Bloodletting illustration. Man wearing a tourniquet, letting blood flow into a bowl. Two other bowls already filled with blood sit nearby, c. 1675. From a German compendium of popular medicine and surgery, compiled for the use of a house of the Franciscan Order, probably in Austria or South Germany. Image from the Wellcome Collection.

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Today we resume our sharings from the Blue House of HYGEIA with an extract from the end of the chapter, ‘The Evolution of Greek Phlebotomy’, from Shigehisa Kuriyama‘s masterpiece of historical scholarship, ‘The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine’. Zone Books · New York, 1999. Pages 212 to 217.

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Plethora gripped the Greek imagination with an intensity that the bare logic of intake and consumption cannot explain. Physicians sometimes exsanguinated their patients until they fainted and passed feces, so terrible was the perceived danger. Plethora was excess, and thus pathological by definition. But contrary to what we would expect (were balance per se the supreme concern), depletion, plethora’s opposite, provoked no comparable anxious vigilance. The compulsion to bleed was inseparable from the fear of excess blood. Galen is explicit: the best preparation for studying his Treatment by Venesection, he advises, is to read his essay on plethora.

Stagnant hot plethoric excess putrefied and inflamed, made even good blood bilious, generated fevers.  One had to bleed quickly, before inflammation (phlenmone) set in. Forestalling inflammation was key. Inflammation arose, Galen thought, from the flux of blood. A wound or fracture could induce the flux, but it might also result from the diversion of a general plethora into some part “most apt to receive” the excess blood. The humoral mix determined the character of the resultant inflammation: blood in which yellow bile predominated produced herpes; very hot bile, erysipelas; hot thick blood, anthrax; phlegm, oidema. A mixture of black bile and blood caused an inflammation known as scirrhus, one form of which could become cancer. A flux of pure black bile produced cancers (karkina). If the Greeks worried far more about inflammation than we do, it was in part because the concept had greater range.

Galen’s concept of inflammation encompassed cancerous lesions, benign tumors, and inflammatory growths. Consequently, his Preternatural Tumors (Peri ton para physin onkon) is really more about what we would consider inflammations than about true tumors (onkoi) in the modern sense. Before François Bichat’s tissue theory and Johannes Mueller’s application of cell theory to pathology, neoplasms, benign tumors, and inflammatory growths were all traced to concentrations of corrupt blood.

Looking at “inflammations” in this way, we begin to appreciate the urgency with which ancient physicians sought to prevent them. Greek physicians recognized that once established, many cancers were fatal; salvation lay in early intervention or, better, prophylaxis. Timely bleeding saved lives. But it would be anachronistic to reduce the ancient obsession with plethora to contemporary fears of cancer. Cancer didn’t loom as large in antiquity as it does now, because most people succumbed sooner to other sicknesses, before they reached the ages when cancer claims its most victims.

Ultimately, the gnawing anxieties about plethora were rooted not so much in the gravity of particular diseases, but in the intuition that plethora was responsible for virtually all disease.

In culling evidence for Hippocratic views on bleeding I cited several passages from Epidemics 1. But in fact remarks on the problem of blood retention and the benefits of blood release form only a minor part of the treatise’s observations about causes and cures. The work lavishes more attention on factors that we tend presently to forget – factors such as seasonal weather and wind.

Galen asserts by contrast that, “Whatever sickens the body from internal evil has a twofold explanation, either plethora or dyspepsia.” The latter results from eating improper foods or an unbalanced diet; the former from taking in more nutriment than is either consumed by the body in its activities or evacuated in wastes. Taken by themselves, Galen’s remarks might seem merely to complement Hippocratic environmentalism – to address the internal causes of disease, while treatises like Epidemics 1 and Airs, Waters, Places described the external circumstances. But in Galenic analysis, the body’s inner state was absolutely fundamental: the presence or absence of internal evil largely determined the harm caused by external elements.

Foreshadowing later ideas of germs, for example, Galen refers to “pestilential seeds” (loimou spermata) of disease. He is interested, however, less in the nature of the seeds per se than in the question of why some people succumb to pestilence while others don’t. His conclusion is unequivocal. “We must always remember… this principle: that none of the causes [of disease] can operate without a predisposition in the patient.” And again, “The greatest part of the generation of disease lies in the preparation of the body.’ Inhaling pathogens doesn’t, in itself, cause sickness. Pestilential seeds take root and grow only in a body predisposed to corruption, a body already made full by overeating, indolence, and sexual indulgence. A plethoric body.

While the theory of the seeds of disease commanded only a minor place in Galen’s pathology (he mentions it in only a few passages), the same belief in the primacy of inner states also undergirded his analysis of the most basic form of external affliction, namely, wounds. Sometimes, he observes, a prick from a very fine needle can induce a huge inflammation. The manifest disparity here between the apparent cause and the effect proves that the chief culprit is actually not the needle but the body into which it enters. If a tiny wound swells massively with pus, it must be because of a preexisting plethora of un-evacuated residues.

In bodies without excess, even large gashes heal quickly, without inflammation and festering. Even in the paradigmatic case of external causation, then, even when a patient suffers cuts or blow, the extent of damage hinges ultimately on the body’s internal complexion – hinges, that is, on plethora or its absence.

How does one recognize plethora? We could have predicted some of the indications: a ruddy complexion, distended veins, a large pulse, and a history of physical inactivity, excessive eating and drinking, suppressed evacuations. What is remarkable about Galen’s diagnosis of plethora, however, is his stress on the patient’s own feelings. The symptoms on which he puts the most weight are heaviness in the whole body, sluggishness, tension in the limbs, pain, and lassitude.

One recognizes plethora, in other words, not just through objective signs such as the pulse, but also and above all in a person’s subjective experience of the body. Heaviness, inertia, tension, pain. These are familiar sensations. At different times, to varying degrees, we all experience them. And this suggests how plethora could once have seemed so widespread, and the need for bloodletting so routine. Scanning the people around us we may spot a few red-faced individuals whom we might judge plethoric; but mostly, it’s hard for us to imagine excess blood as anything but a rare oddity. This is part of what makes past enthusiasm for bloodletting seem so strange.

On the other hand, once we turn from the abstract notion of excess blood to the symptoms that supposedly announce it, the condition assumes a more intimate cast. Though we may never have thought ourselves plethoric, we know what it is to feel heavy and sluggish, or to suffer from tense, aching muscles.

Plethora was thus a disease not only in the detached, clinical sense of humoral imbalance, but also the disease of subjective discomfort, the nagging claim of the body on consciousness. Galen speaks frequently of the heaviness (barutes) of the plethoric body, by which he refers not to its absolute weight, but to the sensation of sluggishness in a body that responds but slowly and grudgingly to the will. His descriptions curiously echo characterizations of the body that we find in Plato, a thinker he greatly admired.

The soul that follows God and obtains sight of the truth, Socrates declares, is freed from all harm; but the soul that cannot follow and fails to see is “filled with forgetfulness and evil, and grows heavy, and when it has grown heavy… falls to the earth.” Evil’s heavy weight, though, is none -other than the burden of the body. Whereas the soul naturally aspires upward to the heavens and to the Good, the body is “burdensome, heavy, and earthly,” and weighs it down.

Especially suggestive here is the origin of blood in food. An old belief had it that the soul could occasionally escape its imprisonment in the darkness of the material body and regain its natural clairvoyance. In sleep, for instance; hence the prescience of dreams. Special diets, on the other hand, transformed the body itself, making it more transparent to psychic visions. Thus legends of the seer Epimenides speculated that he ate no earthly food, but nourished himself on the ethereal fare provided by nymphs.

After predicting the plague at Ephesus, Apollonius defended himself against charges of wizardry by tracing his foresight to an exceptionally light diet, which conferred a celestial· clarity. In his Eclogae propheticae, Clement of Alexandria forcefully advanced ties between fasting and spiritual possibility: “Fasting empties the soul of matter and makes it, with the body, clear and light for the reception of divine truth.” Excessive food, “drags down the intellectual part towards insensibility.” Meals should thus always be plain and simple, to facilitate digestion and secure “lightness of the body.”

For Plato, the soul was light, luminous, and eternal, while the body was sluggish, dark, and corruptible; heaviness was intrinsic to the very condition of embodiment. For physicians, by contrast, the dull inertia of plethora was a temporary pathology – albeit a chronic danger. The coincidence between discourses thus wasn’t exact. Still, clear echoes resonate between Galen’s portrait of plethoric sluggishness and the plight of the Platonic soul imprisoned in flesh. The plethoric body was the body experienced when one was forced to become aware of it, when it ceased to be the easy instrument of will and desire and became a resistant onerous burden that weighed one down.

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