The Greatest Benefit to Mankind: A Medical History of Humanity

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.

* (#ulink_f0bc16cb-93a8-5472-a5c4-1fbbb322fcf9) 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.

* (#ulink_beaf7dc1-983e-5b26-8562-e85508a6c10e) 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 (#ulink_be7ca449-ebc8-5bc4-ac54-43db58b969b9)

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.

THE LEGACY OF GALEN

During a long fallow time of the intellect, some authors passed on the baton of medical learning. Oribasius (325–97), physician to Julian the Apostate, came from a wealthy family in Pergamon in Asia Minor (Galen’s hometown) and studied medicine at Alexandria. Three of his works became influential. The earliest comprised excerpts from the best medical authorities. Its four books described hygiene and diet; the properties of simple drugs and indications for use, and the body – its maladies and treatments from top to toe. What remains of it reveals broad reading and his respect for Galen and Rufus of Ephesus. He also wrote a shorter practical medical compendium for the traveller, and an even briefer summary. He was worried about the state of medicine, bemoaning (in a familiar way) the proliferation of quacks and the want of practical handbooks. Oribasius played an important role as mediator and synthesizer: he preserved excerpts from many authors otherwise lost, created a pattern for later digests, and shaped the package of Galenism that dominated later centuries. Having simplified, synthesized and publicized the master’s writings, his work was rehashed by others in the same mould – Aetius, Alexander of Tralles and Paul of Aegina – before being further systematized by the Arabs.

In North Africa, Caelius Aurelianus (c. 420) produced a large Latin nosographical handbook, De morbis acutis et chronicis [On Acute and Chronic Diseases]. A follower of the Methodist sect, he subscribed to the doctrine of stricture and laxity among atoms and pores: diseases were due either to excessive tension or relaxation. Fragments survive of a medical catechism, of parts of his Latin translation of Soranus’ Gynaecology, and of the eight books on Acute and Chronic Diseases.

The Greek physician Alexander of Tralles (sixth century) was best known for his Libri duodecim [Twelve Books on Medicine], popular in Latin, Greek and Arabic. After travelling in Greece, Italy, Spain and Gaul, he settled in Rome. He was the first European to champion the eastern laxative, rhubarb, later so prized, but was also keen on more exotic remedies, for example live beetles. Henbane, he taught, was effective only if held between the left thumb and index finger while the moon was in Pisces or Aquarius; and he advised epileptics to ‘take a nail of a wrecked ship, make it into a bracelet and set therein the bone of a stag’s heart taken from its body whilst alive; put it on the left arm; you will be astonished at the result.’ Over the next centuries, the rational medicine of antiquity went through a long process of being diluted, or rather spiced up, with more magic ingredients and more exotic recipes.

Slightly later, Paul of Aegina (fl. 640) studied and practised medicine in Alexandria. A Galenist, he wrote on gynaecology and poisons, but his only extant work is his medical encyclopaedia, Epitome medicae libri septem [Seven Books of Medicine]. It opens with pregnancy, the diseases of childhood and of old age, and then passes to diet and regimen. Illness is dealt with in Book II. Maladies affecting specific parts are next treated from top to toe. For mental illness he recommends gentle treatments, including music, but also alludes to satanic possession. Book IV is concerned with skin diseases, beginning with scabies and ‘elephantiasis’ (presumably a form of filariasis) and progressing to herpes, oedemas, cancers and ulcers. Discussion of conditions caused by noxious body humours is followed in Book V by a survey of external agents, principally poisons, with a brief appendix on impostors. Book VI deals with surgery, including an account of tracheotomy, and a final long book is taken up with drugs, including the use of colchicum for gout. As a practical introduction, his Epitome was esteemed by Islamic physicians.

Such writers as Oribasius and Paul of Aegina saw it as their job to stitch extracts from earlier writers into a compendium of teachings and remedies. Their encyclopaedias spread Galen’s influence far and wide; they also reveal emergent tensions between theory and practice. Galen’s insistence on the need for a doctor to understand philosophy was interpreted as a call for logic and book-learning. This encouraged a drift towards treating medicine in terms of set texts. Though Galen had laid down no canon, by AD 500 in Alexandria there was not only a syllabus of Hippocratic texts (those which Galen had followed) but an embryonic Galenic canon, which became known as the sixteen books, taught with commentaries and studied in a set order, beginning with On Sects and the Art of Medicine. Alexandrian scholars also summarized the sixteen books for ease of memory, thus imparting to Galenism a more dogmatic air. Just as Christ’s teachings were theologized by the Church, classical medicine was being given its own orthodoxy. Medicine was becoming a matter of great texts.

While a scholarly tradition maintained itself in the eastern Roman empire, promoting a somewhat stilted Galenism, learned medicine was languishing in the West, where erudite doctors almost disappeared. Schools dwindled and Latin became confined to the Church. Cassiodorus (c. 540–c. 583) advised his monks at Vivarium in southern Italy to tend the sick and trust in God, while recommending a few practical medical texts: ‘read above all the translations of the Herbarium of Dioscorides, which describes with surprising exactness the herbs of the field,’ together with some Latin Hippocrates, Galen’s Method of Healing, Caelius Aurelianus’ On Medicine, and a handful of others. But that amounted to a sparse diet, and such texts were largely practical. The Lorch Book of Medicine, written about 795 in a Benedictine abbey in Germany, similarly contains brief introductory texts on anatomy, the humours and prognostics, and ends with recipes and dietary advice. The range of learned medicine was shrinking.

Knowledge was also transmitted in the West through encyclopaedias like the Etymologiae of Isidore, archbishop of Seville (c. 560–636), a medieval bestseller. Writing amid the turmoil in Spain – Goths ruled the country while Arian heretics (those who denied that Jesus was divine in the same way as God the Father) were bickering with the pope – the young Isidore felt called upon to shore up classical culture. His Etymologiae (the name reflects his passionate interest in the origins of words) takes in theology as well as history, grammar, mathematics, law and virtually all other learning. The fourth book concerns medicine, drawing on late-classical compendia, including the works of Caelius Aurelianus.

Isidore served up a beginner’s guide to Greek science, philosophy and medicine. The physical world was explained in terms of the four qualities (hot, cold, wet, dry), and the four elements (earth, air, fire, and water). The body operated on a similar plan, ruled by the four humours (blood, choler, phlegm, melancholy). Disease in the microcosm was caused by humoral imbalance, and treatment had to restore that equilibrium allopathically by diet, regimen or drugs. The medical sections of his encyclopaedia abstracted learned medicine, but his very title highlighted the new focus of study: words not bodies. Semantics was the key to a cosmos created by the Divine Logos, an orientation symptomatic of the cloistering of learning in the Latin West during those times of which little evidence survives: the ‘Dark Ages’.

The Venerable Bede (c. 672–735) was the English Isidore, a man aware of the need to meld healing and holiness. Although their North-umberland lay on the outer rim of the civilized world, Bede and his monks possessed many medical writings. Indeed, England was unique in producing a medical literature in a non-Latin tongue, Anglo-Saxon. Knowledge of plant remedies was extensive, and the English healer (laece or leech) used chants and charms, predicated on the belief that certain diseases and bad luck were caused by darts shot by elves, while others involved a ‘great worm’, a term applied to snakes, insects, and dragons. Bald and Cild’s do-it-yourself Leechbook (AD 900) mirrors medical tracts common elsewhere in western Europe, simplifying Latin recipes by removing the more exotic ingredients and interweaving local remedies. Disease could be cured by prayers or by invoking saints’ names, by exorcism, or by transferring it to animals, plants or the soil. Christian amulets were prescribed, together with number magic (the Anglo-Saxons favoured nines). For paralysis, ‘scarify the neck after the setting of the sun and silently pour the blood into running water. After that, spit three times, then say: “Have thou this unheal and depart with it”.’

Anglo-Saxon medicine conveys the spirit of early medieval Europe. A basis of classical therapeutics endured, explained by a sprinkling of Greek theory. The emphasis, however, had shifted to practicalities: recipes, meteorological and astrological advice, tips for uroscopy and bleeding, all indicative of an unstable society where books and learning had grown precious. The torch of medicine had meanwhile moved from Galen’s Rome to the east.

ISLAM

The eastern Mediterranean experienced turmoil of its own. Prolonged warfare between the Byzantine (Roman) and Persian empires caused chaos; within Byzantium, ethnic tensions between Greeks, Semites, Persians, Armenians and Slavs were exacerbated by vitriolic doctrinal splits amongst Christian sects. The heroic military efforts of Justinian (r. 524–65) to recover the western Roman Empire and his ruinous building ambitions caused further upheaval. The appearance of bubonic plague in 541 heralded two hundred years of devastating outbreaks. The Greek heritage grew less assured. Learned medicine continued in large cities, especially Alexandria, but most doctors were increasingly working in isolation, and religion assumed a dominant role in everyday life. The scene was set for Islam.

Muhammad (570–632) was a member of the tribe of Quraysh who ruled Mecca. He began life as a poor orphan but rose to become a wealthy merchant. When he was about forty, he received a call, and the Qur’an (Koran) was revealed to him in visions. He gradually assumed the mantle of the last of the prophets in a long line beginning with Adam and Noah. In 622 an assassination plot against the Muslims in Mecca led him to flee to Medina where he commanded a growing following.