Читать книгу Galen on Apodictics - Dmitry A. Balalykin - Страница 4

Alexander L. Gungov

The main objective of Dmitry Alekseevich Balalykin’s book, which appears as the seventh volume of Studies in Medical Philosophy at ibidem Verlag, consists in presenting the philosophical grounds for Galen’s integral theoretical and practical system, emphasizing the understanding and application of the apodictic method. The author clearly states that his concept of apodictics in ancient medicine consists in the understanding of “a combination of the use of anatomical dissections, the physiological experiment, the rational doctrine of general pathology and clinical systematization.” As a physician and distinguished historian of medicine, Balalykin is perfectly up to engaging with the medical side of Galen’s works. In terms of philosophy, the most significant part of Galen’s apodictic method is the “rational doctrine of general pathology and clinical systematization”, which is interpreted by Balalykin with appropriate erudition and skills.

Balalykin examines the ontological, epistemological, logical, and natural-philosophical conceptions of Plato, Aristotle, Anaxagoras, Empedocles, Stoicism (in particular works of Chrysippus), and the ancient аtomism as sources of Galen’s philosophical views (or as philosophical ideas that Galen does not accept but opposes), and their decisive influence on his theoretical medical concepts and clinical findings and claims. Balalykin pays special attention to the notions of eidos, lekton, entelechia, and cataleptic impression, as well as to Aristotle’s doctrine of the four types of causes. In regard to the apodictic method, various types of evidence known in antiquity are considered in his book: apodictic, aimed at reaching the truth; dialectical, meant to get to plausible conclusions, which could serve as hypotheses for further quests in the name of truth or for didactic and other practical purposes, including convincing interlocutors; rhetorical, dedicated to persuasion; and sophistic, striving to win a dispute at any cost, even by means of manipulation and deliberate misleading. In connection with the apodictic method, Aristotle’s categorical syllogism is discussed, whereas Stoic hypothetical syllogism is analyzed as a part of the dialectical method.

The author puts at the heart of his study of the transition from philosophical foundations to medical conclusions the ancient natural philosophical teaching of the three tetrads, followed by a number of ancient thinkers: the four elements—earth, fire, air, and water; the four humors—blood, phlegm, and yellow and black biles; and the four substances—hot, cold, dry, and moist. The book analyzes the fundamental philosophical and medical significance of the balance and imbalance between the members of each tetrad. Balance and imbalance are traced as being inseparable from the theory of homoiomereia in view of what in modern medical language would correspond to a certain extent to nosology, etiology, pathogenesis, therapy, and prognosis. Last but not least, the importance of the Platonic concept of the tripartite nature of the human soul for the understanding of causation in medicine, classification of diseases, control exercised by the higher rational and immortal part of the soul on the health and disorder of the body, as well as the unified origin of somatic and psychic disorders are underlined.

Balalykin has succeeded in structuring and conducting his research in view of the decisive influence of the rich array of philosophical ideas from Classical Greece and the Hellenistic period on Galen's medical theory and clinical practice. He is not tempted to interpret the theoretical legacy of the ancient physician only from the point of view of modern medicine or predominantly in the context of the development of ancient medicine per se, whereas putting into brackets such a seemingly distant and lateral area as ancient philosophy. The author reveals the formation of ontology of health and disorder on the basis of the principle of balance and imbalance within the four tetrads, as well as according to the theory of homoiomereia that defines the structure of the macro- and the microcosm. The quantitative idea of health and disease, as well as the presence of degrees of health and disorder, depend on these principles. Homoiomeres define the anatomical structure of the human body, where there are simple homoiomerous structures and tissues and complex non-homoiomerous organs. By carrying out an ontological line of reasoning, Balalykin repeatedly argues that these principles have allowed Galen to outline his concept of general pathology and to classify diseases. The author convincingly demonstrates that Galen's understanding of the causes of diseases starts from the same ontological basis. From the perspective of the ancient physician we cannot speak of the contemporary meaning of etiology, as in Galen’s classification of causes there is a trend of universalization, whereas etiology deals with the specific causes of pathology within a certain nosologic unit. However, Galen's understanding of the causes of diseases allows him to persist in treatment aimed at eliminating the causes of a pathology (today known as “etiological treatment”) and not simply at eliminating the symptoms. At the level of medical causality, the author makes a point of the four types of causes in Aristotle, shows how they have been transformed by Galen and, foremost, discusses the final cause that the ancient physician considers as a teleology of function of an organ or of the body as a whole. The doctrine of teleology, along with and inseparable from the principle of balance of the three tetrads and the principle of homoiomereia, are the main grounds for Galen’s rejection of the explanation of the ancient Methodists regarding the causes of disease. The assertion of the Methodist physicians, who have adopted the ontology of ancient atomism that the general pathology is due to clogged pores in a certain part of the human body, is unacceptable to him. He is a follower of Plato and Aristotle and the mechanics of the atomism does not correspond to the teleology of function, inherent in the body in the states of health and disease alike. Balalykin explains that the principle of teleology should not be confused with the Stoic determinism of physicians from the Empiric school that is set by blind fate and is completely beyond any rational control. Thus, the author unambiguously shows: the philosophical preconditions at the level of ontology preset Galen's position on medical causality. Furthermore, he clarifies that the mechanisms of diseases, pathogenesis, depend on the same ontological arguments.

According to Balalykin the respective central concepts of Plato’s and Aristotle’s ontology and epistemology, eidos and entelechia, become decisive for the formation of the apodictic method in Galen. The creation and functioning of the sensory world after a model of the non-sensory eidos that guarantees realization in the sensory world of certain patterns, perceptible by the human mind, gives Galen the opportunity to follow in the medical theory and practice a method based on a cognizable necessity. The feasibility of apodictic method is reinforced by the Aristotelian entelechia, which justifies teleological changes both in healthy and diseased persons, and also the state of a person between health and disease. The author points out why Empirics, criticized by Galen, following the Stoic view of lekton adhere to the situational understanding of diseases and cannot perceive the apodictic method that yields the necessary conclusions. Instead, they are forced to rely on a dialectical method that provides nothing more than probabilistic conclusions. Stoic lekton has no ontological status of necessity, unlike eidos and entelechia, because it is not material in character, and for the Stoics this is equivalent to a lack of reality. This means that disease observations—diagnosis of the disease, as well as its treatment decisions—are lektons with probabilistic value. The non-acceptance in principle of the theory leads to the underestimation of medical causality and disinterest in the mechanisms of diseases among physicians from the Empiric school. Moreover, these philosophical reasons limit the diagnostic and therapeutic actions of Empirics to addressing pathological symptoms using their own experience gained in similar situations or the experience of their counterparts, applied depending on the available pharmacological and dietary agents that have proven their effects in such symptomatology. Here, the author is a very shrewd observer when he perceives an essential dialectical feature (‘dialectical’ not in the sense of the ancient dialectic, but of Georg Hegel’s speculative dialectic) according to which the Empirics, by denying the possibility of knowing general principles, are not able to apply individualized treatment and are inevitably entangled in repetitive patterns. Balalykin intuitively and completely justifiably perceives that this paradoxical situation expresses the fact of the transformation of one-sided rational statements into their opposites. The Empirics, following dogmatic one-sided constructions of Stoicism and insisting on the significance of only a singular disease situation, allow an insurmountable gulf between the singular and the universal, thus falling into the lifeless generalization of oversimplification. Galen’s approach, based on Plato’s and Aristotelian philosophical views, freely overcomes the rational one-sidedness and rises up to the level of rational speculative dialectic by perceiving the unity between singular, particular, and universal. The singular symptoms of a patient manifest themselves in an inseparable and individualized unity with the universal and indispensable features of the given disease (according to the modern terminology of the “nosological unit”) and thus form the particular type of a specific patient’s disease. The interpretation of schematization during treatment by the Empirics proves that the assumption and knowledge of universal features of diseases and their treatment does not prevent, but on the contrary supports the application of an individual approach to diagnosis and treatment.

In studying Galen’s apodictics, Balalykin addresses a purely logical problem. He points out that Galen holds on to making necessary conclusions through categorical syllogism, which provides true knowledge, while physicians from the Empiric school, in conformity with their understanding of probable and solely plausible knowledge, use hypothetical syllogism. The author is quite right that in both forms of hypothetical syllogism, pure hypothetical syllogism and hypothetical categorical syllogism, there is an element of hypothesis that gives some probability to the conclusion reached. Nevertheless, it should be taken into consideration that the very inferences of these types of syllogism produce necessary conclusions. The two forms of the inference are known as modus ponens and modus tollens, which are accepted as valid both by traditional formal logic and by its modern symbolic version. Furthermore, the categoricalness of the strict categorical syllogism’s premises is not necessarily identical with their truthfulness and leaves room for a certain dose of probability. There is Aristotle’s well-known claim about the middle term of the categorical syllogism being identified by dialectical means of the art of topics. The truthfulness of categorical syllogism (not just logical validity) is borne not only by the formal laws of this type of inference, but by the overall context in which it takes place. Similarly, the probability of a hypothetical syllogism (again, not just logical validity) depends on the context of its application. We should not neglect the practical reliability of the negative modus of the hypothetical categorical syllogism modus tollens in clinical practice. During the differential diagnostics procedure diseases with similar symptoms are excluded in order to determine the real disease(s). The exclusion is done by the modus tollens rule whereby the absence of a necessary symptom or sign leads to an absence of the corresponding disease. In terms of logical validity, this is a completely necessary and correct conclusion. In medical practice, it excels the positive modus ponens, where the inference is driven from the presence of the cause of a disease to the disease itself, because even the presence of the necessary cause of a disease cannot lead to the disease in the case that the sufficient cause is not also present. However, when discussing the necessary validity of the eliminating modus tollens, we should not forget that it is a common situation in diagnostic practice when the absence of a symptom or sign (in the case it is not a pathognomonic symptom or sign) does not guarantee the absence of the disease we are looking for. This means that the decision to reject or affirm the presence of a disease goes beyond logical necessity, but that does not at all mean, as the author clearly demonstrates, that the decision is not subject to the apodictic method.

It would be entirely justified to state that Galen on Apodictics masterfully demonstrates the philosophical impetus in the formation of the apodictic method in Galen’s clinical practice and theoretical treatises and outlines this method as “an expression of a new type of rationality in the field of medicine” during the Roman Empire. No doubt, Balalykin’s book is a significant and valuable contribution to studies in the field of philosophical analysis of Galen’s works on an international scale and deserves excited and committed readers.