I know that knowledge structures rarely change neatly or suddenly, but I have some understanding that most European and Euroamerican physicians and natural philosophers had rejected the gaelenic model of the human body (where the health of the body is determined by the balance of four “humors” including blood) by the mid-18th century.
Yet in my own studies I encounter “heroic” medicine full of vomits, enemas, and of course bleedings well into the 19th century. It seems like these treatments share a sort of gaelenic concern with keeping the body “in balance.” But if it isn’t humors that we’re now balancing, what is the conception of the human body that makes up the intellectual foundation for these quite extreme forms of medical treatment for sick people?
Thanks!
The moderators are correct -- this is a great question!
Before getting directly to your question, we have to tackle the idea of nosology. Nosology is the classification of diseases -- how we decide what is a disease, how diseases are related to one another, and most importantly for the patients, the treatment implications. As you allude to, the classical nosology is the Four Humors. This is the idea that all human health -- and therefore disease -- is made up by balances of four constituent body fluids: blood, phlegm, black bile, and yellow bile. The Four Humors are, as you suggest, most associated with the Greco-Roman physician Galen, whose works would form the backbone of Arabic/Western medicine for 1500 years. (FWIW, the humors predate Galen by centuries; when he was writing in the second century CE, they were more or less set, but the Hippocratics had quite a lively debate about just how many body fluids there were).
Much traditional Western and Arabic medical advice is based upon this nosology -- different foods would affect different humoral constitutions, as would environments. The materia medica (drugs, essentially) and medical therapies -- especially bloodletting, purgatives, and laxatives -- were ways that a physician could DIRECTLY affect the humoral constitution and hope to heal a sick patient.
The first serious challenge to the Four Humors came from Paracelsus, a Swiss alchemist, in the 15th century CE. I apologize if I'm oversimplifying here -- this in particular is not my area of expertise. Paracelsus felt that human health was not due to balances of body fluids, but balances of chemicals, in particular sulfur (vitriol), mercury (quicksilver), and salt. Different chemicals were related to different diseased organs. In his nosology, there was no reason to use medicinal herbs or bloodletting -- you had to treat by replenishing the chemicals that were misbalanced. It is from Paracelsus and his followers that mercury treatments first arise.
While many of his methods would persist (mercury and vitriol were standard treatments for many conditions, especially syphilis, by the 18th century), his nosology would not. Paracelsians would not last for much longer than Paracelsus' life, and the Four Humors remained the chief explanatory model.
That is, until the birth of "nosology" (my use of the word is something of an anachronism until this point). Starting in the 17th century CE, Thomas Sydenham, a British physician, noted that diseased patients fell into types. Inspired by the new field of botany, he set about to classify diseases into "species". For example, he was the first to separate out "rheumatism" (swollen joints) and define gout as a separate entity. Sydenham himself grasped the implications of this task -- if diseases were discrete entities and not just caused by imbalances in humors, they should have discrete treatments.
Many physicians were inspired by Sydenham, but a few stand out for the point of your question. The first is Sauvages, friend of Carolus Linnaeus, who set about to classify all diseases into classes, orders, genera, and species based on SYMPTOMS. This was, well, complicated, to say the least. His main work was Nosologia methodica sistens moborum classes, genera et species, published in 1763. It listened *2400* diseases, divided into 10 classes, and 40 orders. To quote Walker, " There were 18 kinds of angina, 19 types of asthma, 19 species of dysphagia, 13 different species of anorexia, etc." The next would be Morgagni, who was among the first to notice that on autopsy, specific organs were diseased. Human dissection had been practiced for three hundred years at this point, but the focus was on either anatomy, or on forensics -- discovering cause of death. In 1761, he published De sedibus et causis morborum, which sought to classify disease based on the on changes actually seen in the body.
The final nosology important for this discussion comes from the Paris Clinical School at the dawn of the nineteenth century. Pinel published Nosologie philosophique in 1798. This was an attempt to meld Sauvages and Morgagni. Pinel too grouped diseases into classes, orders, genera, and species -- but he also grouped them by the tissue that was affected. With this, doctors could see, for example, that the tubercules of the lungs, the scrofula of the neck, and the bony lesions of Pott's disease were all in fact manifestations of a single disease (tuberculosis). This nosology would be further expounded on by other members of the Paris Clinical School, especially Bichat and Laennec.
So let's get to your question. It's the beginning of the nineteenth century. You're a young doctor in, say, Boston (where I happen to practice currently). Some of your teachers still hold to the Galenic past, advocating that disease is caused by imbalances in body fluids, and that you need to, say, purge the yellow bile with calomel to induce vomiting, or bleed your patients. I should also add that these traditional treatments were fairly mild; for example, traditional bloodletting would only remove a few ounces of blood at a time, not too different than what my residents remove from my patients for "daily blood tests".
But you have no time for these old ideas. You've read the works of Cullen and of Pinel. You understand that diseases fundamentally affect different body tissues, that the same disease might act in different organs. You've read Corvisart, and maybe Laennec, and you know that you can even percuss on the chest, or listen with Laennec's cylinder, to hear hidden disease inside the human body. So -- how are you going to treat disease?
And this is where we're going to get to "counter-nosologies". Because the standard treatment that Pinel, Laennec, Cullen et al would have offered was ... essentially the same thing we've always done. Bland foods, mild purgatives, and small amounts of bloodletting. And their patients continued to die. Sure, Laennec could diagnose a large tubercule prior to death, but in terms of making a difference to his patient, he was as effective as doctors centuries before.
The irony of these new, fancy methods of classifying disease, juxtaposed with the same old treatments were not lost on a certain subset of physicians. In the United States, the most notable example was Benjamin Rush, a signer of the Declaration of Independence. He was an early adopted of Cullen's nosology, but he ultimately rejected it when he realized it was useless to actually TREAT patients (which, of course, it was). He came to believe that all disease was caused by "inflammation", which could be relieved that allowing the vascular system to relax. He urged doctors to "venerate the lancet", and would prescribe high doses of calomel (mercury chloride). And when yellow fever struck the nation's capital of Philadelphia in the 1790s, Rush stayed to tend to the sick -- and bleed them to death. He would take off 2.5 liters of blood or so (almost half the circulating blood volume of a human adult).
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