The Greatest Benefit to Mankind: A Medical History of Humanity

EGYPT

Egypt rose under the pharaohs in the third millennium BC; the great pyramids on the plateau at Giza, dating from around 2000 BC, show a powerful regime possessed of stupendous ambition and technological virtuosity. The earliest written evidence of their medicine appears in papyri of the second millennium BC, but such records encode far older traditions. Among the medical texts, the most important, discovered in the nineteenth century, are the Edwin Smith and the Georg Ebers papyri.

Sometimes called a book of wounds, the Edwin Smith papyrus (c. 1600 BC, found near Luxor and named after an American Egyptologist) gives a head-to-foot inventory of forty-eight case reports, including various injuries and wounds, their prognosis and treatment. ‘If you examine a man having a dislocation of his mandible, should you find his mouth open, and his mouth cannot close, you should put your two thumbs upon the end of the two rami of the mandible inside his mouth and your fingers under his chin and you should cause them to fall back so that they rest in their places.’ The surgical conditions treated were wounds, fractures and abscesses; circumcision was also performed. Broken bones were set in ox-bone splints, supported by resin-soaked bandages. The papyrus refers to a raft of dressings, adhesive plasters, braces, plugs, cleansers and cauteries.

The Smith papyrus shows there was an empirical component to ancient Egyptian medicine alongside its magico-religious bent. In a similar style, the London papyrus (c. 1350 BC) describes maternal care, and the Kahun papyrus (c. 1850 BC) deals with animal medicine and gynaecology, including methods for detecting pregnancy and for contraception, for which pessaries were recommended made of pulverized crocodile dung and herbs now impossible to identify, mixed with honey. Their contraceptive measures, evidently aimed at blocking the passage of semen, may have worked, since the Egyptians seem to have been able to regulate family size without recourse to infanticide.

The Ebers papyrus (c. 1550 BC), deriving from Thebes, is, however, the principal medical document – indeed the oldest surviving medical book. Over twenty metres long, it deals with scores of diseases and proposes remedies including spells and incantations. This and other sources show the prominence of magic. Amulets were recommended, and treatments typically involved chants and supplications to the appropriate deities, the most popular being the falcon-headed sun god Ra; Thoth, the ibis-headed god of wisdom (later associated with the Greek Hermes or the Roman Mercury); and Isis and her son Horus, the god of health, whose eye formed the motif for a popular charm.

The Ebers papyrus covers 15 diseases of the abdomen, 29 of the eyes, and 18 of the skin, and lists no fewer than 21 cough treatments. About 700 drugs and 800 formulae are referred to, mainly herbs but also mineral and animal remedies. To cure night-blindness fried ox liver was to be taken – possibly a tried-and-tested procedure, as liver is rich in vitamin A, lack of which causes the illness. Eye disorders were common, and there were numerous cures:

To drive away inflammation of the eyes, grind the stems of the juniper of Byblos, steep them in water, apply to the eyes of the sick person and he will be quickly cured. To cure granulations of the eye prepare a remedy of cyllyrium, verdigris, onions, blue vitriol, powdered wood, mix and apply to the eyes.

For stomach ailments a decoction of cumin, goose-fat and milk was recommended, but other remedies sound more exotic, including a drink prepared from black ass testicles, or a mixture of vulva and penis extracts and a black lizard, designed to cure baldness. Also good for hair growth was a compound of hippopotamus, lion, crocodile, goose, snake and ibex fat.

Egyptian medicine credited many vegetables and fruits with healing properties, and used tree resins, including myrrh, frankincense and manna. As in Mesopotamia, plant extracts – notably senna, colocynth and castor oil – were employed as purgatives. Recipes include ox spleen, pig’s brain, honey-sweetened tortoise gall and various animal fats. Antimony, copper and other minerals were recommended as astringents or disinfectants. Containing ingredients from leeks to lapis lazuli – including garlic, onion, tamarisk, cereals, spices, condiments, resins, gums, dates, hellebore, opium and cannabis – compound drugs were administered in the form of pills, ointments, poultices, fumigations, inhalations, gargles and suppositories; they might even be blown into the urethra through a tube.

Archaeological evidence and papyri afford glimpses of Egyptian medical practice, at least among the elite. Part was hierarchically organized and under state control; physicians were appointed to superintend public works, the army, burial grounds and the pharaoh’s palace. Court physicians formed the apex of the medical pyramid. Just as the gods governed different body parts, physicians (swnu) specialized in particular diseases or body organs; in the fifth century BC the Greek Herodotus observed that in Egypt ‘one physician is confined to the study and management of one disease … some attend to the disorders of the eyes, others to those of the head, some take care of the teeth, others are conversant with all diseases of the bowels.’

As in Mesopotamia, the swnu formed one of three divisions of healers. The others were priests of Sekhmet, and sorcerers. Healers whose names have come down include Iri, Keeper of the Royal Rectum, presumably the pharaoh’s enema expert. (Enemas had a divine origin, being invented by ibis-headed Thoth; they were widely used, because Egyptian health lore feared putrefaction in the guts and bowels.) There was also Peseshet, head female physician or overseer, proof of the existence, as in Mesopotamia, of female healers; and the celebrated Imhotep (‘he who cometh in peace’) chief vizier to Pharaoh Zozer (fl. 27 cent, BC), high priest at Heliopolis, renowned as an astrologer, priest, sage and pyramid designer (the Step Pyramid of Sakkarah), but above all as a physician.

Imhotep became a figure akin to the Greek god Asclepius (Aesculapius in Latin). His ‘sayings’ were later recorded and preserved among the classics of Egyptian wisdom, and within a few generations he was being deified. There is, however, little evidence of his cult for another millennium, and only around 300 BC did it blossom. As with Asclepius, Imhotep became associated with healing shrines and temple sleep (incubation cures). Patients would sleep overnight in the inner precincts where they would be visited in their dreams by a god, or an emissary like a snake, and their illness or infertility remedied.

The Egyptians believed well-being was endangered by earthly and supernatural forces alike, in particular evil spirits stealing into the body through the orifices and consuming the victim’s vital substance. Health was associated with correct living, being at peace with the gods, spirits and the dead; illness was a matter of imbalance which could be restored to equilibrium by supplication, spells and rituals. Thus, someone struck blind might invoke a god: ‘Ptah, the lord of Truth, has turned his justice against me; he has rightly chastised me. Have pity on me, deign to regard me with merciful countenance.’ Handling burns, a magician would swab the wound with the milk of a mother of a baby boy, while appealing to Isis by repeating the words the goddess had supposedly used to rescue her son Horus from being burned: ‘There is water in my mouth and a Nile between my legs; I come to quench the fire.’

Surgery was limited to repairing injuries and bone fractures; sutures and cautery were used, and wound dressings to promote healing, which combined honey with grease or resin; but no surgical instruments survive. Anatomical knowledge remained limited to bones and major organs. As mummification suggests, the Egyptians did not share the taboos that have so widely forbidden tampering with corpses, but embalmers formed a separate guild and were of low caste; moreover, since mummification aimed to preserve the body intact, embalmers did not open cadavers up; they eviscerated and extracted the organs through small incisions. The brain was removed through the nose by hooks, though the heart was left in place, being the seat of the soul.

According to Egyptian medical theory, humans were born healthy, but were susceptible to disorders caused not only by demons but by intestinal putrefaction. Life lay in breath, and a speculative heart-centred physiology pictured a mesh of vessels carrying blood, urine, air, semen, tears and solid wastes to all bodily parts. This vascular network was likened to the Nile and its canals and, as with that water-system, the point was to keep it free of obstruction. Rotting food and faeces clogging the system were considered perilous, hence the need to prevent pus formation and to cleanse the innards with laxatives. Herodotus noted that three days each month were set aside for evacuating the body with emetics and enemas.

As with Mesopotamia, Egypt’s imposing political regime made for an organized medical practice. It is, however, with Greek civilization that evidence of recognizable medical discourse first appears.

GREECE

By 1000 BC the communities later collectively known as the Greeks were emerging around the Aegean sea, in Ionia (the western seaboard of Asia Minor or Turkey), the Greek mainland (the Peloponnese), and the intervening islands. How much medical knowledge they took from Egypt remains controversial. On Crete, midway between Africa and the Greek mainland, the remarkable Minoan civilization had developed after 2000 BC, with its dazzling pottery and frescos found at Knossos and other palaces; and the Greeks of the Mycenean period (c. 1200 BC) were in close touch with Egypt, certainly getting drugs from there. But the contrasts between old Egyptian and new Greek medicine are striking.

Little is known of Greek medicine before the appearance of written texts in the fifth century BC Archaic Greece undeniably possessed folk healers, including priest healers employing divination and drugs. From early times (Olympic games are recorded from as early as 776 BC), the love of athletics gave rise to instructors in exercise, bathing, massage, gymnastics and diet. Throughout Greek civilization, as with the Roman later, ideals of manliness required keeping one’s physique in peak condition; admiration for the lithe, fit, attractive warrior shines through classical art and myths. Dancing, martial arts and working out in the gymnasium with the help of trainers – men-only practices, women being excluded from public life – were regarded as essential for the well-being of the body. The archaic warrior developed into the beauty-loving citizen of the polis (city state), with his ideal of a cultivated mind in a disciplined body. Athenian sculpture and painting revered the human form, proudly displaying its naked magnificence and finding in its geometrical forms echoes of the fundamental harmonies of nature. A tradition was thus begun that would climax in the Renaissance image of ‘Vitruvian Man’, the representation of the naked male figure inscribed at the centre of the cosmos.

Glimpses of early Greek medicine are offered by the Homeric epics, dating from before 600 BC but incorporating older narratives. Painstaking scholars have counted some 147 cases of battle wounds in the Iliad (that is, 106 spear thrusts, 17 sword slashes, 12 arrow shots and 12 sling shots). Among survivors of arrow wounds was King Menelaus of Sparta, whose physician extracted the arrow, sucked out the blood and applied a salve. As with other medical interventions in Homer, this shows no Egyptian influence, supporting the idea that, even if Greek practice owed much to Egypt, it rapidly went its own way. Certainly Greek medicine as known from written sources is highly distinctive, for from the beginning Greek medical texts were essentially secular.

Admittedly, Greek society at large drew heavily upon sacred healing. In Homer, Apollo appears as the ‘god of healing’ – now the spreader of plague, now the avenger. In the Iliad deities visited plagues upon humans, and Greek myths abound in injuries inflicted by the gods, for instance Prometheus having his liver torn out by an eagle. Various gods and heroes were identified with health and disease, the chief being Asclepius, who even had the power to raise the dead. A heroic warrior and blameless physician, Asclepius was the son of Apollo, sired upon a mortal mother. Taught herbal remedies by Chiron the centaur, he generously used them to heal humans. Incensed at being cheated of death, Hades (Roman: Pluto), the ruler of the underworld, appealed to the supreme god, Zeus, who obligingly dispatched Asclepius with a thunderbolt (though he was later elevated to the ranks of the gods).

A different version appears in Homer, who portrayed Asclepius as a tribal chief and a skilled wound healer, whose sons became physicians and were called Asclepiads, from whom all Asclepian practitioners descended. As the tutelary god of medicine, Asclepius is usually portrayed with a beard, staff and snake (the origin of the caduceus sign of the modern physician, with its two snakes intertwined, double-helix like, on a winged staff; the shedding of the snakes’ skin symbolized the renewal of life). The god was often shown accompanied by his daughters, Hygeia (health or hygiene) and Panacea (cure-all).

Asclepius eventually became a cult figure and the physicians’ patron. Pindar wrote:

They came to him with ulcers the flesh had grown, or their

Limbs mangled with the grey bronze, or bruised

With the stone flung from afar,

Or the body stormed with summer fever, or chill, and he

Released each man and led him

From his individual grief.

During the third century the cult of Asclepius spread, and by 200 BC every large town in Greece had a temple to the god. The best known of these Asclepieions were on the island of Cos, Hippocrates’ birthplace, and at Epidaurus, thirty miles from Athens, but at least 200 other sites have been uncovered; they played a role similar to medieval healing shrines or to Lourdes today. The major shrines sported splendid temples and their cures were celebrated in memorial inscriptions. Pilgrims stayed the night in special incubation chambers where, before an image of Asclepius, they hoped through ‘temple sleep’ to receive a vision in a dream. The god would either perform the cure himself, or would give the patient a dream to be deciphered by the priest. The restored patient usually raised in the precinct a memorial of this marvel: ‘Hermodikes of Lampsakos was paralysed in body. In his sleep he was healed by the god.’ Physicians rarely acted as dream interpreters, but around the temples religious and secular healing rubbed shoulders.

The Greeks also went in for other religious healing, involving exorcists, diviners, shamans and priests. Certain diseases, notably epilepsy, were ascribed to celestial wrath: the Iliad opens with a plague sent by Apollo, and relief from the appalling great plague of Athens (430 – 427 BC) was sought through invoking the gods.

For all that, Hippocratic medicine, the foundation of Greek written medicine, explicitly grounds the art upon a quite different basis: a healing system independent of the supernatural and built upon natural philosophy. The author of the Hippocratic text, On the Sacred Disease (c. 410 BC), utterly rejected the received idea of a divine origin for epilepsy. He sarcastically paraded the different gods supposed to produce epileptic seizures: if the convulsive patient behaved in a goatlike way, or ground his teeth, the cause allegedly lay in Hera, the mother of the gods; Hecate, the goddess of sorcery, was to blame if the sufferer experienced nightmares and delirium; and so forth. But what evidence was there for any of these fantasies? ‘Men regard its nature and cause as divine from ignorance and wonder’, insisted the author, ‘and this notion is kept up by their inability to comprehend it.’ How foolish! For if a condition ‘is reckoned divine because it is wonderful, instead of one there would be many diseases which would be sacred’. Nowhere in the Hippocratic writings is there any hint of disease being caused or cured by the gods.

This scoffing at the ‘sacred disease’ chimed with an elitist ideal of professional identity. Staking their claims in the medical market-place of the polis, Hippocratic doctors scolded traditional healers. Those pretenders ‘who first referred this disease to the gods’, the author complained, were like conjurors and charlatans. Elevating themselves above such dabblers in divination, the Hippocratics posited a natural theory of disease aetiology. On the Sacred Disease plucked disease from the heavens and brought it down to earth. The true doctor would no longer be an intermediary with the gods but the bedside friend of the sick.

This separation of medicine from religion points to another distinctive feature of Greek healing: its openness, a quality characteristic of Greek intellectual activity at large, which it owed to political diversity and cultural pluralism. In the constellation of city states dotting the mainland and the Aegean islands, healing was practised in the public sphere, and interacted with other mental pursuits. There was no imperial Hammurabic Code and, unlike Egypt, no state medical bureaucracy; nor were there examinations or professional qualifications. Those calling themselves doctors (iatroi) had to compete with bone-setters, exorcists, root-cutters, incantatory priests, gymnasts and showmen, exposed to the quips of playwrights and the criticism of philosophers. Medicine was open to all (as later in Rome, slaves sometimes practised medicine).

Doctrinally, too, there was great multiplicity, in complete contrast to what is known of Babylonian or Egyptian medicine, which have left no trace of controversy, being essentially lists of instructions. Greek medical writers loved speculation and argument, doubtless angling for public attention. Trading facts and chopping logic, physicians jousted to unsaddle their rivals.

The ultimate challenge was to fathom the order of the universe, and because this included the human body viewed as a microcosm of the grand order of nature (macrocosm), such metaphysical speculations had direct medical implications. The earliest Ionian philosophers hoped to identify a single elemental substance, but Parmenides of Elea in southern Italy criticized such monocausal theories. A shaman-like figure, Parmenides (c. 515–450 BC) maintained that the key question concerned not material essence but the processes governing change and stability within a regular universe.

Various solutions to the riddle of the cosmos followed. For the geometer Pythagoras (c. 530 BC), living at Croton in Sicily, the key lay in number and harmony – and the dynamic balance of contraries, based on the opposition of odd and even. For Heraclitus (c. 540–475 BC) the true constant was change itself, in a macrocosm composed of fire and water; for Democritus (c. 460 BC), the essence was a flux of atoms in a void.

Others, like the Sicilian Empedocles (fl. mid-5th century BC), regarded nature as composed of a small number of basic elements (earth, air, fire, and water) combining into temporarily stable mixtures. Building on Parmenides, Empedocles seems to have been the first to advance some of the key physiological doctrines in Greek medicine. These involve the concept of innate heat as the source of living processes, including digestion; the cooling function of breathing; and the notion that the liver makes the blood that nourishes the tissues.

His contemporary, Alcmaeon of Croton (fl. 470 BC), believed that the brain, not the heart, was the chief organ of sensation. This had a real observational basis: examination of the eyeball led him to discern the optic nerve leading into the skull. He gave similar explanations for the sensations of hearing and smelling, because the ear and nostrils suggested passages leading to the brain.

Discounting the role of demons in disease, Alcmaeon treated health in a rather Pythagorean way as the dance of primary pairs of bodily powers – hot and cold, sweet and sour, wet and dry. Seated in the blood, marrow or brain, illness could arise from an external cause or an internal imbalance, caused by too much or too little nutriment. Similar views can be found in several texts in the Hippocratic Corpus (440–340 BC), though no direct influence can be proved. Indeed, all these early writers are obscure, for their opinions survive only through later commentators and critics, such as Plato, who used them for their own polemical purposes.

What is clear is that in classical Greece philosophical speculations about nature became enmeshed in dialogue with medical beliefs about sickness and health; dialogue and debate were integral to Greek intellectual life. Unlike healing in the Near East, elite Greek medicine was not a closed priestly system: it was open to varied influences and accessible to outsiders, guaranteeing its flexibility and vitality.

This openness followed from the fact that Greek civilization developed in multiple centres from Asia Minor to Sicily, and no single sect of doctors possessed a state or professional monopoly. Athens was the first city to support a fair number of full-time healers making a livelihood out of fees, and, according to his younger contemporary Plato (427–347 BC), the great Hippocrates taught all who were prepared to pay.

HIPPOCRATES

All we know about Hippocrates (c. 460–377 BC) is legend. Early hagiographers say he was born on the island of Cos and that he lived a long and virtuous life. The sixty or so works comprising the Corpus were penned by him only in the sense that the Iliad is ascribed to Homer. They derive from a variety of hands, and, as with the books of the Bible, they became jumbled up, fragmented and then pasted together again in antiquity. What is now called the Corpus was gathered around 250 BC in the library at Alexandria, though further ‘Hippocratic’ texts were added later still. Scholarly ink galore has been spilt as to which were authentic and which spurious; the controversy is futile.

The Corpus is highly varied. Some works like The Art are philosophical, others are teaching texts; some, like the Epidemics, read like case notes. What unites them is the conviction that, as with everything else, health and disease are capable of explanation by reasoning about nature, independently of supernatural interference. Man is governed by the same physical laws as the cosmos, hence medicine must be an understanding, empirical and rational, of the workings of the body in its natural environment. Appeal to reason, rather than to rules or to supernatural forces, gives Hippocratic medicine its distinctiveness. It was also to win a name for being patient-centred rather than disease-oriented, and for being concerned more with observation and experience than with abstractions.

Hippocratic medicine did not offer all the answers. The workings of the body and the springs of disease remained thorny issues dividing physicians. This was partly because knowledge was limited. Hippocratic doctors had a sound grasp of surface anatomy, but first-hand knowledge of the innards and living processes depended heavily on wound observation and animal dissection, for in the classical period the dignity the human body enjoyed forbade dissection.

Analogy might help – hens’ eggs offered models for human foetal development, and the digestion of food could be compared to cooking over a fire – but even animal experiments were rare, and the body’s hidden workings had to be deduced largely from what went in and what came out. With internal physiology hidden, disease might be conjecturally explained: On the Sacred Disease argued that epilepsy, as natural as any other disease, was caused by phlegm blocking the airways, which then convulsed the body as it struggled to free itself.

The cardinal concept in the Hippocratic Corpus was that health was equilibrium and illness an upset, an explanation probably owing much to pre-Socratic attempts to understand the stability yet changeability of nature. On Regimen pictured the body as being in perpetual flux: health was a matter of keeping it within bounds. More commonly, notably in On the Nature of Man, the body was viewed as stable until illness subverted it. Imbalance would produce illness if it resulted in undue concentration of fluid in a particular body zone. Thus a flow (defluxion) of humours to the feet would produce gout, or catarrh (defluxion of phlegm from the head to the lungs) would be the cause of coughing. It was the healer’s job to apply his skill to preserving balance or, if illness befell, to restoring it.

What was being kept in balance or upset were bodily fluids or chymoi, translated as ‘humours’. Sap in plants and blood in animals were the fount of life. Other and perhaps less salutary bodily fluids became visible only in case of illness – for example, the mucus of a cold or the runny faeces of dysentery. Two fluids were particularly associated with illness: bile and phlegm, though naturally present in the body, seemed to flow immoderately in sickness. Winter colds were due to phlegm, summer diarrhoea and vomiting to bile, and mania resulted from bile boiling in the brain. Airs, Waters, Places also attributed national characteristics to bile and phlegm: the pasty, phlegmatic peoples of the North were contrasted with the swarthy, hot, dry, bilious Africans. Both were judged inferior to the harmonious Greeks in their ideally equable climate.

Bile and phlegm were visible mainly when exuded in sickness, so it made sense to regard them as harmful. But what of other fluids? Since Homeric times, blood had been associated with life, yet even blood was expelled naturally from the body, as in menstruation or nose-bleeds. Such natural evacuation suggested the practice of blood-letting, devised by the Hippocratics, systematized by Galen, and serving for centuries as a therapeutic mainstay.