organs forming back into lower-quality blood to keep the body nourished which explained wasting in starvation. We discussed the general route of blood's travel but there are a few more details. Veins carried blood to the heart where the right ventricle pumped it through the pulmonary artery to nourish the lungs. Surprisingly, from the lungs, the pulmonary vein was an empty pipe transporting cooling air and pneuma into the left ventricle where it would then be pumped through the aorta to the rest of the body. Big question. How is there suddenly blood in the left ventricle? Well, Galen believed that the septum had invisible pores that allowed interventricular communication, so blood would directly seep into the left ventricle, become pneumatically spirited and spread out to nourish the body in arteries. What was that? Atria? Bah! Such nonsense words will only be seeded some 1200 years in the future by a Da Vinci. For now, pledge your fealty to my tradition. Wan sui, wan sui, wan wan sui! Ahem, so blood was thought not to flow directionally as we understand but more like the tides of a tempestuous sea or river, this way and back that way depending on what amount of nourishment was needed by the organs. You can imagine the arterial pulse would then be explained as a secondary cooling mechanism of the vessels to the blood which also was a form of breathing, ergo we dabbled in a bit of skin-breathing at some point. That about wraps up Galen's theory around the cardiovascular system.

I have more or less illustrated that Galen's cardiovascular system was made as a holistic philosophy tying the body to nature as it was understood in the meanings of the Greco-Roman cosmos. We can now explore what that meant for the regular physician and patient, further discussing why these misconceptions held up long enough to become tradition. The man as monolith. Galenism. Galen's teleological approach (believing the design of man was made purposefully by nature) resonated with the great religions of the region, which naturally assimilated his theories and backed them up with the fervent power of a belief. To question Galen effectively turned into heretical questioning of the orthodoxy. Such were his theories revered by Christian, Jewish and Islamic scholars alike. He already had enough street cred as an emperor's personal physician.

Niconides, Galen of Pergamon.

Health was explained as eukrasis (good balance) and disease as dyskrasis (imbalance) of the humours which, funny enough, has the echo of our modern understanding of homeostasis minus crucial modern concepts like germs and other such disease-causing biologics. Likewise, the aetiology of disease worked very differently from our understanding. Logically the system was closed in that it was only the dynamics and kinetics of the 4 humours but it was also open to environmental triggers that caused disease only through offsetting an imbalance of the humours. Say you walked through a marsh on a winter evening. You would have been exposed to swamp miasma dense in cold and wet spirits resulting in flu-like symptoms — an overproduction of the cold and wet element, Phlegm. You didn't get a germ, silly. The miasma unsettled your humours. We're going to give you hot and dry attribute herbs to combat that. We call this contraria contrariis curantur or simply allopathy — using the opposite attribute of what we determine your disease to be to reassert eukrasis. Yes, apothecaries had a humoral classification for medicinal herbs and practices. Too much blood as sanguine fever, flushed red skin or pounding pulse? We'll take care of that for you. How about we just take away that blood? It works. Promise. Our patients faint. No fever and the pulse is not pounding anymore. They report no more headaches either. Even their skin becomes pale. We don't know that it's actually the shock symptoms of dangerously lowered blood pressure affecting these physiological changes that in the short term deal with the symptoms of some disease and not the actual cause. Our patients' immune system somehow fights off the disease and they get better but we'll call this another big win for phlebotomy. Things like melena were considered the body excreting excess black bile so to assist that process they would concoct toxic emetics or administer black hellebore to cause intense diarrhoea to purge the system. In Galenic tradition exotic treatments were commonplace. Look no further than pigeon shoes prescribed as curatives for bubonic plague. These theories served as a basis for practices such as cauterisation, which is still used to this day. The maxim was "What pharmaceuticals do not cure, surgery cures; what surgery does not cure, fire cures; and what fire does not cure, must be considered incurable."

A phlebotomy colourised

Posthumously his teachings had the medical world in a stagnating chokehold. It was to the extent that much further down the line when Vesalius brought up anatomical discrepancies in Galen's ape-derived descriptions, the powers that be rather believed that humans had degenerated since Galenic time lest Galen be simply wrong. This is to display that dogmatising the theories of one man and refusing to build on or against them halted the progression of academia for a millennium regardless of how seemingly well these theories served them.

Touting what we consider common sense with our relatively robust education system, it's easy to forget that this was a man forging a path out of the Ordinary Abyss. Much like Ren Zu, he also stepped on the tracks that his predecessors left him and made one that would go on to be used in Western medicine for 1500 years unquestioned till the coming of William Harvey, which I would very much love to share with you in a later post. Before that, we'll be making little detour through Ancient China, the Golden Middle East and other medical traditions gravitating around the heart. Till next time fellow overgrounder.