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MEDICINE IN THE AGE OF GALEN
Personal in Greece, medicine remained personal in Rome. No medical degrees were conferred or qualifications required. In the absence of colleges and universities, the private, face-to-face nature of medical instruction encouraged fluidity and diversity; students attached themselves to an individual teacher, sitting at his feet and accompanying him on his rounds. Medical authors frequently engaged in pugnacious polemics, contributing to the proliferation of rival schools.
Many different sorts of medical care were available. Self-help was universal; Celsus’ On Medicine was written for a non-professional readership willing to wield the scalpel as well as the plough and sword. Some healers in Italy were slaves or ex-slaves; others, especially in Asia Minor, hailed from medical dynasties or, like Galen, from prosperous backgrounds. In large cities there were swarms of healers, reputable and dubious, including body-builders, schoolteachers, ‘wise women’, root-gatherers and hucksters. Women were not confined to treating female troubles, and both Soranus and Galen expressed respect for good midwives and nurses; one of Herophilus’ pupils, according to legend, was the Athenian Agnodice, who, distressed by the anguish of women who would rather die than be examined by a man, cross-dressed so as to study and practise medicine. She became a heroine among those rallying support for female medical education in the nineteenth century.
The affluent sick could receive treatment in a doctor’s house, while the poor might hobble to a shrine. In big households there were slave physicians caring for their sick fellows in valetudinaria (hospitals). And in the Roman army, buildings were set aside for treating the sick and wounded. A standard military hospital plan evolved, with individual cells off a long corridor, a large top-lit hall, latrines and baths. A good example has been excavated at Inchtuthil in Scotland. In Rome itself, civil engineering and public works helped to maintain health. Fourteen great aqueducts (some still in use today) brought millions of gallons of fresh water to the capital; public lavatories were installed; dwellings were provided with plumbed sanitation; and civic officials oversaw the water and sewage systems and the public granaries. Vitruvius’ On Architecture (c. 27 BC) set out sanitary ideals for towns, stressing the need for good water supplies.
With the exception of the great plague of Athens in 430 BC, the diseases of the Greek world seem to have been local. This pattern changed with the Roman empire, however, once smallpox, brought back from Mesopotamia by the legions, ravaged the entire Mediterranean. This Antonine plague was the most lethal disease invasion in antiquity.
Disease explanations changed little. Public authorities still ascribed famines and pestilences to the gods, and during the Antonine plague processions were staged, with sacrifices to city-protecting deities. Latter-day Hippocratics continued to emphasize individual susceptibility and bad air (miasma), and stressed dietetics. Galen reiterated a personal, constitutional medicine and said nothing on contagion. Astrology had its devotees, though Galen rejected divination while making use of dream prognostication. What truth there was in astrology and bird divination was explained naturalistically: the flight of birds indicated changes in the weather. He similarly rationalized the use of amulets.
Therapeutics, too, changed little, and the old predilections for diet over drugs and drugs over surgery continued. The range of drugs reaching great cities increased, leading to more complex compounds. For example, theriac, originally prescribed as a snakebite antidote and used as a general tonic, grew extremely elaborate. In the version associated with Mithridates VI, King of Pontus (132–63 BC), it had forty-one ingredients, but Galen’s recipe had swollen to seventy-one ingredients, including vipers’ flesh, ground-up lizard and other animal ingredients. Princes had an interest in such remedies, since they lived in fear of poisoning. Mithridates swallowed antidotes to make himself immune to all known poisons; when his son staged a coup, he sensibly had his father stabbed.
Antiquity produced two writers who put the study of materia medica on a systematic basis. Theophrastus (c. 371-c. 287 BC), a pupil of Aristotle, took over as head of the Peripatetic school of Athens. His two treatises on plants deal respectively with their description (the De historia plantarum [Investigations into Plants]) and their aetiology (the Causis plantarum [Explanations of Plants]). Using as his model Aristotle’s writings on the animal kingdom, he laid the groundwork for botany.
The Investigations classifies plants into trees, shrubs and herbs. Some 550 species and varieties are described, with habitats ranging from the Atlantic to India (his Indian material being gathered by members of Alexander’s expedition in the 320s BC). The second treatise on botany in seven books is intended to account for the common characteristics of plants. His rediscovery in the Renaissance led to the revival of medical botany and botanical gardens.
The other notable writer was Dioscorides (c. AD 40-c. 90), a Greek surgeon to Nero’s army. His De materia medica (written in Greek, but known by its Latin title) is in five books. Book I deals with aromatics like saffron, oils, salves, shrubs and trees; Book II with animals, cereals, and herbs; Book III with roots, juices, herbs and seeds; Book IV with other roots and herbs; and Book V with wines and minerals, including salts of lead and copper. Providing detailed descriptions based largely on external appearance, Dioscorides aimed to enable the doctor to choose the right plant, listed by its pharmacological properties. He noted the various plant names, their uses in treatments, techniques of harvesting, modes of storage and possible adulterants. From an early date, these verbal descriptions were supplemented by drawings. Many of his remedies were common herbs and spices: cinnamon and cassia for instance were said to be valuable for internal inflammations, snake bites, runny nose and menstrual disorders; others were bizarre, like bed bugs mashed with meat and beans for malarial fevers. Some herbs had many properties. The bramble (‘batos’, Rubus fruticosus), according to an early translation,
binds and drys; it dyes ye hair. But the decoction of the tops of it being drank stops ye belly, & restrains ye flux of women, & is convenient for ye biting of ye Prester. And the leaves being chewed do strengthen ye gums, and heal ye Apthae. And ye leaves being applied, do restrain ye Herpetas, & heal ye running ulcers which are in ye head, & ye falling down of the eyes.
Galen described 473 drugs of vegetable, animal and mineral origin as well as a large number of compound drugs. Together with theriac, he recommended two remedies that became universally celebrated, hiera picra and terra sigillata. His hiera picra formula called for aloes, spices and herbs; the compound was made into an electuary. Its ‘signal Virtues’ according to William Salmon, a seventeenth-century commentator, were that it was ‘a good thing to loosen the body … It heats … drys … opens obstruction, and urges thick Phlegmatick humours.’ Terra sigillata (sealed earth) was a greasy clay, containing silica, alumina, chalk, magnesia and oxide of iron, found on the Greek islands of Lemnos, Melos, and Samos. It was formed into large tablet-like units upon which the seal of the place of origin was impressed. It was meant to be drying and binding, and useful against poisons.
INSANITY
Throughout antiquity, one disorder provoked divergent responses, paving the way for lasting controversy. Madness was, of course, well known within the general culture. Herodotus described the mad destructive King Cambyses of Persia mocking religion – who but a madman would dishonour the gods? The deranged Ajax slaughtered sheep in the belief that they were enemy soldiers, a scene presaging Don Quixote’s tilting at windmills. Violence, grief, blood-lust and cannibalism were commonly taken as signs of insanity.
Graeco-Roman law sought to prevent the mad from destroying life, limb and property, and made provision for guardians for the insane. Insanity was a family responsibility and there were no lunatic asylums. The seriously disturbed were restrained at home, while others were allowed to wander, though, as evil spirits (keres) might fly out of them to possess other people, the crazed were feared and shunned.
Madness found medical explanations. In the Hippocratic tradition the most common labels for such conditions were mania and melancholia, the former characterized by excitement, the latter by depression. Both were marked by delusions, and, like all other maladies, were understood Immorally, usually in terms of choler and black bile. In On the Sacred Disease, which claimed madness as well as epilepsy for medicine, the Hippocratic author stated that ‘those maddened through bile are noisy, evil-doers and restless, always doing something inopportune … But if terrors and fears attack, they are due to a change in the brain.’
Hippocratic medicine thus did not envisage an independent discipline of psychiatry, but it did accept certain psychological elements. In one case, a woman with symptoms of depression and incoherent speech was explained as suffering from ‘grief, while another, ‘after a grief, would ‘fumble, pluck, scratch, pick hairs, weep and then laugh, but … not speak’. Melancholy madness caused by black bile was occasionally seen as the spark of genius, originating the notion of melancholy as a disease of superior wits which achieved its most erudite treatment in Robert Burton’s Anatomy of Melancholy (1621). Plato could similarly represent madness as a transcendental divine fire with the power to inspire, a view influential in the Renaissance and the Romantic movement.
Galen held that mania was a disease of yellow bile or the vital spirits in the heart. A cooling regimen was indicated, for mania was a ‘hot’ disease. Soranus devoted chapters to mania and melancholia, describing symptoms in detail and discussing aetiology. Among the causes of mania were ‘continual sleeplessness, excesses of venery, anger, grief, anxiety, or superstitious fear, a shock or blow, intense straining of the senses and the mind in study, business, or other ambitious pursuits’. Something which could later be interpreted as hysteria – a disorder marked by palpitations, migratory pain, breathing difficulties and the globus hystericus – might be attributed to a wandering uterus. By way of cure for many female psychological disorders, doctors recommended marriage.
The consolidation of Greek and Roman medicine over the course of some seven hundred years laid solid foundations for learned medicine, including the naturalistic notion of disease as part of cosmic order, and the idea of the human body as regulated by a constitution, intelligible to experience and reason. It created the ideal of the union of science, philosophy and practical medicine in the learned physician, who would be the personal attendant of the patient rather than a medicine-man interceding with the gods or a functionary working for the state.
For the next thousand years and more, medical knowledge would change little. This was partly the consequence of the break-up of the Mediterranean civilizations, but also because of the solidity of these foundations. Galen’s enduring reputation was the epitome of these beliefs: he unified theory and practice, discourse and the doctor, but his death brought that tradition to a halt.
* The life of learning could be precarious, as is clear from the fate of even the great Alexandrian library. Part was wrecked in 48 BC during riots sparked by Julius Caesar’s arrival; later Christian leaders encouraged the destruction of the Temple of Muses and other pagan idols. And, so legend has it, in AD 395 the last scholar at the museum, the female mathematician Hypatia, was hauled out of the museum by Christian fanatics and beaten to death. The Muslim conquest of the city in the seventh century resulted in the final destruction of the library.
* Pliny compiled a Natural History, completed AD 77, a compendium of all natural learning. Books 12 – 19 deal with botany and 20–27 with materia medica from botanical sources, followed by five books (28–32) on animal materia medica. His remedies proved of great influence, being quarried by Isidore of Seville and subsequent medieval encyclopaedists.
CHAPTER IV MEDICINE AND FAITH
THE PASSAGE FROM THE GLORIOUS DAYS of Rome to the Middle Ages was often violent, especially in the West, with wave after wave of barbarian onslaughts from the East. These culminated in the sack of the Eternal City by Alaric’s Goths in AD 410, which effectively put an end to the western empire and frayed the thread of learned medicine.
Fortified from AD 324 by its new capital, Constantinople (later Byzantium, modern Istanbul) on the Bosphorus, the eastern empire remained a bastion of imperial strength and a treasury of hellenistic learning and culture. From 364, the empire formally split, the two halves being ruled by separate emperors, and by the close of the sixth century the West had splintered further into fragmented kingdoms ruled by descendants of the invading Goths and Vandals. Its economy was feebler than that of the East, its cities declined or collapsed altogether – Londinium (London), once boasting a population of 30,000, became a ghost town – and civic institutions dwindled. In such circumstances, it was inevitable that eastern and western medicine would go separate ways.
CHRISTIANITY
Throughout the Mediterranean the mental climate began to shift from 313 with the Emperor Constantine’s establishment of Christianity as one of the official imperial faiths; from the early fifth century it was the sole official religion. Thereafter, by contrast with the naturalistic bent of Hippocratic and Galenic medicine, healing became more spiced with religion, for the rising Church taught there was a supernatural plan and purpose to everything (every human had a soul to be saved) and Christian doctrines, rituals and sacraments covered every stage through which believers passed from womb to tomb, and beyond.
Religion, of course, shared common ground with medicine. Etymologically, the words ‘holiness’ and ‘healing’ stem from a single root, conveying the idea of wholeness. But early Christianity also made demarcations between the body and the soul, implying the subordination of medicine to religion, and of doctor to priest, the one attending merely to the cure of bodies, the other to the cure of souls. The boundaries between temporal and eternal were of course endlessly blurred, and physic and faith, while generally complementary and enjoying a fairly peaceful coexistence, sometimes tangled in border disputes.
Christian outlooks on the body and sickness drew on various traditions. The faith absorbed aspects of eastern asceticism, which prized the soul or spirit above the flesh, and Jewish healing traditions were also influential. Early Judea had its distinctive healers, not least King Solomon (r. 970–931 BC), who was credited not only with wisdom but with magical and medical powers. Hebrew ideas on healing expressed in the Old Testament (compiled between the eighth and the third centuries BC), and the Talmud (between 70 BC and the second century AD), shared with Egypt and Mesopotamia a religious orientation: disease signified the wrath of God. ‘It shall come to pass’, it was recorded in Deuteronomy,
if thou wilt not hearken unto the voice of the LORD thy God … the LORD shall make the pestilence cleave unto thee, until he have consumed thee from off the land; whither thou goest to possess it.
The LORD shall smite thee with a consumption, and with a fever, and with an inflammation, and with an extreme burning, and with the sword, and with blasting, and with mildew; and they shall pursue thee until thou perish.
Certain maladies were associated with the Almighty’s punishments for sin, including Zara’ath, which has usually been translated as leprosy, though this identification is medically dubious. ‘When a man shall have in the skin of his flesh a rising [a swelling], a scab, or bright spot, and it be in the skin of his flesh like the plague [the spots] of leprosy,’ states the Book of Leviticus,
then he shall be brought unto Aaron the priest, or unto one of his sons the priests; and the priest shall look on the plague in the skin of the flesh: and when the hair in the plague is turned white, and the plague in sight be deeper than the skin of his flesh it is a plague of leprosy: and the priest shall look on him, and pronounce him unclean.
Such polluting diseases were curable by the Lord alone, and this encouraged certain Jews to reject human medicine in favour of divine, citing the fate of King Asa (c. 914–874 BC), who ‘sought not the Lord, but his physicians’, and whose foot sores consequently worsened until he died. Jewish sacred writings have no place for the professional physician as such, nor even for priestly healers; Jahweh alone is the healer. Naaman the leper was instructed by the prophet Elisha to wash himself seven times in the River Jordan, so as to be cleansed; the only surgical operation mentioned in the Old Testament is the religious rite of circumcision.
Suffering could be a godsend and a trial. ‘Blessed is the man whom God correcteth,’ declared Job, singled out by the Lord to undergo great suffering, ‘therefore despise not thou the chastening of the Almighty: For he makes sore, and bindeth up: he woundeth, and his hands make whole.’ For devout Jews, the pagan assumption that a healthy body was a great blessing could seem trifling.
Nevertheless, the Hebrews did develop teachings about the body and its well-being. Blood was probably viewed as the vehicle for the soul (one rationale for kosher meat, from which the blood is drained, and also, in recent times, for the refusal of blood transfusions by Jehovah’s Witnesses), but life lay in the breath. Believing physical cleanliness bespoke spiritual purity, rules were formulated for personal hygiene, social gatherings and sexual intercourse, and prohibitions were issued against eating unclean animals. Though some modern Jewish apologists argue that the dietary bans on pork and shellfish in Leviticus arose from awareness that these foods could pass on diseases such as trichinosis, the fact is that Jewish dietary rituals (kosher food) were principally expressions of precepts about pollution and purification. Nevertheless, cleanliness rites indirectly spurred public health: no well was to be dug near burial or waste ground, water should be boiled before drinking, and waste had to be burned or buried beyond encampments. Judaism also taught the obligation of caring for co-religionists, and by AD 400 Jewish communities were instructed to possess a healer.
Christians often expressed disdain for Jews as the people of the law, exalting by contrast their faith of the spirit; and this difference is discernible in their distinctive approaches to health. But one must not oversimplify: the New Testament presents many models of healing, secular and sacred alike. ‘Costly physicians’ were condemned, but Luke the Evangelist was himself a physician. In the parable of the good Samaritan, the use of wine as a disinfectant reflects Greek wound treatment, whereas in the Acts of the Apostles healing is portrayed as a matter of faith, involving prayer and the laying-on of hands. When Jesus met a man born blind, he asked who had sinned; and he told the man who suffered from a palsy that his sins were forgiven. Sin was thus assumed to be perhaps a cause of sickness, or at least sin and sickness were similar states; in either case spiritual healing might be requisite. ‘Is any sick among you?’, asked the Apostle James: ‘Let him call for the elders of the church, and let them pray over him, anointing him with oil in the name of the Lord; and the prayer of faith shall save the sick, and the Lord shall raise him up.’
Early Christianity exhibits a medley of attitudes towards healing, shaping fluid relations between medicine and the Church. Many old healing practices were dressed up in new Christian garbs; Christian shrines were raised upon the ruins of pagan temples, and the leading healing saints, Cosmas and Damian, were in some respects revampings of the heathen Castor and Pollux.
Christian theology embraced but modified the radical dualism of some Levantine religious and philosophical sects which elevated the immaterial soul while disparaging the mortal body, commonly viewed as the soul’s prison house. Christianity taught that the spirit was eternal; the flesh was weak, corruptible and fallen. Adam and Eve’s disobedience in Eden had brought disease and death into the world and made nakedness a source of shame. The Desert Fathers and saintly hermits pursued ascetic practices designed to deaden desire and restore the spiritual powers enjoyed by Adam in Eden.
Such beliefs challenged the classical, Athenian man-centred and polis-oriented ideals of balance and beauty, looking to mortification of the flesh as the release of the spirit. A glorification of suffering associated with release from the throbbing flesh remained a powerful force within Christianity, especially Catholicism. Thérèse Martin, later canonized as Saint Thérèse of Lisieux, died of tuberculosis in 1897, barely out of her teens. ‘God has deigned to make me pass through many types of trials,’ she affirmed in her diary, ‘I am truly happy to suffer.’
Yet Christianity also taught that man had been created in God’s image in a paradise garden of physical bliss in which disease and death had no part; and it proclaimed the raising up of the bodies of the faithful at the Last Judgment, as prefigured by Christ’s own resurrection. Orthodoxy anathematized the Manichean heresy that viewed the flesh as the Devil’s domain. The human body belonged not to man or Satan but to God, and had to be properly looked after – hence the suicide taboo.
While suffering and disease could appear as chastisement of the wicked or a trial of those the Lord loved, the Church also developed a healing mission. Was not Luke ‘the beloved physician’? And did not Christ, though he told physicians to heal themselves, give proofs of his own divine powers by acts of healing? Some thirty-five such miracles are recorded in the Bible, and the apostles subsequently exercised healing as ‘a gift of the spirit’. From the start, Christianity won converts among those desperate to be cured; and, like a self-fulfilling prophecy, healing miracles proliferated, often wrought by holy relics like drops of the Virgin’s milk. Sober ecclesiastics condemned this vulgar zeal for healing marvels, presenting Christ as the physician of the soul. Whereas members of his congregation brought infants for baptism hoping the holy water would heal leprosy or blindness, St Augustine (354–430) viewed cures by holy oil, relics or baptism not as a routine health service but as providences. Overall, Church fathers steered a middle course, accepting a role, but a subordinate one, for secular medicine.
Christianity made its mark through action. Jewish traditions of help and hospitality were extended, and Christ’s instruction to his disciples to care for the sick and needy assumed institutional form through the appointment of deacons charged with distributing alms. By 250 the Church in Rome had developed an elaborate charitable outreach, with wealthy converts providing food and shelter for the poor. After Constantine’s official recognition of Christianity, alms found expression in bricks and mortar. Leontius, bishop of Antioch from 344 to 358, set up hostels in his see; around 360, Bishop Eustathius of Sebasteia built a poorhouse; and St Basil erected outside the walls of Caesarea ‘almost a new city’ for the sick, poor and leprous.
Similar institutions sprang up somewhat later in the Latin West. A hospital was founded in 390 by Fabiola (d. 399), an affluent Christian convert, who, after two wretched marriages, dedicated her life to charity among Rome’s sick poor. ‘She assembled all the sick from the streets and highways’, wrote her teacher, St Jerome,
and personally tended the unhappy and impoverished victims of hunger and disease. I have often seen her washing wounds which others – even men – could hardly bear to look at … She founded a hospital and gathered there the sufferers from the streets, and gave them all the attention of a nurse. Need I describe the many woes which can befall a human being: the cut-off noses, lost eyes, mangled feet, leprous arms, swollen bellies, withered thighs, the ailing flesh that is filled up by hungry worms? How often she carried home, on her own shoulders, the dirty and poor who were plagued by epilepsy! How she washed the pus from sores which others could not even behold!
Greek and Roman paganism had acknowledged no such duties.
In the East, hospitals (in Greek nosokomeia, places to care for the sick) became large and complex. By the mid sixth century Jerusalem had one with 200 beds, and St Sampson’s in Constantinople was bigger still, with surgical operations being performed and a wing for eye disorders. Edessa had a women’s hospital, and major hospitals at Antioch and Constantinople were divided into male and female wards. By 650, the Pantokrator in Constantinople had a hierarchy of physicians and even teaching facilities, a home for the elderly and, beyond the walls, a leper house. To care for lepers and thus expose oneself to infection was a mark of holiness. Christianity planted the hospital: the well-endowed establishments of the Levant and the scattered houses of the West shared a common religious ethos of charity.
