The Greatest Benefit to Mankind: A Medical History of Humanity

In a tradition going back to Alcmaeon, he also believed that pneuma alone – not blood – was contained in the arteries: it was taken in through the lungs, piped to the heart (which he compared to a blacksmith’s bellows) and then pumped out to fill the arteries. Blood by contrast was formed in the liver and carried by the veins. Why then was it blood that spurted from a cut artery? It was drawn in, Erasistratus reasoned, because nature abhorred a vacuum.

Erasistratus has been portrayed as an early mechanist, because of his model of bodily processes: digestion for instance involved the stomach grinding food. Yet this may be a caricature created by Galen for polemical purposes. Even Galen applauded his remarkable investigations of brain anatomy, while being scathing about his other views, particularly the idea that the arteries contained air alone. Erasistratus was clearly a radical; for want of evidence, he is also a riddle.

In the following centuries medicine, like philosophy, split into sects: Hippocratics, Herophileans and Erasistrateans were later challenged by the Pneumatists, who regarded pneuma as a fifth element which flowed through the arteries, sustaining vitality. All such sects were later given the label of ‘rationalist’, to signal their antagonism to the Empirics, a band of physicians led by Heraclides of Tarentum (fl. 80 BC), who spurned medicine based on speculation about hidden disease causes in favour of one grounded on experience. What mattered, Empirics claimed, was not cause but cure, and so they collected case histories and remedies. Knowledge, they held, could be better gained at the bedside than by dissection; what counted was which drugs worked. Hence theory must bow to experience – a claim later opponents, principally Galen, rejected as shallow.

MEDICINE IN THE ROMAN ERA

Greek medicine spread throughout the Mediterranean, not least to Italy, where the southern cities shared Greek culture – doctors at Elea, Tarentum and Metapontum were like their colleagues in Athens or Alexandria. Rome was different. No-nonsense Roman tradition held that one was better off without doctors. Romans had no need of professional physicians, insisted authors like Cato (234–149 BC), for they were hale and hearty, unlike the effete Greeks. ‘Beware of doctors’, he cried; they would bring death by medicine. ‘It is our duty, my young friends’, reflected Cicero (106–43 BC), ‘to resist old age; to compensate for its defects by a watchful care; to fight against it as we would fight against disease; to adopt a regimen of health; to practise moderate exercise; and to take just enough food and drink to restore our strength and not to overburden it.’

Romans enjoyed bad-mouthing Greek physicians: according to Pliny (AD C. 23–79), who deplored the recent influx of ‘luxury’ and worthless Greek physicians, an inscription, echoing Alexander, was now sprouting up on monuments in Rome: ‘It was the crowd of physicians that killed me.’

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Romans liked to think healing should take place in the family, under the care of the paterfamilias, who would dispense herbs and charms. Cato, who dosed his family on cabbage soup, derided Greek physicians as the antithesis of Roman virtue: they were frauds who cheated patients and ‘have sworn to kill all barbarians with their drugs’. Prejudices such as these may explain the tardy emergence of native Italian physicians.

The contrast drawn by Cato and Pliny between homespun healing and hellenistic speculation was xenophobic prejudice. The real difference was not between Greece and Rome, but between rustic medicine and that of the big city. Greek medicine arrived with city life as Rome was hellenized. For long professional doctors (medici) in Italy were immigrants; the first noted Roman practitioner, Asclepiades (c. 120–30 BC), was a native of Bithynia in Asia Minor. Modified by his pupil, Themison of Tralles (fl. 70 BC), his doctrines gave rise to the Methodist sect. Its physiology was based not upon the Hippocratic four humours but upon corpuscular theory. In the body the proper arrangement of atoms and their intermediate pores produced health; any obstruction or undue looseness led to disease, so health was the balance between tension and relaxation. This atomist physiology enabled the doctor to reduce diagnosis to the ‘common conditions’ – the constricted, the lax and the mixed – deducible from visible symptoms. Hence the Asclepiadean or Methodist doctor did not need intimate familiarity with the life history of his patients: plain symptoms were sufficient. Cure was by opposites, enlarging narrow pores and reducing large ones, for which Asclepiades promoted massage, exercise and cold-water bathing. His slogan cito, tute et jucunde – swiftly, safely, sweetly – is reflected in his rejection of heroic bleeding, his preference for gentle medicines, his prescription of wine and his stress on convalescence. Self-styled Asclepiadeans nourished for three centuries, though their rejection of philosophical reasoning riled Galen, who sneered at their pre-packed therapies.

More light on the infiltration of Greek medicine into Rome is offered by the physician Scribonius Largus (c. AD 1–50). Born in Sicily, he probably learned his craft from hellenistic practitioners on the island, and in AD 43 he accompanied the Emperor Claudius on his campaign to subdue Britain. His sole surviving medical text is a Latin handbook of drug recipes, the Compositiones. It contains 271 recipes for conditions from headache to gout, all claimed of proven value. In his preface, Scribonius set out his views on medical ethics, becoming our earliest witness to the use of the Hippocratic oath. How widespread was his endorsement of a professional ethic is unclear, for no other ancient writer made such an open commitment.

The early empire brought the first surviving survey of medicine in Latin. An encyclopaedic compilation, Celsus’ Artes [The Sciences] originally contained at least twenty-one books, of which only the eight devoted to medicine survive in full. No professional physician but a wealthy estate owner who presumably treated his family and friends, Celsus (fl. AD c. 30) was acquainted with both theory and treatments, writing in an elegant Latin which won him the title of the Cicero of the physicians.

The eight books are introduced by a long preface tracing the story of medicine from the time of the Trojan war, and lamenting the rise of clashing sects: Dogmatists, who stressed the need to seek out unseen causes; Empirics, whose emphasis was on experience; and Methodists, wedded to ‘common conditions’. Medicine, in Celsus’ view, required not just experience but reason.

Celsus’ first book is on the preservation of health and on diet; Book 2 deals with signs the doctor should watch for, and remedies; Book 3 concerns diseases of the whole body – fevers, jaundice and so on; Book 4 lists the diseases of individual body parts in the top-to-toe order which was to become customary; and the lengthy Book 5 falls into two parts, a description of various drugs, and treatments for bites and ulcers. Book 6 handles treatments of diseases of the parts of the body, again from top to bottom. Subsequent books deal with surgery, opening with a brief history of the art, and moving on to a list of surgical conditions occurring anywhere in the body, before examining surgical techniques for individual parts, again from head to heel. The final book deals with fractures, ruptures and luxations, including such ambitious operations as removal of bone splinters from the skull. After surgery the physician must be alert to the four cardinal signs of inflammation – calor, rubor, dolor and tumor (heat, redness, pain and swelling). As the first major medical author writing in Latin and offering a summary of the whole of medicine in a single work, Celsus exercised a powerful influence.

The medical colossus of the Roman era is Galen (AD 129-c. 216), but he had significant contemporaries who stand in his shadow, in part because he belittled them, in part because their works, unlike his, survive only in fragments. One was Aretaeus of Cappadocia (fl. AD 140) who proclaimed his loyalties by writing in Greek and frequently alluding to Hippocrates. His work, known in Latin as De causis et signis acutorum et diuturnorum morborum [Acute and Chronic Diseases] provides the best disease descriptions of any surviving ancient author. A ‘rationalist’, he inclined to the pneumatic school, believing that in the universe and in man alike, pneuma (spirit) bound everything together, and any change in it led to illness.

Aretaeus made disease the hub of his inquiries, recording nothing about his patients – or himself for that matter. He gave fine descriptions, among other things, of dropsy and diabetes, mental disorders and epilepsy. Diabetes represented ‘a liquefaction of the flesh and bones into urine’, so much so that ‘the kidneys and bladder do not cease emitting urine’. His description of tetanus gives evidence of his clinical experience:

Tetanus consists of extremely painful spasms, which are a peril to life and very difficult to relieve. The attack begins in the jaw muscles and tendons, but spreads to the whole body, because all bodily parts suffer in sympathy with the one first affected.

There are three types of spasms. Either the body is stretched, or it is bent either backward or forward. With stretching the disease is called tetanus: the subject is so rigid that he cannot tarn or bend. The spasms are named according to the tension and the position of the forward and backward arching. When the posterior nerves are affected and the patient arches backward, we call the condition opisthotonus; when the anterior nerves are affected and the arching is forward, the condition is called emprosthotonus.

Another doctor then active was Soranus, practising in Ephesus AD C. IOO. His Gynaecology, the largest early treatment of that subject, should be understood in the context of traditional Hippocratic thinking on the diseases of women, which presumably reflected prevailing male prejudices. Children born at seven months were said, implausibly, to have a greater chance of surviving than those born at eight; the ‘wandering womb’ was blamed for hysteria-like illnesses; and the female constitution was an imperfect version of the male. Soranus, however, was sceptical of many of these traditions, and dismissive of the ‘wandering womb’. His Gynaecology, which enjoyed wide circulation, is divided into four sections. The first, dealing with conception and pregnancy, also discusses virginity and the right age for intercourse (not before menarche, at about fourteen). Advice was given on contraception, though Soranus disapproved of abortion by mechanical means. The next section treats labour, recommending the sitting position and the Roman birthing-chair. In case of difficult labour, he taught ‘podalic version’ – easing a hand into the uterus and pulling down one of the baby’s legs, so that it would be born feet-first. The third part examines women’s maladies, including uterine fluxes and womb-caused diseases, and the final section is concerned with problems in the birth itself: how to remove the placenta after birth and tie the umbilical cord.

Another physician associated with Ephesus was Rufus (AD 70–120), who learnt anatomy in Alexandria and spent some time in Rome. He wrote commentaries on several Hippocratic writings, accepting the doctrine of the four humours and of cure by opposites. His writings were praised by Galen. Galen’s sun, however, outshone his ideas, as it did everyone else’s.

GALEN

Galen’s dominion over medicine for more than a millennium was partly the consequence of his prolific pen. More of his opus survives than of any other ancient writer: some 350 authentic titles ranging from the soul to bloodletting polemics – about as much as all other Greek medical writings together. He had vast erudition and a matching ego.

Born in AD 129 in Pergamon (now Bergama, Turkey), one of the fairest cities in the Greek-speaking empire, Galen was the son of a wealthy architect, Nicon, and a shrewish woman (‘My mother … used to bite her serving maids, and was perpetually shouting at my father’). He enjoyed a long, lavish, liberal education; when he was sixteen, his father was visited in a dream by Asclepius, after which the son was piously steered towards medicine. He studied with Alexandrian teachers and travelled in Egypt, learning about drugs from India and Africa. Returning home in 157, he was appointed physician to the gladiators, a job which enlarged his anatomical and surgical expertise, since wounds afforded windows onto the body. But Pergamon was provincial, and in 162 he left for Rome, where public debates against Methodists and high-profile public anatomical displays spread his fame. One of his party tricks, revealing his genius for self-advertisement as well as experiment, was to sever the nerves in the neck of a pig. As these were severed, one by one, the pig continued to squeal; but when Galen cut one of the laryngeal nerves the squealing stopped, impressing the crowd. Leading senators and dignitaries began to employ him, and from AD 169 Galen was in imperial service, first with the emperor’s son, Commodus, and later a succession of emperors. He liked reminding readers that his patients were of the highest rank. ‘Something really amazing happened when the emperor [Marcus Aurelius] himself was my patient’, he wrote:

Just when the lamps were lit, a messenger came and brought me to the Emperor as he had bidden. Three doctors had watched over him since dawn, and two of them felt his pulse, and all three thought that a fever attack was coming. I stood alongside, but said nothing. The Emperor looked first at me and asked why I did not feel his pulse as the other two had. I answered: ‘These two colleagues of mine have already done so and, as they have followed you on the journey, they presumably know what your normal pulse is, so they can judge its present state better.’

When I said this, he bade me, too, to feel his pulse. My impression was that – considering his age and body constitution – the pulse was far from indicating a fever attack, but that his stomach was stuffed with the food he had eaten, and that the food had become a slimy excrement. The Emperor praised my diagnosis and said, three times in a row: ‘That is it. It is just as you say. I have eaten too much cold food.’

He then asked what measures should be taken. I replied what I knew of a similar case, saying: ‘If you were any plain citizen of this country, I would as usual prescribe wine with a little pepper. But to a royal patient as in this case, doctors usually recommend milder treatment. It is enough for a woollen cover to be put on your stomach, impregnated with warm spiced salve.’

Expert in one-upmanship, Galen couched an inflated sense of his importance in terms of the dignity of medicine, scolding colleagues as dimwits. He was invariably right; there is no denying that he was an erudite man and an accomplished philosopher, particularly in constructing an image of the organism as a teleological unity open to reasoning. For him, anatomy proved the truth of Plato’s tripartite soul, with its seats in the brain, heart and liver; and Aristotelian physics with its elements and qualities explained the body system.

Philosophy should promote medicine, Galen taught, though the physician must master philosophy – logic (the discipline of thinking), physics (the science of nature), and ethics (the science of action). Philosophy and medicine were thus counterparts: the best doctor was also a philosopher, while the unphilosophical healer (the Empiric) was like an architect without a plan. A good physician would practise for the love of mankind, while accepting his due rewards in fame and fortune.

The patient’s trust was essential in the healing process. It could be won by a punctilious bedside manner, by meticulous explanation, and by mastery of prognosis, an art demanding experience, observation and logic. Galen brought psychosomatic conditions to light, including uneasiness amongst defendants in court cases or those whose pulses raced through guilty passions.

Galen prided himself on being more than a fine clinician; he was a medical scientist. He performed dissections, mainly of apes, sheep, pigs and goats and even of an elephant’s heart, but not of humans. He knew much skeletal anatomy, but, dissection being out of the question, little internal human anatomy. Two mistakes were particularly critical for the future. Dissections of calves revealed a network of nerves and vessels, the rete mirabile at the base of the brain, earlier found by Herophilus, which he assumed also existed in humans. This, he said, was the site where the vital spirits in the arteries turned into animal spirits. He also misleadingly described the liver (which he believed to be the source of the veins) as grasping the stomach with its lobes as if by fingers, an image derived from dissection of pigs or apes. Forced to apply animal findings to humans, his human womb also had cotyledons like a dog’s. Such mistakes aside, his explanations of anatomical phenomena in terms of the teleology of a divinely ordered universe were internally coherent and provided a rational basis for further investigation.

Gross anatomy and experiments offered paths to understanding, but Galen did not restrict himself to sensory perceptions. By combining his observations with Platonic speculations about the macrocosm at large, he formulated models of concealed bodily structures. Each part functioned only when its basic elements were properly adapted, and any change would result in functional failure or disease. The unknown was thereby explained in terms of a structural/functional physiology. His systematizing zeal was both a boon and a bane.

Galen presented his work as ‘perfecting’ Hippocrates’ legacy, and this gives his oeuvre a remarkable unity, fusing the clinical and the theoretical. Take his writings on fever: fever might result from either an excess of yellow bile, black bile or phlegm (a condition he called cacochymia), or from an excess of blood (plethora). Surplus humours might accumulate in some bodily part where they would cause putrefaction and excessive heat or fever. To remove such superfluities and restore humoral balance, he advocated energetic blood-letting. The physician should let blood from a patient not only when he was ill but prophylactically, whenever a fever was on the cards. Indications were given of when and how much blood to draw, depending on the patient’s age and constitution, the season of the year, the weather and the place. Instead of the earlier Hippocratic treatment of fevers by starvation, Galen urged venesection (letting blood from the veins) to cool the body.

He justified blood-letting in terms of his elaborate pulse lore. Written in the early 170s, his sixteen books on the pulse were divided into four treatises, each four books long. The first, On the Differences between Pulses, displayed his learning, logic and linguistic skills. In the next four books On the Diagnosis of Pulses, he explained how to take the pulse and interpret it, raising key questions. How was it possible to tell whether a pulse was ‘full’, ‘rapid’ or ‘rhythmical’? Such questions he resolved partly from experience and partly by reference to earlier authorities.

On the Causes of Pulsation addressed anatomy. Although Galen was convinced, pace Erasistratus, that arteries contained blood from the heart, his idea of pulsation was quite different from ours. The heart and the artery contracted simultaneously and arterial expansion and contraction were separate, active movements. In contraction, superfluities were expelled; in expansion, atmospheric air was taken in to cool things down and, by mixing with blood in the heart, to generate vital spirits (pneuma). It was this vital spirit which was mainly responsible for creating the pulsative power within the coats of the artery.

Blood, Galen taught, was made in the liver, incorporating ingested foods in the form of chyle; it then moved to the extremities carrying natural spirits which supported the vegetative functions of growth and nutrition. This dark venous blood, passing from the liver to the right ventricle of the heart, divided into two streams. One passed to the lungs via the pulmonary artery; the other crossed the heart through ‘interseptal pores’ into the left ventricle, where it mixed with pneuma (air), became heated, moved thence from the left ventricle to the aorta, and finally to the periphery. His belief that the veins originated in the blood-making liver, carrying nutrition to the parts whenever needed, while the arteries originated in the heart, was one of the errors in his model of the circulatory system which, after dominating medicine for well over a millennium, was challenged by Renaissance anatomy.

From a clinical standpoint, Galen was principally concerned to teach the doctor to read the various pulse phenomena. This he provided in the final part, On Prognosis from the Pulse, where he adopted a double strategy. The first two books described the complaints a specific pulse type might betray: for example, the ‘double-hammer pulse’ was a frequent sign of heart weakness. The last books detailed the sort of pulse found in specific disorders: for example, in hectic fevers the pulse increased in frequency and rapidity.

Whatever the disorder – even blood loss – Galen judged bleeding proper. All depended on knowing where and when to do it, and how much blood to take. For severe conditions he recommended phlebotomy twice a day; the first should be stopped before the patient fainted, but the second time the physician could bleed as far as unconsciousness. Convinced that nature prevented disease by discharging excess blood, he pointed out that menstruation spared women many diseases – gout, epilepsy, apoplexy – to which males were prone. The quantities of blood he removed were large, and would often, to our thinking, have been harmful. His teachings on plethora and venesection remained influential until the nineteenth century.

Galen took clinical Hippocratic medicine and set it within a wider anatomo-physiological framework. In broad terms this built on the Platonic doctrine of a threefold division of the soul, which distinguished vital functions into processes governed by vegetative, animal, and rational ‘souls’ or ‘spirits’. Animal life was possible only because of the existence of pneuma. Within the human body, pneuma (air), the life breath of the cosmos, was modified by the three principal organs, the liver, heart and brain, and distributed by three types of vessels: veins, arteries and nerves. Pneuma, modified by the liver, became the nutritive soul or natural spirits which supported the vegetative functions of growth and nutrition; this nutritive soul was distributed by the veins. The heart and arteries were responsible for the maintenance and distribution of innate heat and pneuma or vital spirits to vivify the parts of the body. The third alteration, occurring in the brain, ennobled vital spirits into animal spirits, distributed through the nerves (which Galen thought of as empty ducts) to sustain sensation and movement.

For Galen, anatomy, logic and experience fitted together. Not least because he had an explanation for everything, Galenic medicine proved monumental, as he intended it should:

I have done as much for medicine as Trajan did for the Roman Empire when he built bridges and roads through Italy. It is I, and I alone, who have revealed the true path of medicine. It must be admitted that Hippocrates already staked out this path … he prepared the way, but I have made it passable.

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.