Kitabı oxu: «The Greatest Benefit to Mankind: A Medical History of Humanity»

CONTENTS

COVER

TITLE PAGE

COPYRIGHT

PRAISE

DEDICATION

I Introduction

II The Roots of Medicine

III Antiquity

IV Medicine and Faith

V The Medieval West

VI Indian Medicine

VII Chinese Medicine

VIII Renaissance

IX The New Science

X Enlightenment

XI Scientific Medicine in the Nineteenth Century

XII Nineteenth-Century Medical Care

XIII Public Medicine

XIV From Pasteur to Penicillin

XV Tropical Medicine, World Diseases

XVI Psychiatry

XVII Medical Research

XVIII Clinical Science

XIX Surgery

XX Medicine, State and Society

XXI Medicine and the People

XXII The Past, The Present and the Future

FURTHER READING

INDEX

ACKNOWLEDGEMENTS

ABOUT THE AUTHOR

ABOUT THE PUBLISHER

CHAPTER I INTRODUCTION

THESE ARE STRANGE TIMES, when we are healthier than ever but more anxious about our health. According to all the standard benchmarks, we’ve never had it so healthy. Longevity in the West continues to rise – a typical British woman can now expect to live to seventy-nine, eight years more than just half a century ago, and over double the life expectation when Queen Victoria came to the throne in 1837. Break the figures down a bit and you find other encouraging signs even in the recent past; in 1950, the UK experienced 26,000 infant deaths; within half a century that had fallen by 80 per cent. Deaths in the UK from infectious diseases nearly halved between 1970 and 1992; between 1971 and 1991 stroke deaths dropped by 40 per cent and coronary heart disease fatalities by 19 per cent – and those are diseases widely perceived to be worsening.

The heartening list goes on and on (15,000 hip replacements in 1978, over double that number in 1993). In myriad ways, medicine continues to advance, new treatments appear, surgery works marvels, and (partly as a result) people live longer. Yet few people today feel confident, either about their personal health or about doctors, healthcare delivery and the medical profession in general. The media bombard us with medical news – breakthroughs in biotechnology and reproductive technology, for instance. But the effect is to raise alarm more than our spirits.

The media specialize in scare-mongering but they also capture a public mood. There is a pervasive sense that our well-being is imperilled by ‘threats’ all around, from the air we breathe to the food in the shops. Why should we now be more agitated about pollution in our lungs than during the awful urban smogs of the 1950s, when tens of thousands died of winter bronchitis? Have we become health freaks or hypochondriacs luxuriating in health anxieties precisely because we are so healthy and long-lived that we now have the leisure to enjoy the luxury of worrying?

These may be questions for a psychologist but, as this book aims to demonstrate, they are also matters of historical inquiry, examining the dialectics of medicine and mentalities. And to understand the dilemmas of our times, such facts and fears need to be put into context of time and place. We are today in the grip of opposing pressures. For one thing, there is the ‘rising-expectations trap’: we have convinced ourselves that we can and should be fitter, more youthful, sexier. In the long run, these are impossibly frustrating goals, because in the long run we’re all dead (though of course some even have expectations of cheating death). Likewise, we are healthier than ever before, yet more distrustful of doctors and the powers of what may broadly be called the ‘medical system’. Such scepticism follows from the fact that medical science seems to be fulfilling the wildest dreams of science fiction: the first cloning of a sheep was recently announced and it will apparently be feasible to clone a human being within a couple of years. In the same week, an English widow was given permission to try to become pregnant with her dead husband’s sperm (but only so long as she did it in Belgium). These are amazing developments. We turn doctors into heroes, yet feel equivocal about them.

Such ambiguities are not new. When in 1858 a statue was erected in the recently built Trafalgar Square to Edward Jenner, the pioneer of smallpox vaccination, protests followed and it was rapidly removed: a country doctor amidst the generals and admirals was thought unseemly (it may seem that those responsible for causing deaths rather than saving lives are worthy of public honour). Even in Greek times opinions about medicine were mixed; the word pharmakos meant both remedy and poison – ‘kill’ and ‘cure’ were apparently indistinguishable. And as Jonathan Swift wryly reflected early in the eighteenth century, ‘Apollo was held the god of physic and sender of diseases. Both were originally the same trade, and still continue.’ That double idea – death and the doctors riding together – has loomed large in history. It is one of the threads we will follow in trying to assess the impact of medicine and responses to it – in trying to assess Samuel Johnson’s accolade to the medical profession: ‘the greatest benefit to mankind.’

‘The art has three factors, the disease, the patient, the physician,’ wrote Hippocrates, the legendary Greek physician who has often been called the father of medicine; and he thus suggested an agenda for history. This book will explore diseases, patients and physicians, and their interrelations, concentrating on some more than others. It is, as its sub-title suggests, a medical history.

My focus could have been on disease and its bearing on human history. We have all been reminded of the devastating effects of pestilence by the AIDS epidemic. In terms of death toll, cultural shock and socio-economic destruction, the full impact of AIDS cannot yet be judged. Other ‘hot viruses’ may be coming into the arena of history which may prove even more calamitous. Historians at large, who until recently tended to chronicle world history in blithe ignorance of or indifference to disease, now recognize the difference made by plague, cholera and other pandemics. Over the last generation, distinguished practitioners have pioneered the study of ‘plagues and peoples’; and I have tried to give due consideration to these epidemiological and demographic matters in the following chapters. But they are not my protagonists, rather the backdrop.

Equally this book might have focused upon everyday health, common health beliefs and routine health care in society at large. The social history of medicine now embraces ‘people’s history’, and one of its most exciting developments has been the attention given to beliefs about the body, its status and stigmas, its race, class and gender representations. The production and reproduction, creation and recreation of images of Self and Other have formed the subject matter of distinguished books. Such historical sociologies or cultural anthropologies – regarding the body as a book to be decoded – reinforce our awareness of the importance, past and present, of familiar beliefs about health and its hazards, about taboo and transgression. When a body becomes a clue to meaning, popular ideas of health and sickness, life and death, must be of central historical importance. I have written, on my own and with others, numerous books exploring lay health cultures in the past, from a ‘bottom-up’, patients’ point of view, and hope soon to publish a further work on the historical significance of the body.

This history, however, is different. It sets the history of medical thinking and medical practice at stage centre. It concentrates on medical ideas about disease, medical teachings about healthy and unhealthy bodies, and medical models of life and death. Seeking to avoid anachronism and judgmentalism, I devote prime attention to those people and professional groups who have been responsible for such beliefs and practices – that is healers understood in a broad sense. This book is principally about what those healers have done, individually and collectively, and the impact of their ideas and actions. While placing developments in a wider context, it surveys medical theory and practices.

This approach may sound old-fashioned, a resurrection of the Whiggish ‘great docs’ history which celebrated the triumphal progress of medicine from ignorance through error to science. But I come not to praise medicine – nor indeed to blame it. I do believe that medicine has played a major and growing role in human societies and for that reason its history needs to be explored so that its place and powers can be understood. I say here, and I will say many times again, that the prominence of medicine has lain only in small measure in its ability to make the sick well. This always was true, and remains so today.

I discuss disease from a global viewpoint; no other perspective makes sense. I also examine medicine the world over. Chapter 2 surveys the emergence of health practices and medical beliefs in some early societies; Chapter 3 discusses the rise of formal, written medicine in the Middle East and Egypt, and in Greece and Rome; Chapter 4 explores Islam; separate chapters discuss Indian and Chinese medicine; Chapter 8 takes in the Americas; Chapter 15 surveys medicine in more recent colonial contexts, and other chapters have discussions of disorders in the Third World, for instance deficiency diseases. The book is thus not narrowly or blindly ethnocentric.

Nevertheless, I devote most attention to what is called ‘western’ medicine, because western medicine has developed in ways which have made it uniquely powerful and led it to become uniquely global. Its ceaseless spread throughout the world owes much, doubtless, to western political and economic domination. But its dominance has increased because it is perceived, by societies and the sick, to ‘work’ uniquely well, at least for many major classes of disorders. (Parenthetically, it can be argued that western political and economic domination owes something to the path-breaking powers of quinine, antibiotics and the like.) To the world historian, western medicine is special. It is conceivable that in a hundred years time traditional Chinese medicine, shamanistic medicine or Ayurvedic medicine will have swept the globe; if that happens, my analysis will look peculiarly dated and daft. But there is no real indication of that happening, while there is every reason to expect the medicine of the future to be an outgrowth of present western medicine – or at least a reaction against it. What began as the medicine of Europe is becoming the medicine of humanity. For that reason its history deserves particular attention.

Western medicine, I argue, has developed radically distinctive approaches to exploring the workings of the human body in sickness and in health. These have changed the ways our culture conceives of the body and of human life. To reduce complex matters to crass terms, most peoples and cultures the world over, throughout history, have construed life (birth and death, sickness and health) primarily in the context of an understanding of the relations of human beings to the wider cosmos: planets, stars, mountains, rivers, spirits and ancestors, gods and demons, the heavens and the underworld, and so forth. Some traditions, notably those reflected in Chinese and Indian learned medicine, while being concerned with the architecture of the cosmos, do not pay great attention to the supernatural. Modern western thinking, however, has become indifferent to all such elements. The West has evolved a culture preoccupied with the self, with the individual and his or her identity, and this quest has come to be equated with (or reduced to) the individual body and the embodied personality, expressed through body language. Hamlet wanted this too solid flesh to melt away. That – except in the context of slimming obsessions – is the last thing modern westerners want to happen to their flesh; they want it to last as long as possible.

Explanations of why and how these modern, secular western attitudes have come about need to take many elements into account. Their roots may be found in the philosophical and religious traditions they have grown out of. They have been stimulated by economic materialism, the preoccupation with worldly goods generated by the devouring, reckless energies of capitalism. But they are also intimately connected with the development of medicine – its promise, project and products.

Whereas most traditional healing systems have sought to understand the relations of the sick person to the wider cosmos and to make readjustments between individual and world, or society and world, the western medical tradition explains sickness principally in terms of the body itself – its own cosmos. Greek medicine dismissed supernatural powers, though not macrocosmic, environmental influences; and from the Renaissance the flourishing anatomical and physiological programmes created a new confidence among researchers that everything that needed to be known could essentially be discovered by probing more deeply and ever more minutely into the flesh, its systems, tissues, cells, its DNA.

This has proved an infinitely productive inquiry, generating first knowledge and then power, including on some occasions the power to conquer disease. The idea of probing into bodies, living and dead (and especially human bodies) with a view to improving medicine is more or less distinctive to the European medical tradition. For reasons technical, cultural, religious and personal, it was not done in China or India, Mesopotamia or pharaonic Egypt. Dissection and dissection-related experimentation were performed only on animals in classical Greece, and rarely. A medicine that seriously and systematically investigated the stuff of bodies came into being thereafter – in Alexandria, then in the work of Galen, then in late medieval Italy. The centrality of anatomy to medicine’s project was proclaimed in the Renaissance and became the foundation stone for the later edifice of scientific medicine: physiological experimentation, pathology, microscopy, biochemistry and all the other later specialisms, to say nothing of invasive surgery.

This was not the only course that medicine could have taken; as is noted below, it was not the course other great world medical systems took, cultivating their own distinct clinical skills, diagnostic arts and therapeutic interventions. Nor did it enjoy universal approval: protests in Britain around 1800 about body-snatching and later antivivisectionist lobbies show how sceptical public opinion remained about the activities of anatomists and physicians, and suspicion has continued to run high. That was the direction, however, which western medicine followed, and, bolstered by science at large, it generated a powerful momentum, largely independent of its efficacy as a rational social approach to good health.

The emergence of this high-tech scientific medicine may be a prime example of what William Blake denounced as ‘single vision’, the kind of myopia which (literally and metaphorically) comes from looking doggedly down a microscope. Single vision has its limitations in explaining the human condition; this is why Coleridge called doctors ‘shallow animals’, who ‘imagine that in the whole system of things there is nothing but Gut and Body’. Hence the ability of medicine to understand and counter pathology has always engendered paradox. Medicine has offered the promise of ‘the greatest benefit to mankind’, but not always on terms palatable to and compatible with cherished ideals. Nor has it always delivered the goods. The particular powers of medicine, and the paradoxes which its rationales generate, are what this book is about.

It may be useful to offer a brief resumé of the main themes of the book, by way of a sketch map for a long journey.

All societies possess medical beliefs: ideas of life and death, disease and cure, and systems of healing. Schematically speaking, the medical history of humanity may be seen as a series of stages. Belief systems the world over have attributed sickness to illwill, to malevolent spirits, sorcery, witchcraft and diabolical or divine intervention. Such ways of thinking still pervade the tribal communities of Africa, the Amazon basin and the Pacific; they were influential in Christian Europe till the ‘age of reason’, and retain a residual shadow presence. Christian Scientists and some other Christian sects continue to view sickness and recovery in providential and supernatural terms; healing shrines like Lourdes remain popular within the Roman Catholic church, and faith-healing retains a mass following among devotees of television evangelists in the United States.

In Europe from Graeco-Roman antiquity onwards, and also among the great Asian civilizations, the medical profession systematically replaced transcendental explanations by positing a natural basis for disease and healing. Among educated lay people and physicians alike, the body became viewed as integral to law-governed cosmic elements and regular processes. Greek medicine emphasized the microcosm/macrocosm relationship, the correlations between the healthy human body and the harmonies of nature. From Hippocrates in the fifth century BC through to Galen in the second century AD, ‘humoral medicine’ stressed the analogies between the four elements of external nature (fire, water, air and earth) and the four humours or bodily fluids (blood, phlegm, choler or yellow bile and black bile), whose balance determined health. The humours found expression in the temperaments and complexions that marked an individual. The task of regimen was to maintain a balanced constitution, and the role of medicine was to restore the balance when disturbed. Parallels to these views appear in the classical Chinese and Indian medical traditions.

The medicine of antiquity, transmitted to Islam and then back to the medieval West and remaining powerful throughout the Renaissance, paid great attention to general health maintenance through regulation of diet, exercise, hygiene and lifestyle. In the absence of decisive anatomical and physiological expertise, and without a powerful arsenal of cures and surgical skills, the ability to diagnose and make prognoses was highly valued, and an intimate physician-patient relationship was fostered. The teachings of antiquity, which remained authoritative until the eighteenth century and still supply subterranean reservoirs of medical folklore, were more successful in assisting people to cope with chronic conditions and soothing lesser ailments than in conquering life-threatening infections which became endemic and epidemic in the civilized world: leprosy, plague, smallpox, measles, and, later, the ‘filth diseases’ (like typhus) associated with urban squalor.

This personal tradition of bedside medicine long remained popular in the West, as did its equivalents in Chinese and Ayurvedic medicine. But in Europe it was supplemented and challenged by the creation of a more ‘scientific’ medicine, grounded, for the first time, upon experimental anatomical and physiological investigation, epitomized from the fifteenth century by the dissection techniques which became central to medical education. Landmarks in this programme include the publication of De humani corporis fabrica (1543) by the Paduan professor, Andreas Vesalius, a momentous anatomical atlas and a work which challenged truths received since Galen; and William Harvey’s De motu cordis (1628) which put physiological inquiry on the map by experiments demonstrating the circulation of the blood and the heart’s role as a pump.

Post-Vesalian investigations dramatically advanced knowledge of the structures and functions of the living organism. Further inquiries brought the unravelling of the lymphatic system and the lacteals, and the eighteenth and nineteenth centuries yielded a finer grasp of the nervous system and the operations of the brain. With the aid of microscopes and the laboratory, nineteenth-century investigators explored the nature of body tissue and pioneered cell biology; pathological anatomy came of age. Parallel developments in organic chemistry led to an understanding of respiration, nutrition, the digestive system and deficiency diseases, and founded such specialities as endocrinology. The twentieth century became the age of genetics and molecular biology.

Nineteenth-century medical science made spectacular leaps forward in the understanding of infectious diseases. For many centuries, rival epidemiological theories had attributed fevers to miasmas (poisons in the air, exuded from rotting animal and vegetable material, the soil, and standing water) or to contagion (person-to-person contact). From the 1860s, the rise of bacteriology, associated especially with Louis Pasteur in France and Robert Koch in Germany, established the role of pathogenie micro-organisms. Almost for the first time in medicine, bacteriology led directly to dramatic new cures.

In the short run, the anatomically based scientific medicine which emerged from Renaissance universities and the Scientific Revolution contributed more to knowledge than to health. Drugs from both the Old and New Worlds, notably opium and Peruvian bark (quinine) became more widely available, and mineral and metal-based pharmaceutical preparations enjoyed a great if dubious vogue (e.g., mercury for syphilis). But the true pharmacological revolution began with the introduction of sulfa drugs and antibiotics in the twentieth century, and surgical success was limited before the introduction of anaesthetics and antiseptic operating-room conditions in the mid nineteenth century. Biomedical understanding long outstripped breakthroughs in curative medicine, and the retreat of the great lethal diseases (diphtheria, typhoid, tuberculosis and so forth) was due, in the first instance, more to urban improvements, superior nutrition and public health than to curative medicine. The one early and striking instance of the conquest of disease – the introduction first of smallpox inoculation and then of vaccination – came not through ‘science’ but through embracing popular medical folklore.

From the Middle Ages, medical practitioners organized themselves professionally in a pyramid with physicians at the top and surgeons and apothecaries nearer the base, and with other healers marginalized or vilified as quacks. Practitioners’ guilds, corporations and colleges received royal approval, and medicine was gradually incorporated into the public domain, particularly in German-speaking Europe where the notion of ‘medical police’ (health regulation and preventive public health) gained official backing in the eighteenth century. The state inevitably played the leading role in the growth of military and naval medicine, and later in tropical medicine. The hospital sphere, however, long remained largely the Church’s responsibility, especially in Roman Catholic parts of Europe. Gradually the state took responsibility for the health of emergent industrial society, through public health regulation and custody of the insane in the nineteenth century, and later through national insurance and national health schemes. These latter developments met fierce opposition from a medical profession seeking to preserve its autonomy against encroaching state bureaucracies.

The latter half of the twentieth century has witnessed the continued phenomenal progress of capital-intensive and specialized scientific medicine: transplant surgery and biotechnology have captured the public imagination. Alongside, major chronic and psychosomatic disorders persist and worsen – jocularly expressed as the ‘doing better but feeling worse’ syndrome – and the basic health of the developing world is deteriorating. This situation exemplifies and perpetuates a key facet and paradox of the history of medicine: the unresolved disequilibrium between, on the one hand, the remarkable capacities of an increasingly powerful science-based biomedical tradition and, on the other, the wider and unfulfilled health requirements of economically impoverished, colonially vanquished and politically mismanaged societies. Medicine is an enormous achievement, but what it will achieve practically for humanity, and what those who hold the power will allow it to do, remain open questions.

The late E. P. Thompson (1924–1993) warned historians against what he called the enormous condescension of posterity. I have tried to understand the medical systems I discuss rather than passing judgment on them; I have tried to spell them out in as much detail as space has permitted, because engagement with detail is essential if the cognitive power of medicine is to be appreciated.

Eschewing anachronism, judgmentalism and history by hindsight does not mean denying that there are ways in which medical knowledge has progressed. Harvey’s account of the cardiovascular system was more correct than Galen’s; the emergence of endocrinology allowed the development in the 1920s of insulin treatments which saved the lives of diabetics. But one must not assume that diabetes then went away: no cure has been found for that still poorly understood disease, and it is becoming more prevalent as a consequence of western lifestyles. Indeed one could argue that the problem is now worse than when insulin treatment was discovered.

Avoiding condescension equally does not mean one must avoid ‘winners’ history. This book unashamedly gives more space to the Greeks than the Goths, more attention to Hippocrates than to Greek root-gatherers, and stresses strands of development leading from Greek medicine to the biomedicine now in the saddle. I do not think that ‘winners’ should automatically be privileged by historians (I have myself written and advocated writing medical history from the patients’ view), but there is a good reason for bringing the winners to the fore-ground – not because they are ‘best’ or ‘right’ but because they are powerful. One can study winners without siding with them.

Writing this book has not only made me more aware than usual of my own ignorance; it has brought home the collective and largely irremediable ignorance of historians about the medical history of mankind. Perhaps the most celebrated physician ever is Hippocrates yet we know literally nothing about him. Neither do we know anything concrete about most of the medical encounters there have ever been. The historical record is like the night sky: we see a few stars and group them into mythic constellations. But what is chiefly visible is the darkness.

CHAPTER II THE ROOTS OF MEDICINE

PEOPLES AND PLAGUES

IN THE BEGINNING WAS THE GOLDEN AGE. The climate was clement, nature freely bestowed her bounty upon mankind, no lethal predators lurked, the lion lay down with the lamb and peace reigned. In that blissful long-lost Arcadia, according to the Greek poet Hesiod writing around 700 BC, life was ‘without evils, hard toil, and grievous disease’. All changed. Thereafter, wrote the poet, ‘thousands of miseries roam among men, the land is full of evils and full is the sea. Of themselves, diseases come upon men, some by day and some by night, and they bring evils to the mortals.’

The Greeks explained the coming of pestilences and other troubles by the fable of Pandora’s box. Something similar is offered by Judaeo-Christianity. Disguised in serpent’s clothing, the Devil seduces Eve into tempting Adam to taste the forbidden fruit. By way of punishment for that primal disobedience, the pair are banished from Eden; Adam’s sons are condemned to labour by the sweat of their brow, while the daughters of Eve must bring forth in pain; and disease and death, unknown in the paradise garden, become the iron law of the post-lapsarian world, thenceforth a vale of tears. As in the Pandora fable and scores of parallel legends the world over, the Fall as revealed in Genesis explains how suffering, disease and death become the human condition, as a consequence of original sin. The Bible closes with foreboding: ‘And I looked, and behold a pale horse’ prophesied the Book of Revelation: ‘and his name that sat on him was Death, and Hell followed with him. And power was given unto them over the fourth part of the earth, to kill with sword, and with hunger, and with death, and with the beasts of the earth.’

Much later, the eighteenth-century physician George Cheyne drew attention to a further irony in the history of health. Medicine owed its foundation as a science to Hippocrates and his successors, and such founding fathers were surely to be praised. Yet why had medicine originated among the Greeks? It was because, the witty Scotsman explained, being the first civilized, intellectual people, with leisure to cultivate the life of the mind, they had frittered away the rude vitality of their warrior ancestors – the heroes of the Iliad – and so had been the first to need medical ministrations. This ‘diseases of civilization’ paradox had a fine future ahead of it, resonating throughout Nietzsche and Freud’s Civilization and its Discontents (1930). Thus to many, from classical poets up to the prophets of modernity, disease has seemed the dark side of development, its Jekyll-and-Hyde double: progress brings pestilence, society sickness.

Stories such as these reveal the enigmatic play of peoples, plagues and physicians which is the thread of this book, scotching any innocent notion that the story of health and medicine is a pageant of progress. Pandora’s box and similar just-so stories tell a further tale moreover, that plagues and pestilence are not acts of God or natural hazards; they are of mankind’s own making. Disease is a social development no less than the medicine that combats it.

In the beginning … Anthropologists now maintain that some five million years ago in Africa there occurred the branching of the primate line which led to the first ape men, the low-browed, big-jawed hominid Australopithecines. Within a mere three million years Homo erectus had emerged, our first entirely upright, large-brained ancestor, who learned how to make fire, use stone tools, and eventually developed speech. Almost certainly a carnivorous hunter, this palaeolithic pioneer fanned out a million years or so ago from Africa into Asia and Europe. Thereafter a direct line leads to Homo sapiens who emerged around 150,000 BC.

The life of early mankind was not exactly arcadian. Archaeology and palaeopathology give us glimpses of forebears who were often malformed, racked with arthritis and lamed by injuries – limbs broken in accidents and mending awry. Living in a dangerous, often harsh and always unpredictable environment, their lifespan was short. Nevertheless, prehistoric people escaped many of the miseries popularly associated with the ‘fall’; it was later developments which exposed their descendants to the pathogens that brought infectious disease and have since done so much to shape human history.

The more humans swarmed over the globe, the more they were themselves colonized by creatures capable of doing harm, including parasites and pathogens. There have been parasitic helminths (worms), fleas, ticks and a host of arthropods, which are the bearers of ‘arbo’ (arthropod-borne) infections. There have also been the micro-organisms like bacteria, viruses and protozoans. Their very rapid reproduction rates within a host provoke severe illness but, as if by compensation, produce in survivors immunity against reinfection. All such disease threats have been and remain locked with humans in evolutionary struggles for the survival of the fittest, which have no master plot and grant mankind no privileges.

Despite carbon-dating and other sophisticated techniques used by palaeopathologists, we lack any semblance of a day-to-day health chart for early Homo sapiens. Theories and guesswork can be supported by reference to so-called ‘primitive’ peoples in the modern world, for instance Australian aborigines, the Hadza of Tanzania, or the !Kung San bush people of the Kalahari. Our early progenitors were hunters and gatherers. Pooling tools and food, they lived as nomadic opportunistic omnivores in scattered familial groups of perhaps thirty or forty. Infections like smallpox, measles and flu must have been virtually unknown, since the micro-organisms that cause contagious diseases require high population densities to provide reservoirs of susceptibles. And because of the need to search for food, these small bands did not stay put long enough to pollute water sources or accumulate the filth that attracts disease-spreading insects. Above all, isolated hunter-foragers did not tend cattle and the other tamed animals which have played such an ambiguous role in human history. While meat and milk, hides and horns made civilization possible, domesticated animals proved perennial and often catastrophic sources of illness, for infectious disease riddled beasts long before spreading to humans.

Our ‘primitive’ ancestors were thus practically free of the pestilences that ambushed their ‘civilized’ successors and have plagued us ever since. Yet they did not exactly enjoy a golden age, for, together with dangers, injuries and hardships, there were ailments to which they were susceptible. Soil-borne anaerobic bacteria penetrated through skin wounds to produce gangrene and tetanus; anthrax and rabies were picked up from animal predators like wolves; infections were acquired through eating raw animal flesh, while game would have transmitted the microbes of relapsing fever (like typhus, a louse-borne disease), brucellosis and haemorrhagic fevers. Other threats came from organisms co-evolving with humans, including tapeworms and such spirochaetes as Treponema, the agent of syphilis, and the similar skin infection, yaws.

Hunter-gatherers being omnivores, they were probably not malnourished, at least not until rising populations had hunted to extinction most of the big game roaming the savannahs and prairies. Resources and population were broadly in balance. Relative freedom from disease encouraged numbers to rise, but all were prey to climate, especially during the Ice Age which set in from around 50,000 BC. Famine took its toll; lives would have been lost in hunting and skirmishing; childbirth was hazardous, fertility probably low, and infanticide may have been practised. All such factors kept numbers in check.

For tens of thousands of years there was ample territory for dispersal, as pressure on resources drove migration ‘out of Africa’ into all corners of the Old World, initially to the warm regions of Asia and southern Europe, but then farther north into less hospitable climes. These nomadic ways continued until the end of the last Ice Age (the Pleistocene) around 12,000–10,000 years ago brought the invention of agriculture.

Contrary to the Victorian assumption that farming arose out of mankind’s inherent progressiveness, it is now believed that tilling the soil began because population pressure and the depletion of game supplies left no alternative: it was produce more or perish. By around 50,000 BC, mankind had spilled over from the Old World to New Guinea and Australasia, and by 10,000 BC (perhaps much earlier) to the Americas as well (during the last Ice Age the lowering of the oceans made it possible to cross by land bridge from Siberia to Alaska). But when the ice caps melted around ten thousand years ago and the seas rose once more, there were no longer huge tracts of land filled with game but empty of humans and so ripe for colonization. Mankind faced its first ecological crisis – its first survival test.

Necessity proved the mother of invention, and Stone Age stalkers, faced with famine – elk and gazelle had thinned out, leaving hogs, rabbits and rodents – were forced to grow their own food and settle in one place. Agriculture enhanced mankind’s capacity to harness natural resources, selectively breeding wild grasses into domesticated varieties of grains, and bringing dogs, cattle, sheep, goats, pigs, horses and poultry under control. This change had the rapidity of a revolution: until around 10,000 years ago, almost all human groups were hunter-gatherers, but within a few thousand years cultivators and pastoralists predominated. The ‘neolithic revolution’ was truly epochal.

In the fertile crescent of the Middle East, wheat, barley, peas and lentils were cultivated, and sheep, pigs and goats herded; the neolithic peoples of south-east Asia exploited rice, sweet potatoes, ducks and chickens; in Mesoamerica, it was maize, beans, cassava, potatoes and guinea pigs. The land which a nomadic band would have stripped like locusts before moving on was transformed by new management techniques into a resource capable of supporting thousands, year in, year out. And once agriculture took root, with its systematic planting of grains and lentils and animal husbandry, numbers went on spiralling, since more could be fed. The labour-intensiveness of clearing woodland and scrub, weeding fields, harvesting crops and preparing food encouraged population growth and the formation of social hierarchies, towns, courts and kingdoms. But while agriculture rescued people from starvation, it unleashed a fresh danger: disease.

The agricultural revolution ensured human domination of planet earth: the wilderness was made fertile, the forests became fields, wild beasts were tamed or kept at bay; but pressure on resources presaged the disequilibrium between production and reproduction that provoked later Malthusian crises, as well as leading to ecological deterioration. As hunters and gatherers became shepherds and farmers, the seeds of disease were sown. Prolific pathogens once exclusive to animals were transferred to swineherds and goatherds, ploughmen and horsemen, initiating the ceaseless evolutionary adaptations which have led to a current situation in which humans share no fewer than sixty-five micro-organic diseases with dogs (supposedly man’s best friend), and only slightly fewer with cattle, sheep, goats, pigs, horses and poultry.

Many of the worst human diseases were created by proximity to animals. Cattle provided the pathogen pool with tuberculosis and viral poxes like smallpox. Pigs and ducks gave humans their influenzas, while horses brought rhinoviruses and hence the common cold. Measles, which still kills a million children a year, is the result of rinderpest (canine distemper) jumping between dogs or cattle and humans. Moreover, cats, dogs, ducks, hens, mice, rats and reptiles carry bacteria like Salmonella, leading to often fatal human infections; water polluted with animal faeces also spreads polio, cholera, typhoid and viral hepatitis.

Settlement helped disease to settle in, attracting disease-spreading insects, while worms took up residence within the human body. Parasitologists and palaeopathologists have shown how the parasitic roundworm Ascaris, a nematode growing to over a foot long, evolved in humans, probably from pig ascarids, producing diarrhoea and malnutrition. Other helminths or wormlike fellow-travellers became common in the human gut, including the Enterobius (pinworm or threadworm), the yards-long tapeworm, and the filarial worms which cause elephantiasis and African river blindness. Diseases also established themselves where agriculture depended upon irrigation – in Mesopotamia, Egypt, India and around the Yellow (Huang) River in China. Paddyfields harbour parasites able to penetrate the skin and enter the bloodstream of barefoot workers, including the forked-tailed blood fluke Schistosoma which utilizes aquatic snails as a host and causes bilharzia or schistosomiasis (graphically known as ‘big belly’), provoking mental and physical deterioration through the chronic irritation caused by the worm. Investigation of Egyptian mummies has revealed calcified eggs in liver and kidney tissues, proving the presence of schistosomiasis in ancient Egypt. (Mummies tell us much more about the diseases from which Egyptians suffered; these included gallstones, bladder and kidney stones, mastoiditis and numerous eye diseases, and many skeletons show evidence of rheumatoid arthritis.) In short, permanent settlement afforded golden opportunities for insects, vermin and parasites, while food stored in granaries became infested with insects, bacteria, fungoid toxins and rodent excrement. The scales of health tipped unfavourably, with infections worsening and human vitality declining.^*

Moreover, though agriculture enabled more mouths to be fed, it meant undue reliance on starchy cereal monocultures like maize, high in calories but low in proteins, vitamins and minerals; reduced nutritional levels allowed deficiency diseases like pellagra, marasmus, kwashiorkor and scurvy to make their entry onto the human stage. Stunted people are more vulnerable to infections, and it is a striking comment on ‘progress’ that neolithic skeletons are typically some inches shorter than their palaeolithic precursors.

MALARIA

Settlement also brought malaria. ‘There is no doubt’, judged the distinguished Australian immunologist, Macfarlane Burnet (1899–1985), ‘that malaria has caused the greatest harm to the greatest number’ – not through cataclysms, as with bubonic plague, but through its continual winnowing effect. First in sub-Saharan Africa and elsewhere since, conversion of forests into farmland has created environments tailormade for mosquitoes: warm waterholes, furrows and puddles ideal for rapid breeding. Malaria is worth pausing over, since it has coexisted with humans for thousands of years and remains out of control across much of the globe.

The symptoms of malarial fevers were familiar to the Greeks, but were not explained until the advent of tropical medicine around 1900. They are produced by the microscopic protozoan parasite Plasmodium, which lives within the body of an Anopheles mosquito, and is transmitted to humans through mosquito bites. The parasites move through the bloodstream to the liver, where they breed during an incubation stage of a couple of weeks. Returning to the blood, they attack red blood cells, which break down, leading to waves of violent chills and high fever.

Malarial parasites have distinct periodicities. Plasmodium vivax, the organism causing benign tertian malaria, once present in the English fenlands, has an incubation period of ten to seventeen days. The fever lasts from two to six hours, returning every third day (hence ‘tertian’); marked by vomiting and diarrhoea, such attacks may recur for two months or longer. In time, as Greek doctors observed, the spleen enlarges, and the patient becomes anaemic and sometimes jaundiced. Quartan malaria, caused by Plasmodium malariae, is another mild variety.

Malignant tertian malaria, caused by Plasmodium falciparum, is the most lethal, producing at least 95 per cent of all malarial deaths. The incubation period is shorter but the fever more prolonged; it may be continuous, remittent or intermittent. Plasmodium falciparum proliferates fast, producing massive destruction of red blood cells and hence dangerous anaemia; the liver and spleen also become enlarged.

Malaria may sometimes appear as quotidian fever, with attacks lasting six to twelve hours – the result of multiple infection. Patients may also develop malarial cachexia, with yellowing of the skin and severe spleen and liver enlargement; autopsy shows both organs darkened with a black pigment derived from the haemoglobin of the destroyed red blood cells. What the ancients called melancholy may have been a malarial condition.

Malaria shadowed agricultural settlements. From Africa, it became established in the Near and Middle East and the Mediterranean littoral. The huge attention Graeco-Roman medicine paid to ‘remittent fevers’ shows how seriously the region was affected, and some historians maintain the disease played its part in the decline and fall of the Roman empire. Within living memory, malaria remained serious in the Roman Campagna and the Pontine marshes along Italy’s west coast.

Coastal Africa was and remains heavily malarial, as are the Congo, the Niger and hundreds of other river basins. Indigenous West African populations developed a genetically controlled characteristic, the ‘sickle-cell’, which conferred immunity against virulent Plasmodium falciparum. But, though protective, this starves its bearers, who are prone to debility and premature death: typical of such evolutionary trade-offs, gains and losses are finely balanced.

India was also ripe for malarial infection. Ayurvedic medical texts (see Chapter Six) confirm the antiquity of the disease in the subcontinent. China, too, became heavily infected, especially the coastal strip from Shanghai to Macao. And from the sixteenth century Europeans shipped it to Mesoamerica: vivax malaria went to the New World in the blood of the Spanish conquistadores, while falciparum malaria arrived with the African slaves whom the Europeans imported to replace the natives they and their pestilences had wiped out.

Malaria was just one health threat among many which set in with civilization as vermin learned to cohabit with humans, insects spread gastroenteric disorders, and contact with rodents led to human rickettsial (lice-, mite- and tick-borne) arbo diseases like typhus. Despite such infections encouraged by dense settlement and its waste and dirt, man’s restless inventive energies ensured that communities, no matter how unhealthy, bred rising populations; and more humans spawned more diseases in upward spirals, temporarily and locally checked but never terminated. Around 10,000 BC, before agriculture, the globe’s human population may have been around 5 million; by 500 BC it had probably leapt to 100 million; by the second century AD that may have doubled; the 1990 figure was some 5,292 million, with projections suggesting 12 billion by 2100.

Growing numbers led to meagre diets, the weak and poor inevitably bearing the brunt. But though humans were often malnourished, parasite-riddled and pestilence-smitten, they were not totally defenceless. Survivors of epidemics acquired some protection, and the mechanisms of evolution meant that these acquired sophisticated immune systems enabling them to coexist in a ceaseless war with their microbial assailants. Immunities passed from mothers across the placenta or through breast-feeding gave infants some defence against germ invasion. Tolerance was likewise developed towards parasitic worms, and certain groups developed genetic shields, as with the sickle-cell trait. Biological adaptation might thus take the edge off lethal afflictions.

THE ERA OF EPIDEMICS

Some diseases, however, were not so readily coped with: those caused by the zoonoses (animal diseases transmissible to man) which menaced once civilization developed. By 3000 BC cities like Babylon, with populations of scores of thousands, were rising in Mesopotamia and Egypt, in the Indus Valley and on the Yellow River, and later in Mesoamerica. In the Old World, such settlements often maintained huge cattle herds, from which lethal pathogens, including smallpox, spread to humans, while originally zoonostic conditions – diphtheria, influenza, chickenpox, mumps – and other illnesses also had a devastating impact. Unlike malaria, these needed no carriers; being directly contagious, they spread readily and rapidly.

The era of epidemics began. And though some immunity would develop amongst the afflicted populations, the incessant outreach of civilization meant that merchants, mariners and marauders would inevitably bridge pathogen pools, spilling diseases onto virgin susceptibles. One nation’s familiar ‘tamed’ disease would be another’s plague, as trade, travel and war detonated pathological explosions.

The immediate consequence of the invasion of a town by smallpox or another infection was a fulminating epidemic and subsequent decimation. Population recovery would then get under way, only for survivors’ heirs to be blitzed by the same or a different pestilence, and yet another, in tide upon tide. Settlements big enough to host such contagions might shrink to become too tiny. With almost everybody slain or immune, the pestilences would withdraw, victims of their own success, moving on to storm other virgin populations, like raiders seeking fresh spoils. New diseases thus operated as brutal Malthusian checks, sometimes shaping the destinies of nations.

Cities assumed a decisive epidemiological role, being magnets for pathogens no less than people. Until the nineteenth century, towns were so insanitary that their populations never replaced themselves by reproduction, multiplying only thanks to the influx of rural surpluses who were tragically infection-prone. In this challenge and response process, sturdy urban survivors turned into an immunological elite – a virulently infectious swarm perilous to less seasoned incomers, confirming the notoriety of towns as death-traps.

The Old Testament records the epidemics the Lord hurled upon the Egypt of the pharaohs, and from Greek times historians noted their melancholy toll. The Peloponnesian War of 431 to 404 BC, the ‘world war’ between Athens and Sparta, spotlights the traffic in pestilence that came with civilization. Before that war the Greeks had suffered from malaria and probably tuberculosis, diphtheria and influenza, but they had been spared truly calamitous plagues. Reputedly beginning in Africa and spreading to Persia, an unknown epidemic hit Greece in 430 BC, and its impact on Athens was portrayed by Thucydides (460 – after 404 BC). Victims were poleaxed by headaches, coughing, vomiting, chest pains and convulsions. Their bodies became reddish or livid, with blisters and ulcers; the malady often descended into the bowels before death spared sufferers further misery. The Greek historian thought it killed a quarter of the Athenian troops, persisting on the mainland for a further four years and annihilating a similar proportion of the population.

What was it? Smallpox, plague, measles, typhus, ergotism and even syphilis have been proposed in a parlour game played by epidemiologists. Whatever it was, by killing or immunizing them, it destroyed the Greeks’ ability to host it and, proving too virulent for its own good, the disease disappeared. With it passed the great age of Athens. Most early nations probably experienced such disasters, but Greece alone had a Thucydides to record it.

Epidemics worsened with the rise of Rome. With victories in Macedonia and Greece (146 BC), Persia (64 BC) and finally Egypt (30 BC), the Roman legions vanquished much of the known world, but deadly pathogens were thus given free passage around the empire, spreading to the Eternal City itself. The first serious outbreak, the so-called Antonine plague (probably smallpox which had smouldered in Africa or Asia before being brought back from the Near East by Roman troops) slew a quarter of the inhabitants in stricken areas between AD 165 and 180, some five million people in all. A second, between AD 211 and 266, reportedly destroyed some 5,000 a day in Rome at its height, while scourging the countryside as well. The virulence was immense because populations had no resistance. Smallpox and measles had joined the Mediterranean epidemiological melting-pot, alongside the endemic malaria.

Wherever it struck a virgin population, measles too proved lethal. There are some recent and well-documented instances of such strikes. In his Observations Made During the Epidemic of Measles on the Faroe Islands in the Year 1846, Peter Panum (1820–85) reported how measles had attacked about 6,100 out of 7,864 inhabitants on a remote island which had been completely free of the disease for sixty-five years. In the nineteenth century, high mortality was also reported in measles epidemics occurring in virgin soil populations (‘island laboratories’) in the Pacific Ocean: 40,000 deaths in a population of 150,000 in Hawaii in 1848, 20,000 (perhaps a quarter of the population) on Fiji in 1874.

Improving communications also widened disease basins in the Middle East, the Indian subcontinent, South Asia and the Far East. Take Japan: before AD 552, the archipelago had apparently escaped the epidemics blighting the Chinese mainland. In that year, Buddhist missionaries visited the Japanese court, and shortly afterwards smallpox broke out. In 585 there was a further eruption of either smallpox or measles. Following centuries brought waves of epidemics every three or four years, the most significant being smallpox, measles, influenza, mumps and dysentery.

This alteration of occasional epidemic diseases into endemic ones typical of childhood – it mirrors the domestication of animals – represents a crucial stage in disease ecology. Cities buffeted by lethal epidemics which killed or immunized so many that the pathogens themselves disappeared for lack of hosts, eventually became big enough to house sufficient non-immune individuals to retain the diseases permanently; for this an annual case total of something in the region of 5,000–40,000 may be necessary. Measles, smallpox and chickenpox turned into childhood ailments which affected the young less severely and conferred immunity to future attacks.

The process marks an epidemiological watershed. Through such evolutionary adaptations – epidemic diseases turning endemic – expanding populations accommodated and surmounted certain once-lethal pestilences. Yet they remained exposed to other dire infections, against which humans were to continue immunologically defenceless, because they were essentially diseases not of humans but of animals. One such is bubonic plague, which has struck humans with appalling ferocity whenever populations have been caught up in a disease net involving rats, fleas and the plague bacillus (Yersinia pestis). Diseases like plague, malaria, yellow fever, and others with animal reservoirs are uniquely difficult to control.

PLAGUE

Bubonic plague is basically a rodent problem. It strikes humans when infected fleas, failing to find a living rat once a rat host has been killed, pick a human instead. When the flea bites its new host, the bacillus enters the bloodstream. Filtered through the nearest lymph node, it leads to the characteristic swelling (bubo) in the neck, groin or armpit. Bubonic plague rapidly kills up to two-thirds of those infected. There are two other even more fatal forms: septicaemic and, deadliest of all, pneumonic plague, which doesn’t even need an insect vector, spreading from person to person directly via the breath.

The first documented bubonic plague outbreak occurred, predictably enough, in the Roman empire. The plague of Justinian originated in Egypt in AD 540; two years later it devastated Constantinople, going on to massacre up to a quarter of the eastern Mediterranean population, before spreading to western Europe and ricocheting around the Mediterranean for the next two centuries. Panic, disorder and murder reigned in the streets of Constantinople, wrote the historian Procopius: up to 10,000 people died each day, until there was no place to put the corpses. When this bout of plague ended, 40 per cent of the city’s population was dead.

It was the subsequent plague cycle, however, which made the greatest impact. Towards 1300 the Black Death began to rampage through Asia before sweeping westwards through the Middle East to North Africa and Europe. Between 1346 and 1350 Europe alone lost perhaps twenty million to the disease. And this pandemic was just the first wave of a bubonic pestilence that raged until about 1800 (see Chapter 5).

Trade, war and empire have always sped disease transmission between populations, a dramatic instance being offered by early modern Spain. The cosmopolitan Iberians became subjects of a natural Darwinian experiment, for their Atlantic and Mediterranean seaports served as clearing-houses for swarms of diseases converging from Africa, Asia and the Americas. Survival in this hazardous environment necessitated becoming hyper-immune, weathering a hail of childhood diseases – smallpox, measles, diphtheria, gastrointestinal infections and other afflictions rare today in the West. The Spanish conquistadores who invaded the Americas were, by consequence, immunological supermen, infinitely more deadly than ‘typhoid Mary’; disease gave them a fatal superiority over the defenceless native populations they invaded.

TYPHUS

Though the Black Death ebbed away from Europe, war and the movements of migrants ensured that epidemic disease did not go away, and Spain, as one of the great crossroads, formed a flashpoint of disease. Late in 1489, in its assault on Granada, Islam’s last Iberian stronghold, Spain hired some mercenaries who had lately been in Cyprus fighting the Ottomans. Soon after their arrival, Spanish troops began to go down with a disease never before encountered and possessing the brute virulence typical of new infections: typhus. It had probably emerged in the Near East during the Crusades before entering Europe where Christian and Muslim armies clashed.

It began with headache, rash and high fever, swelling and darkening of the face; next came delirium and the stupor giving the disease its name – typhos is Greek for ‘smoke’. Inflammation led to gangrene that rotted fingers and toes, causing a hideous stench. Spain lost 3,000 soldiers in the siege but six times as many to typhus.

Having smuggled itself into Spain, typhus filtered into France and beyond. In 1528, with the Valois (French) and Habsburg (Spanish) dynasties vying for European mastery, it struck the French army encircling Naples; half the 28,000 troops died within a month, and the siege collapsed. As a result, Emperor Charles V of Spain was left master of Italy, controlling Pope Clement VII – with important implications for Henry VIII’s marital troubles and the Reformation in England.

With the Holy Roman Empire fighting the Turks in the Balkans, typhus gained a second bridgehead into Europe. In 1542, the disease killed 30,000 Christian soldiers on the eastern front; four years later, it struck the Ottomans, terminating their siege of Belgrade; while by 1566 the Emperor Maximilian II had so many typhus victims that he was driven to an armistice. His disbanded troops relayed the disease back to western Europe, and so to the New World, where it joined measles and smallpox in ravaging Mexico and Peru. Typhus subsequently smote Europe during the Thirty Years War (1618–48), and remained widespread, devastating armies as ‘camp fever’, dogging beggars (road fever), depleting jails (jail fever) and ships (ship fever).

It was typhus which joined General Winter to turn Napoleon’s Russian invasion into a rout. The French crossed into Russia in June 1812. Sickness set in after the fall of Smolensk. Napoleon reached Moscow in September to find the city abandoned. During the next five weeks, the grande armée suffered a major typhus epidemic. By the time Moscow was evacuated, tens of thousands had fallen sick, and those unfit to travel were abandoned. Thirty thousand cases were left to die in Vilna alone, and only a trickle finally reached Warsaw. Of the 600,000 men in Napoleon’s army, few returned, and typhus was a major reason.

Smallpox, plague and typhus indicate, how war and conquest paved the way for the progress of pathogens. A later addition, at least as far as the West was concerned, was cholera, the most spectacular ‘new’ disease of the nineteenth century.

COLONIZATION AND INDUSTRIALIZATION

Together with civilization and commerce, colonization has contributed to the dissemination of infections. The Spanish conquest of America has already been mentioned; the nineteenth-century scramble for Africa also caused massive disturbance of indigenous populations and environmental disruption, unleashing terrible epidemics of sleeping sickness and other maladies. Europeans exported tuberculosis to the ‘Dark Continent’, especially once native labourers were jammed into mining compounds and the slums of Johannesburg. In the gold, diamond and copper producing regions of Africa, the operations of mining companies like De Beers and Union Minière de Haute Katanga brought family disruption and prostitution. Capitalism worsened the incidence of infectious and deficiency diseases for those induced or forced to abandon tribal ways and traditional economies – something which medical missionaries were pointing out from early in the twentieth century.

While in the period after Columbus’s voyage, advances in agriculture, plant-breeding and crop exchange between the New and Old Worlds in some ways improved food supply, for those newly dependent upon a single staple crop the consequence could be one of the classic deficiency diseases: scurvy, beriberi or kwashiorkor (from a Ghanaian word meaning a disease suffered by a child displaced from the breast). Those heavily reliant on maize in Mesoamerica and later, after it was brought back by the conquistadores, in the Mediterranean, frequently fell victim to pellagra, caused by niacin deficiency and characterized by diarrhoea, dermatitis, dementia and death. Another product of vitamin B₁ (thiamine) deficiency is beriberi, associated with Asian rice cultures.

The Third World, however, has had no monopoly on dearth and deficiency diseases. The subjugation of Ireland by the English, complete around 1700, left an impoverished native peasantry ‘living in Filth and Nastiness upon Butter-milk and Potatoes, without a Shoe or stocking to their Feet’, as Jonathan Swift observed. Peasants survived through cultivating the potato, a New World import and another instance of how the Old World banked upon gains from the New. A wonderful source of nutrition, rich in vitamins B₁ B₂ and C as well as a host of essential minerals, potatoes kept the poor alive and well-nourished, but when in 1727 the oat crop failed, the poor ate their winter potatoes early and then starved. The subsequent famine led Swift to make his ironic ‘modest proposal’ as to how to handle the island’s surplus population better in future:

a young healthy Child, well nursed is, at a Year old, a most delicious, nourishing and wholesome Food; whether Stewed, Roasted, Baked, or Boiled; and, I make no doubt, that it will equally serve in a Fricassee, or Ragout … I grant this Food will be somewhat dear, and therefore very proper for Landlords.

With Ireland’s population zooming, disaster was always a risk. From a base of two million potato-eating peasants in 1700, the nation multiplied to five million by 1800 and to close on nine million by 1845. The potato island had become one of the world’s most densely populated places. When the oat and potato crops failed, starving peasants became prey to various disorders, notably typhus, predictably called ‘Irish fever’ by the landlords. During the Great Famine of 1845–7, typhus worked its way through the island; scurvy and dysentery also returned. Starving children aged so that they looked like old men. Around a million people may have died in the famine and in the next decades millions more emigrated. Only a small percentage of deaths were due directly to starvation; the overwhelming majority occurred from hunger-related disease: typhus, relapsing fevers and dysentery.

The staple crops introduced by peasant agriculture and commercial farming thus proved mixed blessings, enabling larger numbers to survive but often with their immunological stamina compromised. There may have been a similar trade-off respecting the impact of the industrial Revolution, first in Europe, then globally. While facilitating population growth and greater (if unequally distributed) prosperity, industrialization spread insanitary living conditions, workplace illnesses and ‘new diseases’ like rickets. And even prosperity has had its price, as Cheyne suggested. Cancer, obesity, gallstones, coronary heart disease, hypertension, diabetes, emphysema, Alzheimer’s disease and many other chronic and degenerative conditions have grown rapidly among today’s wealthy nations. More are of course now living long enough to develop these conditions, but new lifestyles also play their part, with cigarettes, alcohol, fatty diets and narcotics, those hallmarks of life in the West, taking their toll. Up to one third of all premature deaths in the West are said to be tobacco-related; in this, as in so many other matters, parts of the Third World are catching up fast.

And all the time ‘new’ diseases still make their appearance, either as evolutionary mutations or as ‘old’ diseases flushed out of their local environments (their very own Pandora’s box) and loosed upon the wider world as a result of environmental disturbance and economic change. The spread of AIDS, Ebola, Lassa and Marburg fevers may all be the result of the impact of the West on the ‘developing’ world – legacies of colonialism.

Not long ago medicine’s triumph over disease was taken for granted. At the close of the Second World War a sequence of books appeared in Britain under the masthead of The Conquest Series’. These included The Conquest of Disease, The Conquest of Pain, The Conquest of Tuberculosis, The Conquest of Cancer, The Conquest of the Unknown and The Conquest of Brain Mysteries, and they celebrated ‘the many wonders of contemporary medical science today’. And this was before the further ‘wonder’ advances introduced after 1950, from tranquillizers to transplant surgery. A signal event was the world-wide eradication of smallpox in 1977.

In spite of such advances, expectations of a conclusive victory over disease should always have seemed naive since that would fly in the face of a key axiom of Darwinian biology: ceaseless evolutionary adaptation. And that is something infectious disease accomplishes far better than humans, since it possesses the initiative. In such circumstances it is hardly surprising that medicine has proved feeble against AIDS, because the human immunodeficiency virus (HIV) mutates rapidly, frustrating the development of vaccines and antiviral drugs.

The systematic impoverishment of much of the Third World, the disruption following the collapse of communism, and the rebirth of an underclass in the First World resulting from the free-market economic policies dominant since the 1980s, have all assisted the resurgence of disease. In March 1997 the chairman of the British Medical Association warned that Britain was slipping back into the nineteenth century in terms of public health. Despite dazzling medical advances, world health prospects at the close of the twentieth century seem much gloomier than half a century ago.

The symbiosis of disease with society, the dialectic of challenge and adaptation, success and failure, sets the scene for the following discussion of medicine. From around 2000 BC, medical ideas and remedies were written down. That act of recording did not merely make early healing accessible to us; it transformed medicine itself. But there is more to medicine than the written record, and the remainder of this chapter addresses wider aspects of healing – customary beliefs about illness and the body, the self and society – and glances at medical beliefs and practices before and beyond the literate tradition.

MAKING SENSE OF SICKNESS

Though prehistoric hunting and gathering groups largely escaped epidemics, individuals got sick. Comparison with similar groups today, for instance the Kalahari bush people, suggests they would have managed their health collectively, without experts. A case of illness or debility directly affected the well-being of the band: a sick or lame person is a serious handicap to a group on the move; hence healing rituals or treatment would be a public matter rather than (as Western medicine has come to see them) private.

Anthropologists sometimes posit two contrasting ‘sick roles’: one in which the sick person is treated as a child, fed and protected during illness or incapacity; the other in which the sufferer either leaves the group or is abandoned or, as with lepers in medieval Europe, ritually expelled, becoming culturally ‘dead’ before they are biologically dead. Hunter-gatherer bands were more likely to abandon their sick than to succour them.

With population rise, agriculture, and the emergence of epidemics, new medical beliefs and practices arose, reflecting growing economic, political and social complexities. Communities developed hierarchical systems, identified by wealth, power and prestige. With an emergent division of labour, medical expertise became the métier of particular individuals. Although the family remained the first line of defence against illness, it was bolstered by medicine men, diviners, witch-smellers and shamans, and in due course by herbalists, birth-attendants, bone-setters, barber-surgeons and healer-priests. When that first happened we cannot be sure. Cave paintings found in France, some 17,000 years old, contain images of men masked in animal heads, performing ritual dances; these may be the oldest surviving images of medicine-men.

Highly distinctive was the shaman. On first encountering such folk healers, westerners denounced them as impostors. In 1763 the Scottish surgeon John Bell (1691–1780) described the ‘charming sessions’ he witnessed in southern Siberia:

[the shaman] turned and distorted his body into many different postures, till, at last, he wrought himself up to such a degree of fury that he foamed at the mouth, and his eyes looked red and staring. He now started up on his legs, and fell a dancing, like one distracted, till he trod out the fire with his bare feet.

These unnatural motions were, by the vulgar, attributed to the operations of a divinity … He now performed several legerdemain tricks; such as stabbing himself with a knife, and bringing it up at his mouth, running himself through with a sword and many others too trifling to mention.

This Calvinist Scot was not going to be taken in by Asiatic savages: ‘nothing is more evident than that these shamans are a parcel of jugglers, who impose on the ignorant and credulous vulgar.’ Such a reaction is arrogantly ethnocentric: although shamans perform magical acts, including deliberate deceptions, they are neither fakes nor mad. Common in native American culture as well as Asia, the shaman combined the roles of healer, sorcerer, seer, educator and priest, and was believed to possess god-given powers to heal the sick and to ensure fertility, a good harvest or a successful hunt. His main healing techniques have been categorized as contagious magic (destruction of enemies, through such means as the use of effigies) and direct magic, involving rituals to prevent disease, fetishes, amulets (to protect against black magic), and talismans (for good luck).

In 1912 Sir Baldwin Spencer (1860–1929) and F.J. Gillen (1856–1912) described the practices of the aborigine medicine-man in Central Australia:

In ordinary cases the patient lies down, while the medicine man bends over him and sucks vigorously at the part of the body affected, spitting out every now and then pieces of wood, bone or stone, the presence of which is believed to be causing the injury and pain. This suction is one of the most characteristic features of native medical treatment, as pain in any part of the body is always attributed to the presence of some foreign body that must be removed.

Stone-sucking is a symbolic act. As the foreign body had been introduced into the body of the sick man by a magical route, it had to be removed in like manner. For the medicine-man, the foreign body in his mouth attracts the foreign body in the patient.

As such specialist healers emerged, and as labour power grew more valuable in structured agricultural and commercial societies, the appropriate ‘sick role’ shifted from abandonment to one modelled on child care. The exhausting physical labour required of farm workers encouraged medicines that would give strength; hence, together with drugs to relieve fevers, dysentery and pain, demand grew for stimulants and tonics such as tobacco, coca, opium and alcohol.

In hierarchical societies like Assyria or the Egypt of the pharaohs, with their military – political elites, illness became unequally distributed and thus the subject of moral, religious and political teachings and judgments. Its meanings needed to be explained. Social stratification meanwhile offered fresh scope for enterprising healers; demand for medicines grew; social development created new forms of healing as well as of faith, ritual and worship; sickness needed to be rationalized and theorized. In short, with settlement and literacy, conditions were ripe for the development of medicine as a belief-system and an occupation.

APPROACHES TO HEALING

Like earthquakes, floods, droughts and other natural disasters, illness colours experiences, outlooks and feelings. It produces pain, suffering and fear, threatens the individual and the community, and raises the spectre of that mystery of mysteries – death. Small wonder impassioned and contested responses to sickness have emerged: notions of blame and shame, appeasement and propitiation, and teachings about care and therapeutics. Since sickness raises profound anxieties, medicine develops alongside religion, magic and social ritual. Nor is this true only of ‘primitive’ societies; from Job to the novels of Thomas Mann, the experience of sickness, ageing and death shapes the sense of the self and the human condition at large. AIDS has reminded us (were we in danger of forgetting) of the poignancy of sickness in the heyday of life.

Different sorts of sickness beliefs took shape. Medical ethnologists commonly suggest a basic divide: natural causation theories, which view illness as a result of ordinary activities that have gone wrong – for example, the effects of climate, hunger, fatigue, accidents, wounds or parasites; and personal or supernatural causation beliefs, which regard illness as harm wreaked by a human or superhuman agency. Typically, the latter is deliberately inflicted (as by a sorcerer) through magical devices, words or rituals; but it may be unintentional, arising out of an innate capacity for evil, such as that possessed by witches. Pollution from an ‘unclean’ person – commonly a corpse or a menstruating woman – may thus produce illness. Early beliefs ascribed special prominence to social or supernatural causes; illness was thus injury, and was linked with aggression.

This book focuses mostly upon the naturalistic notions of disease developed by and since the Greeks, but mention should be made of the supernatural ideas prominent in non-literate societies and present elsewhere. Such ideas are often subdivided by scholars into three categories: mystical, in which illness is the automatic consequence of an act or experience; animistic, in which the illness-causing agent is a personal supernatural being; and magical, where a malicious human being uses secret means to make someone sick. The distribution of these beliefs varies. Africa abounds in theories of mystical retribution, in which broken taboos are to blame; ancestors are commonly blamed for sickness. Witchcraft, the evil eye and divine retribution are frequently used to explain illness in India, as they were in educated Europe up to the seventeenth century, and in peasant parts beyond that time.

Animistic or volitional illness theories take various forms. Some blame objects for illness – articles which are taboo, polluting or dangerous, like the planets within astrology. Other beliefs blame people – sorcerers or witches. Sorcerers are commonly thought to have shot some illness-causing object into the victim, thus enabling healers to ‘extract’ it via spectacular rituals. The search for a witch may involve divination or public witch-hunts, with cathartic consequences for the community and calamity for the scapegoat, who may be punished or killed. Under such conditions, illness plays a key part in a community’s collective life, liable to disrupt it and lead to persecutions, in which witchfinders and medicine men assume a key role.

There are also systems that hinge on spirits – and the recovery of lost souls. The spirits of the dead, or nature spirits like wood demons, are believed to attack the sick; or the patient’s own soul may go missing. By contrast to witchcraft, these notions of indirect causation allow for more nuanced explanations of the social troubles believed to cause illness; there need be no single scapegoat, and purification may be more general. Shamanistic healers will use their familiarity with worlds beyond to grasp through divination the invisible causes behind illness. Some groups use divining apparatus – shells, bones or entrails; a question will be put to an oracle and its answer interpreted. Other techniques draw on possession or trance to fathom the cause of sickness.

Responses to sickness may take many forms. They may simply involve the sick person hiding away on his own, debasing himself with dirt and awaiting his fate. More active therapies embrace two main techniques – herbs and rituals. Medicines are either tonics to strengthen the patient or ‘poisons’ to drive off the aggressor. Choice of the right herbal remedy depends on the symbolic properties of the plant and on its empirical effects. Some are chosen for their material properties, others for their colour, shape or resonances within broader webs of symbolic meaning. But if herbs may be symbolic, they may also be effective; after much pooh-poohing of ‘primitive medicine’, pharmacologists studying ethnobotany now acknowledge that such lore provided healers with effective analgesics, anaesthetics, emetics, purgatives, diuretics, narcotics, cathartics, febrifuges, contraceptives and abortifacients. From the herbs traditionally in use, modern medicine has derived such substances as salicylic acid, ipecac, quinine, cocaine, colchicine, ephedrine, digitalis, ergot, and other drugs besides.

Medicines are not necessarily taken only by the patient, for therapy is communal and in traditional healing it is the community that is being put to rights, the patient being simply the stand-in. Certain healing rituals are rites de passage, with phases of casting out and reincorporation; others are dramas; and often the patient is being freed from unseen forces (exorcism). Some rituals wash a person clean; others use smoke to drive harm out. A related approach, Dreckapotheke, involves dosing the patient with disgusting decoctions or fumigations featuring excrement, noxious insects, and so forth, which drive the demons away.

A great variety of healing methods employ roots and leaves in elaborate magical rituals, and all communities practise surgery of some sort. Many tribes have used skin scarifications as a form of protection. Other kinds of body decoration, clitoridectomies and circumcision are common (circumcision was performed in Egypt from around 2000 BC). To combat bleeding, traditional surgeons used tourniquets or cauterization, or packed the wound with absorbent materials and bandaged it. The Masai in East Africa amputate fractured limbs, but medical amputation has been rare. There is archaeological evidence, however, from as far apart as France, South America and the Pacific that as early as 5000 BC trephining was performed, which involved cutting a small hole in the skull. Flint cutting tools were used to scrape away portions of the cranium, presumably to deliver sufferers from some devil tormenting the soul. Much skill was required and callous formations on the edges of the bony hole show that many of the patients survived.

BODY LORE

Illness is thus not just biological but social, and concepts of the body and its sicknesses draw upon powerful dichotomies: nature and culture, the sacred and the profane, the raw and the cooked. Body concepts incorporate beliefs about the body politic at large; communities with rigid caste and rank systems thus tend to prescribe rigid rules about bodily comportment. What is considered normal health and what constitutes sickness or impairment are negotiable, and the conventions vary from community to community and within subdivisions of societies, dependent upon class, gender and other factors. Maladies carry different moral charges. ‘Sick roles’ may range from utter stigmatization (common with leprosy, because it is so disfiguring) to the notion that the sick person is special or semi-sacred (the holy fool or the divine epileptic). An ailment can be a rite de passage, a childhood illness an essential preliminary to entry into adulthood.

Death affords a good instance of the scope for different interpretations in the light of different criteria. The nature of ‘physical’ death is highly negotiable; in recent times western tests have shifted from cessation of spontaneous breathing to ‘brain death’. This involves more than the matter of a truer definition: it corresponds with western values (which prize the brain) and squares with the capacities of hospital technology. Some cultures think of death as a sudden happening, others regard dying as a process advancing from the moment of birth and continuing beyond the grave. Bodies are thus languages as well as envelopes of flesh; and sick bodies have eloquent messages for society.

It became common wisdom in the West from around 1800 that the medicine of Orientals and ‘savages’ was mere mumbo-jumbo, and had to be superseded. Medical missions moved into the colonies alongside their religious brethren, followed in due course by the massive health programmes of the modern international aid organizations. By all such means Europeans and Americans sought to stamp out indigenous practices and beliefs, from the African witchdoctors and spirit mediums to the vaidyas and hakims of Hindu and Islamic medicine in Asia. Native practices were grounded in superstition and were perilous to boot; colonial authorities moved in to prohibit practices and cults which they saw as medically, religiously or politically objectionable, thereby becoming arbiters of ‘good’ and ‘bad’ medicine. Western medicine grew aggressive, convinced of its unique scientific basis and superior therapeutic powers.

This paralleled prejudices developing towards folk or religious medicine within Europe itself. The sixteenth-century French physician Laurent Joubert (1529–83) wrote a huge tome exposing ‘common fallacies’. Erreurs populaires [1578] systematically denounced the ‘vulgar errors’ and erroneous sayings of popular medicine regarding pregnancy, childbirth, lying-in, infant care, children’s diseases and so forth, insisting that ‘such errors can be most harmful to man’s health and even his life’. ‘Sometimes babies, boys as well as girls, are born with red marks on their faces, necks, shoulders or other parts of the body,’ Joubert noted. ‘It is said that this is because they were conceived while their mother had her period … But I believe that it is impossible that a woman should conceive during her menstrual flow.’ Another superstition was that whatever was imprinted upon the imagination of the mother at the time of conception would leave a mark on the body of her baby.

Elite medicine sought to discredit health folklore, but popular medicine has by no means always been misguided or erroneous. Recent pharmacological investigations have demonstrated the efficacy of many traditional cures. It is now known, for instance, that numerous herbal decoctions – involving rue, savin, wormwood, pennyroyal and juniper – traditionally used by women to regulate fertility have some efficacy. Today’s ‘green pharmacy’ aims at the recovery of ancient popular medical lore, putting it to the scientific test.

Once popular medicine had effectively been defeated and no longer posed a threat, scholarly interest in it grew, and great collections of ‘medical folklore’ and ‘medical magic’, stressing their quaintness, were published in the nineteenth century. But it is a gross mistake to view folk medicine as a sack of bizarre beliefs and weird and wonderful remedies. Popular medicine is based upon coherent conceptions of the body and of nature, rooted in rural society. Different body parts are generally represented as linked to the cosmos; health is conceived as a state of precarious equilibrium among components in a fluid system of relations; and healing mainly consists of re-establishing this balance when lost. Such medical beliefs depend on notions of opposites and similars. For example, to stop a headache judged to emanate from excessive heat, cold baths to the feet might be recommended; or to cure sciatica, an incision to the ear might be made on the side opposite to the pain.

Traditional medicine views the body as the centre or the epitome of the universe, with manifold sympathies linking mankind and the natural environment. Analogy and signatures are recurrent organizing principles in popular medicine. By their properties (colour, form, smell, heat, humidity, and so on) the elements of nature signal their meaningful associations with the human body, well and sick. For instance, in most traditional medicine systems, red is used to cure disorders connected with blood; geranium or oil of St John’s wort are used against cuts. Yellow plants such as saffron crocus (Crocus sativus) were chosen for jaundice, or the white spots on the leaves of lungwort (Pulmonaria officinalis) showed that the plant was good for lung disease, and so on. Sometimes it was argued that remedies had been put in places convenient for people to use. So, in England, the bark of the white willow (Salix alba) was valued for agues, because the tree grows in moist or wet soil, where agues chiefly abound, as the Revd Edmund Stone, of Chipping Norton in Oxfordshire, observed in his report to the Royal Society of London in 1763:

the general maxim, that many natural maladies carry their cures along with them, or that their remedies lie not far from their causes, was so very apposite to this particular case, that I could not help applying it; and that this might be the intention of Providence here, I must own had some little weight with me.

Maintaining health required understanding one’s body. This was both a simple matter (pain was directly experienced) and appallingly difficult, for the body’s interior was hidden. Unable to peer inside, popular wisdom relied upon analogy, drawing inferences from the natural world. Domestic life gave clues for body processes – food simmering on the hob became a natural symbol for its processing in the stomach – while magic, folksong and fable explained how conception and birth, growth, decay and death mirrored the seedtime and the harvest. The landscape contained natural signs: thus peasant women made fertility shrines out of springs. To fathom abnormalities and heal ailments, countryfolk drew upon the suggestive qualities of strange creatures like toads and snakes (their distinctive habits like hibernation or shedding skins implied a special command over life and death), and also the evocative profiles of landscape features like valleys and caves, while the phases of the moon so obviously correlated with the menstrual cycle.

Nature prompted the idea that the healthy body had to flow. In an agrarian society preoccupied with the weather and with the changes of the seasons, the systems operating beneath the skin were intuitively understood as fluid: digestion, fertilization, growth, expulsion. Not structures but processes counted. In vernacular and learned medicine alike, maladies were thought to migrate round the body, probing weak spots and, like marauding bands, most perilous when they targeted central zones. Therapeutics, it was argued, should counter-attack by forcing or luring ailments to the extremities, like the feet, where they might be expelled as blood, pus or scabs. In such a way of seeing, a gouty foot might even be a sign of health, since the big toe typically afflicted was an extremity far distant from the vital organs: a foe in the toe was trouble made to keep its distance.

In traditional medicine, as I have said, health is a state of precarious balance – being threatened, toppled and restored – between the body, the universe and society. More important than curing is the aim of preventing imbalance from occurring in the first place. Equilibrium is to be achieved by avoiding excess and pursuing moderation. Prevention lies in living in accord with nature, in harmony with the seasons and elements and the supernatural powers that haunt the landscape: purge the body in spring to clean it of corrupt humours, in summer avoid activities or foods which are too heating. Another preventative is good diet – an idea encapsulated in the later advice, ‘an apple a day keeps the doctor away’. Foods should be consumed which give strength and assimilate natural products which, resembling the body, are beneficial to it, such as wine and red meat: ‘meat makes flesh and wine makes blood’, runs a French proverb. The idea that life is in the blood is an old one. ‘Epileptic patients are in the habit of drinking the blood even of gladiators,’ noted the Roman author Pliny (AD C. 23–79): ‘these persons, forsooth, consider it a most effectual cure for their disease, to quaff the warm, breathing, blood from man himself, and, as they apply their mouth to the wound, to draw forth his very life.’

Clear-cut distinctions have frequently been drawn between ‘science’ and ‘superstition’ but, as historians of popular culture today insist, in societies with both a popular and an elite tradition (high and low, or learned and oral cultures), there has always been complex two-way cultural traffic in knowledge, or more properly a continuum. While often aloof and dismissive, professional medicine has borrowed extensively from the folk tradition.

Take, for instance, smallpox inoculation. There had long been some folk awareness in Europe of the immunizing properties of a dose of smallpox, but it was not until around 1700 that this knowledge was turned to use. The first account of artificial inoculation was published in the Philosophical Transactions of the Royal Society of London in 1714, and widespread publicity was achieved thanks to the observations of Lady Mary Wortley Montagu (1689–1762), wife of the British consul in Constantinople, that Turkish peasant women routinely performed inoculations. One English country doctor who practised inoculation was Edward Jenner. In his native Gloucestershire it was also known in the farming community that there was a disease of cattle – cowpox – which was occasionally contracted by human beings, particularly dairy-maids who milked the cows. This led Jenner to the idea behind vaccination; elite medicine clearly had much to learn from folk tradition.

We must thus avoid taking for granted the antagonistic presence of two distinct traditions: the scientific and the superstitious, the right and the wrong. In all complex societies there have been various ways of thinking about the body, health and disease. In early modern Europe there was nothing mutually exclusive about different types of therapeutics or styles of healing. The English parson-physician, Richard Napier (1559–1634), was a graduate of Oxford University and a learned scholar. Yet he was also an exponent of religious healing: he would pray for the recovery of his patients, and to protect them ‘against evil spirits, fairies, witcheries’ he would also give them protective sigils and amulets to wear, as well as purges. And when the diarist Samuel Pepys (1633 – 1703), who later became president of the Royal Society of London, surveyed his health and found himself in exceptionally good condition, he was unsure of the cause. On 31 December 1664, he balanced his books for the year:

So ends the old year, I bless God with great joy to me; not only from my having made so good a year of profit, as having spent £420. and laid up £540 and upward.

But I bless God, I never have been in so good plight as to my health in so very cold weather as this is, nor indeed in any hot weather these ten years, as I am at this day and have been these four or five months. But I am at a great loss to know whether it be my Hare’s fote, or taking every morning a pill of Turpentine, or my having left off the wearing of a gowne.

As this suggests, for Pepys as for others, religion, magic and medicine coalesced for therapeutic ends. Bread baked on Good Friday would never go mouldy; if stored, it would treat all manner of disease; rings made out of silver collected at the Eucharist would cure convulsions; the sacrament of confirmation would ward off sickness. Such beliefs had been encouraged within the proliferating healing rites of medieval Catholicism. In Protestant countries, with the anathematizing of pilgrimages, relics, holy waters, invocation of saints and the like at the Reformation, similar rituals continued, though essentially without express ecclesiastical authorization.

Medical magic was accepted by the unlettered and the elite alike until at least the seventeenth century, and was thought to operate in many ways. Disease could be transferred, transplanted or transformed. A sick person should boil eggs in his own urine and then bury them; as the ants ate them, the disease would also be eaten up. To heal a swollen neck, one was to draw a snake along it, put the snake in a tightly corked bottle and bury it; as the snake decayed, the swelling would go. Similarly, whooping cough sufferers should stand on the beach at high tide; when the tide went out, it carried the cough with it. Warts might be treated by touching them with a pebble; the pebbles were placed in a bag which was ‘lost’ as the sufferer went to church. Whoever found the bag acquired the warts too.

It was also widely believed that disease could be transferred to the dead. The sick person should clutch a limb of someone awaiting burial; the disease would then leave his or her body and enter the corpse. This mode of magic explains why mothers crowded around a scaffold, struggling to get their sickly infants into contact with an executed felon’s body.

The doctrine of signatures linking humans and nature, microcosm and macrocosm, was of course interwoven with astrology – a learned science as well as a popular belief. Understanding of the heavens was seen as providing the key to the particular properties of herbs and minerals. Plants governed by Venus, herbalists explained, were aids to fertility and childbirth; those under Mars provided strength, and the moon played a crucial part.

Above all, magic functioned with religion in popular healing. Christianity endorsed an articulate symbolic cosmology which asserted the supreme potency of non-material forces. Roman Catholicism etched onto believers’ minds the notion of miracle cures and the healing powers of sacraments, relics, Latin incantations, invocation of saints and holy waters. Popular therapeutic magic and religious healing could be interchangeable. Rejecting Catholic ‘superstition’, Protestants fought such ‘contamination’ of religion with magic; but the Reformation’s iconoclasm towards magic within the Church encouraged it to flourish in a kind of ‘black market’ outside. Modernizing forces – literacy, the availability of commercial medicines, the rise of the medical profession – gradually peripheralized such beliefs. But the finger of God might continue to be seen in visitations of illness and injury. ‘Last Wednesday night while carrying a bucket of water from the well,’ noted the Revd Francis Kilvert (1840–79) in his journal on 26 December 1874, ‘Hannah Williams slipped upon the icy path and fell heavily upon her back. We fear her spine was injured for though she suffers acute pain in her legs she cannot move them. The poor wild beautiful girl is stopped in her wildness at last, and perhaps by the finger of God.’

What must be stressed is the ceaseless dialectic of popular and educated medicine, and everything between. Superficially at least, the distinctive medical systems seem to have nothing in common but animosity. The medical missionary and explorer, David Livingstone (1813 – 73), recorded an exchange between representatives of quite different medical systems:

MEDICAL DOCTOR: Hail, friend! How very many medicines you have about you this morning! Why, you have every medicine in the country here.

RAIN DOCTOR: Very true, my friend; and I ought; for the whole country needs the rain which I am making.

M.D: So you really believe that you can command the clouds? I think that can be done by God alone.

R.D: We both believe the very same thing. It is God that makes the rain, but I pray to him by means of these medicines, and, the rain coming, of course it is then mine.

As the Rain Doctor recognized, they had more in common than met the eye. And the similarities yet differences between diverse medical systems and practices have always been evident to the sick themselves. In modern Taiwan, for instance, the sick use modern western doctors for certain ailments, traditional Chinese medicine for others, Japanese medicine and local herbal medicine and healers.

This sense of difference in commonness should help focus our attention to what is special to modern western scientific medicine: it is one healing system among many, yet it has, formally at least, in large measure broken with the traditional wisdom of the body. Herein lie its strengths and weaknesses. A distinguished historian of medicine, Jean Starobinski, writes,

The historian who hopes to make sense out of the development of medicine cannot simply list the discoveries in the field, adding them up as if one grew spontaneously out of the other. These conquests have been made possible only by a never-ending struggle against entrenched error, and by an unflagging recognition that the accepted methods and philosophical principles underlying basic research must be constantly revised.… Disease is as old as life, but the science of medicine is still young.

Contained within those remarks are the ideology of western medicine and some genuine historical insights. The following pages explore these ambiguities.

* Smallpox, the largest of all viruses, is the product of a long evolutionary adaptation of cowpox to humans – something clearly perceived two hundred years ago by Edward Jenner. His An Inquiry into the Causes and Effects … of the Cow Pox (1798) noted that:

The deviation of man from the state in which he was originally placed by nature seems to have proved to him a prolific source of diseases. From the love of splendour, from the indulgence of luxury, and from his fondness for amusement he has familiarized himself with a great number of animals, which may not originally have been intended for his associates.

Jenner thus perceived the dangers animals posed to human health. Now, in the late 1990s, the transmission chain between the cattle disease, bovine spongiform encephalopathy (BSE), and the human Creutzfeldt-Jakob Disease (CJD), is a hot epidemiological and political issue in Europe.

CHAPTER III ANTIQUITY

AT THE END OF THE LAST ICE AGE about ten thousand years ago, a revolution began which decisively changed the symbiosis of society and disease. As we saw in the previous chapter, communities learned to master animals, to herd them for food, yoke them for traction, and spur them to war. Familiarity with soils, seeds and seasons made it possible to harvest crops regularly. Settlements grew, and with them arts and crafts. Story-telling and public memory were cultivated and the gods propitiated through priestly rituals. With the Bronze Age (from about 4000 BC), metal-working was improved, the wheel exploited, the reckoning of time and space rationalized and the calendar invented. Learning was encouraged, cities administered, tributes extracted, treasure hoarded, laws promulgated, empires enlarged. All such developments – the ABC of civilization – brought new approaches to healing and, for the first time, the writing down of medical practice. Medicine entered history.

MESOPOTAMIA

By around 3000 BC the warm and fertile region in the Middle East watered by the Tigris and the Euphrates was cradling some of the world’s first great civilizations: Ur on the Euphrates, founded by the Sumerians, a hundred miles upriver from the Persian Gulf; Babylon, farther up the Euphrates; Assyria, centred on Assur, and later Nineveh on the Tigris, near Mosul in modern Iraq. Assyria destroyed Babylon; Nineveh reached its height under its kings Sennacherib (r. 705–681 BC) and Assurbanipal (r. 668–627 BC); its fall to the Persians in 608 BC is celebrated in the Bible.

All these Mesopotamian (‘land between the rivers’) kingdoms have left magnificent remains, archaeological and written, which permit reconstruction of their dynasties and deities, and the agrarian and bureaucratic infrastructures that sustained them. Their healing practices remain cloudy, but among the 30,000 or so surviving clay tablets covered with cuneiform writing there are about a thousand from the library of Assurbanipal on medicine, containing diagnoses and prognostications, remedies and their ingredients. These date from the seventh century BC, though the Sumerian/Assyrian healing traditions they record go back much further.

The chief text, called ‘The Treatise of Medical Diagnosis and Prognosis’, comprises some three thousand entries on forty tablets. It is basically a fist of ailments, and some are identifiable today: ‘the patient coughs continually. What he coughs up is thick and frequently bloody. His breathing sounds like a flute. His hand is cold, his feet are warm. He sweats easily, and his heart activity is disturbed’ – this sounds like tuberculosis. Eye disorders are prominent, and mention of ‘stinking disease’ and distended bellies suggests the vitamin-deficiency diseases symptomatic of the new grain-growing economies.

The framework for disease interpretation was largely omen-based, using divination based on inspection of the livers of sacrificed animals (hepatoscopy), because the liver was regarded as the seat of life. Prognostication may also have involved techniques like observing a flickering flame. Medical practice mixed religious rites and empirical treatments. Mention is made of three types of healers, presumably cooperating with one another: a seer (bârû), specializing in divination; a priest (âshipu), who performed incantations and exorcisms; and a physician (âsû), who employed drugs and did bandaging and surgery. An official head physician presided, and court doctors were expected to take an oath of office and allegiance.

The sixth king of the first dynasty of Babylon, Hammurabi (17 28–1686 BC) was a mighty ruler who made Babylon feared. Alongside the mathematical treatises, dictionaries, astrological, magical writings and other forms of learning that gave lustre to his reign, his greatest work was a legal code, whose 282 laws deal with the regulation of society, family life and occupations. The Code of Hammurabi, engraved on a two-metre-high stele found in 1901 at Susa in Iran and preserved in the Louvre, includes medical instructions for physicians. Its rules set out fees for treatment, with a sliding scale adjusting rewards according to the patient’s rank (nobleman, commoner or slave), together with terrifying draconian fines for incompetence or failure. ‘If a physician has performed a major operation on a lord with a bronze lancet and has saved the lord’s life … he shall receive ten shekels of silver’ (more than a craftsman’s annual pay); but if he caused the death of such a notable, his hand would be chopped off. A doctor causing the death of a slave would have to replace him.

The Mesopotamian peoples saw the hand of the gods in everything: disease was caused by spirit invasion, sorcery, malice or the breaking of taboos; sickness was both judgment and punishment. An Assyrian text of around 650 BC describes epileptic symptoms within a demonological framework:

If at the time of his possession, while he is sitting down, his left eye moves to the side, a lip puckers, saliva flows from his mouth, and his hand, leg and trunk on the left side jerk like a slaughtered sheep, it is migtu. If at the time of possession his mind is awake, the demon can be driven out; if at the time of his possession his mind is not so aware, the demon cannot be driven out.

Headaches, neck pain, intestinal ailments and impotence were read as omens, and remedies involved identifying the demons responsible and expelling them by spells or incantation, though when maladies were the work of a god they might be a portent of death. Sicknesses were also ascribed to cold, dust and dryness, putrefaction, malnutrition, venereal infection and other natural causes.

Physical symptoms might be treated with empirical remedies. The Babylonians drew on an extensive materia medica – some 120 mineral drugs and twice that number of vegetable items are listed in the tablets. Alongside various fats, oils, honey, wax and milk, active ingredients included mustard, oleander and hellebore; colocynth, senna and castor oil were used as laxatives; while wound dressings were compounded with dried wine dregs, salt, oil, beer, juniper, mud or fat, blended with alkali and herbs. They had discovered distillation, and made essence of cedar and other volatile oils. Use of dog dung seems to smack of Dreckapothecary treatments, faecal ingredients designed to drive off demons.

Such empirical remedies accompanied a prognostic bent reflecting Babylonian preoccupations with astrology, the casting of horoscopes and soothsaying through examination of animal entrails (haruspicy). Viewing disease as largely supernatural, Mesopotamian medicine might be regarded as sorcery systematized. Parallels to this are offered by Egyptian medicine, which developed at the same time and presents comparable healing practices involving prayers, magic, spells and sacrifices, together with practical drug treatments and surgery.

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.

The last of the humours, black bile (melancholy), entered disease theory late, but in On the Nature of Man it assumed the status of an essential, if mainly harmful, humour. Visible in vomit and excreta, it was perhaps thought of as contributing to the dark hue of dried blood. Indeed, the idea of four humours may have been suggested by observation of clotted blood: the darkest part corresponded to black bile, the serum above the clot was yellow bile, the light matter at the top was phlegm. Black bile completed a coherent, symmetrical grid in binary oppositions, and the four humours – blood, yellow bile, black bile and phlegm – proved wonderfully versatile as an explanatory system. They could be correlated to the four primary qualities – hot, dry, cold and wet; to the four seasons, to the four ages of man (infancy, youth, adulthood and old age), to the four elements (air, fire, earth and water), and the four temperaments. They thus afforded a neat schema with vast explanatory potential. On the assumption, for example, that blood predominated in spring and among the young, precautions against excess could be taken, either by eliminating blood-rich foods, like red meat, or by blood-letting (phlebotomy) to purge excess. The scheme (which finds parallels in Chinese and Indian medicine) could be made to fit with observations, and afforded rationales for disease explanation and treatment within a causal framework.

The Hippocratics specialized in medicine by the bedside, prizing trust-based clinical relations:

Make frequent visits; be especially careful in your examinations, counteracting the things wherein you have been deceived at the changes. Thus you will know the case more easily, and at the same time you will also be more at your ease. For instability is characteristic of the humours, and so they may also be easily altered by nature and by chance.

… Keep a watch also on the faults of the patients, which often make them lie about the taking of things prescribed. For through not taking disagreeable drinks, purgative or other, they sometimes die. What they have done never results in a confession, but the blame is thrown upon the physician.

Their therapeutic stance was ‘expectant’: they waited and watched their patients, talking, winning trust and giving a helping hand to the ‘healing power of nature’ (vis medicatrix naturae) emphasized in the text On Ancient Medicine. Believing that ‘our natures are the physicians of our diseases’, they scorned heroic interventions and left risky procedures to others. The Oath forbade cutting, even for the stone, and other texts reserved surgery for those used to handling war wounds. That was a sensible division of labour, but surgery was also regarded as an inferior trade, the work of the hand rather than the head – a fact reflected in its name: ‘surgery’ derives from the Latin chirurgia, which comes from the Greek cheiros (hand) and ergon (work). Surgery was handiwork.

The Hippocratic doctor might disown the knife, but he prided himself on his knowledge of surgical matters – indeed the Corpus contains much now regarded as such, including a treatise On Head Injuries. Hippocratic advice proved highly influential: wounds should be kept dry, but suppuration was deemed essential to healing; the pus supposedly derived from vitiated blood which needed to be expelled from the body: pus was thus a desirable evacuation. Fractures were to be reduced and immobilized with splints and bandages. For bladder stones, catheterization was advocated, never lithotomy – such operations were left to ‘such as are craftsmen therein’; and, as a last resort in case of gangrene, amputation might be performed (vascular ligature was unknown).

Hippocratic surgical texts were thus conservative in outlook, encouraging a tradition in which doctors sought to treat complaints first through management, occasionally through drugs and finally, if need be, by surgical intervention. Hippocrates and Galen alike were dubious about surgery for cancer.

Drug therapy too was cautious. The preferred Hippocratic treatment lay in dietary regulation. Unlike sheep and goats, humans could not eat rough food; good diet was crucial to health and so, as the saying went, the first cook was the first physician. But diet meant more than food and drink – diatetica (dietetics), the cornerstone of the healing art, involved an entire lifestyle. Ancient authors linked this therapy to athletic training, and to the well-regulated life as urged by philosophers. On Regimen gave advice on taking exercise, so important to the culture of free-born Greeks, and also on sex, bathing and sleep. In winter, for instance, ‘sexual intercourse should be more frequent … and for older men more than for the younger’.

Hippocratic healing was patient-oriented, focusing on ‘dis-ease’ rather than diseases understood as ontological entities. But observation identified certain illness patterns. To the Hippocratics the paradigm acute disease was fever, and its model seems to have been malaria, the seasonal onset and regular course of which allowed it to be documented and explained in terms of humours and times of the year. Though ignorant of the role played by mosquitoes, Hippocratic physicians had a shrewd grasp of the connexions between fever and weather, season and locality. Airs, Waters, Places observed that if the rains occurred normally in autumn and winter, the year would be healthy, but if they were delayed until spring, many fever cases would occur during the summer, ‘for whenever the great heat comes on suddenly while the earth is soaked by reason of the spring rains … the fevers that attack are of the acutest type.’

Hippocratic physicians posited a broad correlation between humours and times of the year. In each season, one humour was thought to predominate. Bodily phlegm increased during the winter because, being cold and wet, it was akin to the chilly and rainy weather of a Mediterranean winter; colds, bronchitis and pneumonia were then more prevalent. When spring came, blood increased in quantity, and diseases would follow from a plethora of blood, including spring fever outbreaks (primarily benign tertian malaria), dysentery and nose-bleeds. By summer, the weather was hotter and drier, yellow bile (hot and dry) increased, and so the diseases resulting from yellow bile would multiply, that is severe fevers (falciparum malaria). With the cooler weather at the end of summer, fevers waned, but many would display the consequences of repeated fever attacks, their skins showing a dirty yellowish tinge and their spleens enlarged. The autumnal decline of fevers indicated to the Hippocratic physician that yellow bile had diminished while black bile was increasing. Seemingly the most problematic humour, black bile makes good sense in the light of awareness of the effects of malarial fevers. Philiscus, whose evidently malarial condition was described in Epidemics I, suffered from black urine and his ‘spleen stuck out’; the spleen was considered the seat of black bile. Faced with fevers, Hippocratic doctors predictably did not attempt anything heroic. Valuing regimen and diet, they gave barley water, hydromel (honey and water) or oxymel (honey and vinegar) – a ‘low’ diet with adequate fluids.

The doctor should therefore observe sickness, attending the patient and identifying symptom clusters and their rhythms. Airs, Waters, Places took it as axiomatic that understanding of locales would enable the healer on arrival in a faraway town to grasp the local diseases, so that he could ‘achieve the greatest triumphs in the practice of his art’, something important in a competitive market.

The art of diagnosis involved creating a profile of the patient’s way of life, habitation, work and dietary habits. This was achieved partly by asking questions, and partly by the use of trained senses:

When you examine the patient, inquire into all particulars; first how the head is … then examine if the hypochondrium and sides be free of pain, for … if there be pain in the side, and along with the pain either cough, tormina or bellyache, the bowels should be opened with clysters … The Physician should ascertain whether the patient be apt to faint when he is raised up, and whether his breathing is free.

Hippocratics prided themselves on their clinical acuity, being quick to pick up telltale symptoms, as with the facies hippocratica, the facial look of the dying: ‘a protrusive nose, hollow eyes, sunken temples, cold ears that are drawn in with the lobes turned outward, the forehead’s skin rough and tense like parchment, and the whole face greenish or black or blue-grey or leaden’. Experience was condensed into aphorisms; for instance, ‘when sleep puts an end to delirium, it is a good sign.’

Hippocratic doctors cultivated diagnostic skills, but the technique they really prized was prognosis – a secular version of the prognostications of earlier medicine:

It appears to me a most excellent thing for the physician to cultivate Prognosis; for by foreseeing and foretelling, in the presence of the sick, the present, the past, and the future, and explaining the omissions which patients have been guilty of, he will be the more readily believed to be acquainted with the circumstances of the sick; so that men will have confidence to intrust themselves to such a physician.

This skill had a social function: prognostic flair created a favourable impression, setting the gifted healer above quacks and diviners. To be able to tell a patient’s medical history and prospects displayed acuity. And by declaring, if need be, that death was impending, a healer escaped blame for apparent failure.

Hippocratics made no pretence to miracle cures, but they did undertake that they would first and foremost do no harm (primum non nocere) and presented themselves as the friends of the sick. This philanthropic disposition attested the physician’s love of his art – above fame and fortune – and reassured anxious patients and their relatives. Such concerns are addressed in the Hippocratic Oath (see box, opposite).

For all its later prominence, little is known about the Oath’s origins, except that it dates from between the fifth and third centuries BC. It certainly did not set general standards of conduct, for the sanctity it accords to human life is anomalous to classical moral thought and practice, abortion and infanticide being familiar practices, condoned by Plato and Aristotle. The fact that it prohibits prescribing a ‘destructive pessary’ suggests a Pythagorean influence, with their belief in the transmigration of souls.

The Oath foreshadowed the western paradigm of a profession (one who professes an oath) as a morally self-regulating discipline among those sharing craft knowledge and committed to serving others. But it was equally an agreement between apprentice and teacher. As it makes clear, Hippocratic medicine was a male monopoly, although male physicians might cooperate with midwives and nurses.

Hippocratic medicine had its weaknesses – it knew little of the inner workings of the body – but its striking innovation lay in perceiving sickness as a disturbance in the health of the individual, who would then be accorded devoted personal attention. ‘Life is short, the art long, opportunity fleeting, experience fallacious, judgment difficult,’ proclaims the first of the Hippocratic aphorisms, outlining the arduous but honourable labour of the physician.

The significance of Hippocratic medicine was twofold: it carved out a lofty role for the selfless physician which would serve as a lasting model for professional identity and conduct, and it taught that understanding of sickness required understanding of nature.

MEDICINE AND PHILOSOPHY

With Greek philosophers praising health as one of the greatest blessings of life, medicine became implicated in wider debates about human nature and the status of the body. The earliest writer to mention Hippocrates and his theories, Plato (427–437 BC) developed a series of analogies to divide human nature into three functions – reason, spirit, and appetites – located respectively within the brain, the heart and the liver, and all potentially in conflict. Only in the philosopher would reason, aided by spirit, triumph over sordid desires. The Republic’s distinctions between reason and appetite, mind and body, was of utmost philosophical and psychological significance. Plato’s place in later medical thinking, however, rests on the Timaeus (c. 375 BC). This pictured the body as built up from transcendental geometrical shapes. The human frame was constructed by the Creator with specific purposes in mind; hence medicine had a discernible teleology. Somatic in orientation, the Timaeus taught that morality was not simply a matter of education; behaviour might also be determined by organic constituents, by excesses or deficiencies in the spinal marrow which affected the sensations of pleasure and pain; madness might thus have a physiological cause, to be treated by medical means. Because the mind was influenced by the body, the doctor had a part to play in teaching virtue. Advancing a physiology compatible with Hippocratic medicine, the Timaeus became a highly influential text, linking medicine and philosophy, health and politics.

THE OATH

I swear by Apollo the healer, by Aesculapius, by Health and all the powers of healing, and call to witness all the gods and goddesses that I may keep this Oath and Promise to the best of my ability and judgment.

I will pay the same respect to my master in the Science as to my parents and share my life with him and pay all my debts to him. I will regard his sons as my brothers and teach them the Science, if they desire to learn it, without fee or contract. I will hand on precepts, lectures and all other learning to my sons, to those of my master and to those pupils duly apprenticed and sworn, and to none other.

I will use my power to help the sick to the best of my ability and judgment; I will abstain from harming or wronging any man by it.

I will not give a fatal draught to anyone if I am asked, nor will I suggest any such thing. Neither will I give a woman means to procure an abortion.

I will be chaste and religious in my life and in my practice.

I will not cut, even for the stone, but I will leave such procedures to the practitioners of that craft.

Whenever I go into a house, I will go to help the sick and never with the intention of doing harm or injury. I will not abuse my position to indulge in sexual contacts with the bodies of women or of men, whether they be freemen or slaves.

Whatever I see or hear, professionally or privately, which ought not to be divulged, I will keep secret and tell no one.

If, therefore, I observe this Oath and do not violate it, may I prosper both in my life and in my profession, earning good repute among all men for all time. If I transgress and forswear this Oath, may my lot be otherwise.

‘The soul and body being two, they have two arts corresponding to them,’ Plato stated, making similar links in the Gorgias: ‘there is the art of politics attending on the soul; and another art attending on the body, of which I know no single name, but which may be described as having two divisions, one of them gymnastic, and the other medicine.’ Thanks to Plato, western thinking could consider medicine as having its share in understanding human nature. Greek thinking thus emphasized the common ground between what would later become the separate disciplines of philosophy, medicine and ethics. Health depended upon temperance and wisdom, or proper self-control. Achieved through moderation in eating, drinking, sex and exercise, bodily health became the template for healthy thinking (sōphrosynē, soundness of mind). To later Stoic philosophers likewise, the wisdom of the sage required the attainment of true health; for their part Epicureans stressed the supreme desirability of freedom from pain.

Plato’s pupil Aristotle also put forward hugely influential views on the constitution of life. A doctor’s son from Stagira in Thrace, Aristotle (384–322 BC) went to Athens to study with Plato, later becoming tutor to Alexander the Great (356–323 BC). His towering role in theorizing about metaphysics and cosmology, ethics, politics, poetics and thinking itself involved many achievements: the creation of a scientific method; the pursuit of teleological ways of thinking; and the impetus he gave to biological research. Questioning Plato’s transcendental ideas, Aristotle called for the systematic observation of nature. Whereas Plato distrusted sense experience, his pupil launched a programme of empirical investigation into the natural world – into zoology, botany and meteorology. Nature did nothing in vain, so body parts had to be explained in respect of their purpose (teleology). Aristotle discussed such final causes in terms of a wider fourfold theory of causation. For nearly two thousand years, Aristotelian methodology provided the framework for scientific investigation.

Later hailed by Dante as the ‘master of the men who know’, Aristotle was the first who systematically used dissection findings (animal not human) as a grounding for his biomedical theories. What he recorded occasionally puzzled his successors. In his description of the heart, he refers to ‘three chambers’ connected to the lung; later investigators were baffled which animals he was referring to. While revealing the veins as a connected system of vessels extending from the heart throughout the whole body, he did not distinguish between veins and arteries, applying the same term to both.

Observing the embryo developing within eggs, Aristotle perceived the beating heart as the first sign of life, concluding that it must be the prime mover of life and coeval with the whole body. The blood contained within the heart and blood vessels became correspondingly decisive. Blood was the nutrient the vessels absorbed from the intestines: ‘this explains why the blood diminishes in quantity when no food is taken, and increases when much is consumed.’

The idea of a nervous system paralleling the veins and arteries was as yet unformulated, so it is not surprising that Aristotle did not locate the seat of the soul, the source of movement and sensation, within the brain, but in the heart, stressing its physiological primacy within the human body. It was also the source of innate heat; pulsation was the result of a sort of boiling movement (ebullition) in the blood, causing it to press against the heart walls and pour out into the blood vessels. The heart’s heat dilated the lungs, fresh air rushed in, cooled the blood, and, warmed by the blood’s heat, was then expired. The brain had a part to play in these vital processes. Being naturally cold, it served as a refrigerator, helping to cool the blood’s innate heat. It also brought on sleep. Its function was that of a regulator, adjusting the organism as a whole.

The discussions of psychology in Aristotle’s On the Soul, On Sleep and Waking, On Sensation and On Memory long intrigued doctors and philosophers alike; and two thousand years later his teleological doctrines shaped the physiology of William Harvey (See Chapter Nine). In the shorter term his anatomy was taken up and revised by the next generation, particularly by Diocles of Carystos (fl. 320 BC), and two doctors working in Alexandria, Herophilus and his contemporary Erasistratus.

ALEXANDRIAN MEDICINE

Aristotle’s royal pupil, Alexander, routed all his rivals, lamented there were no more worlds to conquer, and expired in 323 BC, supposedly exclaiming, ‘I die by the help of too many physicians.’ His destruction of the Persian Emperor Darius III had brought Egypt within the hellenistic sphere of influence, and after Alexander’s death science gained a prominent place at the court of King Ptolemy, who ruled from 323 to 282 BC and established his capital at Alexandria, at the mouth of the Nile.

King Ptolemy’s main cultural creations, the Alexandrian Library and the Museum (sanctuary of the Muses) installed Greek learning in a new Egyptian environment: Archimedes, Euclid and the astronomer Ptolemy were later to teach there. The library became a wonder of the scholarly world, eventually containing, it was said, 700,000 manuscripts, and its facilities included an observatory, zoological gardens, lecture halls and rooms for research.^*

Thanks to Alexander’s conquests, the hellenistic world stretched from the Persian Gulf to Sicily, with Greek becoming the lingua franca of the elite. One consequence was a remarkable increase of new information on animals, plants, minerals and drugs. Alexandria also attracted medical talent, notably Herophilus of Chalcedon (c. 330–260 BC and his contemporary, Erasistratus of Ceos (c. 330–255 BC). Their writings having been lost, we know about them only through later physicians. Cornelius Celsus (fl). AD 60 reported that they dissected, or at least experimented upon, living humans, which is not inconceivable, for Greeks may have used their privileged status in Alexandria to experiment on their inferiors, especially condemned criminals.

Herophilus was apparently a student of Praxagoras of Cos (fl. 340 BC), who had improved Aristotelian anatomy by distinguishing arteries from veins. Praxagoras saw the arteries as air tubes, similar to the trachea and bronchi, conducting the breath of life (pneuma) from the lungs to the left side of the heart and thence through the aorta and other arteries to the whole body. The arteries stemmed from the heart; the veins, by contrast, Praxagoras believed, arose from the liver, their function being to carry the blood, created from digested food, to the rest of the body. The combining of blood and pneuma generated innate heat.

Herophilus practised medicine in Alexandria under the first two Ptolemies, apparently dissecting human cadavers in public. He wrote at least eleven treatises. Three were on anatomy: it was he who discovered and named the prostate and the duodenum (from the Greek for twelve fingers, the length of gut he found). He also wrote on the pulse as a diagnostic guide, on therapeutics, ophthalmology, dietetics and midwifery, and a polemic ‘Against Common Notions’.

Continuing Praxagoras’ differentiation between veins and arteries, Herophilus pointed out that the coats of the arteries were much thicker than those of the veins. Unlike Praxagoras, however, he held that the arteries were filled not with air but with blood. His most striking dissection feat was the delineation of the nerves. Demonstrating their source in the brain enabled him to conclude that they played the part preceding thinkers had ascribed to the arteries: transmitting motor impulses from the soul (intelligence centre) to the extremities. Rebutting Aristotle, he thus established the importance of the brain, distinguishing the cerebrum from the cerebellum and displaying the nerve paths from the brain and spinal cord. His description of the rete mirabile, the network of arteries at the base of the brain, shows he dissected animals as well as human corpses, since it does not exist in humans.

Herophilus also devoted attention to the liver and to ‘veins’ ending in glandular bodies which, he believed, nourished the intestines but did not pass to the liver. These ‘veins’ must have been the lacteals or chyle-vessels, whose function was explained by Aselli some two thousand years later. Praxagoras’ interest in the pulse was taken up by Herophilus. Identifying pulsation as derived from the heart, he developed a speculative classification of different classes of pulse, on the basis of magnitude, strength, rate and rhythm, and is reputed to have tried to calculate pulse by means of a portable water clock.

Erasistratus is far more nebulous and controversial. He supposedly studied medicine in Athens before settling in Alexandria, where he experimented on living animals and perhaps humans. His main discoveries concerned the brain which, like Herophilus but unlike Aristotle, he regarded as the seat of intelligence. He too distinguished the cerebrum from the cerebellum, described the cerebral ventricles within the brain, and distinguished between motor and sensory nerves. Nerves were hollow tubes containing pneuma (‘spirit’ or air), which transmitted sensation, enabling muscles to produce motion.

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.’^*

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.

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.