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The Greatest Benefit to Mankind: A Medical History of Humanity
Roy Porter


�Yet another compulsively readable, astonishingly encyclopaedic book from Roy Porter…his best to date: an epic, one-volume narrative history of man’s struggle with the infirmities of his body, from Aesculapius to AIDS.’ SIMON SCHAMA�Whether you are interested in the advent of the stethoscope, the history of yellow fever, the bubonic plague or, closer to home, coronary heart disease, the feminist influence on medicine, drug abuse, childbearing or cancer, this book provides the historic background to these and other medical questions… The Greatest Benefit to Mankind is a first-class introduction to medical history. Like a well constructed broadsheet leader, it excites thought and discussion, as well as providing many answers.’ THOMAS STUTTAFORD, The TimesMedicine advances ever faster, and with it a capacity not just to overcome sickness, but to transform the very nature of life. Starting in antiquity, Roy Porter’s titanic history examines the traditions of both East and West to chart how this revolution came about and how life for human beings in some parts of the world has ceased to be �nasty, brutish and short’. The Greatest Benefit to Mankind becomes from the moment of publication the standard work on its subject. It is also a magnificent entertainment and a delight to read.













THE

GREATEST BENEFIT

TO MANKIND


A Medical History of

Humanity from

Antiquity to the Present




ROY PORTER

















COPYRIGHT (#u000707b0-8f1a-5843-92cd-158ca5bc88d2)


William Collins

An imprint of HarperCollinsPublishers Ltd. 1 London Bridge Street London SE1 9GF

www.harpercollins.co.uk (http://www.harpercollins.co.uk/)

First published in Great Britain by HarperCollins Publishers 1997

Copyright В© Roy Porter 1997

Roy Porter has asserted the moral right to be identified as the author of this work

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PRAISE (#u000707b0-8f1a-5843-92cd-158ca5bc88d2)


More from the reviews:

�An endlessly beguiling grand tour d’horizon… Nobody could do this colossal subject better justice than Professor Porter.’

MICHAEL BYWATER, New Statesman

�History as compulsive as this is a splendid reminder of the essential truth [of mortality]… an admirable and a richly enjoyable book’

New Scientist

�What? Yet another compulsively readable, astonishingly encyclopaedic book from Roy Porter? The Greatest Benefit to Mankind might be his best to date: an epic, one-volume narrative history of man’s struggle with the infirmities of his body, from Aesculapius to AIDS. The author’s perceptiveness is, as usual, scalpel-sharp; his manner genially bedside; his erudition invigorating. To get the full benefit of Dr Porter’s tonic, take a dose of the book at least once a day and retire early to bed.’

SIMON SCHAMA

�Riveting … one of the abiding impressions left by this astonishingly erudite historical survey is of the enormous intellectual effort across all cultures to try and understand the origins of illness. Another is what perilous lives we have led, especially since we created cities to live in. There is prodigious labour here, as well as generous helpings of wit… This fine book is much more than a chronicle of the rise of modern medical science. It is also a splendidly salutary reminder of the precariousness and pain of the human lot through most of our history. After reading it, anyone who has ever attended a birth, overcome an infection by taking a pill or had a pain-free operation, should be left profoundly grateful to be living in the second half of the 20th century, rather than any of the centuries before.’

JON TURNEY, Financial Times

�Excellent … In this fine book, Porter has managed to weave together both approaches to the history of medicine. On the one hand he has drawn thumbnail sketches of the rich variety of personalities whose achievements were seminal to the slow evolution of the field. His choices are nothing if not catholic: Galen, William Harvey, Louis Pasteur and like giants were not unexpected; Jacob Bigelow, Dock and other pioneers of medical education may be less familiar; and the Egyptian healer Iri, keeper of the royal rectum is a genuine collector’s piece. Yet at the same time Porter has managed to set each stage of this complex story in its social and demographic framework. Even more remarkably, he has maintained this dualistic approach in accounts of medical practice in ancient Greece, China and India, through its Arab-Islamic period and in medieval England to the present day. Yet this massive fact-filled volume is written so eloquently, with such style, insight and humour that it is extremely difficult to put down… Porter has performed a great service to today’s (and tomorrow’s) doctors and to the community at large by placing the current medical scene in its broad historical perspective. And in so doing he has managed to write a wonderfully entertaining book. His synthesis of the modern doctor’s dilemma is spot on. All those who have the daunting task of trying to redefine the goals of medical practice for the future should read this book and then read it again. It is a magnificent achievement.’

DAVID WEATHERALL, THES

�The richness of the historical information is matched by the vividness of his assessment of present dangers from the resurgence of disease.’

JOHN MADDOX, New Statesman, Books of the Year

�Porter is both immensely learned and highly readable. Readers who, like myself, enjoy discovering unexpected facts will find this book a treasure trove… Roy Porter’s mammoth medical history is an extraordinary achievement; it is lively and full of fascinating information.’

ANTHONY STORR, Observer

�A marvellous canter through 10,000 years of disease, diagnosis and death’

TIM RADFORD, Guardian

�Big, broad-minded, compendious yet lively and extremely readable’

Scotsman

�A bedside book which can be guaranteed to interest, educate and soothe the most disturbed insomniac. The book is amusingly – even racily written. Porter’s role as a commentator has not detracted from historical detail, as the anecdotal style with which he describes the intricacies of medical practice throughout the ages makes it blend seamlessly with his analyses of social conditions. Although doctors and patients who have lived and worked through the medical revolution of the post-antibiotic era, and all the other changes of the past 50 years, may find this book particularly fascinating, it also makes interesting reading to those who have no previous specialised knowledge in either history or medicine. The Greatest Benefit to Mankind is as much a gigantic essay on medicine as it is a textbook and is particularly effective in revealing the changes in medicine over the past 150 years, together with the social and political changes which first prompted them … Porter is particularly stimulating when writing on the history of mental disease… Readers will find enough detail to make them glad that they live in a time where there are anaesthetics, surgical teams and a sophisticated pharmaceutical industry, but the descriptions are not so gory that the insomniac who seeks relief within its covers will later fear to turn out the lights.’

THOMAS STUTTAFORD, The Times

�Most impressive… a titanic 800-pager which ranges from pre-history to the present… Porter is the master of the telling quotation… He is also the first historian to tackle the complexities of medicine’s recent past, with the extraordinary therapeutic revolution of the post-war years.’

JAME SLEFANU, Daily Telegraph

�An impressive sweep from the Greeks to the present day… [The Greatest Benefit to Mankind] bears endless dipping into. It is a unique reference book, mixing an abundance of factual material with lively sociological insights. Certainly no medical student should be without it’

JOHN CORNWELL, Sunday Times Christmas Books 1997.

�I intend to keep this book within reach for years to come… text book history at its best… Porter matches strong opinions to his mastery of the facts.’

ALFRED W CROSBY, Nature

�This book is so stimulating and thought-provoking that, frankly, by the time I’d finished it I was in such a brain-overloaded anxiety state that I had to resort to one of modern medicine’s great innovations – a Valium pill.’

VAL HENNESSY, Daily Mail

�Excellent’

Evening Standard, Christmas Books

�To combine enormous knowledge and a delightful style and a highly idiosyncratic point of view is Roy Porter’s special gift, and it makes his new book alive and fascinating and provocative on every page.’

OLIVER SACKS

�Sprawlingly compendious, encyclopaedically detailed and utterly free from any sort of triumphalist condescension about present achievement and past superstition… Every clinician, every aspirant clinician, every patient should read this wise book.’

BRIAN MORTON, Scotland on Sunday

�Mr Porter, a formidably learned man, seems in this history to have omitted no discovery and no medical scientist of any importance… this account is completely without the cynicism which disfigures so much recently written medical history.’

Economist

�Only the unique artistry or Roy Porter could have created this panoramic and perfectly magnificent intellectual history of medicine. It makes no difference whether one reads it for its wisdom, insight, inimitable perspective, or simply for its plenitude of information – this is the book that delivers it all, plus the sheer joy of hearing the distinct voice of one of today’s most fascinating commentators on the development of the ancient art of healing.’

SHERWIN B. NULAND

�Intelligent and highly readable’

AMANDA FOREMAN, Independent

�Intelligent analysis… Porter stresses at the beginning and reiterates powerfully throughout his captivating text, the authority and legitimacy of scientific medicine in Western society has lain only in small measure in its ability to cure the sick… interesting and provocative.’

LARA MARKS, History Today

�Everything he writes is highly readable and his erudition is formidable.’

ANTHONY DANIELS, Sunday Telegraph

�The solid virtues of The Greatest Benefit include clarity, calm and expertise in the art of the compressed anecdote: as in this sentence which concludes the career of the laughing gas pioneer: �Wells lost medical support, grew depressed, became addicted to chloroform, and after arrest in New York for hurling sulphuric acid at two prostitutes, committed suicide in jail’. The quotes are often very funny or very sad.’

ERIC CHRISTIANSEN, Spectator

�Interesting… abounding in titbits of curious information.’

WILLIAM H. McNEILL, TLS

�This huge book is an amazing achievement’

Irish Independent

�A hugely enjoyable exploration of medicine and history. From hunter-gatherer to heart transplant, a matrix of ideas and events is woven, seamlessly incorporating medicine, philosophy, science and history. A seductive spell is cast… the prose flows effortlessly, the material well-organised and anecdotally fascinating… A great read.’

ALAN MUNRO, British Journal of General Practice

�Wonderful… A powerful overview’

British Medical Journal

�In this excellent book, Porter combines the presentation of full details concerning the science, art and practice of medicine through the ages with a refreshingly critical approach… readable and accessible to a wide audience, outshining other more traditional histories of medicine… truly a major achievement.’

International History of Nursing Journal




DEDICATION (#u000707b0-8f1a-5843-92cd-158ca5bc88d2)


TO

MikulГЎЕЎ Teich,

true friend and scholar


Sick – Sick – Sick … O Sick – Sick – Spew

DAVID GARRICK, in a letter

I’m sick of gruel, and the dietetics,

I’m sick of pills, and sicker of emetics,

I’m sick of pulses, tardiness or quickness,

I’m sick of blood, its thinness or its thickness, –

In short, within a word, I’m sick of sickness!

THOMAS HOOD, �Fragment’, c. 1844

They are shallow animals, having always employed their minds about Body and Gut, they imagine that in the whole system of things there is nothing but Gut and Body.

SAMUEL TAYLOR COLERIDGE, on doctors (1796)




CONTENTS


COVER (#u6fa374a3-52aa-5e84-81ac-187b805f0071)

TITLE PAGE (#ud29b370b-3387-56f2-87e0-14593496e575)

COPYRIGHT

PRAISE

DEDICATION (#u5f105158-00ac-5468-b0c6-04bdd1bfc55b)

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 (#u000707b0-8f1a-5843-92cd-158ca5bc88d2)


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 (#ulink_a3eb2082-11c1-5fc2-93bf-3e0edff11e0a) surveys the emergence of health practices and medical beliefs in some early societies; Chapter 3 (#ulink_0248b0d1-b7f0-5ef5-ac5b-1b4665eb9008) discusses the rise of formal, written medicine in the Middle East and Egypt, and in Greece and Rome; Chapter 4 (#ulink_3b03811e-d5c1-531a-b296-34e601c35f73) explores Islam; separate chapters discuss Indian and Chinese medicine; Chapter 8 (#ulink_dd258c41-49ec-5675-ba28-d2f331b89964) takes in the Americas; Chapter 15 (#litres_trial_promo) 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 resumГ© 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 (#u000707b0-8f1a-5843-92cd-158ca5bc88d2)


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.


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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 (#ulink_8dc1f652-d30b-511b-a533-c140fc389852)).

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 B


(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 B


B


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 mГ©tier 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 ВЈ420. and laid up ВЈ540 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.

* (#ulink_a5b12b56-a9ab-572e-98d0-fb13f9015068) 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 (#u000707b0-8f1a-5843-92cd-158ca5bc88d2)


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 (bГўrГ»), specializing in divination; a priest (Гўshipu), who performed incantations and exorcisms; and a physician (ГўsГ»), 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.


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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.’


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

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

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

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

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

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

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

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

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

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

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

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




GALEN


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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




MEDICINE IN THE AGE OF GALEN


Personal in Greece, medicine remained personal in Rome. No medical degrees were conferred or qualifications required. In the absence of colleges and universities, the private, face-to-face nature of medical instruction encouraged fluidity and diversity; students attached themselves to an individual teacher, sitting at his feet and accompanying him on his rounds. Medical authors frequently engaged in pugnacious polemics, contributing to the proliferation of rival schools.

Many different sorts of medical care were available. Self-help was universal; Celsus’ On Medicine was written for a non-professional readership willing to wield the scalpel as well as the plough and sword. Some healers in Italy were slaves or ex-slaves; others, especially in Asia Minor, hailed from medical dynasties or, like Galen, from prosperous backgrounds. In large cities there were swarms of healers, reputable and dubious, including body-builders, schoolteachers, �wise women’, root-gatherers and hucksters. Women were not confined to treating female troubles, and both Soranus and Galen expressed respect for good midwives and nurses; one of Herophilus’ pupils, according to legend, was the Athenian Agnodice, who, distressed by the anguish of women who would rather die than be examined by a man, cross-dressed so as to study and practise medicine. She became a heroine among those rallying support for female medical education in the nineteenth century.

The affluent sick could receive treatment in a doctor’s house, while the poor might hobble to a shrine. In big households there were slave physicians caring for their sick fellows in valetudinaria (hospitals). And in the Roman army, buildings were set aside for treating the sick and wounded. A standard military hospital plan evolved, with individual cells off a long corridor, a large top-lit hall, latrines and baths. A good example has been excavated at Inchtuthil in Scotland. In Rome itself, civil engineering and public works helped to maintain health. Fourteen great aqueducts (some still in use today) brought millions of gallons of fresh water to the capital; public lavatories were installed; dwellings were provided with plumbed sanitation; and civic officials oversaw the water and sewage systems and the public granaries. Vitruvius’ On Architecture (c. 27 BC) set out sanitary ideals for towns, stressing the need for good water supplies.

With the exception of the great plague of Athens in 430 BC, the diseases of the Greek world seem to have been local. This pattern changed with the Roman empire, however, once smallpox, brought back from Mesopotamia by the legions, ravaged the entire Mediterranean. This Antonine plague was the most lethal disease invasion in antiquity.

Disease explanations changed little. Public authorities still ascribed famines and pestilences to the gods, and during the Antonine plague processions were staged, with sacrifices to city-protecting deities. Latter-day Hippocratics continued to emphasize individual susceptibility and bad air (miasma), and stressed dietetics. Galen reiterated a personal, constitutional medicine and said nothing on contagion. Astrology had its devotees, though Galen rejected divination while making use of dream prognostication. What truth there was in astrology and bird divination was explained naturalistically: the flight of birds indicated changes in the weather. He similarly rationalized the use of amulets.

Therapeutics, too, changed little, and the old predilections for diet over drugs and drugs over surgery continued. The range of drugs reaching great cities increased, leading to more complex compounds. For example, theriac, originally prescribed as a snakebite antidote and used as a general tonic, grew extremely elaborate. In the version associated with Mithridates VI, King of Pontus (132–63 BC), it had forty-one ingredients, but Galen’s recipe had swollen to seventy-one ingredients, including vipers’ flesh, ground-up lizard and other animal ingredients. Princes had an interest in such remedies, since they lived in fear of poisoning. Mithridates swallowed antidotes to make himself immune to all known poisons; when his son staged a coup, he sensibly had his father stabbed.

Antiquity produced two writers who put the study of materia medica on a systematic basis. Theophrastus (c. 371-c. 287 BC), a pupil of Aristotle, took over as head of the Peripatetic school of Athens. His two treatises on plants deal respectively with their description (the De historia plantarum [Investigations into Plants]) and their aetiology (the Causis plantarum [Explanations of Plants]). Using as his model Aristotle’s writings on the animal kingdom, he laid the groundwork for botany.

The Investigations classifies plants into trees, shrubs and herbs. Some 550 species and varieties are described, with habitats ranging from the Atlantic to India (his Indian material being gathered by members of Alexander’s expedition in the 320s BC). The second treatise on botany in seven books is intended to account for the common characteristics of plants. His rediscovery in the Renaissance led to the revival of medical botany and botanical gardens.

The other notable writer was Dioscorides (c. AD 40-c. 90), a Greek surgeon to Nero’s army. His De materia medica (written in Greek, but known by its Latin title) is in five books. Book I deals with aromatics like saffron, oils, salves, shrubs and trees; Book II with animals, cereals, and herbs; Book III with roots, juices, herbs and seeds; Book IV with other roots and herbs; and Book V with wines and minerals, including salts of lead and copper. Providing detailed descriptions based largely on external appearance, Dioscorides aimed to enable the doctor to choose the right plant, listed by its pharmacological properties. He noted the various plant names, their uses in treatments, techniques of harvesting, modes of storage and possible adulterants. From an early date, these verbal descriptions were supplemented by drawings. Many of his remedies were common herbs and spices: cinnamon and cassia for instance were said to be valuable for internal inflammations, snake bites, runny nose and menstrual disorders; others were bizarre, like bed bugs mashed with meat and beans for malarial fevers. Some herbs had many properties. The bramble (�batos’, Rubus fruticosus), according to an early translation,

binds and drys; it dyes ye hair. But the decoction of the tops of it being drank stops ye belly, & restrains ye flux of women, & is convenient for ye biting of ye Prester. And the leaves being chewed do strengthen ye gums, and heal ye Apthae. And ye leaves being applied, do restrain ye Herpetas, & heal ye running ulcers which are in ye head, & ye falling down of the eyes.

Galen described 473 drugs of vegetable, animal and mineral origin as well as a large number of compound drugs. Together with theriac, he recommended two remedies that became universally celebrated, hiera picra and terra sigillata. His hiera picra formula called for aloes, spices and herbs; the compound was made into an electuary. Its �signal Virtues’ according to William Salmon, a seventeenth-century commentator, were that it was �a good thing to loosen the body … It heats … drys … opens obstruction, and urges thick Phlegmatick humours.’ Terra sigillata (sealed earth) was a greasy clay, containing silica, alumina, chalk, magnesia and oxide of iron, found on the Greek islands of Lemnos, Melos, and Samos. It was formed into large tablet-like units upon which the seal of the place of origin was impressed. It was meant to be drying and binding, and useful against poisons.




INSANITY


Throughout antiquity, one disorder provoked divergent responses, paving the way for lasting controversy. Madness was, of course, well known within the general culture. Herodotus described the mad destructive King Cambyses of Persia mocking religion – who but a madman would dishonour the gods? The deranged Ajax slaughtered sheep in the belief that they were enemy soldiers, a scene presaging Don Quixote’s tilting at windmills. Violence, grief, blood-lust and cannibalism were commonly taken as signs of insanity.

Graeco-Roman law sought to prevent the mad from destroying life, limb and property, and made provision for guardians for the insane. Insanity was a family responsibility and there were no lunatic asylums. The seriously disturbed were restrained at home, while others were allowed to wander, though, as evil spirits (keres) might fly out of them to possess other people, the crazed were feared and shunned.

Madness found medical explanations. In the Hippocratic tradition the most common labels for such conditions were mania and melancholia, the former characterized by excitement, the latter by depression. Both were marked by delusions, and, like all other maladies, were understood Immorally, usually in terms of choler and black bile. In On the Sacred Disease, which claimed madness as well as epilepsy for medicine, the Hippocratic author stated that �those maddened through bile are noisy, evil-doers and restless, always doing something inopportune … But if terrors and fears attack, they are due to a change in the brain.’

Hippocratic medicine thus did not envisage an independent discipline of psychiatry, but it did accept certain psychological elements. In one case, a woman with symptoms of depression and incoherent speech was explained as suffering from �grief, while another, �after a grief, would �fumble, pluck, scratch, pick hairs, weep and then laugh, but … not speak’. Melancholy madness caused by black bile was occasionally seen as the spark of genius, originating the notion of melancholy as a disease of superior wits which achieved its most erudite treatment in Robert Burton’s Anatomy of Melancholy (1621). Plato could similarly represent madness as a transcendental divine fire with the power to inspire, a view influential in the Renaissance and the Romantic movement.

Galen held that mania was a disease of yellow bile or the vital spirits in the heart. A cooling regimen was indicated, for mania was a �hot’ disease. Soranus devoted chapters to mania and melancholia, describing symptoms in detail and discussing aetiology. Among the causes of mania were �continual sleeplessness, excesses of venery, anger, grief, anxiety, or superstitious fear, a shock or blow, intense straining of the senses and the mind in study, business, or other ambitious pursuits’. Something which could later be interpreted as hysteria – a disorder marked by palpitations, migratory pain, breathing difficulties and the globus hystericus – might be attributed to a wandering uterus. By way of cure for many female psychological disorders, doctors recommended marriage.

The consolidation of Greek and Roman medicine over the course of some seven hundred years laid solid foundations for learned medicine, including the naturalistic notion of disease as part of cosmic order, and the idea of the human body as regulated by a constitution, intelligible to experience and reason. It created the ideal of the union of science, philosophy and practical medicine in the learned physician, who would be the personal attendant of the patient rather than a medicine-man interceding with the gods or a functionary working for the state.

For the next thousand years and more, medical knowledge would change little. This was partly the consequence of the break-up of the Mediterranean civilizations, but also because of the solidity of these foundations. Galen’s enduring reputation was the epitome of these beliefs: he unified theory and practice, discourse and the doctor, but his death brought that tradition to a halt.

* (#ulink_f0bc16cb-93a8-5472-a5c4-1fbbb322fcf9) The life of learning could be precarious, as is clear from the fate of even the great Alexandrian library. Part was wrecked in 48 BC during riots sparked by Julius Caesar’s arrival; later Christian leaders encouraged the destruction of the Temple of Muses and other pagan idols. And, so legend has it, in AD 395 the last scholar at the museum, the female mathematician Hypatia, was hauled out of the museum by Christian fanatics and beaten to death. The Muslim conquest of the city in the seventh century resulted in the final destruction of the library.

* (#ulink_beaf7dc1-983e-5b26-8562-e85508a6c10e) Pliny compiled a Natural History, completed AD 77, a compendium of all natural learning. Books 12 – 19 deal with botany and 20–27 with materia medica from botanical sources, followed by five books (28–32) on animal materia medica. His remedies proved of great influence, being quarried by Isidore of Seville and subsequent medieval encyclopaedists.





CHAPTER IV MEDICINE AND FAITH (#ulink_be7ca449-ebc8-5bc4-ac54-43db58b969b9)


THE PASSAGE FROM THE GLORIOUS DAYS of Rome to the Middle Ages was often violent, especially in the West, with wave after wave of barbarian onslaughts from the East. These culminated in the sack of the Eternal City by Alaric’s Goths in AD 410, which effectively put an end to the western empire and frayed the thread of learned medicine.

Fortified from AD 324 by its new capital, Constantinople (later Byzantium, modern Istanbul) on the Bosphorus, the eastern empire remained a bastion of imperial strength and a treasury of hellenistic learning and culture. From 364, the empire formally split, the two halves being ruled by separate emperors, and by the close of the sixth century the West had splintered further into fragmented kingdoms ruled by descendants of the invading Goths and Vandals. Its economy was feebler than that of the East, its cities declined or collapsed altogether – Londinium (London), once boasting a population of 30,000, became a ghost town – and civic institutions dwindled. In such circumstances, it was inevitable that eastern and western medicine would go separate ways.




CHRISTIANITY


Throughout the Mediterranean the mental climate began to shift from 313 with the Emperor Constantine’s establishment of Christianity as one of the official imperial faiths; from the early fifth century it was the sole official religion. Thereafter, by contrast with the naturalistic bent of Hippocratic and Galenic medicine, healing became more spiced with religion, for the rising Church taught there was a supernatural plan and purpose to everything (every human had a soul to be saved) and Christian doctrines, rituals and sacraments covered every stage through which believers passed from womb to tomb, and beyond.

Religion, of course, shared common ground with medicine. Etymologically, the words �holiness’ and �healing’ stem from a single root, conveying the idea of wholeness. But early Christianity also made demarcations between the body and the soul, implying the subordination of medicine to religion, and of doctor to priest, the one attending merely to the cure of bodies, the other to the cure of souls. The boundaries between temporal and eternal were of course endlessly blurred, and physic and faith, while generally complementary and enjoying a fairly peaceful coexistence, sometimes tangled in border disputes.

Christian outlooks on the body and sickness drew on various traditions. The faith absorbed aspects of eastern asceticism, which prized the soul or spirit above the flesh, and Jewish healing traditions were also influential. Early Judea had its distinctive healers, not least King Solomon (r. 970–931 BC), who was credited not only with wisdom but with magical and medical powers. Hebrew ideas on healing expressed in the Old Testament (compiled between the eighth and the third centuries BC), and the Talmud (between 70 BC and the second century AD), shared with Egypt and Mesopotamia a religious orientation: disease signified the wrath of God. �It shall come to pass’, it was recorded in Deuteronomy,

if thou wilt not hearken unto the voice of the LORD thy God … the LORD shall make the pestilence cleave unto thee, until he have consumed thee from off the land; whither thou goest to possess it.

The LORD shall smite thee with a consumption, and with a fever, and with an inflammation, and with an extreme burning, and with the sword, and with blasting, and with mildew; and they shall pursue thee until thou perish.

Certain maladies were associated with the Almighty’s punishments for sin, including Zara’ath, which has usually been translated as leprosy, though this identification is medically dubious. �When a man shall have in the skin of his flesh a rising [a swelling], a scab, or bright spot, and it be in the skin of his flesh like the plague [the spots] of leprosy,’ states the Book of Leviticus,

then he shall be brought unto Aaron the priest, or unto one of his sons the priests; and the priest shall look on the plague in the skin of the flesh: and when the hair in the plague is turned white, and the plague in sight be deeper than the skin of his flesh it is a plague of leprosy: and the priest shall look on him, and pronounce him unclean.

Such polluting diseases were curable by the Lord alone, and this encouraged certain Jews to reject human medicine in favour of divine, citing the fate of King Asa (c. 914–874 BC), who �sought not the Lord, but his physicians’, and whose foot sores consequently worsened until he died. Jewish sacred writings have no place for the professional physician as such, nor even for priestly healers; Jahweh alone is the healer. Naaman the leper was instructed by the prophet Elisha to wash himself seven times in the River Jordan, so as to be cleansed; the only surgical operation mentioned in the Old Testament is the religious rite of circumcision.

Suffering could be a godsend and a trial. �Blessed is the man whom God correcteth,’ declared Job, singled out by the Lord to undergo great suffering, �therefore despise not thou the chastening of the Almighty: For he makes sore, and bindeth up: he woundeth, and his hands make whole.’ For devout Jews, the pagan assumption that a healthy body was a great blessing could seem trifling.

Nevertheless, the Hebrews did develop teachings about the body and its well-being. Blood was probably viewed as the vehicle for the soul (one rationale for kosher meat, from which the blood is drained, and also, in recent times, for the refusal of blood transfusions by Jehovah’s Witnesses), but life lay in the breath. Believing physical cleanliness bespoke spiritual purity, rules were formulated for personal hygiene, social gatherings and sexual intercourse, and prohibitions were issued against eating unclean animals. Though some modern Jewish apologists argue that the dietary bans on pork and shellfish in Leviticus arose from awareness that these foods could pass on diseases such as trichinosis, the fact is that Jewish dietary rituals (kosher food) were principally expressions of precepts about pollution and purification. Nevertheless, cleanliness rites indirectly spurred public health: no well was to be dug near burial or waste ground, water should be boiled before drinking, and waste had to be burned or buried beyond encampments. Judaism also taught the obligation of caring for co-religionists, and by AD 400 Jewish communities were instructed to possess a healer.

Christians often expressed disdain for Jews as the people of the law, exalting by contrast their faith of the spirit; and this difference is discernible in their distinctive approaches to health. But one must not oversimplify: the New Testament presents many models of healing, secular and sacred alike. �Costly physicians’ were condemned, but Luke the Evangelist was himself a physician. In the parable of the good Samaritan, the use of wine as a disinfectant reflects Greek wound treatment, whereas in the Acts of the Apostles healing is portrayed as a matter of faith, involving prayer and the laying-on of hands. When Jesus met a man born blind, he asked who had sinned; and he told the man who suffered from a palsy that his sins were forgiven. Sin was thus assumed to be perhaps a cause of sickness, or at least sin and sickness were similar states; in either case spiritual healing might be requisite. �Is any sick among you?’, asked the Apostle James: �Let him call for the elders of the church, and let them pray over him, anointing him with oil in the name of the Lord; and the prayer of faith shall save the sick, and the Lord shall raise him up.’

Early Christianity exhibits a medley of attitudes towards healing, shaping fluid relations between medicine and the Church. Many old healing practices were dressed up in new Christian garbs; Christian shrines were raised upon the ruins of pagan temples, and the leading healing saints, Cosmas and Damian, were in some respects revampings of the heathen Castor and Pollux.

Christian theology embraced but modified the radical dualism of some Levantine religious and philosophical sects which elevated the immaterial soul while disparaging the mortal body, commonly viewed as the soul’s prison house. Christianity taught that the spirit was eternal; the flesh was weak, corruptible and fallen. Adam and Eve’s disobedience in Eden had brought disease and death into the world and made nakedness a source of shame. The Desert Fathers and saintly hermits pursued ascetic practices designed to deaden desire and restore the spiritual powers enjoyed by Adam in Eden.

Such beliefs challenged the classical, Athenian man-centred and polis-oriented ideals of balance and beauty, looking to mortification of the flesh as the release of the spirit. A glorification of suffering associated with release from the throbbing flesh remained a powerful force within Christianity, especially Catholicism. Thérèse Martin, later canonized as Saint Thérèse of Lisieux, died of tuberculosis in 1897, barely out of her teens. �God has deigned to make me pass through many types of trials,’ she affirmed in her diary, �I am truly happy to suffer.’

Yet Christianity also taught that man had been created in God’s image in a paradise garden of physical bliss in which disease and death had no part; and it proclaimed the raising up of the bodies of the faithful at the Last Judgment, as prefigured by Christ’s own resurrection. Orthodoxy anathematized the Manichean heresy that viewed the flesh as the Devil’s domain. The human body belonged not to man or Satan but to God, and had to be properly looked after – hence the suicide taboo.

While suffering and disease could appear as chastisement of the wicked or a trial of those the Lord loved, the Church also developed a healing mission. Was not Luke �the beloved physician’? And did not Christ, though he told physicians to heal themselves, give proofs of his own divine powers by acts of healing? Some thirty-five such miracles are recorded in the Bible, and the apostles subsequently exercised healing as �a gift of the spirit’. From the start, Christianity won converts among those desperate to be cured; and, like a self-fulfilling prophecy, healing miracles proliferated, often wrought by holy relics like drops of the Virgin’s milk. Sober ecclesiastics condemned this vulgar zeal for healing marvels, presenting Christ as the physician of the soul. Whereas members of his congregation brought infants for baptism hoping the holy water would heal leprosy or blindness, St Augustine (354–430) viewed cures by holy oil, relics or baptism not as a routine health service but as providences. Overall, Church fathers steered a middle course, accepting a role, but a subordinate one, for secular medicine.

Christianity made its mark through action. Jewish traditions of help and hospitality were extended, and Christ’s instruction to his disciples to care for the sick and needy assumed institutional form through the appointment of deacons charged with distributing alms. By 250 the Church in Rome had developed an elaborate charitable outreach, with wealthy converts providing food and shelter for the poor. After Constantine’s official recognition of Christianity, alms found expression in bricks and mortar. Leontius, bishop of Antioch from 344 to 358, set up hostels in his see; around 360, Bishop Eustathius of Sebasteia built a poorhouse; and St Basil erected outside the walls of Caesarea �almost a new city’ for the sick, poor and leprous.

Similar institutions sprang up somewhat later in the Latin West. A hospital was founded in 390 by Fabiola (d. 399), an affluent Christian convert, who, after two wretched marriages, dedicated her life to charity among Rome’s sick poor. �She assembled all the sick from the streets and highways’, wrote her teacher, St Jerome,

and personally tended the unhappy and impoverished victims of hunger and disease. I have often seen her washing wounds which others – even men – could hardly bear to look at … She founded a hospital and gathered there the sufferers from the streets, and gave them all the attention of a nurse. Need I describe the many woes which can befall a human being: the cut-off noses, lost eyes, mangled feet, leprous arms, swollen bellies, withered thighs, the ailing flesh that is filled up by hungry worms? How often she carried home, on her own shoulders, the dirty and poor who were plagued by epilepsy! How she washed the pus from sores which others could not even behold!

Greek and Roman paganism had acknowledged no such duties.

In the East, hospitals (in Greek nosokomeia, places to care for the sick) became large and complex. By the mid sixth century Jerusalem had one with 200 beds, and St Sampson’s in Constantinople was bigger still, with surgical operations being performed and a wing for eye disorders. Edessa had a women’s hospital, and major hospitals at Antioch and Constantinople were divided into male and female wards. By 650, the Pantokrator in Constantinople had a hierarchy of physicians and even teaching facilities, a home for the elderly and, beyond the walls, a leper house. To care for lepers and thus expose oneself to infection was a mark of holiness. Christianity planted the hospital: the well-endowed establishments of the Levant and the scattered houses of the West shared a common religious ethos of charity.




THE LEGACY OF GALEN


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

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

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

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

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

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

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

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

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

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




ISLAM


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

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

By the time of his death, practically all of Arabia had been won over for Islam, and a century later his adherents had conquered half of Byzantine Asia, all of Persia, Egypt, the Maghreb (North Africa) and Spain, where Cordova became capital of the western caliphate, the Baghdad of the West, the source of Hispano – Arabian culture, together with Seville and Toledo, which peaked in the twelfth century, and later still Granada. Unlike Christianity, Islam was not a proselytizing faith which saw itself as superseding earlier ones, and the Qur’an granted Christians and Jews special status as �People of the Book’ (ahl al-Kitab), adherents of the other scripture-based faiths. Before the papacy launched the Crusades, Christians, Jews, Muslims and others rubbed along well together. What brought some unity to the Arab empire was not religion but a common language.

The pre-Islamic Near and Middle East possessed a popular medicine akin to that of the Mediterranean. Materia medica included plants and herbs familiar to Greek medicine, though certain remedies were distinct. Truffle juice was applied to eye disorders, clarified butter was used against fever, dates were prescribed for children’s maladies, while camel’s urine toned up the system. Cupping, cautery and leeches were employed for blood-letting; wounds were disinfected with alkali-rich saltwort, and ashes were applied to stanch bleeding. Knowledge of internal organs was meagre, and surgery was basic.

Interwoven with these practices were animist beliefs. Ill health was widely attributed to spirits. To restore well-being, the sick had to outwit them or recruit the protection of superior magical powers. The forces responsible for ill health were the jinn and the evil eye (al-’ayn), a glance believed to harm those upon whom it fell. The jinn (plural :jinni, whence genie) was a lesser spirit interfering with human beings; one could see, bargain with and even kill jinni, and they could bring good luck as well as bad. Healthwise, however, their activity was harmful, and they were held particularly to blame for fevers, madness and children’s diseases.

Avoidance of sickness thus demanded practical and magical precautions to ward off evil spirits. There were incantations against ailments like leg ulcers and night-blindness, and charms guaranteed a safe delivery for pregnant women. Popular observances countered unwelcome visitations from spirits: thus a boy suffering from a blistered lip would beg for food and then toss any offerings to the dogs; as the blister had originally been attracted by his eating food, it would be drawn to the scraps and so transferred to the dogs. Practical medicine was everyone’s business, but those who, like bleeders and cuppers, possessed particular skills were paid for their services, while the magical side of traditional medicine was performed by diviners, seers and charmers.

Initially the rise of Islam posed no threat to this traditional lore. The Qur’an has almost nothing to say about medicine, apart from advice to the faithful to wash for prayer and praise for the healing powers of honey. Scripture accepted the jinn, and Islam raised no objection to the indigenous medicine of conquered provinces; formal learning, including medicine, continued in the (Christian) Jacobite and Nestorian monasteries of Syria and Mesopotamia.

The seventh and eighth centuries, however, brought the transformation of Islam from a simple monotheistic creed to a formal faith, laying down theological orthodoxy. Popular medicine became mired in controversy because of its animistic bent, and many traditional practices were condemned. Conflict was sharpened by the fact that, in the centuries after the Prophet’s death (632), discussion of issues tended to be dominated by claims that Muhammad or his companions must have pronounced on the matter. Such pious dicta grew into a distinct corpus called hadith, the sayings of the Prophet. Old-style healers also began to claim Muhammad’s support: traditions alleged to be from the Prophet told, for example, that �the evil eye is real’; that there was medicinal power in his saliva; and that the water of the well of Zamzam in Mecca had healing properties. Being God’s word, the Qur’an too must have great powers. Hence, to assist a woman in labour, certain verses should be written on a slate, cleaned off, and the water given her to drink. The parallels with Christian healing are plain.

As Islam developed, traditional medicine was called into question. One major dilemma was plague. Early views had attributed epidemics to the jinn. This explanation was displaced by beliefs setting pestilence within the monotheistic framework of an Allah who was the ordainer of all things (including disease), yet was just and merciful. Though with the growth of Islam, many folkloric practices were attacked, medicine itself was not called into question, since Islam taught that �God sends down no malady without also sending down with it a cure.’

It is often held that a distinctive Arab – Islamic medicine dates from the time of the Prophet and stems from a hospital (bimaristan: Persian for house for the sick) and academy at Jundishapur, near Susa in southern Persia. Jundishapur was certainly a meeting-place for Arab, Greek, Syriac and Jewish intellectuals, but there is no evidence that any medical academy existed there. Only in the early ninth century did Arab – Islamic learned medicine take shape. The first phase of this revival lay in a major translation movement, arising during the reign of Harun al-Rashid (r. 786–809) and gaining impetus in the caliphate of his son, al-Ma’mum (r. 813–33). It was stimulated by a socioeconomic atmosphere favourable to the pursuit of scholarship, a perceived need among both Muslims and Christians for access in Arabic to ancient medicine, and the ready availability of the relevant texts.

Crucial in this �age of translations’ was the establishment in Baghdad, capital of the Islamic empire under the Abbasid caliphs, of the Bayt al-Hikma (832), a centre where scholars assembled texts and translated into Arabic a broad range of non-Islamic works. The initial translation work was dominated by Christians, thanks to their skills in Greek and Syriac. The main figure was Hunayn ibn Ishaq (d. 873), later known in the West as Johannitius, a Nestorian Christian from the southern Iraqi town of al-Hira. Hunayn, who travelled to the Byzantine empire in search of Galenic treatises and was said to wander the streets of Baghdad reciting Homer in Greek, was amazingly prolific. With his pupils, he translated 129 works of Galen into Arabic (and others into Syriac), providing the Arabic world with more Galenic texts than survive today in Greek.

Encouraged by official patronage, the translation drive proceeded rapidly. Hundreds of Greek texts were rendered into accurate and elegant Arabic; works in Syriac and Sanskrit were also translated, reflecting the cosmopolitanism of ninth-century Baghdad. The impact was enormous, not least in view of the hundreds of ancient texts saved in Arabic for posterity. The favoured author was Galen, and he thereby became the father figure for Arabic medicine. Even the Hippocratic Corpus was known primarily through his commentaries.

Continuing into the early eleventh century, the translation movement revived learned medicine, made Arabic a tongue for original scholarship, and gave Islamic culture access to a galaxy of learning. The early translators also launched an original medical literature of their own. Hunayn authored essays on ophthalmology, known as his Kitab al-’ashr maqalat fi l-’ayn [Book of the Ten Treatises on the Eye]. His Medical Questions and Answers, a student text book, adopted the threefold scheme of discussing first the natural organisation of the body, then neutral factors, and finally unnatural (or contra-natural) disease – a handling reproduced by all Arabic writers in the Galenic tradition. By the late ninth century medical men had access to a stock of ancient texts in superior Arabic translations and an expanding corpus of original scholarship glossing Greek works.

This in turn created a need for fresh syntheses, leading to the supreme achievement of Arab – Islamic medicine, the medical compendia. The first was the Firdaws al-hikma [Paradise of Wisdom] by ’Ali ibn Rabban al-Tabari (c. 850), in which the author, an Islamic convert, sought to collect a summa of medical erudition worthy for presentation to the Caliph al-Mutawakkil. His sources were Arabic and Persian translations of ancient classics, and his citations included not only Hippocrates, Galen and Dioscorides but Persian and Indian writers (this Indian element was soon, however, eclipsed by the Greek tradition).

Persia produced one of the greatest Muslim physicians and philosophers, Muhammad ibn Zakariya al-Razi, known in the West as Rhazes (865–925), author of some 200 treatises. In his youth (anecdotes tell us) al-Razi studied and practised medicine at the bimaristan of Baghdad. He later returned to Rayy, near Teheran, as head of its hospital, at the invitation of Persia’s ruler, Mansur ibn Ishaq; al-Razi dedicated to him Al-Kitab al-mansuri fi’l-tibb [The Mansurian Book of Medicine], a manual in ten books. The first six ran through such concerns as anatomy, physiology and materia medica, while the last four dealt with clinical matters: diagnosis, therapy, surgery and pathology, discussing diseases from head to foot. His separate work, al-Tibb al-ruhani [Spiritual Physic] handled diseases of the soul within a discussion of philosophy. Having won fame in Rayy, al-Razi went to Baghdad to take charge of its new al-Mu’tadidi Hospital. He spent his declining years in Rayy suffering from glaucoma, before becoming blind.

Al-Razi developed a medical philosophy. In the first chapter (�On the Excellence and Praise of Reason’) of al-Tibb al-ruhani, he asserted that reason (al-’aql) was the ultimate authority which �should govern, and not be governed; should control, and not be controlled; should lead, and not be led’. He condemned slavish authority, devoting a large book, Fi’l-Shukuk ’ala Jalinus [Doubts about Galen], to criticism of precepts in Galen, beginning with al-Burhan [Demonstration], and ending with his large work, Fi’l-Nabd [On the Pulse]. In his introduction to Fi’l-Shukuk, he nevertheless declared himself Galen’s disciple; but since the art of healing was a form of philosophy, it could neither renounce criticism nor benefit from worshipping the dead. Extolling the progress of scientific knowledge, he wrote in Fi Mihnat al-tabib [On Examining Physicians and on Appointing Them] that �he who studies the works of the Ancients, gains the experience of their labour as if he himself had lived thousands of years spent on investigation.’ Nevertheless �all that is written in books is worth much less than the experience of a wise doctor.’

Al-Razi’s best-known work, al-Hawi fi’l-tibb [Continens, or Comprehensive Book of Medicine], was a commonplace book of detailed notes and transcribed bits of texts, beginning with diseases of the head and working down. Devoted to specific subjects, these files were gradually filled with jottings; the result was a kind of filing system, organized by subject though lacking overall form. Al-Razi incorporated case histories from earlier sources, notably Galen, but he also registered his own cases, recording the patient’s name, age, sex and occupation. Clinical observations of his own illnesses are also preserved: notes on how he had treated throat inflammation by gargling with strong vinegar; elsewhere he wrote about his swollen right testicle (emetics helped recovery). From these notes, al-Razi took the material for books such as al-Qulani [Cholic] and al-Jadari wa’l-hasba [Smallpox and Measles]. Hitherto all exanthemata (infections causing rashes) had tended to be lumped together; al-Razi was the first to distinguish them as separate diseases: �The physical signs of measles are nearly the same as those of smallpox, but nausea and inflammation are more severe, though the pains in the back are less. The rash of measles usually appears at once, but the rash of smallpox spot after spot.’ It is intriguing to find measles regarded as the more severe.

Al-Razi had many asides on medical practice: noblemen, he judged, echoing Galen, were entitled to special consideration in prescribing; for them unpleasant tasting drugs should be made palatable. But he did not neglect the poor, for whom he wrote his Man la yahduruh al-tabib [Who has no Physician to Attend Him]. Khawass al-ashya’ [Properties of Things] included the role of alchemy in medicine and the secret recipes and remedies of nature. Experience must be the touchstone of truth:

since many wicked people tell lies with regard to such properties, and we do not possess decisive means to distinguish the truth of rightful men from the false testimony of liars – save only actual experience – it will be useful not to leave these claims scattered but to collect and write them all. We shall not accept any property as authentic unless it has been examined and tried.

Al-Razi won renown, and his medical works later enjoyed ascendancy in the Latin West. In 1279 al-Hawi fi’l-tibb was Latinized under the title of Continens by the Sicilian Jew Faraj ibn Salim (Farragut), and printed five times between 1488 and 1542. His al-Mansuri fi’l-tibb [Liber ad Almansorem] and his al-Tibb al-muluki [Liber regius] were also popular. His work was in turn mentioned by Abu Rayhan ibn Ahmad al-Biruni (Al-Biruni, 973–c. 1050), who wrote on a variety of subjects: astronomy and astrology, mathematics, geography, history, philosophy and religion, mechanics, mineralogy and medicine. As well as editing al-Razi, he translated much of Galen’s otherwise lost Commentary on the Hippocratic Oath.

The Arabic medical compendium culminated in two works of the tenth and eleventh centuries. ’Ali ibn al’-Abbas al-Majusi (Haly Abbas, d. late tenth century) was a native of al-Ahwaz in southern Persia, but little is known about his life. Following al-Razi’s example, he divided his Kamil al-sina’a al-tibbiya [The Complete Medical Art] into two sections, on theoretical and on practical medicine, each including ten treatises on specialized topics, and his introduction surveyed the development of medicine up to his own times. Well-organized, practical, and devoting greater attention than al-Razi to anatomy and surgery, it secured al-Majusi’s medical reputation, winning a place second only to Ibn Sina’s Qanun.

The talents of Abu Ali al-Husayn ibn ’Abdallah ibn Sina (Avicenna, 980–1037) were evident from early youth. A Persian tax-collector’s son, he could, it is piously recorded, recite the Qur’an at the age of ten and was practising medicine by sixteen. If somewhat mythologized, Ibn Sina represents the pinnacle of the Galenic ideal of the philosopher – physician in Islam: he was the first scholar to create a complete philosophical synthesis in Arabic.

In a wandering life driven by burning intellectual curiosity, Ibn Sina held positions as a jurist, a teacher of philosophy, an administrator, and as physician to various courts. His autobiography boasts that his writing was done on horseback during military campaigns, in hiding, in prison and even after drinking bouts. The outcome was two hundred and seventy tides which include two monumental encyclopaedias, one on science (Kitab al-Shifa) and one on medicine (Kitab al-Qanun).

The Kitab al-Qanun [Canon, or The Medical Code] arranges in its million words the whole of medical science: the legacies of Hippocrates, Galen, Dioscorides and the late Alexandrian physicians, enriched by the works of Arab predecessors. It consists of five books arranged by subject, with subdivisions and summaries. Book I deals with general principles, starting with the theory of the elements, humours and temperaments and moving on to anatomy, physiology, hygiene, aetiology, symptoms and treatment of diseases. Book II is on materia medica, describing the physical properties of simple drugs, and how to collect and preserve them (a separate section lists 760 drugs alphabetically). Book III deals with specific diseases, classified from head to heel, together with the aetiology, symptoms, diagnosis, prognosis and treatment of each. Anatomy is also discussed. Book IV is concerned with diseases, such as fevers, affecting the whole body; it also covers ulcers, abscesses, swellings, pustules, fractures and injuries, as well as poisons, and there is even a section on anorexia and obesity. Book V describes compound drugs – theriacs, electuaries, emetics, pessaries, liniments, and so on – together with their medicinal uses.

In addition to the Canon, Ibn Sina wrote about forty works on medical subjects. The best known is Urjuza fi’l-tibb [A Medical Poem], a summary of the principles of medicine in verse as a mnemonic aid to students. But it was the Qanun that became the authoritative text on medicine for centuries, both in Islam, where it remains influential, and in Latin Christendom, earning him such tides as the �Galen of Islam’. His pre-eminent standing in the Latin West is symbolized by Dante’s ennobling him between Hippocrates and Galen.

Critics have alleged that al-Razi’s and Ibn Sina’s work stifled independent thought. Certainly the Canon was taught and annotated, but some of the commentaries were highly critical, notably that of the Andalusian physician, Ibn Rushd (Averroës, 1126–98). Criticism of its anatomy section also gave rise to the description by Ibn al-Nafis (d. 1288) of the pulmonary (lesser) circulation, nearly three hundred years before Servetus and Realdo Colombo (see below).

All these great compendia originated in Persia, but texts were also produced elsewhere, including the work of Abu’l-Qasim Khalaf ibn Abbas al-Zahrawi (Albucasis, 936–1013). Born in Cordova, al-Zahrawi was author of a medical compendium entitled Al-Tasrif li-man ’ajaza ’an al-ta’lif [The Recourse of Him Who Cannot Compose (a Medical Work of His Own)]. Some 1500 pages in length, and divided into thirty treatises, it offers information on topics elsewhere neglected, including surgery, midwifery and child-rearing, and detailed accounts of bleeding, cupping and cautery. Treatise 30, the most celebrated, deals with surgery, describing operations for the stone, cauterization of wounds, sutures, obstetrical and dental procedures, setting fractures and dislocations, procedures for opening abscesses and eye surgery, to say nothing of 200 illustrations of medical and dental instruments, many of which he designed himself. This surgical treatise won enormous acclaim in the Latin West.

Albucasis gave a definitive account of cautery, which was central to Arabic surgical practice, being used to open abscesses, burn skin tumours and haemorrhoids, cleanse wounds, and stanch blood flow. Like bloodletting, it was also performed in the treatment of internal diseases, and Albucasis advised the cauterizing iron for almost every ailment, including epilepsy, stroke and melancholy. Apart from him, it is unlikely that the Arabic surgical authors ever practised surgery themselves.

Also Spanish-born was Abu-l-Walid Muhammad ibn Ahmad ibn Muhammad ibn Rushd (d. 1198), latinized as Averroës. Physician, philosopher and jurist, Ibn Rushd is known in the West for his classic commentaries on Aristotle. Coming from a long line of lawyers, he served as a judge in Cordova and Seville and also as physician to the ruling Almohad family – though he later came under attack for his views, leading to exile and the burning of his philosophical works. His major medical text is the encyclopaedic al-Kulliyat [The Book of General Principles], written between 1153 and 1169. Consisting of seven books dealing with anatomy, health, pathology, symptoms, dietetics and drugs, hygiene and therapeutics, it was conceived as a companion to al-Taisir, written by his colleague, Ibn Zuhr (Avenzoar, c. 1091–1162), which dealt with specific diseases. Together they constituted a comprehensive medical treatise, becoming familiar in the West through their Hebrew and Latin translations [Colliget], and printed together in Venice in 1482. On physiological issues he preferred Aristotelian explanations over Galen’s, but he was not a slavish follower, and both the Colliget and the Commentaries show independent thinking.

Rabbi Moshe ben Maimun (1135–1204: Moses Maimonides or Abu ’Imran ibn ’Ubdaidalla Musa ibn Maimun) was another scholar who testifies to the intellectual pre-eminence of Spain at this time. The ascendancy of a fanatic Muslim ruling group forced the Jewish Maimonides, like Averroës, to flee Cordova in 1148, and he spent the next ten years in exile. In 1158, he settled in Fez, but moved on a few years later to Cairo where he stayed until his death. His medical practice earned him celebrity; in 1174 he was appointed court physician to Saladin, sultan of Egypt and Syria, and he became the head of the Jewish community in Egypt.

Paralleling the Islamic intellectuals of his day, Maimonides was a polymath, combining philosophy, logic, theology, astronomy and medicine. Apart from his major fourteen-volume religious work, the Mishneh Torah, which is in Hebrew, his books were written in Arabic. His ten medical works, all surviving, mostly in Arabic but some only in Hebrew translation, include the Extracts from Galen, a collection of Galen’s writings, and a Commentary on the Hippocratic Aphorisms. His Medical Aphorisms is of particular interest because of its criticism of Galen for preferring Aristotelian over biblical cosmology. He emphasized the duties of physicians: �may I never see in the patient anything but a fellow creature in pain.’

There are various treatises on individual topics (on haemorrhoids, asthma, poisons and their antidotes, and so forth), but Maimonides’ most famous medical book was his Regimen of Health – short, much reproduced, often translated, and full of solid advice:

How can a person heal his intestines if they are slightly constipated? If he is a young boy, he should eat salty foods, cooked and spiced with olive oil, fish brine and salt, without bread, every morning; or he should drink the liquid of boiled spinach or cabbage in olive oil and fish brine and salt. If he is an old man, he should drink honey mixed with warm water in the morning and wait approximately four hours, and then he should eat his meal. He should do this for one day or three or four days if it is necessary, until his intestines soften.

While not adding anything original to Graeco – Arabic medicine, Maimonides’ considerable literary output earned him respect, and, like other contemporaries, he was widely cited by leading European authorities such as Henri de Mondeville, Arnald of Villanova and Guy de Chauliac.

An original aspect of Arab – Islamic medicine was its contribution to pharmacology. The lands overrun by Arab warriors yielded an abundance of plants, animals and minerals; hence, whereas Dioscorides’ materia medica had included less than a thousand plants, animals and minerals, that of Ibn al-Baytar (d. 1248) astonishingly listed over 3000 items, including 800 botanical drugs, 145 mineral drugs, and 130 animal drugs. The medical formulary of al-Kindi (Yaqub ibn-Ishaq al-Kindi, c. 800–870) served as a source for Arabic treatises on pharmacology, botany, zoology and mineralogy. His writings contained many Persian, Indian or Oriental drugs unknown to the Greeks, including camphor, cassia, senna, nutmegs and mace, tamarind and manna.

In the eleventh century, al-Biruni described more than a thousand simples in his Kitab al-Saydanah fi al Tibb [Book of Pharmacy in the Healing Art]. The Minhaj al-Dukkan via Dustur al-’yan [Handbook for the Apothecary Shop], written in Cairo in 1259 by the Jewish pharmacist Abu al-Muna Kohen al-’Attar, was much more than a mere formulary of the materia medica. Intended to provide instruction for his son, it included drug synonyms, recipes for syrups, remedies to aid digestion, fumigations and liniments and pharmaceutical weights – and also covered the duties and shop practices of the pharmacist.

The word �drug’ is of Arabic origin, as are alcohol (it then referred to a sulphurous powder), alkali, syrup, sugar, jujube and spinach; and many new drugs were introduced by the Arabs – benzoin, camphor, myrrh, musk, laudanum, naphtha, senna and alcohol. From the time of the �father’ of Arabic alchemy, Jabir ibn Hayyan (Jebir or Geber), who lived in the tenth century, they developed the alchemical techniques of crystallization, filtration, distillation and sublimation, alongside investigations into the properties of things contained in a �secrets of nature’ tradition paralleling that in the West. They created the first pharmacies, which also served as rendezvous for the exchange and discussion of information.

Overall, the value of Arab contributions to medicine lies not in their novelty but in the thoroughness with which they preserved and systematized existing knowledge. Great effort was devoted to its dissemination and medical texts were repeatedly copied. Over 5000 medical manuscripts in Arabic, Turkish, and Persian survive in libraries in Turkey alone, with more than fifty copies of Ibn Sina’s Qanun, and still more transcripts of the many later commentaries on it. And though the era of the great Arabic medical compendia ended with the Qanun, such works long continued as foci of scholarly attention, commentaries in turn becoming the bases for super-commentaries, such as that of ’Ala’ al-Din ibn al-Nafis (1200–88).

Growing up in Damascus, Ibn al-Nafis studied at the famous Nuri hospital there. As with so many Arabic physicians, his interests were wide: medicine, logic, grammar and theology; he also wrote numerous commentaries on Hippocrates and Ibn Sina. His Mujiz al-Qanun, an epitome of Ibn Sina’s Canon, was vastly popular, but the work for which he is best known today is the commentary on the anatomy of Ibn Sina, the Sharh Tashrih al-Qanun, since one passage contains the first description of the pulmonary circulation.

Contrary to the Galenic description of the passage of blood from the right ventricle directly through �invisible pores’ to the left ventricle, Ibn al-Nafis states that no blood could pass through the interventricular septum, �the substance of the heart there being impermeable … therefore, the blood must pass only through the lungs’. He thus proposed for the first time the pulmonary circuit of the blood:

This is the right cavity of the two cavities of the heart. When the blood in this cavity has become thin, it must be transferred into the left cavity, where the pneuma is generated. But there is no passage between these two cavities; the substance of the heart there seems impermeable. It neither contains a visible passage, as some people have thought, nor does it contain an invisible passage which would permit the passage of blood, as Galen thought.… It must, therefore, be that when the blood has become thin, it is passed into the arterial vein [pulmonary artery] to the lung, in order to be dispersed inside the substance of the lung, and to mix with the air. The finest parts of the lung are then strained, passing into the venous artery [pulmonary vein] reaching the left of the two cavities of the heart.

His description, however, seems to have fallen into obscurity. A similar description of the pulmonary circuit appeared in 1553 by the Spaniard Michael Servetus, and then in 1559 by the Italian, Realdo Colombo, but there is no evidence that either had access to his work.




HEALTH CARE


What of health care in general in Islam? Damascus and Cairo were no dirtier or cleaner than Naples, Paris, or any other pre-modern cities. Livestock was kept at home, waste left in the streets, and epidemics wrought havoc. Medieval sources frequently refer to �pestilence’, sometimes smallpox, though the greatest scourge was bubonic plague, which devastated the region in wave after wave between 541 and 749, returning as the Black Death in 1347–9. Cairo, the world’s second largest city with half a million people, lost half its population.

To serve the sick, a range of medical practitioners and services was on offer. The formative period was marked by the predominance of Christian doctors, with lesser numbers of Jews and pagans. Many physicians had several occupations, and sidelines in trade were common. Healing remained more flexible and unregulated than in Christendom: there were no licensing requirements, no fixed curricula or sites for learning medicine, and no laws defining the profession. Islamic society tolerated a spectrum of practitioners and remedies, partly because popular lore was upheld by custom and the approval of the Prophet. In any case, learned medicine was often unavailable in the countryside, and within the cities it was beyond most people’s pockets.

There were various ways to prepare for a medical career. Some doctors were self-taught, like Ibn Sina. Others underwent formal study under a teacher. Muslims sometimes taught in mosques, and hospitals were natural places for instruction, since patients were to hand and many hospitals had libraries. Teaching methods and curricula varied according to the master, though instruction often focused on the key Galenic works. Mathematics and logic were also studied, and the novice had an array of manuals, later supplemented by the cribs generated around Ibn Sina’s Qanun. Textual mastery was paramount; texts were usually read aloud and learnt by heart, and classwork meant sitting with a mentor who posed questions and glossed obscurities. Anatomy was not taught in a hands-on manner, since dissection was abhorrent to Muslim sensibilities: the dead were believed to feel pain, and dissection was desecration. Clinical experience was obtained in hospitals: physicians used patients to illustrate maladies and problems to students who trailed them on their rounds. Pupils probably shouldered certain basic duties, such as venesection.

Physicians had certain public duties to fulfil, some quite bureaucratic. Doctors were frequently called upon to make official statements – for example, when a leper was seeking public assistance. Jewish physicians were often leaders of their communities, and Muslims found themselves in administrative positions such as army physician or hospital medical superintendent.

The hospital, though not part of a wider �health policy’, was a centre of Islamic medical practice. These institutions (the greatest were in Baghdad, Damascus, Cairo and Cordova) were initially inspired by the precedent of sick-relief services offered at Christian monasteries, although the Islamic hospital became a more elaborate medical institution. The first was apparently founded in Baghdad around 805 on the initiative of Harun al-Rashid, and this was followed by others. The movement spread to Persia, and by the twelfth century a hospital graced every large Islamic town; thirty-four have been identified in Muslim cities from Spain to Moghul India. One of the best known was built in Cairo in 1283 by al-Mansur Qalawun, who dedicated it to all who needed care – rich and poor, old and young, male and female, of all faiths. It had special wards for physical and mental diseases, a surgery, pharmacy, dispensary, library and lecture rooms, and a chapel for Christians as well as a mosque; it was still in use when Napoleon invaded Egypt.

Separate hospitals for the insane were also set up. The Qur’an required humane care of the mad, and the first institutions created primarily for mental cases appeared in Muslim lands. Called maristans, these had a good reputation, and European travellers marvelled at the humanity shown to the insane. The Islamic tradition had some impact, the first European mental hospitals being built in former Muslim Spain, beginning with Granada in 1365.

Nevertheless, the role of hospitals in medieval Islam should not be exaggerated. They were a drop in the ocean for the vast size of the populations they had to serve, and their true function lay in highlighting ideals of compassion and bringing together the activities of the medical profession.

With Cordoba falling to the Christians in 1236 and Baghdad sacked by the Mongols in 1258, Arab civilization was beginning to decline after 1300. The Ottoman Turks who dominated the Levant in the succeeding centuries did not inspire new intellectual glories. Nevertheless, the medical system described flourished in the Muslim world until the nineteenth century, when it gradually receded before the tide of modern western medicine. It continues in India and Pakistan as Yunani medicine.





CHAPTER V THE MEDIEVAL WEST (#ulink_9bf11971-91eb-5c6f-90f5-ff7dd57e262b)


BARBARIAN INVASIONS, the collapse of the western Roman empire, and the rise of warrior fiefdoms spelt catastrophe for civilization and its amenities – including the teaching and practice of learned medicine. City life collapsed in Europe into a landscape dominated by castles and cathedrals, with literate men and women confined to monastic cloisters. The medical thread was, however, unbroken, even if it frayed and threatened to snap. Through what are known as the Dark Ages medical manuscripts were at least preserved, copied and studied within the sanctuaries provided by abbeys and cathedral schools. The medicine they kept alive was, however, but a shadow of its brilliance in Galen’s day: a basic survival kit when book-learning itself was under threat.

The revival of formal medicine took place centuries later in the backward West than in the Islamic world – not until around 1100, emerging first in Salerno in southern Italy, thirty miles south of Naples and seventy miles from the glorious Benedictine monastery of Monte Cassino. And it had to be imported and replanted.




THE WEST COMES TO LIFE AGAIN


The Salerno medical school was supposedly founded by four scholars – a Latin teacher, a Jew, an Arab and a Greek who had brought to the West the writings of Hippocrates. This legend carries a figurative truth. Sited in mid-Mediterranean and protected by the modernizing Norman dukes of Sicily, Salerno lay at a crossroads – cultural, economic and ethnic. In 1063, Alphanus (d. 1085), a Benedictine monk of Monte Cassino who had become archbishop of Salerno, travelled to Constanti nople where he became acquainted with Greek medical texts. His Premnon Physicon introduced into the Latin-speaking world a Christianized Galenism, while his writings on the humours and the pulse reflected Byzantine medicine. Together Alphanus’s works amount to a more philosophical approach to medicine than that hitherto available in the West, hellenizing it and enabling the physician to set himself above the workaday healer.

Later Salernitan teaching texts continued the latinization of Greek writings, and Salerno channelled Arabic medicine into the West, under the stimulus of Constantinus Africanus (c. 1020–87). A native of Carthage (in modern Tunisia) who became a monk of Monte Cassino, Constantine relayed texts of Arabic and Greek medicine, the most important of his translations being the Pantegni [The Whole Art] of Haly Abbas (d. 994). Many Greek texts which had been translated into Arabic were now latinized by Constantine, notably Galen’s Method of Healing, his commentaries on Hippocrates’ Aphorisms, his Regimen in Acute Diseases, Prognostic and the Art of Medicine. Constantine also made a version of Hunayn’s (Johannitius’) Medical Questions, known as the Liber Ysagogarum [Isagogue or Introduction]. By the mid-twelfth century these texts were seeping beyond Italy.

Constantinc’s translations were crucial, providing as they did the means whereby Latin Christendom gained access to the tradition of Hippocratic learning rationalized by Galen and digested by the Arabs. For the first time since the sixth century, Latin speakers could share in contemporary medical thinking. Providing a framework for medical teaching on diagnosis and therapy, the Liber Ysagogarum became a foundation text in the medical schools which sprang up in Italy and France, forming the basis of the Articella (see below).

The Liber Ysagogarum also broadened and gave greater prominence to the Galenic idea of the �six non-naturals’ – food and drink, environment, sleep, exercise, evacuations (including sexual) and state of mind; by regulating these, natural body balance could be preserved in the medical analogue to monastic rule. Stressing regimen, the non-naturals set the mould for medieval therapeutics, particularly in popular health books emanating from Salerno. The Regimen sanitatis salernitanum [Salernitan Regime of Health], a book of verses probably compiled in the thirteenth century and sometimes credited to Arnald of Villanova (1240–1311), supplied tips for healthy living from youth to old age, highlighting hygiene, exercise, diet and temperance. The first of the home health manuals, its enduring popularity is shown by the number of later printed editions: some 240 versions in Latin and other European languages, as well as Hebrew and Persian. And no wonder, since it was simple and even entertaining in its advocacy, alongside Galenic venesection, of Drs Quiet, Diet and Merryman.


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Salernitan translations and teachings created a new canon of medical authority known as the Articella [Little Art of Medicine], which included the Liber Ysagogarum and Hippocrates’ Aphorisms and Prognostic, supplemented by Galen’s Tegni and the Hippocratic On Regimen in Acute Diseases in a translation by Gerard of Cremona (fl. 1150–87). Rapidly becoming canonical, the Articella or Ars medicinae marked a turning point in the revival of medicine in the West. It combined translations from Greek and Arabic; it was concerned with theory, providing a basis of philosophical knowledge organized around key themes; its discussions set medicine within a wider conception of nature; and its Aristotelian orientation appealed to university scholastics. Not least, the Articella gave medicine a distinctly Galenic complexion. Pre-Salernitan compendia had included texts drawn from the Methodist as well as the Hippocratic tradition; Galen had not eclipsed all others. But the Articella texts were wholly Galenic: a proper doctor could thenceforth be defined as a man who knew his Galen.

Learned medicine continued to develop, thanks to the rise of universities (discussed below) and further access to scholarship via translation. The business of Latin translation proceeded through several stages. The first, the Salernitan, involved both Greek and Arabic texts. From the 1140s, there was a great outpouring of Latin translations from Arabic made in Muslim Spain, sometimes by way of Hebrew intermediaries. This development, which included philosophical texts, especially Aristotle, as well as medical, was led by Gerard of Cremona. Settling in Toledo, he translated an incredible quantity of material from Arabic – twenty-four works on medicine alone, including the Qanun of Avicenna, the Liber Almansorius of Rhazes (al-Razi), the last part of Albucasis’ De cirurgia, the Ars parva and other works of Galen, and the Commentary on Galen’s Art of Medicine by Haly Rodoan (Ali-ibn Ridwan). The Qanun or Canon of Medicine became the cornerstone of the medical curriculum at the University of Montpellier, remaining a textbook there until 1650! These translations created a richer terminology for learned medicine in Latin and provided Galenic medicine with a logical backbone. Medicine could now speak the language of scholasticism.

A century later there came a further burst of translations, mainly in Spain and Italy, latinizing other major works of Arabic science. These included the Continens [All-Embracing Book] of al-Razi (trans. 1282); and the Colliget [The Book of Universals] of Ibn Rushd, translated in Padua in 1283. The key figure in this drive was Arnald of Villanova. After studying medicine at Montpellier, he became a teacher and a polymath. Not only a translator of medical works, he was physician to the popes and the Aragonese royal family in Spain; later in life, he pored over theology, propounding heterodox ideas – his astrological computations predicted the world would end in 1378. As a theoretician, Arnaud aspired to rationalize Galenic medical theory with mathematical precision, by drawing on Arabic writers, notably al-Kindi and Averroës.

His Italian contemporary Pietro d’Abano (1257-c. 1315) made versions directly from Greek manuscripts he had carried back from Constantinople, including the beginning of a translation of Galen’s On the Use of the Parts of the Body. Niccolò da Reggio (fl. 1315–48) translated over fifty Galenic writings, many for the first time, including the entire text of that work. There was also translation from Latin into the vernacular, in growing demand when town life was reviving and courts and burghers were hungry for knowledge. The Surgery of John of Arderne (c. 1307–70), discussed below, exists in both Latin and English versions, and Bartholomew the Englishman’s (d. 1260) De proprietatibus rerum (1246) [On the Properties of Things] also enjoyed wide circulation in both tongues. Parts of the Articella were made available in French and English, and even in Welsh and Gaelic. For a couple of centuries, the translation movement had no less momentous consequences in Europe than in Islam, bolstering the prestige of antiquity and canonizing a Galenic medicine set in an arabized Aristotelian framework. Medical knowledge was buttressed not just by its classical heritage but by its place within the divine scheme of Christianity.




RELIGION


Medicine and religion intersected at many points. Conventional histories of medicine still retail the view that the Church arrested medical progress, for instance, by supposedly banning dissection. Some ecclesiastics did indeed disparage medicine – St Bernard of Clairvaux (1090–1153) asserted that �to consult physicians and take medicines befits not religion and is contrary to purity’ – and it was a popular gibe that ubi tres physici, ibi duo athei (where there are three doctors, there are two atheists); but in general such judgments miss the mark. Medieval hospitals have been criticized for their religious ethos, but without the Christian virtue of charity would such hospitals have existed at all?

The Church’s position was clear: the divine was above the temporal. Sometimes the Lord’s will was to punish sinners with plagues; sometimes it was man’s duty to preserve life and health, for the glory of God and the salvation of souls. But the body was to be subordinated to the soul, and healing, like every other temporal activity, had to be under ecclesiastical regulation. Thus in the case of the dying, it was more important that they should be blessed by a priest than bled by a doctor. Concern for salvation occasionally led to suspicions being voiced against Jewish doctors: the Lateran Council of 1215 forbade practitioners not approved by the Church from attending the sick, but this applied only on paper, for the highly valued Jewish doctors were everywhere, especially in Spain.

Monks and clerics, for long the only body of learned men, commonly practised medicine, while in the northern European universities medical students often entered minor holy orders. Petrus Hispanus (Peter of Spain c. 1210–77), whose Thesaurus pauperum [Treasury of the Poor] was popular despite its recommendation of pig shit to stanch nosebleeds, even became Pope in 1276 as John XXI. (He died a year later when the roof of a palace he had built collapsed; one trusts he was a better doctor than architect.) Various ecclesiastical regulations were passed covering medicine; the aim was not to curb it but to uphold the Church’s dignity and prevent clerics developing lucrative sidelines which would seduce them from holy poverty and divine service. Thus when the Lateran Council of 1215 forbade clerics in higher orders from shedding blood, this was not (as often interpreted) an attack on surgery: it aimed, not unlike the Hippocratic oath, to detach the clergy from a manual and bloody craft. Clerics could continue to practise healing but not for gain. Nor did the Church authorities prohibit dissection: in 1482 Pope Sixtus IV informed the University of Tübingen that, provided the body came from an executed criminal and was finally given a Christian burial, there was no objection to human anatomy.

The Benedictine rule states that �the care of the sick is to be placed above and before every other duty, as if indeed Christ were being directly served by waiting on them’; hence it is no surprise that monasteries became key medical centres, more important than universities prior to 1300. As well as offering shelter for pilgrims, most had an infirmary (infirmarium) for sick monks. Separate hospital facilities were founded for the general public.

Healing shrines flourished, and scores of saints were invoked – rather as in Egyptian medicine, each organ of the body and each complaint acquired a particular saint. Supplanting the pagan Asclepius, Damian and Cosmas became the patron saints of medicine. Brothers living in Cilicia (Asia Minor) around the close of the third century, they became celebrated for their healing powers. Their martyrdom under Diocletian is stirring stuff: despite being burnt, stoned, crucified and sawn in half, they survived, perishing only after decapitation. The pair appear in the heraldry of barber-surgeon companies, and churches were dedicated to them, often claiming to house their remains in fine reliquaries. Their chief medical miracle credits them with the first transplant: they amputated a (white) man’s gangrenous leg and grafted in its place that of a dead Moor. In many paintings depicting this scene, the patient, with one leg white and one leg black, lies supine as the spectators stare awestruck upon the miracle.

In addition to this pair, St Luke or St Michael might be called upon for all manner of illnesses, but other saints were specialists: St Anthony was invoked for erysipelas (St Anthony’s fire); St Artemis for genital afflictions, St Sebastian for pestilence. St Christopher dealt with epilepsy, St Roch protected against plague buboes (he had visited many sufferers on missions of mercy, fell sick himself, then was healed by an angel); St Blaise was good for goitre and other neck complaints, St Lawrence for backache, St Bernardine for the lungs, St Vitus for chorea (St Virus’s dance) and St Fiacre for sore arses. St Apollonia became the patron saint of toothache because all her teeth had been knocked out during her martyrdom, while St Margaret of Antioch was the patron of women in labour. Out walking, she had encountered a dragon, which swallowed her whole. In its stomach, she piously made the sign of the cross; this materialized into a real cross, growing until the dragon burst open, thus delivering the saint.

Healing shrines developed a great range of relics, pious images and souvenirs. Some, like Bury St Edmunds or Rocquemadour in the south of France, attracted pilgrims by the thousand. The blood of St Thomas a Becket cured blindness, insanity, leprosy and deafness – and ensured Canterbury’s popularity. In Catholic Europe, many medieval shrines continue to this day.

Certain diseases, for instance the much-feared epilepsy, assumed supernatural connotations and cures; Hippocrates would have turned in his grave! Treatments for the falling sickness involved a mishmash of folklore, humoral medicine, sorcery, pagan beliefs and pious healing. John of Gaddesden (1280–1349), physician to Edward II and compiler of the encyclopaedic Rosa anglica medicinae [The English Rose of Medicine], recommended reciting the gospel over an epileptic patient while bedecking him with peony and chrysanthemum amulets or the hair of a white dog. The folk conviction that mistletoe cured the falling sickness was given a sacred rationalization: keeping watch over his father’s flocks, the young King David saw a woman collapse in a fit. When he prayed for a remedy, an angel appeared to him, announcing, �Whoever wears the oak mistletoe in a finger ring on the right hand, so that the mistletoe touches the hand, will never again be bothered by the falling sickness.

Mistletoe was also used in other ways against epilepsy. In central Europe, the stalk was hung round children’s necks to prevent seizures, while in Scandinavia countryfolk carried a knife with a handle cut from oak mistletoe. In the mid seventeenth century, the leading experimentalist and founder-member of the Royal Society, Robert Boyle, was still endorsing pulverized mistletoe: �as much as can be held on a sixpence coin, early in the morning, in black cherry juice, during several days around the full moon’. The pious Boyle believed in religious cures, but sought their scientific basis.




HOSPITALS


Medieval hospitals were religious foundations through and through. Those planted in the West had originally been small and mainly for pilgrims; their late medieval successors were often more impressive. St Leonard’s in York had 225 sick and poor in 1287; still larger were the civic hospitals of Milan, Siena and Paris. In Florence alone, a city of some 30,000 inhabitants, there were over thirty foundations by the fifteenth century. Some had only ten beds, others hundreds. In England hospitals and almshouses totalled almost five hundred by 1400, though few were of any size or significance. London’s St Bartholomew’s dates from 1123 and St Thomas’s from around 1215. At Bury St Edmunds six hospitals were endowed between 1150 and 1260 to cater for lepers, pilgrims, the infirm and the aged.

Small hospitals were essentially hostels or hospices lacking resident medical assistance, but physicians were in attendance by 1231 at the Paris Hôtel Dieu, next to Notre Dame, and Sta Maria Nuova in Florence was gradually medicalized: from twelve beds in 1288 for �the sick and the poor’, this �first hospital among Christians’, as one Florentine patriot called it, expanded by 1500 to a medical staff of ten doctors, a pharmacist and several assistants, including female surgeons. Although catering largely for the indigent, it had eight private rooms �reserved for the sick of the higher classes’. Within hospital walls the Christian ethos was all-pervasive.

In hospital expansion the Crusades played their part, since crusading orders such as the Knights of St John of Jerusalem (later the Knights of Malta), the Knights Templar, and the Teutonic Knights built hospitals throughout the Mediterranean and German-speaking lands. By the fourteenth century non-military brotherhoods, such as the Order of the Holy Spirit, were also running infirmaries from Alsace to Poland, while the Order of St John of God appeared in Spain in the sixteenth century, building insane asylums and putting up about 200 hospitals in the New World.




LEARNED MEDICINE


The great age of hospital building from around 1200 coincided with the flourishing of universities in Italy, Spain, France and England, sustained by the new wealth and confidence of the High Middle Ages. Paris was founded in 1110; Bologna in 1158; Oxford in 1167, Montpellier in 1181, Cambridge in 1209, Padua in 1222 and Naples in 1224. The universities extended the work of Salerno in medical education. By the 1230s Montpellier was drawing medical students from afar; there, as in Paris, Bologna, Oxford and other centres, medical teaching initially developed informally, but teachers later banded themselves into an official faculty.

There were some differences between the clerically dominated universities of the north like Paris, Cologne and Oxford, where the theology faculty was supreme, and the more secular ones of Montpellier and Italy, where arts and law faculties led; but all had much in common. The Bachelor of Medicine (MB) took around seven years of study, including a preliminary Arts training; a medical doctorate (MD) was awarded after around ten years’ study. Hence there were hardly swarms of medical students: Bologna granted 65 degrees in medicine and only one in surgery between 1419 and 1434; Turin a mere 13 between 1426 and 1462. The single big school and true centre of excellence was Padua, where medical students comprised one tenth of the student population. Its medical faculty was unusually large, numbering 16 in 1436 – Oxford had only a single MD teaching.

Following the model established in universities at large, medical education was based on set books, usually parts of the Articella and Avicenna’s Canon, expounded in lectures. It was also heavily influenced by the new Aristotelianism associated with Thomas Aquinas (1226–74) and Albertus Magnus (1200–80). A Dominican monk who taught at the new university of Cologne, Albert was wrongly credited with many medicinal recipes and occult treatises, as well as with the De secretis mulierum [On the Secrets of Women], all of which blocked his canonization until 1931.

After perhaps seven years’ study beyond the Arts degree, doctoral graduation rested on having attended the requisite lectures, disputations and oral examinations and – at some universities, including Bologna and Paris – on having worked under a physician (such clinical experience had to be acquired extra-murally). From about 1300 at Bologna and a generation later at Montpellier, university requirements further demanded that students attend a dissection, to supplement traditional anatomical lessons on dead animals. The academic justification of a medical education lay in the acquisition of rational knowledge (scientia) within a natural philosophical framework. Medical professors aimed to prove that their discipline formed a noble chapel of the temple of science and philosophy; the learned physician who knew the reasons for things would not be mistaken for the hireling with a knack for healing.

Renaissance humanists and subsequent historians have sneered at medieval academic medicine for its Galenolatry and its abstract disputation topics (�Can sleep be harmful?’). But formulaic teaching was unavoidable in an age when books were few. And if much of the knowledge seems rather formal, this is because the student had to understand the medieval forerunner of what is now prized as �basic science’: the theory of the physical world and its laws and purposes. Grasp of universal truths was needed to comprehend individual cases, and the ability to reason and cite chapter and verse raised the true physician above the empiric.

Graduates got the pick of the patients; princes and patricians in Italy, France and Spain welcomed cultured doctors who could explain the whys and wherefores. The duties of physicians in the service of King Edward III of England were clearly laid down:

And muche he should talke with the steward, chamberlayn, assewer, and the maister cooke, to devyse by counsayle what metes and drinkes is best according with the Kinge.… Also hym ought to espie if any of this courte be infected with leperiz or pestylence, and to warn the soveraynes of hym, till he be purged clene, to keepe hym oute of courte.

The learned physician claimed, in the Hippocratic manner, to prevent disorders or restore health by dietetics and drugs. For that he would need to form a diagnosis. Feeling the pulse and scrutinizing urine (uroscopy) were routine, and the doctor’s consilium (advice) would be a personal prognosis based on a patient’s history. Drug prescriptions were also personalized, involving compound mixtures (polypharmacy), often called �Galenicals’.

Highly prized was medical mathematics, which sought to achieve an understanding of the significance for health of the motions of the heavens, in a tradition going back to the Hippocratic Epidemics and embracing subsequent developments in Ptolemaic astronomy and astrology. Following Galen, disease was enumerated as involving sequences of �critical days’ when an illness would reach crisis point and then either subside or prove fatal. The physician on Chaucer’s Canterbury pilgrimage was proud of his astrological learning:

With us ther was a DOCTOUR OF PHISYK,

In al this world ne was ther noon him lyk

To speke of phisik and of surgerye;

For he was grounded in astronomye.

He kepte his pacient a full greet del

In houres, by his magik naturel.

Wel coude he fortunen the ascendent

Of his images for his pacient.

He knew the case of everich maladye,

Were it of hoot or cold, or moiste, or drye,

And where engendred, and of what humour;

He was a verrey parfit practisour.

Medical astrology might require arcane and labyrinthine calculations, but there were handy charts to illustrate planetary influences over the organs of the body and their maladies. Princely courts often housed a physician-astrologer, though it could prove a risky trade: the physician John of Toledo (d. 1275) was accused of dabbling in necromancy, and thrown into prison.

Zodiacs and nativities were also used to ascertain the right time for blood-letting. Recommended in spring and the beginning of September, its benefits, according to the Salernitan Rule of Health, included sound sleep, toning up the spirits, calmness, and better sight and hearing. Bleeding was left mainly to surgeons and barber-surgeons, who also cupped, pulled teeth, leeched, gave enemas, curetted fistulas, applied ointments, drained running sores, sutured wounds, removed superficial tumours and stopped haemorrhaging. Descriptions of trusses and eyeglasses began to appear in the thirteenth century.

Dietetics, by contrast, was the main therapeutic recourse of the physician regulating lifestyle in accordance with the six non-naturals. Spurred by the revival of international commerce, pharmacy also developed, especially in Venice, where drugs imported from the East were traded in large stores (apothecai), which came to mean a druggist’s shop.

Relations between physicians and surgeons were not always plain-sailing, especially with eminent surgeons like Henri de Mondeville, Guy de Chauliac and John of Arderne (c. 1307–70) laying claim to learning as well as a good eye, a steady hand and a sharp blade. According to de Mondeville, �it is impossible to be a good surgeon if one is not familiar with the foundations and general rules of medicine [and] it is impossible for anyone to be a good physician who is absolutely ignorant of the art of surgery.’

Among the famous early surgical writers was Lanfranc of Milan (c. 1250–1306). Italian by birth, he settled in Paris where he wrote his Chirurgia magna, an expansion of his more popular Chirurgia parva. They were both translated into French, Italian, Spanish, German, English, Dutch and Hebrew. The Grand Surgery is divided into sections on general principles, and on anatomy, embryology, ulcers, fistulas, fractures and luxations, baldness and skin diseases, phlebotomy and scarification, cautery and diseases of various organs. There is also a lengthy section on herbs and pharmacy. Lanfranc was valued by his distinguished successors, de Mondeville and de Chauliac.

Henri de Mondeville (c. 1260-f. 1320) was born in Normandy, studying at Montpellier, Paris and Bologna. Travelling widely, he spent some time as a military surgeon to the French royal family, and lectured in surgery and anatomy at Montpellier and Paris. He planned his Cyrurgia (begun in 1306 but never completed) along traditional lines, opening with anatomy and moving on to wounds. Attention was paid to the contentious topic of wound treatment. Mondeville advocated simple bathing of wounds and immediate closure, followed by dry dressings with minimal loss of flesh or skin. His preference was for dry healing without pus formation, a view contradicting Hippocratic wisdom but already advocated by Hugo of Lucca (c. 1160–1257) and his disciple, Theoderic (1205–96), who had boldly maintained in his Chirurgia (1267) that �it is not necessary that pus be formed in wounds’.

This new approach met opposition from supporters of conventional wound salves: plasters and powders designed to promote suppuration; since Greek times it had been taught that certain types of pus (known as �laudable pus’) were beneficial, conveying poisoned blood out of the body. The Salernitan school had thus recommended keeping wounds open to allow for suppuration and healing per intentio secundam (by second intention), from the base of the wound up.

The most prominent surgeon of the next generation was Guy de Chauliac (1298–1368), educated at Montpellier and Bologna. His great work, the Chirurgia magna, was fully comprehensive, covering anatomy, inflammation, wounds, ulcers, fractures, dislocations and miscellaneous diseases belonging to surgery. An astonishing exercise in surgical erudition, it contains no fewer than 3299 references to other works, including 890 quotations from Galen. This parade of sources was calculated, since Chauliac was concerned to show surgery to be a learned art:

The conditions necessary for the surgeon are four: first, he should be learned, second, he should be expert: third, he must be ingenious, and fourth, he should be able to adapt himself. It is required for the first that the surgeon should know not only the principles of surgery, but also those of medicine in theory and practice.

Chauliac’s Chirurgia was translated into several languages. In the pus bonum et laudibile debate, he did not exactly take sides, though he appears to have been hostile to traditional wound salves, judging they did more harm than good. The work also contains fascinating details about his own times, including first-hand reports of the Black Death, descriptions of surgical instruments and operations, and his often damning judgments on his contemporaries. Like most medieval practitioners, he offered a pot-pourri of Hippocratic treatments and ones of a magico-religious flavour. Epileptics, for instance, were to write in their own blood on a piece of parchment the names of the Three Wise Men, and to recite three Pater Nosters and three Ave Marias daily for three months.

The most distinguished English surgeon was John of Arderne, who served under John of Gaunt in the Hundred Years War and produced a Treatment of Anal Fistulas. For this operation, his technique was to place the patient in the lithotomy position. Four ligatures were taken up through the fistula, and their ends, drawn down through the anus, were knotted to stop the bleeding. Next, he pushed one grooved instrument through the fistula into the rectum, where it made contact with another. He then made a bold cut with his scalpel to remove the whole intervening segment, and stopped the bleeding between the ligatures with a hot sponge. The wound was cared for by cleaning and the patient was given daily enemas.




MEDICINE AND THE PEOPLE


From the twelfth century, Europe blossomed: population rose, trade boomed, and courts and cities acquired a new sophistication. Such circumstances helped medicine. Though learned physicians were at the top of the tree, they constituted only a small fraction of all those offering medical services, and larger towns attracted a diversity of healers. Around 1400 Florence boasted not only graduates of Padua and Bologna, but bone-setters from Rome and families specializing in eye-diseases, hernia and the stone. Herbalists, midwives and pedlars of folk remedies thrived, and parish priests plied pious cures.

With numbers rising, medicine needed to organize itself. This happened first in urban Italy, where medical guilds assumed responsibilities for apprenticeship, examination of candidates, location of pharmacists and supervision of drugs, food and herbs. As early as 1236 Florentine physicians and pharmacists grouped into a single guild, recognized as one of the city’s seven major crafts.

Medical organization took various forms. In southern Europe there was no great gulf between surgeon and physician: surgery was a desirable skill for a physician to acquire. In Frederick II’s regulations for the Kingdom of Sicily (c. 12 31), a licence to practice medicine could be gained only after five years of study which included surgery, and in Italy the chance to learn surgery at university helped to prevent professional rancour between the two branches. Elsewhere the gap widened, however, for beyond Italy surgery was excluded from the academic curriculum. In northern Europe surgical training and practice were organized on a guild basis, through apprenticeship, and so were regarded by physicians as infra dig.

In Paris, the surgeons’ organization began in 1210 when the College of St Cosme (Côme or Cosmas) was established. Its members were divided into the long- and the short-robed, only the former being entitled to operate. Training was mainly practical and the college granted three degrees: a bachelor’s, a licence and a master’s. A three-cornered tussle developed between physicians of the faculty, the surgeons of the college, and the barbers, who did bleeding and the like. The introduction of anatomy added to the confusion, for dissections were under the direction of a physician but the knife-work was performed by a surgeon. Not till 1516 was the conflict resolved, with the surgeons ceding precedence to the physicians, for both could unite in antipathy towards the �ignorant’ barbers. In the German states and England, the barber-surgeon became typical, but in Italy, Spain and southern France, that hybrid occupation never gained prominence.

In London, the Fellowship of Surgeons came into being in 1368–9, and a Company of Barbers was chartered in 1376. The tiny band of university-trained physicians did not organize themselves until 1423, when a group led by the cleric and court physician, Gilbert Kymer (c. 1385–1463) petitioned for a joint college �for the better education and control of physicians and surgeons practising in the city’. Not until the founding of the College of Physicians of London in 1518 could the physicians regulate metropolitan practice. Though intra-professional conflicts flared, they were not universal. In small cities like Bristol or Norwich, physicians, surgeons and barbers found strength in unity. And, in any event, professional tussles in the late medieval centuries reflect the surging number of healers and their dawning sense of civic standing.

This proliferation provoked attempts by princes and city authorities at regulation and �protection’. In the Kingdom of Sicily the royal physician took charge of licensing, while in the 1340s the Aragonese King Peter licensed Jewish practitioners who had been denied medical degrees from Christian universities. Church authorities often licensed midwives, on the grounds that their morals needed to be impeccable.

Urban expansion also explains the emergence, initially in northern Italy, of community-employed public physicians. The earliest known public contracts for such medici condotti were at Reggio in 1211 and in neighbouring Bologna in 1214, where the appointee was to treat soldiers as well as citizens. Contracts typically imposed a residence requirement, balanced the doctor’s private and public duties, and set scales of fees. Especially in time of plague, the civic doctor was to assist at inquests and trials, to attend hospitals, and to tend injuries resulting from judicial torture.

This system spread. By 1300, public physicians were found in all the large towns of northern Italy; a century later the office was almost universal in northern and central Italy and in the Venetian territories in Dalmatia and Greece, and it had also been adopted in major centres in Provence, Aragon and Valencia. By 1500 civic doctors were being appointed in northern France, Flanders and many German cities, though Britain lagged behind.

Meanwhile rising urban populations contributed to overcrowding and worsening sanitary problems, due to the contamination of drinking water and food, waste accumulation and the keeping of livestock. Water began to be piped into towns, and by 1300 Bruges had built a municipal water system. Many towns paved their main thoroughfares; every large house in Paris was required to have a chamber draining into the sewers, and Milan passed ordinances for cesspools and sewers. Some German cities prohibited pig-pens facing onto the street; municipal slaughterhouses were established, and cities also tried to monitor food markets and curb river pollution. For example, tanners were not allowed to wash their skins or dyers to dump their waste in public waters. Nonetheless filth began to pose mounting threats. Plague struck in the fourteenth century (see below) and typhus from the close of the fifteenth.




LEPROSY


Certain diseases loomed large both in reality and in the public imagination, notably leprosy, now called Hansen’s disease after Armauer Hansen (1841–1912), the discoverer of the bacillus Mycobacterium leprae. Its physical symptoms – scaly flesh, mutilated fingers and toes and bone degeneration, in short �uncleanliness’ – made it seem a living death and led to deeply punitive attitudes. The disease has a puzzling history. From as early as 2400 BC Egyptian sources contain references to a skin condition interpreted as leprosy, and 900 years later, the Ebers papyrus mentions a leprous disease seemingly confirmed by Egyptian skeleton evidence. True leprosy probably existed in the Levant from biblical times, but the term was also used for various dermatological conditions producing disfiguring ulcers and sores.

Leprosy became highly stigmatized. Authorized by ancient Levitical decrees, leper laws were strict in medieval Europe. They were forbidden all normal social contacts and became targets of shocking rites of exclusion. They could not marry, they were forced to dress distinctively and to sound a bell warning of their approach. According to the liturgical handbook, the Sarum Use, in thirteenth-century England,

I forbid you ever to enter churches, or go into a market, or a mill, or a bakehouse, or into any assemblies of people.

I forbid you ever to wash your hands or even any of your belongings in spring or stream of water of any kind …

I forbid you ever henceforth to go out without your leper’s dress, that you may be recognized by others …

I forbid you to have intercourse with any woman except your wife…

I forbid you to touch infants or young folk, whosoever they may be, or to give them or to others any of your possessions.

I forbid you henceforth to eat or drink in any company except that of lepers …

They were segregated in special houses outside towns, lazarettos, following the injunction in Leviticus that the �unclean’ should dwell beyond the camp. There was also a leper mass, conducted with the victim in attendance, declaring the sufferer to be �dead among the living’, and the 1179 Lateran Council ordered them cast out from society, with their own burial places. The only consolation the Church gave was to interpret the leper’s suffering as a purgatory on earth, destined to bring swifter reward in heaven. God, proclaimed de Chauliac, loved the leper; after all, did not the Bible (Matthew 8:3) show Jesus extending his hand, saying �be thou clean’?

Leprosy provided a prism for Christian thinking about disease. No less a religious than a medical diagnosis, it was associated with sin, particularly lust, reflecting the assumption that it was spread by sex. In The Testament of Cresseid by Robert Henryson (fl. 1470–1500), the heroine is punished by God with leprosy for her lust and pride. Lepers were thus scapegoated with Jews and heretics in what historians have called a �persecuting society’.

From the eleventh century there was a rapid surge in the number of hospitals built to house lepers. By 1226 there may have been around 2,000 in France alone, and in England about 130. By 1225 there were a staggering 19,000 leprosaria in Europe, offering shelter while enforcing isolation. Yet by 1350 leprosy was in decline. The epidemiology of that watershed is much disputed: some have speculated that the Black Death killed so many that the disease died out, others that it might be connected with the rise of tuberculosis, which has a similar but more aggressive pathogen; the TB bacillus could have elbowed out the leprosy. But though the disease waned, its menace remained, becoming a paradigm for later diseases of exclusion, and for persecution generally. Leprosaria were used for the poor and those suspected of carrying infectious diseases. Some became hospitals: on the then outskirts of Paris, the HГґpital des Petites Maisons, near the monastery of St Germain des PrГ©s, founded as a leprosarium, was used for the mentally disordered and for indigent syphilitics. St Giles-in-the-Fields, then just outside London, was a lazaretto and later a hospital, as were the hospitals for incurables built outside Nuremberg.




PLAGUE


The Black Death is the most catastrophic epidemic ever to have struck Europe, killing perhaps twenty million people in three years. Absent from Europe for eight hundred years since the plague of Justinian, it was endemic for the next three centuries. The Great Pestilence of 1347–51 probably originated in China; in 1346 it migrated from beyond Tashkent in central Asia to the Black Sea, where it broke out among the Tatars fighting Italian merchants in the Crimea. A chronicler tells how the Christians took refuge in the citadel at Kaffa (Feodosia), where they were besieged. Plague forced the Tatars to raise the siege, but before withdrawing they invented biological warfare by catapulting corpses of plague victims over the citadel walls, causing the disease to flare among the Christians. When they in turn escaped, it travelled with them into the Mediterranean, breaking out in Messina and Genoa and raging through the rest of Europe. According to Fra Michele di Piazze,

In the first days of October 1347, twelve Genoese galleys fleeing before the wrath of our Lord over their wicked deeds, entered the port of Messina. The sailors brought in their bones a disease so violent that whoever spoke a word to them was infected and could in no way save himself from death … Those to whom the disease was transmitted by infection of the breath were stricken with pains all over the body and felt a terrible lassitude. There then appeared, on a thigh or an arm, a pustule like a lentil. From this the infection penetrated the body and violent bloody vomiting began. It lasted for a period of three days and there was no way of preventing its ending in death.

Within a couple of years, plague killed around a quarter of Europe’s population – and far more in some towns; the largest number of fatalities caused by a single epidemic disaster in the history of Europe. This provoked a lasting demographic crisis. Thousands of villages were abandoned, and by 1427 Florence’s population had plummeted by 60 per cent from over 100,000 to about 38,000. A Europe which had been relatively epidemic-free turned into a crucible of pestilences, spawning the obsessions haunting late medieval imaginations: death, decay and the Devil, the danse macabre and the Gothic symbols of the skull and crossbones, the Grim Reaper and the Horsemen of the Apocalypse.

Boccaccio (1313–75) gave the most graphic account of plague in the Decameron, a collection of tales related by a group of young men and women who had fled Florence to escape it (the regular advice was �flee early, flee far, return late’). Noting that most of the afflicted died within three days, he recorded:

Such was the cruelty of heaven and to a great degree of man that between March [1348] and the following July it is estimated that more than 100,000 human beings lost their lives within the walls of Florence, what with the ravages attendant on the plague and the barbarity of the survivors towards the sick.

So virulent was the plague, �that the sick communicated it to the healthy who came near them, just as a fire catches anything dry or oily near it’ (a sign that ordinary people regarded it as contagious). �How many valiant men, how many fair ladies, breakfasted with their kinsfolk and that same night supped with their ancestors in the other world.’

Social breakdown followed. In Siena, wrote one survivor,

Father abandoned child, wife husband, one brother another … none could be found to bury the dead for money or friendship … they died by the hundreds, both day and night, and all were thrown in ditches and covered with earth. And as soon as those ditches were filled, more were dug. And I, Agnolo di Tura … buried my five children with my own hands.

Though epidemiological controversies have raged, the Black Death was almost certainly bubonic plague, caused by transmission of the bacillus Yersinia pestis from rats to humans via fleas (notably Xenopsylla cheopis). When the bacillus enters the body through the bite of an infected flea (it can disgorge up to 24,000 in one bite), the disease follows the pattern called bubonic. After a six-day incubation, victims suffer chest pains, coughing, vomiting of blood, breathing troubles, high fever and dark skin blotches caused by internal bleeding (hence the name Black Death), as well as hard, painful egg-sized swellings (buboes) in the lymph nodes in the armpit, groin, neck and behind the ears. Restlessness, delirium, and finally coma and death generally follow. Not all the features familiar in contemporary Asia match those recounted in medieval chronicles. The swift onset suggests that some direct human-to-human transmission also took place, perhaps in the form of pneumonic plague, spread by droplet infection.

Many explanations were inevitably offered: God in His wisdom had sent plague to punish mankind for its sins; it might be the result of planetary conjunctions; amongst the �natural causes’, alterations in the environment could cause a �pestilential atmosphere’ resulting from effluvia, vapours from stagnant pools, dungheaps, decaying corpses, the breath of sufferers themselves – or poisoning of the air by �enemies’ such as Jews. Laymen like Boccaccio referred to contagion, but most medical theorists, loyal to their Greek learning, stood by constitutional factors: if the body was robust, illness should not result; if not, one would sicken and die.

Responses depended upon which theory was accepted. If the plague was truly God-sent, only prayer and fasting could be effective. This encouraged flagellant bands to trudge from town to town, whipping each other, hoping by their lashings and denunciations of Jews and sinners to propitiate divine wrath; which in turn sparked persecution of Jews, who were accused of poisoning the wells. In Basel, Jews were penned up in a wooden building and burnt alive; 2000 were said to have been slaughtered in Strasbourg and 12,000 in Mainz; while in July 1349 the flagellants led the burghers of Frankfurt into the Jewish quarter for a wholesale massacre. But, however pious, the flagellants themselves posed a serious threat to public order by creating panic and challenging authority, leading Pope Clement VI to prohibit them.

Seeking to protect themselves with long leather gowns, gauntlets, and masks with snouts stuffed with aromatic herbs, physicians put the accent on individual treatment, on the assumption that plague involved atmospheric putrefaction. They recommended sniffing amber-scented nosegays and pomanders and administering strong-smelling herbs – aloes, dittany, myrrh and pimpernel, all supposed to have cleansing properties, to say nothing of those princes of pharmacy, mithridatium and theriac. Fires should be lit and rooms fumigated with aromatic wood or vinegar. Writing in 1401, the Florentine doctor Lapo Mazzei (1350–1412) suggested �it would help you to drink, a quarter of an hour before dinner, a full half-glass of good red wine, neither too dry nor too sweet.’

Faced with plague, physicians had no power to effect public-health measures; that was the magistrate’s business. In Venice a committee of three nobles laid down burial regulations, banning the sick from entering the city and jailing intruders. In Milan, the council sealed in the occupants of affected houses and left them to die (perhaps this draconian measure worked: Milan had only a 15 per cent death rate). In Florence a committee of eight was given dictatorial powers, though ordinances requiring the killing of dogs and cats ironically removed the very animals that might have contained the rats. At that time, however, no one had any reason to suspect rats.

Secular and religious strategies were sometimes at odds. In 1469, despite the risks of congregating in large numbers, the civic authorities in Brescia allowed the Corpus Christi procession to go ahead because deliverance, hoped the pious, would come through divine intervention. By contrast, in time of plague the Venice Health Board banned preaching, processions and feast-day assemblies. Churches were locked, and in 1523 and 1529 even the shrine of St Roch, a popular intercessor against plague, was shut.

Certain routines became standard. The committees appointed to co-ordinate public health measures began to remove the sick to leper houses beyond city limits (hence �lazaretto’ came to mean a plague hospital), while also establishing a system of exclusion, banning persons or goods from entering or leaving. Such measures were adopted throughout Italy. In 1377 Ragusa (Dubrovnik, Croatia) instituted a regular thirty-day isolation period on a nearby island for all arriving from plague-infected areas; in 1397 this was increased to forty, thus becoming a true quarantine (quarantenaria, forty days). Marseilles took similar action in 1383; Venice imposed quarantine measures in 1423; in 1464 Pisa followed and Genoa three years later.

Before the fifteenth century such health boards, composed of nobles and officials, were ad hoc creations. In Milan, however, a permanent magistracy �for the preservation of health’ was established around 1410, with (by 1450) a staff of a physician, surgeon, notary and barber, two horsemen, three footmen and, sensibly, two grave-diggers. Doctors acted not as full members of such boards but as advisers. Other Italian cities followed; in 1486, Venice appointed a permanent Commission of Public Health, consisting of three noblemen; Florence set up a similar commission of five in 1527, and Lucca one of three in 1549. Bills of Mortality were initiated in Milan, listing names and causes of death. Health Boards extended quarantines and the closing of borders, and health passes were introduced. In these respects, north European towns lagged behind Italy by more than a century.

The regulation of markets, streets, hospitals and cemeteries, the control of beggars, prostitutes and Jews – in short, public health measures – fell under the health boards. Resentment was expressed about their cost and powers, especially since economic disaster was almost inevitable once plague had been declared official, with commerce and travel suspended and markets closed.

Obliquely, therefore, medical practitioners became more involved in public administration. Midwives, too, performed policing functions. Laws required them to report illegitimate births, and to press unmarried mothers for the names of the father, so as to secure financial support for the babies. The oaths sworn by English midwives seeking a bishop’s licence included promises to extract the truth about paternity and to refuse requests for secret births.




MADNESS


Alongside leprosy and plague, another condition of public concern was insanity. Madness remained particularly disputed. On Galen’s authority, medical writers distinguished four main categories: frenzy, mania, melancholy and fatuity, each the result of a particular humoral imbalance. Folklore believed the moon caused lunacy; theology saw it as a consequence of diabolical possession or sorcery. Some viewed it as divinely inspired, perhaps involving the gift of tongues; others praised the innocence of the village idiot; while troubadours might sing of tragic love-madness.

Nor was there agreement over remedies. Some advocated drugs and bleeding to sedate the demented and evacuate peccant humours. Shock treatment might be tried, such as hurling a maniac into a river. For demoniacal possession, there was exorcism, while certain saints had the power to cure madness. Three shrines enjoyed a special reputation: St Mathurin at Larchant and St Acairius at Haspres (both in northern France), and St Dymphna at Geel in Flanders. A hospice built there to house the mentally ill proved too small and many were lodged in village households. From this a special �family colony’ developed, in which the mentally ill were tended by the villagers. The Geel community still exists.

Public attitudes towards the insane were mixed. German municipalities sometimes expelled idiots or insane persons, whipping them out of town – though the celebrated �ship of fools’ is not a reality but a literary conceit, symbolizing humanity’s follies. The insane were cared for in monasteries; various towns had madmen’s towers (Narrentürme); in Paris, special cells were set aside at the Hôtel Dieu; and the Teutonic Knights’ hospital at Elbing had a madhouse (Tollhaus). Specialized hospitals began to appear, notably under the influence of Islam in Spain: Granada (1365), Valencia (1407), Zaragoza (1425), Seville (1436), Barcelona (1481) and Toledo (1483). The priory of St Mary of Bethlehem in London, founded in 1247, was by 1403 housing six men �deprived of reason’; it developed into the notorious Bedlam. Such moves towards incarceration were counterbalanced by the image of the mad person as a holy fool, while in the �feast of fools’ medieval society came to terms with mental alienation through the carnival notion of the world turned upside down – madness as dionysian release.

The insane also became linked to witchcraft, with demonic possession serving as an explanation for deranged behaviour. Haunted by plague and heresy, the late medieval church warned against the Devil and his minions; women were considered particularly susceptible to Satan; and during the next 300 years the witch-craze seized Europe, leading to the execution, often after judicial torture, of upwards of 50,000 victims, mainly women (the figure of nine million burnings, often cited in feminist writings, is pure fantasy).

An individual of whom much is known is the English mystic, Margery Kempe (b. 1393). A wealthy woman who owned a brewery in King’s Lynn, she fell victim to puerperal insanity and began to behave oddly. Undertaking pilgrimages to Jerusalem, Rome and Spain, she described her spiritual experiences. The Book of Margery Kempe (c. 1423), perhaps the very first English autobiography, reveals the contested borderland between illness and religious experience. To some of her companions she was a sick woman, indeed a confounded nuisance with her non-stop wailings; to others, she was the mouthpiece of God – or was possessed by the Devil. �Many said’, she wrote,

there was never saint in heaven that cried as she did, and from that they concluded she had a devil within her which caused that crying. And this they said openly, amid much more evil talk. She took everything patiently for our Lord’s love, for she knew very well that the Jews said much worse of His own person than people did of her, and therefore she took it the more meekly.




WOMEN


Margery Kempe’s difficulties derived in part from perceptions of her gender; certain disorders were associated with women and their reproductive systems. Giving birth is depicted in medieval texts as an all-female business, the mother being supported by relatives, neighbours and a midwife. Midwives rose in status, as some town councils paid them to act in an official capacity in cases involving female illness, obstetrics and infant care. They were called upon to test for virginity or sterility, and to certify infant deaths.

A few obstetrical texts were directed to female readers, and male writers discussed gynaecological problems and prescribed remedies for female sexual disorders, advising not least on contraception. The Treasury of the Poor, ascribed to Peter of Spain (later Pope John XXI), gave over a hundred prescriptions concerning fertility, aphrodisiacs and contraceptives, presumably derived from popular tradition. Medical attitudes towards sex were far from puritanical, for sexual release was regarded as requisite for humoral balance, and female orgasm was widely believed essential for conception.

Female healers abounded, sometimes learning their craft from a male member of the family, and a few women wrote medical texts. Hildegard of Bingen (1098–1179), who had been put in a convent at the age of eight and began having religious visions soon after, practised medicine in her role as abbess of Rupertsberg. Her main work was the Liber simplicis medicinae (c. 1150–60) [Book of Simple Medicine], on the curative powers of herbs, stones and animals; she also wrote on the natural causes of diseases. These texts summarize traditional lore concerning the medical uses of animals, vegetables and minerals, advising treatments on the principle of opposites, while for terrible diseases like leprosy she commended exotic remedies involving unicorn liver and lion heart. Herbs were God’s gifts; either they would cure or the patients �will die for God did not will that they should be healed’.

Another acclaimed woman healer is more enigmatic. Obstetrical writings and other treatises of women’s disorders are attributed to a certain Trotula, said to be a female member of the medical school of Salerno during the twelfth century; but �Trotula’, anglicized as �Dame Trot’, was more likely a male writing in drag. Texts called The English Trotula long circulated, containing advice on conception, pregnancy and childbirth and motherhood (nursing mothers should avoid highly salted or spiced food).

A few female healers were accepted into the Florentine practitioners’ guild, and English records show women called �leech’ or �medica’; at St Leonard’s Hospital, York, a Sister Ann was described in 1276 as a medica. But women were excluded in the later Middle Ages, marginalized by professional conflicts and guild restrictive practices. In 1421, the English physician Gilbert Kymer and his cronies petitioned Parliament to ban women from practising. The limitation of medical and surgical practice to those who had received a university training or were enrolled in a guild tended to confine women to nursing, midwifery and home physic.

Control of midwifery became more common from the fifteenth century. The Papal Bull of 1484 denouncing witchcraft drew attention to alleged attacks by sorceresses on virility and fertility; in their viciously misogynistic Malleus maleficarum (1486) [Hammer of Witches], the Dominicans Henricus Institoris (Heinrich Kramer, fl. 1470–1501) and Jacob Sprenger (fl. 1468–94) accused midwives of murdering babies in the womb, roasting them at sabbaths or offering them to the Devil. There is little evidence, however, that female healers were charged with witchcraft.

Medieval authors on sex and childbirth (or �generation’ as the subject was known) drew on a variety of traditions: Aristotle, Galen, Soranus and the Bible. The standard view was that men and women shared a common physiology, but in perfect and flawed versions. Female generative organs were like those of men, but inverted and inferior – the vagina was an inverted penis which had never fully developed. Thus, the female form was a faulty version of the male, weaker, because menstruation and tearfulness displayed a watery, oozing physicality; female flesh was moister and flabbier, men were more muscular. A woman’s body was deficient in the vital heat which allowed the male to refine into semen the surplus blood which women shed in menstruation; likewise, women produced milk instead of semen. Women were leaky vessels (menstruating, crying, lactating), and menstruation was polluting.

De secretis mulierum [On Women’s Secrets] spelt out the harmful effects of menstruation:

women are so full of venom in their time of menstruation that they poison animals by their glance; they infect children in the cradle; they spot the cleanest mirror; and whenever men have sexual intercourse with them, they are made leprous and sometimes cancerous.

The womb was an unstable organ, making women less balanced than men. Social consequences followed from these physiological teachings. According to the instigator of the Reformation, Martin Luther (1483–1546),

Men have broad and large chests, and small narrow hips, and more understanding than women, who have but small and narrow breasts, and broad hips, to the end they should remain at home, sit still, keep house, and bear and bring up children.

Controversies flared among doctors, philosophers and theologians over the gendering and engendering of the body. The roles of the male and female in fecundation were disputed, as Aristotle’s distinction between superior male �form’ and inferior female �matter’ (seed and seedbed), clashed with the Galenic theory of the confluence of male and female semen to make a baby. Such niceties could have weighty implications: how, for example, had the Virgin Mary conceived Christ – was it from menstrual blood, or was such blood a waste product? Contrasting explanations could also be given regarding the means and the moment of the soul’s entering the foetus.

In the later Middle Ages, medical and Christian views cross-fertilized at many points as the body assumed heightened significance in the humanistic theology of the times. While some, like the early Church Fathers, still viewed it as the prison of the spirit, new emphasis came to be placed on the soul’s incarnation in the flesh, the doctrine of immanentism. In the consecration of the host in the eucharist, the bread was transubstantiated into Christ’s body, turning miraculously to flesh. There was similar stress on bodily resurrection at the Last Judgment. In Catholic rituals, a saint’s power was associated with relics of the body: a hallowed bone, tooth or toenail protecting against evil; hence the booming relics business.




BODIES


Theological concerns loomed large in readings of the body, yet medicine too was concerned with the implications of the theory of embodiment and the soul. Scholastic medicine subscribed to the Chain of Being or Scale of Nature, with man as the midpoint between angels and brutes, distinguished from the beasts by possession of a rational soul. One consequence of this doctrine was that, considered in a purely physical light, the human body could be described in the same terms as that of a pig or a monkey. Belief in such a continuum of creation explains why the earliest medieval anatomies, conducted at Salerno and Bologna, could be performed on animals: the human soul was unique, so similarities between human and animal cadavers were not theologically worrying.

The first recorded public human dissection was conducted in Bologna around 1315 by Mondino de’ Luzzi (c. 1270–1326). Born into a medical family, Mondino graduated at Bologna, and rose to a chair of medicine there. His fame rests on his Anatomia mundini (c. 1316), which became the standard text on the subject. Built on personal experience of human dissection, the Anatomia was a brief, practical guide, treating the parts of the body in the order in which they would be handled in dissection, beginning with the abdominal cavity, the most perishable part. Relying on Galen and the Arabs, the Anatomia perpetuated old errors derived from animal dissections, such as the five-lobed liver and the three-ventricled heart. Mondino’s achievement derived from his intuition that the developing university-based education of his day required an introductory anatomy manual. The first printed version appeared in 1478, followed by at least forty editions – a clear recognition of how central anatomy was becoming to medical expertise.

Hitherto anatomy had played little part in medical education; it had no place in the Articella or the medical school of Salerno, though pigs had been dissected there. But from Mondino’s time learned physicians began to enunciate the view that medicine should be anatomy-based. Thereafter academic physicians gloried in public displays of human dissection and anatomy theatres were built. Dissection was justified largely in terms of natural philosophy and piety (the body demonstrated the wisdom of the Creator); the surgical benefits were rarely mentioned – clear evidence of the professional function of physicians’ anatomical knowledge.

Various factors contributed to the rise of human anatomy, among them Galen’s prestige (after all Galen had prided himself upon his dissecting abilities). Tampering with human remains was far from unknown in medieval Christendom. The wish to bring dead crusaders back from the Holy Land for burial had led to the custom of boiling up bodies to leave only the bones, and to the preservation of the heart of the deceased. Though this practice was condemned by Boniface VIII in 1300, the papal ban proved ineffective. From around 1250, autopsies also became regular in Italian, French and German towns, with surgeons called in to investigate homicide and establish cause of death. The step from a coroner’s postmortem to dissection was small.

Public dissection was spectacle, instruction and edification all in one. The corpse would be that of an executed criminal, presupposing municipal cooperation. It was sometimes staged in a church, usually in winter, since cold slowed putrefaction. Mondino’s order of dissection of the three main bodily cavities – first the lower abdomen, then the thorax and the skull – was designed with decay in mind. In illustrations of dissections, a physician resplendent in academic robes sits on a throne, intoning from a Galenic anatomical text, while a surgeon slits the cadaver with his knife, and a teaching assistant points out notable features. Whether or not dissections were actually conducted in this way, what is conveyed is the ritual of the performance: religious, civic, and university authorities agreed that the occasion must be accorded due gravity.

Book-driven anatomy – a demonstration of what was already known, within the explanatory framework of learned medicine – served many purposes, providing guidance to the student, who would not have been able to see much for himself. From Bologna, human dissection spread; the next key centre was Padua, which was popular with foreign students. In Spain, the first public dissection took place at Lerida in 1391; Vienna held its first in 1404. In England and Germany anatomy teaching with a human corpse did not become routine before 1550.

Anatomy had an impact upon medical illustrations – a subject bedevilled by modern prejudices about �realism’, for medievals who drew �childish’ images of the bones and arteries have been adversely contrasted with the new �scientific’ artists of the Renaissance (notably Leonardo da Vinci), admired for their realistic anatomical drawings. But the comparison is misleading. For one thing, Leonardo at times followed tradition rather than his eye, adopting, for instance, the standard five-lobed liver. For another, it is wrong to think that the apparent crudity of medieval images reveals ineptitude. Late medieval illustrations were not meant to depict minute documentary detail; they were diagrammatic teaching aids, schematically representing general truths – mnemonic rather than photographic.

The most common type of medieval medical illustration was the �Zodiac man’: a male figure marked up with blood-letting points or with the zodiac signs (Taurus controlled and cured diseases of the neck and throat, Scorpio the genitals, Capricorn the knees, Pisces the feet, and so forth). The right way and place to let blood was gauged by study of the constellations and the moon. There was also the group known as the �five-picture series’, standing for the five systems: arteries, veins, bones, nerves and muscles. Squatting figures with legs astride were occasionally used to show diseases, wounds and the influence of the stars and planets on body parts. There were also charts explaining how to examine urine. The success of such images is evident: they survived into the age of print, wound-men in particular continuing to crop up in surgery texts.

The late Middle Ages wear a gloom-laden appearance: painters gave Death a mocking grin and portrayed him accosting peasants, merchants and princes. Perhaps for this reason, and because it was roundly disparaged by Renaissance humanists, medieval medicine has never enjoyed a good press. Proud of recovering Hippocrates and Galen in the original Greek, humanists chid and despised their muddle-headed predecessors.

We should not blindly accept these judgments. Much was afoot before 1500: in particular the fifteenth century brought a rise in practical medicine, associated with the books of practica and case-histories (consilia) produced by Italian professors. Bedside consultations, autopsies and the spread of dissection gave Italian medical training an increasingly hands-on emphasis. It is ironic that from the 1490s the medical humanists reverted to theory, to philology and medicine’s �sacred’ books, notably through the Galen revival.

The later Middle Ages also consolidated the role of medicine in European society, with new institutions and regulations. At the time when the Salerno school was founded, physicians were to be found only in monasteries and palaces; five hundred years later they had infiltrated society (remember the physician on Chaucer’s pilgrimage) and were facing competition from other practitioners like barber-surgeons, professional bickering being but one sign of this growing medical presence. Other domains of life were falling under medical control: health officials directed urban hygiene and combated plague. From birth to death – and even beyond, if one had the misfortune to be cut up for a public anatomy display – medicine gained a hold that it had previously lacked or lost.

* (#ulink_a8e40533-7a42-500f-8938-9983cc9d3aba) Take for instance this section in the English translation by Sir John Harington (1561–1612) (who was, incidentally, the inventor of the water-closet):

Although you may drink often while you dine,

Yet after dinner touch not once the cup, …

To close your stomach well, this order suits,

Cheese after flesh, Nuts after fish or fruits.





CHAPTER VI INDIAN MEDICINE (#ulink_f37c29c6-062f-51a9-a4ff-41904df117e1)


EACH AREA OF THE GLOBE has created a medicine of its own. The neolithic revolution in India and China produced civilizations comparable in complexity and achievements to the developments discussed in the Middle East, the Levant and the eastern Mediterranean, like these, founded upon an agrarian economy sustaining, and sustained by, political overlords and large urban settlements. In the great Asiatic empires social hierarchy and the consequent division of labour facilitated the emergence of specialist healers, together with priests, wise men and bureaucrats.

The consolidation of writing encouraged learned traditions which helped to give permanence to particular corpuses of medical (as well as religious and philosophical) erudition. As with the writings of Hippocrates and Galen in the West, the result tended to be a glorification of tradition, and the associated belief that a fixed, permanent and perfect medicine had, in a quasi-divine manner, been handed down from some far-distant origin. It was the duty of successors to uphold such a tradition, protecting and purifying it against the threat of corruption. Such values imparted into Asian medical systems a great durability; they certainly gave no encouragement to innovation. Indian and Chinese medicine alike proved tenacious and encouraged myths of an essential unchangingness – though this was actually belied by developments. The consequence was that both traditional Indian and traditional Chinese medicine continued in place; yet both experienced in due course a tense and ambiguous encounter with western �scientific medicine’, which left them compelled to take aspects of it on board.




EARLY INDIA


As in many other parts of the world, the first settled agricultural communities in India appeared at the end of the last Ice Age about ten thousand years ago; around 3000 BC, as archaeology reveals, developments took place around the Indus river leading to elaborate civilization. Excavations of the imposing Indus cities of Harappa, Mohenjo-daro and Lothal have revealed what must have been a complex urban social order, with well-defined social and occupational hierarchies. As well as priests, healers must have existed: perhaps the function was twinned. Remains of great public water tanks in these cities suggest communal bathing and hence cleansing rites, perhaps linking ritual to hygiene.

Around 1500 BC, this Indus civilization seems to have fallen into decay; the explanation for this may lie in climatic and environmental changes affecting the water courses. Meanwhile, the Indo-European peoples were migrating into south Asia, and their civilization achieved a position of dominance in the subcontinent. Brotherhoods of hereditary priests (brahmana) grew powerful, becoming the masters and guardians of Sanskrit religious teachings called veda (the knowledge). Though there is no distinctive �Vedic medicine’, such religious writings shed some indirect light on contemporary beliefs about health and healing.

It seems that a magico-religious outlook on illnesses and treatments became established which broadly parallels Mesopotamian or Egyptian practices. Distinctive healing powers were associated with particular deities, it being believed that diseases could be produced by wicked spirits or by happenstance. The deities who brought disease visitations were to be propitiated by rites involving mantra (incantations), supplications and expiation. Herbs were valued for their therapeutic powers, while injuries and broken bones were attributed to everyday causes; but some diseases – conditions like yaksma (perhaps consumption) and takman (fevers associated with the monsoon season) – were judged to be signs of demonic and magical interventions. Beliefs about the body and its workings came from various sources. Vedic rites involved the use of animal and human sacrifice, and the ceremonial texts contain some listings of anatomical parts. Some basic forms of surgery were also recorded, cauterization being employed to stanch wounds, and reeds were used as catheters to relieve the retention of urine. Vedic writings speak of the value of water, whether to be bathed in, drunk or ritually applied.

From perhaps 1000 BC, Veda constituted the main faith of north India. Other groups also were appearing, seemingly dedicated to making religion a more spiritual matter and placing emphasis upon the need to lead a life of moral uprightness. Alongside many individual ascetics, the chief and best known of such groups was the Buddhist community, founded by Gautama Sakyamuni (the Buddha, 563–483 BC). Others included those subsequently called the Jains. These gatherings gave rise to new medical practices.

The monastic rule which governed the lives of Buddhist monks, dedicated to acquiring the �peace of mind brought about by the abandonment of desire’, declared that among their meagre belongings should be included five elementary medicines: fresh butter, clarified butter (ghee), oil, honey and molasses. This list expanded in time to embrace a large pharmacopoeia and divers foodstuffs. Archaeological evidence from the fourth century AD shows that some Buddhist monasteries included a sick-room, which may have developed into a more distinct hospital, at around the same time as the emergence of hospitals in the Christian West. Initially, the monks’ healing activities were for fellow brethren, but, as in the West, the monasteries also served the lay community.

In contrast to the earlier Vedic medicine, which is not at all similar to Ayurveda, there are striking resemblances between these Buddhist texts and later Ayurvedic texts on medicinal herbs and on specific treatments. In terms of origins and influences, the Ayurvedic texts are themselves misleading, since they claim a derivation from the Vedic tradition. The reality is that, while the situation is complex and controversial, they probably developed out of the newer ascetic milieu. Best scholarly opinion today holds that the ascetic communities of the fourth century BC onwards, particularly the Buddhist community, played a vital part in the evolution of Ayurveda.




AYURVEDIC MEDICINE


The archetypal system of Indian medicine is called Ayurveda – the knowledge (Sanskrit: veda) needed for longevity (ayus). Ayurvedic teachings amount to a code of life and consist of practical advice concerning all aspects of life, from washing to diet, from exercise to regimen, within a wider Hindu religious philosophy of rebirth, renunciation, and the maintenance of the balance of the soul. Their theoretical foundation lies in the notion of three basic bodily humours (dosas) – wind, bile, and phlegm – which reflect the macrocosmic forces of wind, sun and moon. There are also seven fundamental bodily constituents: chyle, blood, flesh, fat, bone, marrow and semen. The Ayurvedic pharmacopoeia is mainly herbal, prescribing an assortment of therapies including ointments, enemas, douches, massage, sweating and surgery. Though metallic compounds came into medical use from around AD 1000, these remained marginal; opium too was brought in, apparently from Islamic sources, to relieve dysentery. For achieving health, the canonical texts stress temperance in all matters – food, sleep, exercise, sex and medicines themselves. The healthy life is to be consonant with the harmonies of the universe and true religious teachings.

Written in Sanskrit, the earliest surviving Ayurveda texts date from the early centuries of the Christian era; traditional claims among practitioners that Ayurveda dates back thousands of years are pious. Of the various Sanskrit writings that expound the Ayurveda, the earliest are the Caraka Samhita [Caraka’s Compendium] and the Susruta Samhita [Susruta’s Compendium], supposedly the work of the sages Caraka and Susruta. Very substantial in bulk, they form the cornerstone of Ayurveda. A third early text, the Bhela Samhita, survives only in a single damaged manuscript.

The Caraka Samhita tradition is connected with north-western India, and in particular the ancient university of Taksasila; the Susruta Samhita was supposedly composed in Benares on the River Ganges. Their original composition date is a matter of speculation: earlier versions may derive from as far back as the time of the Buddha (early fourth century BC). Caraka may date to around AD 100; Susruta to the fourth century. The Sanskrit texts which became canonical represent the works in the form they had attained around AD 1000.

There are other subsequent prominent Brahminic texts. These include the Astangahrdaya Samhita of Vagbhata (AD C. 600), which includes midwifery, the Rugviniscaya of Madhavakara (AD C. 700), the Sarngadhara Samhita of Sarngadhara (c. fourteenth century AD), and the Bhavaprakasa of Bhavamisra (sixteenth century). Madhavakara’s work broke new ground through rearranging medical topics according to pathological categories, thereby establishing the model of thematic grouping followed by almost all later works. Sarngadhara was the first Sanskrit author to introduce new foreign elements, including opium and metallic compounds, into the materia medica, and the use of pulse lore in diagnosis and prognosis.

The Caraka Samhita and the Susruta Samhita stem from a common intellectual tradition. The Caraka Samhita is marked by long reflective and philosophical passages, including discussions of causality and so forth. The Susruta Samhita for its part contains extensive descriptions of sophisticated surgical techniques: eye operations, plastic surgery, etc., which do not appear in the Caraka Samhita at all or only in less detail. Both are huge compendia of medical teachings on subjects such as a balanced diet; the powers of plants and vegetables; the causes and symptoms of various maladies; epidemic diseases; the right techniques for examining patients; the parts of the body; conception, pregnancy and the way to take care of foetuses; diagnosis and prognosis; stimulants and aphrodisiacs; the nature and treatment of fever, heated blood, swellings, urinary and skin disorders, consumption, insanity, epilepsy, dropsy, piles, asthma, coughs and hiccups and scores of other conditions; cupping, blood-letting, the use of leeches, and many other treatments; the right use of alcohol; the properties of vegetables, nuts, and other materia medica; the use of enemas – and all alongside incantations, omens and fears of sorcery.

The medicines described in the Caraka Samhita and the Susruta Samhita comprise a rich menu of animal, vegetable, and mineral substances. For dealing with the 200 diseases and 150 other conditions mentioned, the Caraka Samhita refers to 177 materials of animal derivation, including snake dung, the milk, flesh, fat, blood, dung, or urine of such animals as the horse, goat, elephant, camel, cow and sheep, the eggs of the sparrow, pea-hen and crocodile, beeswax and honey, and various soups; 341 items of vegetable origin (seeds, flowers, fruit, tree-bark and leaves), and 64 substances of mineral origin (assorted gems, gold, silver, copper, salt, clay, tin, lead and sulphur). The use of dung and urine are standard; since the cow is a holy animal to orthodox Hindus, all its products are purifying. Cow dung was judged to possess disinfectant properties and was prescribed for external use, including fumigation; urine was to be applied externally in many recipes.

The Caraka Samhita praises the virtuous healer: �Everyone admires a twice-born [brahmin] physician who is courteous, wise, self-disciplined, and a master of his subject. He is like a guru, a master of life itself.’ Quacks, by contrast, are roundly condemned: �As soon as they hear someone is ill, they descend on him and in his hearing speak loudly of their medical expertise.’ In respect of the true physician, the Caraka Samhita tenders an Oath of Initiation, comparable to the Hippocratic Oath. A pupil in Ayurvedic medicine had to vow to be celibate, to speak the truth, to adhere to a vegetarian diet, to be free of envy, and never to carry weapons. He was to obey his master and pledge himself to the relief of his patients, never abandoning or taking sexual advantage of them. He was not to treat enemies of the king or wicked people, and had to desist from treating women unattended by their husbands or guardians. The student had to visit the patient’s home properly chaperoned, and respect the confidentiality of all privileged information pertaining to the patient and his or her household.

The diagnostic and therapeutic aspects of Ayurveda depended on knowledge of the canonical Sanskrit texts. The good physician (vaidya) memorized material consisting largely of verses which specified the correlations between the three humours (wind, bile and phlegm), and the various symptoms, complaints and treatments. He conducted an examination of his patient which took into account the symptoms, in the process recalling verses applicable to the patient’s condition. These would trigger remembrance of further verses containing the same combinations of humoral references, all of which would lead to a prognosis and a proposed therapy.

The Ayurvedic schemes of substances, qualities and actions offered the vaidya an effective combination of solid learned structure and freedom to act. The practice of Ayurveda depended heavily upon oral traditions, passed down from master to pupil, in which a huge magazine of memorized textual material was recreated to fit particular circumstances, while remaining faithful to the fundamental meaning of the text. (The role of precedent within English Common Law offers a parallel.)

The Susruta Samhita is distinctive for its wide-ranging section on surgery, which describes how a surgeon should be trained and the various operations he should perform. There are, among other things, descriptions of cutting for stone, couching for cataract, the way to extract arrowheads and splinters, suturing, and the examination of human corpses as part of the study of anatomy. The text maintains that surgery is the oldest and most useful of the eight branches of medical knowledge, and elaborate surgical techniques are described. However, there is little evidence to confirm that these practices persisted. A description of the couching operation for cataract exists in the ninth-century Kalyanakaraka by Ugraditya, and texts based on the Susruta Samhita copy out the sections on surgery with other material. But medical texts give no evidence of any continuous development of surgical thinking; no ancient or even medieval surgical instruments survive; nor is surgery described in literary or other sources. A parallel may be found in the apparent fate of surgery within the Islamic tradition.

One possible explanation for this apparent waning of surgery is that, as the caste system grew more rigid, taboos concerning physical contact became stronger and, a little like Hippocratic doctors, vaidyas may have shunned therapies which involved applying the knife to the body, transferring their attention to less intrusive approaches, including examination of the pulse and the tongue. Whatever the reasons, the early sophistication of surgical knowledge seems to have been an isolated phenomenon in the development of the Indian medical tradition.

There is, however, one well-documented historical event which suggests that surgery akin to the Susruta Samhita remained widely known. In March 1793, an operation was undertaken in Poona of significance for the later course of plastic surgery. A Maratha named Cowasjee, a bullock driver with the English army, having been captured by Tipu Sultan’s forces, had his nose and one hand cut off – a customary punishment for adultery. He turned to a man of the brickmakers’ caste to have his face repaired. Thomas Cruso (d. 1802) and James Trindlay, surgeons in the Bombay Presidency, witnessed this operation, publishing in 1794 an account of what they had seen, with an engraving of the patient and diagrams of the skin-graft procedure. The obscure brick-maker, reported the English surgeons, had performed a superb skin-graft and nose reconstruction using a technique superior to anything they had ever seen. It was taken up in Europe and became known as the �Hindu method’.

This may seem to be proof of the persistence of Susruta’s surgery during the course of well over a thousand years, but there are puzzling elements to the tale – notably the fact that rhinoplasty of this kind is not delineated in any detail in the Susruta Samhita. Furthermore, as a member of the brickmakers’ caste, the surgeon who performed the Poona operation was not himself a vaidya. He probably knew no Sanskrit: his skill lay in his hands, not in his head. It is conceivable that this represents a survival of a procedure from Susruta’s time, but if so it seems to have been passed down independently of the practice of educated physicians. There is no evidence from other written sources of the practice of such operations in the intervening period.

A similar puzzle is posed by smallpox. Before the nineteenth century, inoculation was popular knowledge and widely used for protection against the disease, with the expectation that a mild episode would follow. After the graft the patient was kept quarantined in a controlled environment. A detailed account by an English surgeon, dating from 1767, describes the practice and states that it was widespread in Bengal. No trace of inoculation appears, however, in any Sanskrit medical text. The disease was undeniably identified in Ayurvedic writings, where it is called the �lentil’ disease, but again the link between theory and practice is tenuous. It seems that techniques recorded in texts, though still related in the learned tradition, fell into disuse, while new developments were widely practised without being inscribed in approved medical learning.

In this light it is easy to fall into the trap of assuming that the Ayurvedic tradition was static and �timeless’ – that later texts did no more than to elaborate a coherent and comprehensive set of teachings set out, once and for all, in the Caraka Samhita and the Susruta Samhita. This supposition is given some support by the fact that these two texts do present themselves as unchanging bodies of knowledge; moreover, it is in line with native and foreign stereotypes of India as the fountain-head of eternal truths. But while the canonical texts present the appearance of homogeneity, research into the development of Sanskrit Ayurvedic literature has revealed that numerous authors dissented from orthodox viewpoints. In the course of time new diseases were reported and identified. From the sixteenth century syphilis (known as �foreigners’ disease’ in Sanskrit) was described in texts (mercury, brought to India by Islamic physicians, was used to treat it); and from the eighteenth century writings embraced disease descriptions evidently borrowed from western medicine.

There were also innovations in diagnostics. Close attention to urine, and techniques for its inspection, stem from the eleventh century. Before the thirteenth century there is no mention of pulse examination in Sanskrit texts, but it subsequently developed into a key diagnostic method. A technique called �examination of the eight bases’ (astasthanapariksa) – the routine diagnostic method for examining the patient’s pulse, urine, faeces, tongue, eyes, general appearance, voice and skin – emerged in the sixteenth century. Novel prognostic techniques also came into use. For example, from about the same time, a procedure was taught whereby a bead of oil was dropped on the surface of a patient’s urine. The remaining span of his life was read from the way the oil spread.

In therapy, a discernible shift lay in the rise of standardized compound medicines (yoga). Consisting of a large number of ingredients, yoga is regularly described in terms of its specific effectiveness against a particular ailment; this brings into question the conventional western view that Ayurvedic medicine was invariably holistic.

Though Ayurveda is the most familiar tradition of indigenous Indian medicine, others have flourished in the subcontinent, notably the Siddha system of the Tamils and the Yunani medicine of Islam. Other assorted therapies are also visible, from folk medicine and shamanism to faith-healing and astrology.

In south India, the form of medicine evolved in the Tamil-speaking areas was dissimilar in certain aspects to Ayurveda. Known as Siddha medicine (Tamil: cittar), this was basically an esoteric magical and alchemical system, presumably heavily influenced by tantric ideas. It was characterized by a greater use of metals, in particular mercury, than in Ayurveda, and prized a substance called muppu, credited with possessing great powers for physical and spiritual transformation. Pulse taking was highly valued for diagnosis. The semi-legendary founders of Siddha medicine include Bogar, who is said to have journeyed to China, teaching and learning alchemical lore, and Ramadevar, who supposedly travelled to Mecca, teaching the Arabs the arts of alchemy.

From earliest times, Ayurvedic medicine handled and treated a range of children’s maladies, blaming them on the evil influence of celestial demons (graha, seizer), believed to attack children. The Sanskrit term graha was subsequently used to mean �planet’, and although grahas are clearly described as celestial beings in the Susruta Samhita, later rites for planetary propitiation are targeted at the same types of influence. Indian astrology and religious ordinances contain texts for placating heavenly bodies, as well as astrological prognostications regarding such matters as pregnancy and the sex of unborn children, dream interpretation, sickness and death. According to an early and significant legal work, �one desirous of prosperity, of removing evil or calamities, of rainfall [for farming], long life, bodily health and one desirous of performing magic rites against enemies and others should perform sacrifice to planets.’

A work exemplifying the close relationship between medicine and astrology as therapeutic systems is the Virasimhavaloka by Virasimpa, written in AD 1383, probably in Gwalior. It deals with diseases from three points of view: astrology, religion, and medicine. The body parts are matched to the constellations and planets in an intricate scheme of influences and associations, and it is the astrologer’s task to read this pattern of symbols to understand the patient’s problem before advising remedies such as charms, expiations, prayers and herbs.

The Bower manuscript, one of the oldest surviving Indian works, contains a text on divination by dice. It reveals the outlook of a fifth-century healer interested in the therapeutic powers of garlic, in elixirs for eternal life, in the treatment of eye diseases, herbal medicines, butter decoctions, aphrodisiacs, oils, the care of children, and spells against snake-bites, as well as divination.




NEW ARRIVALS


Islam brought new medical practices to India, having a major impact after the eleventh-century Turco-Afghan invasions of Gujarat, and becoming entrenched especially around Lahore, Agra, Lucknow and Delhi. These were known as Yunani Tibb – Yunani (or unani) being an Indian representation of the word �Ionian’. Yunani medicine derives in large part from Galenic medicine as interpreted in Ibn Sina’s Al-Qanun fi’l-tibb [Canon], and continues to flourish in India today. It is practised by hakims (physicians) in rural areas especially and is advocated among those who wish to embrace a distinctively Islamic medicine.

Yunani medicine and Ayurveda have interacted to some degree, especially in materia medica. Though the primary languages of Yunani medicine are Persian and Arabic, there are also certain Sanskrit texts. Yunani postulates four basic humours, as distinct from Ayurveda’s three, and it has more of an orientation towards treatments in hospitals. The major difference between them is their clientèle. Broadly, Yunani physicians treat Muslim patients, and Ayurvedic physicians treat Hindus.

In the first half of the sixteenth century Portuguese settlers came to Goa. The first medical book printed in India was the Coloquios dos Simples, e Drogas he Cousas Mediçinais da India (1563) [Colloquies on the Medical Simples and Drugs of India] by Garcia d’Orta (1490–1570). D’Orta had gathered his material from local physicians, and the signs are that there was a free exchange of medical ideas at that time between the Portuguese and the Indians. Relationships however declined, and after 1600 the Portuguese introduced restrictions which in effect banned Hindu physicians in Goa.

Dutch East India Company officials showed great interest in the natural history and medicines of the Malabar coast where they traded and settled. Heinrich van Rheede (1637–91), the Dutch governor, published between 1686 and 1703 a work containing nearly 800 plates of Indian plants. Paul Herman’s (1646–95) herbarium and Museum Zeylanicum provided major sources for Linnaeus’s Flora Zeylanica (1747).

The British arrived around 1600. Facing unfamiliar and severe health problems, East India Company traders were keen to learn from the local vaidyas and hakims, and Indian doctors were curious about British surgery, since the art had lapsed among vaidyas. It was observed by Sir William Sleeman (1788–1856) that �the educated class, as indeed all classes, say that they do not want our physicians, but stand much in need of our surgeons.’

British physicians were initially prompted to adopt Indian methods by the problems involved in shipping medical stores from Europe. In time, however, they grew increasingly critical of the crudeness of indigenous drugs and contemptuous of what they saw as the shortcomings of Indian medicine. With characteristic ethnocentricity, East India Company attitudes towards Indian medicine hardened. When medical colleges had been founded in Bengal and elsewhere under the British Raj, the study of Ayurveda was given a semblance of support alongside British medicine; but with changes in educational policy after 1835 and the suppression of Ayurvedic teaching in state-funded medical colleges, British support for Ayurvedic training ceased. Ayurvedic physicians continued to practise, although their training was reduced to the traditional family apprenticeship system.

In the twentieth century, with the rise of the Indian independence movement, indigenous traditions received active encouragement from nationalists. In recent decades there have been divided loyalties: since independence in 1947, the Indian government has oscillated between commitment to western medicine in the name of progress, and acceptance of the fact that Ayurvedic medicine is widely practised, especially in the countryside, and commands sturdy loyalties. Many Indian physicians have a strong incentive to devote themselves to western medicine – it is a passport to practise throughout the world.

In 1970, the Indian Parliament passed the Indian Medicine Central Council Act, setting up a central council for Ayurveda. Since then government-accredited colleges and universities have provided professional training and qualifications. This training, however, includes some basic education in western methods, family planning and public health. In 1983, there were approximately one hundred officially approved Ayurvedic training colleges, many attached to universities. But although the number of Ayurvedic and Yunani colleges and dispensaries has multiplied since independence, government funding has been minimal. Popular perception is said to be that the students in the indigenous medical schools failed to gain admission to modern western medical or professional universities.

The traditions combine and are rarely exclusive. Private Ayurvedic practitioners make use of modern western treatments, often on the wishes of their patients: western-style injections are widely regarded as a powerful, almost magical cure. In a small 1970s study of fifty-nine indigenous practitioners in Punjab and Mysore, researchers found that the vast majority of drugs being used were antibiotics and similar western medicines. The idea that Ayurvedic physicians deal purely in herbs, roots, and therapeutic massage is a nostalgic myth. Today in India, the patient may take any of many available paths towards greater health. There exist side by side physicians of cosmopolitan medicine, Ayurveda, and Yunani, as well as others such as homoeopaths, naturopaths, traditional bone-setters, yoga teachers and faith-healers.

The trend, however, is towards the greater assimilation of western medicine, especially among the wealthy and cosmopolitan. It is noteworthy that Ayurvedic medicine has not yet achieved the vogue in the West acquired by Indian philosophy and (thanks to fascination with acupuncture and the yin-yang system) by Chinese medicine.





CHAPTER VII TRADITIONAL CHINESE MEDICINE (#ulink_5a167f72-891e-57d6-af0c-f68ac7dd087c)


Rather like the Ayurvedic medicine just discussed, traditional Chinese medicine has often been presented as an authentic incarnation of timeless wisdom. Chinese medicine, assert its champions (and occasionally its detractors) has been passed down essentially unchanged since the dawn of civilization. This characterization, along with claims that, unlike western biomedicine, it is holistic and draws only upon mild �natural’ substances, is to some extent a propaganda exercise. Even so, the impressive antiquity of Chinese medicine, and its distinctive attitudes towards knowledge of the human body, provide some justification for the contrast. Traditional values and canonical texts were, indeed, highly valued and, unlike the West, novelity has never been prized in the Chinese medical tradition, or for that matter in Chinese thought and culture at large.

While distinctive, Chinese medicine is not totally unlike other medical traditions, and that is partly because it is not wholly indigenous. Over the centuries it has absorbed many outside influences, from India, Tibet, central and south-east Asia, while for the last hundred and fifty years it has been forced to adjust to western medicine. Certain of the key drugs in the Chinese pharmacopoeia were introduced from abroad – ginseng from Korea, musk from Tibet, camphor, cardamom and cloves from south-east Asia, frankincense and myrrh from the Middle East. The needling techniques behind acupuncture may have originated in central Asian shamanic healing. Indian Buddhism brought teachings concerning the soul and salvation which prescribed care for the ill and infirm. Buddhist charms were incorporated into classical Chinese therapy, while, in medieval times at least, cataract surgery was performed which probably derived from India (such operations later lapsed). Indian medical theories are not wholly compatible with Chinese models, however; and though some have held that Ayurvedic or even Greek influences are present in the use of such categories as �hot’ and �cold’ in Chinese medicine, these are better seen not as borrowings but as transcultural.

While Chinese medicine thus assimilated beliefs and practices from elsewhere, the reverse was happening as well. As the Chinese tongue, Confucianism and Chinese Buddhism were embraced by elites through south east Asia, so too was Chinese medicine. Along with Buddhism, it had been introduced to Korea by the sixth century AD, and Buddhist priests relayed it from there to Japan. (In modern Korea, Chinese medicine is known as hanui: and in Japan as kanpo.) From the sixteenth century, Chinese medicine arrived with migrants to Taiwan, the Philippines and elsewhere – all regions where Chinese medicine flourishes today alongside the western variety.

Alongside herbs such as ginseng and Chinese rhubarb, distinctive features of Chinese medicine, notably moxibustion and acupuncture, became reasonably familiar to Westerners from the seventeenth century onwards: from Japan, the Dutchmen Wilhem Ten Rhyne (1647–1700) and Engelbert Kaempfer (1651–1716) sent home accounts of acupuncture, including maps of the acupuncture channels. Yet this had no noticeable impact upon European medicine, even though after 1800 acupuncture enjoyed a certain vogue, especially in France.




CHINESE HEALING


Peasants traditionally went to folk or religious healers, for in popular thinking the supernatural was seen as a major cause of illness – sickness was believed to be created by demons or to be punishment for violating or neglecting one’s ancestors, who might then need to be propitiated with sacrifices. Learned medicine, by contrast, was wholly an elite matter, taught and practised by educated men, who treated clients from the middle and higher strata of society and from the state bureaucracy. This learned medicine was grounded on a corpus of texts: works on medical theory; on the classification, diagnosis and treatment of diseases (including collections of case histories); and on drugs and prescriptions.

The earliest surviving texts (over ten thousand specialized medical writings have come down) date back about twenty-two centuries, and incorporate even earlier materials. Dynastic circumstances account for this timing. The Chinese Empire became politically unified in 221 BC, and the emperors of the Han dynasty (206 BC – AD 220) established a body of political, philosophical and religious teachings. This period brought about the formation of the medical canon which constitutes the theoretical basis for the �high classical’ medical tradition and which was to set the mould for subsequent medical doctrines and developments. An integrated empire promoted the idea of a unified body, while policy-making for a flourishing state encouraged thinking about health. Thereafter the human body was envisaged, by analogy, to the state, as a series of operations which built up, allocated and processed precious and scarce resources, through communications networks. Good medicine was like good government.

Four core works make up the �high classical’ tradition, all of unknown authorship. They are the Yellow Emperor’s Inner Canon of Medicine (Huangdi Neijing), so called because it includes a dialogue between the �yellow emperor’ Huang-ti and his chief minister, Ch’i Po; the Divine Husbandman’s Materia Medica; the Canon of Problems; and the Treatise on Cold-Damage Disorders. The former two enjoy scriptural status, being considered as preserving the wisdom of legendary sages; every learned physician would be expected to be word-perfect with those. The latter two, for their part, were also classics which physicians would also be expected to know inside out; but they were thought to originate not in divine revelation but in experience, which was open to being queried, revised and even contradicted.

The Inner Canon contains teachings on core subjects: the physiological make-up of the body, including the circulation of qi (roughly: energy); health and the onset and prognosis of diseases; and therapy through needling (bloodletting or acupuncture). It depicts the human body like a kingdom, with organs like the heart and liver regarded as functions, or functionaries, working in harmony through communications and transport systems – the vessels and channels of the body (analogous to China’s great rivers), through which qi would flow.

The Canon of Problems addresses eighty-one �difficult issues’ which arise from the Inner Canon, relating mostly to diagnosis and needling treatment. Its significance alongside the Inner Canon was unquestioned until the Song dynasty (960–1279), but thereafter, where discrepancies were noted between the two works, it was assumed that the writer of the Canon of Problems had failed to grasp the authoritative teachings of the Inner Canon.

The Treatise on Cold Damage Disorders, for its part, deals with the identification and treatment of diseases caused by external cold factors (shanghan bing): approximately what western medicine would designate acute infectious fevers. Diagnosis follows what is known as the Six Warps theory, and therapy is not by needling but by drugs. Formulae are given for more than a hundred prescriptions – for countering fever, diarrhoea, and so forth – and many such items from the pharmacopoeia are still in use.

In the twelfth century Chinese physicians began to refine shanghan (cold factor) theory, developing the notion of heat-factor disorders (wenre bing), and thereby distinguishing between disorders in terms of their separate aetiologies. This tendency became more pronounced during the seventeenth century, when China was buffeted by waves of serious epidemics. Criticism of cold-damage theory then led to a succession of works on heat-factor disorders, especially the Wenre lun of Ye Tianshi (c. 1740), which elaborated the �triple burners’ (san jiao) system of disease classification.

Lastly, the Divine Husbandman’s Materia Medica includes descriptions of the properties and uses of over three hundred vegetable, animal and mineral drugs, arranged into three classes: upper, middle and lower. Viewed as gentle and cumulative in action, drugs of the upper class were meant to promote health and longevity; the more potent lower class of drugs was to be employed once the patient had actually fallen sick. This longevity-oriented pharmacy was abandoned in later materia medica, giving way to systems based on curative qualities, with items being categorized according to a scheme of correspondences between yin yang and wu xing (the �five phases’ or �five processes’). Thousands of materia medica listings were written down over the centuries, the principal one being the late sixteenth-century Bencao gangmu.




THE TRADITION


How have these ancient texts have been able to retain such uninterrupted authority? Was it because Chinese medicine was, at bottom, hidebound or metaphysically oriented, its physicians being concerned first and foremost with dogma and only secondarily with hard evidence and the cutting-edge of experience? Some have seen it that way, and there have been critics who have dismissed Chinese medicine as nothing more than an elaborate verbal tapestry. Sinophiles, by contrast, argue that the story of Chinese medicine is one of the progressive winnowing of the grains of science from the chaff of ignorance and superstition. Along such (seemingly Whiggish) lines it has been claimed that Chinese physicians evolved theories (such as the model of the heart as a pump) which match or even surpass the evolution of western scientific medicine.

Facing these problems of interpretation, it is crucial to remember that the Chinese medical tradition presents an example of a classical model of knowledge. The role of basic concepts such as yin yang, for instance, remains definitive, even though their meanings were capable of modification. Canonical works were regarded as the sure guides to understanding the human body (microcosm) and its relations to the macrocosm. As in the other text-based learning, there has been a scholarly predisposition in the Chinese tradition towards ironing out doctrinal conflicts by means of an attempted reconciliation in higher synthesis.

Like Greek medicine, Chinese teachings were built upon the conviction that the body represents a microcosm of Nature and society. Corporeal processes follow rhythms comparable to those governing the workings of the universe. �A human body is the counterpart of a state’, observed in Inner Canon:

�The spirit [the body’s governing vitalities, shen] is like the monarch; the Blood xue is like the ministers; the qi is like the people. Thus we know that one who keeps his own body in order can keep a state in order. Loving care for one’s people is what makes possible for a state to be secure; nurturing one’s qi is what makes it possible to keep the body intact.’

Health is dependent on the maintenance of internal bodily equilibrium, and also of harmony between the body, the environment, and the larger order of things. Healing is a matter of knowing how this harmony can be restored, for which the physician must be a philosopher as well as a technician.

Classical Chinese medical theory thus views the body as a physical entity subject to natural processes: sickness can be brought on either by some internal upset or by such external factors as cold, humidity or pestilence. Before the Han Dynasty came to power (c. 600–200 BC), ailments had often been blamed on evil spirits, or �wind’, which took possession of the soul: cures might be achieved by exorcism or drugs, and charms and sigils were also used to fend off demonic assaults. Because they were not yet properly anchored to their soul, the young were particularly vulnerable – one class of children’s afflictions is still termed �fright’.

Belief in supernatural disorders was to be eroded, however, and from the earliest systematic formulations of cosmological principles around 200 BC, sicknesses were regarded by physicians as determined by certain natural principles, rather as in the Hippocratic teachings. Chinese natural philosophy deals less in things than in relations, processes and cycles of transformation. The key to the natural world is qi (also rendered ch’i), variously translated as �air’ �vapours’ or �energy’, and somewhat resembling the pneuma or spiritus of Graeco-Roman medicine. In natural philosophy, qi, which permeates the cosmos, is something which stimulates a process of transformation, or is the medium through which such processes take place. In living beings, qi can be designated as �vital energies’ whose circulation sustains life itself. Life arises from a build-up of qi; its dissipation is marked by death. To preserve good health, a person must nurture the qi which sustains bodily functions. Qi can also be disruptive, however – �pathogenic’ qi brings illness on.

A concept fundamental for understanding the distribution of qi is the yin yang pairing, crucial from the Yellow Emperor’s Inner Canon of Medicine onwards. Yin possesses the qualities which superficially seem the diametrical opposite of yang – pairings like lower-upper, inner-outer, cold-hot, feminine-masculine, dark-light, wet-dry, etc. But these must not be read as fixed contraries; they are always relational and complementary – in any particular situation, yin and yang are symbiotic and subject to continual cyclical change.

Yin and yang are functions of space and time. Yang is more exterior, yin more interior. Once pathogenic qi penetrates the outer yang qi, which make up the body’s defences, it reaches the interior regions of yin qi which supply the body with nourishment and growth, and thereby turns more threatening. Like every other natural process, a malady will run through active yang phases and latent yin phases: once yang sickness has reached crisis point, it moves into a yin phase, which requires a distinctive treatment. Yin yang relations, in short, are complex, and must be appreciated from various viewpoints. In health and sickness alike, the body is in continual need of vigilant monitoring.

Wu xing (Five Phases) has often been translated as �five elements’, but that is misleading as there is no true parallel to the Greek notion of elements; the term �phases’ better suggests the dynamic quality involved. The Five Phases are wood, fire, earth, metal and water, paralleling the five viscera (heart, liver, spleen, lungs and kidneys), and all the other corresponding �fives’ (tastes, climates, odours, emotions, sounds, etc.). Each phase represents a class of action or interaction. Physiologically speaking, wood denotes a growth phase and a branching development; fire a phase of rapid upward dispersal, and so forth. Each phase is characterized by a distinctive colour, odour, sensation, bodily secretion, etc. and definite chains of relations result. The liver, for instance, is identified with the phase of wood, and the spleen with the phase of soil. Wood, perhaps in the form of a wooden spade, could move soil; hence, a relationship between liver and spleen could be explained as resulting from the tendency of the liver to govern the functions of the spleen.

The theory covering the patterning of these phases is known as �systematic correspondence’, embracing a vision of health as natural harmony within a holistic system. The Five Phases spontaneously beget each other in this sequence (the order of �mutual production’), while a sequence of �mutual restraint’ also applies – wood, earth, water, fire, metal. The body thus comprises a microcosm whose processes, healthy and pathological alike, are regarded as governed by the universal characteristics of qi, yin yang and the Five Phases.

Within the body, qi has two aspects – these are not material but processual. The yang element, likewise called qi, represents the capacity for action and transformation; the yin component, called xue (literally �blood’), represents the capacity for circulation, nourishment and development. Another vital substance (jing), translated as �essence’, includes both the nourishment gained from food and also (via the Taoist tradition) the reproductive substances like semen necessary for procreation. The vital forces circulate through the body in regular cycles through the circulation passages. These circulation tracts linking the visceral systems include the anatomically identifiable blood vessels but also involve invisible pathways along which qi travels in its various incarnations.

Before the systematic correspondence theory was elaborated, Chinese thinking about tracts and viscera seems to have conformed fairly closely with western anatomy. Early texts associate certain tracts with blood vessels, while others sketch in the location of the viscera. Chinese physicians were never interested in the mechanical models of the body promoted in the West after Descartes; nor, as medical theory became oriented from matter to processes, was close anatomical knowledge of the organs themselves expected.

Classical medical theory teaches there are five yin visceral systems: the cardiac, hepatic, splenetic, pulmonary and renal. These create, transform, govern, and accumulate qi, xue and jing. There are also six yang systems: gall-bladder, stomach, large intestine, small intestine, urinary bladder and the san jiao (�triple burner’). These process food to generate qi, xue and jing, and discharge waste. Despite apparent analogues with Western anatomical thinking about organs like the heart, lungs and liver, the emphasis is always upon functions – the Chinese body is above all a functional organism. The �triple burner’, which arose late in Chinese medicine, does not map onto any anatomical part of all, yet possesses a well-defined complement of functions. The connections between the visceral systems, and the sequences in which malfunctioning in one affects the others, are to be grasped in terms of the theory of systematic correspondence. Because the relationships between the viscera and the associated organs, senses, emotions and secretions are seen holistically, there can be no such thing in Chinese medical thinking as �Cartesian’ mind/body dualism, strict �localism’, or the aetiological specificity of �one cause, one symptom’ pathology.

When qi is circulating in the proper manner through the body, external threats are held at bay, harmony prevails, and good health is enjoyed and maintained through temperate behaviour. There are many ways to produce healthy qi: through diet, exercise, preventative acupuncture, moxa cauterization, meditation or sexual self-control. Such methods not only reinforce health but aid longevity: some texts envisage a lifespan of over a hundred years, while others aspire, in the Taoist manner, to immortality.

Illness (bing) by contrast results from imbalances of yin and yang, causing disturbance of qi circulation, which then impairs the normal operation of the visceral systems and the vital fluids. Obstruction, surplus or depletion of qi or xue in one of the visceral systems upset its functioning and distribution through the organism in ways determined by phase dynamics and modified in the individual case by the sufferer’s own constitution. If caught early in its yang (external) phase, the imbalance can be treated and health restored, but once the life-threatening yin phases are reached, the harm may be irreversible.

In these theories, a disorder can be produced either by the invasion of an external threat (noxious qi) or by internally generated imbalance. �Excesses’ are the main danger, but deficiencies can also do harm – gynaecological disorders, for instance, are supposed common among widows deprived of sex. External pathogens include heat and cold, damp, poisons, fright (especially in the case of children), or sexual intercourse with ghosts.

The presentation of a disorder in the particular case is shaped not only by the pathogen, but also by the sufferer’s constitution, which influences its phase dynamics. The state of disorders caused by any specific type of pathogen (cold damage disorders, for example) thus conforms to a general pattern but allows infinite variations. Though diagnostic handbooks tended to classify disorders for convenience’s sake by symptoms rather than causes, maladies could not truly be cured until their fundamental causes were fathomed.

Classical Chinese medicine thus embraced a humoral and constitutional approach to illness – �biomedical’ concepts of disease are foreign to its basic thinking. In the seventeenth century, however, a wave of epidemics led physicians to propose the existence of certain types of pathogenic qi, which entered the body through the nose and mouth, and which, as in the case of tuberculosis or smallpox, could be communicated by contact. This was a new concept closer to the western one of infectious diseases, but one employed for a limited category of disorders only.




PRACTICE


On being called in, a physician was expected to identify the patient’s ailment and its progress before assessing treatments. On the assumption that its primary cause would be veiled by all manner of complicating symptoms, it was crucial to know the constitution and medical history of the patient, which would shape the course of the disorder and indicate likely responses to treatment. The practitioner’s task would be to break the symptoms down into a manageable set of dynamic characteristics: the fundamental cause, how the qi was affected, which visceral systems were impaired. He might relate symptoms to the Five Phases. Examining a patient with cold feet, he would attempt to determine which of the Five Phases that particular sufferer had greatest affinity for. Cold limbs would suggest Water, which might be confirmed by the presence of a foul odour, whereas a fragrant smell would point to Earth.

Another such diagnostic system was the �Six Warps’, first spelt out in the Treatise on Cold Damage. This sorted out manifestations according to the degree of permeation of pathogenic qi. From the seventeenth century, this procedure was elaborated by heat-factor disorder theorists into a four-level classification based on the position of symptoms among the �triple burners’ (san jiao). The most popular diagnostic grid, however, was the �Eight Rubrics’, first outlined in the Inner Canon, which involved four sets of polar opposites of diagnostic relevance: inner-outer, cold-hot, depletion-repletion, and yin-yang.

From the earliest medical texts, pulse-taking is commended alongside the observation of other physical and emotional evidence. The pulse was believed to provide key information about the circulation of qi, thus indicating bodily imbalances and how the visceral systems were affected. Pulse-lore became a sophisticated art, the wrist pulse being sounded at three different depths at three different places, and gauged according to such criteria as force, fulness, duration, resonance, rhythm and general �feel’. According to Wang Shu-ho in his twelve-volume Mei Ching (AD 280) [Book of the Pulse]: �The human body is likened to a chord instrument, of which the different pulses are the chords, The harmony or discord of the organism can be recognized by examining the pulse, which is thus fundamental for all medicine’. Up to two hundred different varieties of pulses were identified.

Consideration was also given to the patient’s complexion, breathing, emotional condition, temperature, pain, appetite and digestion. Deep-seated visceral effects could be elucidated in well-charted ways. Ailments of the hepatic system, for instance, were manifested in the state of the eyes and were linked to anger; kidney disorders affected the bones, ears and the sexual capacities, and drew fear responses. Emotional or intellectual maladies were construed not as �psychiatric’ disorders per se, but as symptoms of general constitutional conditions.

The physician would take a case history from the patient and his or her family, investigating the immediate causes of the disorder (exposure to rain, over-eating, etc.), but also laying bare the perennial behavioural patterns discernible in the symptoms (insomnia, pain, appetite loss, fever, childbirth complications). Diagnostic techniques were to grow more elaborate over the centuries. Tongue examination was formalized in the nineteenth century, while the twentieth-century brought the incorporation of temperature measurements, blood-sugar levels and blood-count into case histories. Nevertheless, the essentials of the �Four Methods of Examination’ were, and still are, interrogation, pulse-taking, ocular inspection, and examination by sounds and smells.

Therapy is thought to involve two phases: it eliminates the pathogenic qi and counters its effects, while building up the orthogenic qi that constitutes the body’s own defences. A therapeutic plan would typically be developed. Life-threatening symptoms of an acute disorder such as coma or high fever had to be treated urgently before deep-seated imbalances could be tackled, but immediate treatments would always take those basic problems into account. For instance, certain yin drugs were judged effective for reducing acute fever, but if that were symptomatic of a yang depletion, yin drugs would simply make bad worse. The physician had to adjust his therapeutic strategies stage by stage as the malady was gradually brought under control.

Almost all complaints – even skin injuries – were understood as �internal’. Thus bad eyes had to be cured through treatment of the hepatic system, and a visceral system disorder could be relieved only by restoring the yin and yang balance, not by surgical removal of a diseased organ. Surgery was never part of mainstream Chinese medicine – nor were dissections staged, since Confucianism forbade the mutilation of corpses.

Associated with Taoist alchemy, drugs form by far the most important therapeutic agent. There are thousands of familiar prescriptions (fang) which have been written out for centuries. Drugs were thought to operate in various ways: some eliminated pathogenic qi, others replaced depleted qi or blood, lessened heat, or served as sudorifics or as laxatives. Most prescriptions included cocktails of drugs in measured proportions: perhaps a strong shot of a powerful �principal’ drug to thin viscid blood, smaller quantities of a �leading’ drug to direct the main agent to the affected visceral system, an �auxiliary’ to make the principal drug more palatable, and another to prevent undesirable side-effects. Medicines were taken in the form of pills, powders, syrups, infusions or decoctions made up by the physician or a pharmacist. Some could be purchased ready-made as nostrums, others were kept secret or handed down within a family.

Of distinctive importance were acupuncture and moxibustion therapies. Acupuncture involves puncturing the skin with fine metal needles one-half to several inches long. The needles, sometimes driven in with great force, sometimes inserted gently, are set at different depths, and the site of insertion is crucial. Once inserted, the needles are twirled and vibrated. The oldest surviving atlas of insertion points is found in the Inner Canon, but they go back further. The physiology of acupuncture rests on the Taoist doctrine that the life force circulates through the entire body. The acupuncture points – there were already 365 by the second century, and the number grew still larger – are located on fourteen invisible lines or meridians running from head to toe; specific points on those meridians �control’ certain physical conditions. Since disease is the outcome of imbalance in the body’s qi, and suffering or sickness is the manifestation of imbalance, acupuncture needles introduce a balancing and restorative qi.

Moxibustion is a technique involving the burning of small pellets (usually of dried mugwort) on points on the skin, a practice somewhat analogous to Western cupping. The idea is that the heat produced should stimulate qi in affected bodily parts. Like acupuncture, moxibustion is believed to produce stimulus at key nodal points along the qi circulation tracts; unblocking obstructed qi, it redirects it to depleted viscera and so restore proper circulation. Physicians mainly used drug therapy, but there were also acupuncture specialists who did not prescribe drugs, and lay people often performed both processes within the family. In 1601 Yang Chi-chou published his Chen-chiu ta-ch’eng [Complete presentation of needling and cauterization] in ten volumes, offering a survey of the literature and theories of acupuncture and moxibustion.

In elite medicine, doctor/patient relations were regulated by strict protocols. Physical contact between physicians and superior patients was kept to a minimum; females might remain hidden behind a screen, communicating with the physician only through a husband or maidservant. Obstetrics was not performed by physicians; for that there were lower-class adepts, as there were also for massage.

While the masses might believe that illness was caused by malevolent ghosts, irate ancestors, insulted gods, karma and sin, classical Chinese medicine was secular, as were the kinds of healers mentioned in the texts. One was the so-called �Confucian physician’ (ruyi), a gentleman scholar of good background who studied and practised the medical arts in a philanthropic spirit and was expected to treat the poor gratis. The second approved practitioner was the �hereditary physician’ (shiyi). He typically came from a medical dynasty, so his training included apprenticeship as well as book-learning. Such families would gain a name for themselves by specializing in a particular disorder or by possessing some nostrum. Some had the status of regular family doctors, receiving an annual retainer from well-to-do clients. These two categories of healer hardly amounted to an organized corps of professional physicians in the modern western sense: the closest to that were those who took state medical examinations before going on to serve as imperial medical officers. Their status, however, was not high.

The medical corpus also refers to a mass of quacks, itinerants, shamans, priests, masseurs and �old women’. Being neither scholars, philosophers nor gentlemen, they all lacked prestige. Female healers were dismissed in medical texts as both ignorant and rapacious; but, despite male misgiving, large numbers of midwives and wet-nurses met the health-care needs of gentlewomen. The Korean state even brought in formal medical training for women in the fourteenth century, though they were regarded as of inferior standing.

Common people, when sick, sought aid from a variety of healers, many of them religious. Sacred healing still retains its importance throughout East Asia, and has even enjoyed a recovery in the People’s Republic of China. The first hospices and charitable medical services in China were set up by Buddhist monks in the early centuries AD. Committed as they were to strict social order, Confucians also took health responsibilities seriously; they saw the health of the body politic and the well-being of the people as equivalents, believing that being dutiful to one’s inferiors proved one’s fitness to rule.

When Buddhist monasteries were nationalized in the ninth century under the Tang dynasty, the imperial authorities assumed responsibility for their infirmaries. State initiatives continued throughout the Song and Yuan dynasties, when the compilation of pharmacopoeias was sponsored and charitable pharmacies and clinics founded. The decline of state medical services during the late Ming Dynasty (c. 1500–1644) prompted a rise in private charities.




MODERN DEVELOPMENTS


Until the nineteenth century, Chinese medicine more or less matched its European counterpart in authority and efficacy. Chinese physicians showed little interest in European medicine, but the Japanese became familiar with western science through the Europeans allowed to reside in the port of Nagasaki, and what was called �Dutch scholarship’ (rangaku) flourished. Japanese rangaku physicians took up anatomy and surgery, introducing Jennerian vaccination in 1824. These developments helped undermine the prestige of kanpo, and schools of western medicine began to spring up. International politics, however, was a greater force of change than curative efficacy: by 1850, both Japan and China were confronted by European gunboats, and by a western medicine daily more confident of its own scientific superiority.

In 1869, the Japanese Meiji rulers resolved to adopt the German system of medical training and, while kanpo was not banned, its practice was subject to restrictions. Japan established a state system of western medical education and services, and by 1900 three imperial and eleven other state colleges of western medicine existed, which by 1912 had trained 14,552 physicians – around two-thirds of all those in practice. Many Japanese medical students were sent to Germany for their education.

The Chinese were exposed to western medicine through the missionaries who streamed in after the treaties following the Opium Wars. Some reformers held Chinese medicine partly responsible for the Empire’s backwardness and defeats, while others sought not to scrap but to reinforce it. In any case, the weak late Qing regime was in no position to effect Meiji-style reforms. In the end the chief force for change came not from the state but from the hated foreigners, above all the Chinese Medical Missionary Association, founded in 1886, which, together with the Rockefeller-funded Chinese Medical Commission, aimed to transform medical services and training, partly through the �union medical colleges’, established in Peking (Beijing) and other key cities after 1903. Yet by 1913, there were still only 500 Chinese medical students receiving training in all the mission services throughout the empire.

Republican China (1911–49) sought to establish a modern state medical system. By 1926 about one hundred cities had western-style medical services, which the Nanjing-based Nationalist government turned into the nuclei for health institutions, organizing a chain of medical education, hospitals and health centres stretching from the capital right down to rural paramedics. Peasant health-care was given priority: village health workers received training in smallpox, typhoid and diphtheria vaccination, in hygiene, the diagnosis and treatment of minor complaints, and referral of serious illnesses to specialists. The system drew upon western medicine and, whilst Chinese medicine was not banned, it came to be seen as old-fashioned, not least by Marxist revolutionaries.

After 1948, this nationalist health-care structure was taken over wholesale by the new People’s Republic, though under the Marxist regime Chinese medicine could also be depicted as �socialist’ and integrated into the Communist system. Science was exalted as the key to the future, yet patriotic sentiment, reinforced by anti-capitalist ideology, also gave Chinese medicine a renewed symbolic authority, leading to professional parity with western medicine (readily condemned as �bourgeois’). The emphasis on functions and holism within traditional Chinese medicine could be squared with the �dialectical materialism’ of Marxism-Leninism.

At the top of the tree, Chinese-style physicians are today required to have a basic training in western-style medicine, and vice versa. Indeed, in the late 1950s, when China was desperately short of skilled medical practitioners, thousands of doctors were withdrawn from regular medical practice for a three-year study of traditional medicine, and Beijing invested heavily in clinics and medical schools for Chinese medicine. The �barefoot doctors’ of the Mao era included amongst their skills simple acupuncture and a knowledge of Chinese materia medica.

The balance between western and Chinese practice has fluctuated, and the ideal of a �syncretic medicine’, combining the best of both, has become an attractive one. Attempts have been made to set Chinese medicine on an experimental, scientific footing. In line with this, there has been a move from functionalism to materialism in medical thinking, accompanied by tendencies to reduce traditional terms of Chinese medical art to their modern biomedical equivalents: thus xue classically ranges over a spectrum of meanings, only one of which corresponds to the biomedical concept of �blood’. While most practitioners continue to recognize this distinction, the trend is towards using the readings interchangeably. Materialism thus provides a way of translating Chinese medical theory and therapeutics into western scientific terms, and thence of mobilizing experimental laboratory techniques. The pharmacological effects of Chinese drugs have been tested, the siting of the acupuncture tracts investigated, and explanations advanced of the effects of acupuncture anaesthesia in terms of endorphins.

The classics continue to shape the thinking of contemporary practitioners: no Chinese medicine practitioner can be trained without becoming familiar with the canonical works. But, linguistically, classical Chinese is no longer essential for medical education, and physicians may cull their knowledge of the medical canon from selections in modern textbooks. Utilitarian priorities mean that many practitioners today gain only a smattering of the theoretical rationales underpinning therapy. Formerly Chinese medical practitioners won their prestige through textual erudition; now they assume the trappings of western medicine, and even traditional physicians wear white coats.

From a wider perspective, it is evident that there has been a great parting of the ways between eastern and western medicine. Initially they shared certain common assumptions, inscribed in hallowed texts, about the harmonies and balance of the healthy body. Western medicine alone radically broke with this. An entirely new practice grew up in Europe – scientific medicine – building upon the new sorts of knowledge, programmes and power which followed from dissection and the pathological anatomy it made possible.

Tensions thus opened up between the western and the eastern traditions which remain unresolved to this day. As early as the late eighteenth century, European surgeons visiting China were already expressing open contempt for traditional Chinese medicine; it was ignorant of anatomy and hence had no �scientific’ basis. Westerners found it laughable that Chinese doctors thought they could diagnose illness on the basis of the pulse alone. And though acupuncture gained some devotees in nineteenth-century France and Britain, it has been only in recent years that the claims of Chinese medicine have found a broader acceptance in the West. This is due partly to a new multiculturalism, and partly to rejection in some quarters of high-tech values; but it also owes much to �scientific’ explanations of acupuncture anaesthesia and other aspects of Chinese practices. Whether East and West will ever meet or even converge, medically, remains unclear, and only time will tell whether the current popularity in the West of acupuncture and Chinese medical outlooks will last.





CHAPTER VIII RENAISSANCE (#ulink_4c003164-6c45-5b21-8ea4-6cfb9ae19e63)

THE OLD WORLD AND THE NEW


THE MOST MOMENTOUS EVENT FOR HUMAN HEALTH was Columbus’s landfall in 1492 on Hispaniola (now the Dominican Republic and Haiti). The Europeans’ discovery of America forged contact between two human populations isolated from each other for thousands of years, and the biological consequences were devastating, unleashing the worst health disaster there has ever been, and precipitating the conquest of the New World by the Old World’s diseases.

The forebears of the �Indians’ Columbus encountered in his attempt to find a short-cut to the �Indies’ or China were hunter-gatherers. Before or around 10,000 BC such people had crossed the Bering Straits from Asia to Alaska via a land bridge created by the fall in sea levels during the last Ice Age. They were relatively disease-free; lacking domesticated animals, they had no walking disease-carriers except themselves, and on their travels they encountered no other humans.

The melting of the great North American glaciers isolated that continent while opening it up to the newcomers, who spread south. In time the Maya, Aztec and Inca to the south and the Mississippian peoples of North America settled into sedentary agriculture, cultivating maize and beans, cassava and potatoes, and in some cases building complex civilizations centred on vast cities – which spawned all the familiar health problems. Tuberculosis developed, as did pinta and other treponemal infections, including non-venereal syphilis, various disorders caused by intestinal parasites, and Chagas’ disease. With agriculture came the nutritional maladies typical of monocultures.

The Amerindian peoples developed their own forms of medicine, with priests, shamans and sorcerers conducting healing rituals. Supernatural powers were believed to inflict pestilence to punish misdeeds, and in Mexico and Peru disease was connected with witchcraft and the malevolent shades of dead animals, demons and deities. Native Americans acquired knowledge of the healing properties of various vegetable products: Peruvian Indians chewed coca leaves against hunger and fatigue, while cacao (cocoa) was the Aztecs’ most important tonic and medicinal beverage, powdered and boiled in water with honey, vanilla and pepper. The Incas had herbs for headaches and other pains; and they used scopolamine, a poison from the datura plant, as an anaesthetic. Broken bones were treated with fat from the ñandu, an ostrich-like bird, and llama kidney juice was dropped into aching ears.

North American Indian tribes had a less extensive materia medica. They used sassafras, holly, sunflower seeds and infusions of flaxseed, inhaled the smoke from burning twigs to treat chest conditions, and used decoctions of mushrooms and peyote as hallucinogens. A Spanish explorer, Cabeza de Vaca, travelling in the 1520s through what is now Texas, observed the healing practices of the native Indians: �their method of cure is to blow on the sick, the breath and the laying-on of hands supposedly casting out the infirmity.’ He had no doubt what to think of that: �We scoffed at their cures.’

The New World peoples were not living in a golden age, but they had been spared Eurasian afflictions. Thus they were vulnerable virgin soil, entirely without resistance to epidemics imported by the conquistadores. This was not the first time Spanish conquest had brought diseases to a virgin population. In the fifteenth century, the Iberian conquest of the Canary islands had meant total devastation of the native inhabitants, the Guanches, whose immune systems were helpless against European infections. Originally there were some 100,000 Guanches; by 1530 only a handful was left, and in the seventeenth century they became extinct, spectacular victims of what has been called ecological imperialism.

The first epidemic, which struck Hispaniola in 1493, may have been swine influenza, carried by pigs aboard Columbus’s ships. Other deadly diseases then struck in hammerblows, so that New World populations were reeling even before smallpox reached the Caribbean in 1518. That outbreak killed one third to one half of the Arawaks on Hispaniola and spread from there to Puerto Rico and Cuba. A few Spaniards fell sick but none died and, as ever, all was attributed to God’s will, in support of the Christian conquest.

Smallpox accompanied Hernan Cortés (1485–1547) to Montezuma’s Aztec Mexico, where the main town was Tenochtitlan (modern Mexico City); with some 300,000 people, it was three times the size of Seville. Contact spread the disease among the natives outside the city and then within. In 1521, Cortés attacked with 300 Spaniards. Three months later, when the city fell, the conqueror learned that half its people had died, including Montezuma and his successor: �a man could not put his foot down unless on the corpse of an Indian.’ The same happened when Pizarro (c. 1475–1541) took on the Incas: smallpox ran ahead of him to Peru. By 1533, when he entered Cuzco to plunder its treasure, the Incas were incapable of serious resistance.

Infections thus primed and sped conquest, rippling outwards to fell countless indigenes the Spanish troops did not have to butcher. The consequent epidemics did not merely exterminate vast numbers, they destroyed the will to resist – the psychological impact was as devastating as the physical. Between 1518 and 1531, perhaps one third of the total Indian population died of smallpox, while the Spanish hardly suffered. With allies like microbes, the Europeans did not require many soldiers or much military acumen.

These initial smallpox outbreaks were only the beginning of a long, mainly unintentional, but almost genocidal germ onslaught unleashed against the Amerindians. Waves of measles – 1519 (Santa Domingo), 1523 (Guatemala) and 1531 (Mexico) – influenza, and finally typhus followed, all bringing devastating mortalities. In 1529 measles killed two thirds of those who had just survived smallpox; two years later it had killed half the Hondurans, ravaged Mexico, raced through Central America and attacked the Incas. Repeated epidemics followed, one of the worst being that of typhus, which towards 1600 killed about two million people in the Mexican highlands. By then, 90 per cent of the local inhabitants had died in successive outbreaks, and the fabric of life had fallen to pieces.

Though the mainland populations of Mexico and the Andes gradually recovered, in the Caribbean and in parts of Brazil decline verged upon extinction; from as early as 1520, the Spanish imported slaves from Africa to meet the labour shortages in their lucrative Peruvian silver mines. African slaves, in turn, brought malaria and yellow fever, creating further disasters. Guns and germs enabled small European bands to conquer half a continent in what might be called, to echo Gibbon, another victory of barbarism over civilization.

In later centuries the North American Indian population was similarly devastated by the English and French, sometimes by the fiendish distribution of smallpox-infected blankets and clothes. In 1645, smallpox killed half the Hurons; the same happened later with the Cherokees in the Charleston area, and with the Omahas and the Mandans. Not one European fell sick of smallpox in 1680, when the Revd Increase Mather (1639–172 3) tersely recorded that �the Indians began to be quarrelsome … but God ended the controversy by sending the smallpox among the Indians’. The wholesale destruction of indigenous New World populations continued for over three hundred years; twenty million slaves had to be shipped to America to fill the vacuum, causing cruelty and suffering on a scale not matched until the regimes of Hitler and Stalin.




SYPHILIS


European expansion produced the �Columbian exchange’, a highly unequal disease trade-off in which Columbus may have brought one killer disease back from the Americas: syphilis. This broke out in 1493–4 during a war between Spain and France being waged in Italy. When Naples fell to the French, the conquerors indulged in the usual orgy of rape and pillage, and the troops and their camp-followers then scattered throughout Europe. Soon, a terrible venereal epidemic was raging. It began with genital sores, progressing to a general rash, to ulceration, and to revolting abscesses eating into bones and destroying the nose, lips and genitals, and often proving fatal.

Initially, it was called the �disease of Naples’, but rapidly became the �French Pox’ and other terms accusing this or that nation: the Spanish disease in Holland, the Polish disease in Russia, the Russian disease in Siberia, the Christian disease in Turkey and the Portuguese disease in India and Japan. For their part, the Portuguese called it the Castilian disease, and a couple of centuries later Captain Cook (1728–79), exploring the Pacific, rued that the Tahitians �call the venereal disease Apa no Britannia – the British disease’ (he thought they’d caught it from the French).

That some of the Spaniards at the siege of Naples had accompanied Columbus suggested an American origin for the pox (or �great pox’, to distinguish it from smallpox). It certainly behaved in Europe like a new disease, spreading like wildfire for a couple of decades. �In recent times’, reflected one sufferer, Joseph Gruenpeck (c. 1473–c. 1532):

I have seen scourges, horrible sicknesses and many infirmities affect mankind from all corners of the earth. Amongst them has crept in, from the western shores of Gaul, a disease which is so cruel, so distressing, so appalling that until now nothing so horrifying, nothing more terrible or disgusting, has ever been known on this earth.

Syphilis, we now know, is one of several diseases caused by members of the Treponema group of spirochetes, a corkscrew-shaped bacterium.


(#ulink_4d6fee65-672a-5708-ab53-919862741107) There are four clinically distinct human treponematoses (the others are pinta, yaws and bejel) and their causative organisms are virtually identical, suggesting all are descendants of an ancestral spirochete which adapted to different climates and human behaviours.

What caused this terrible outbreak? Many epidemiological possibilities have been mooted. It is feasible that some American treponemal infection merged with a similar European one to become syphilis, with both initial infections subsequently disappearing. Others maintain that venereal infections had long been present in Europe but never properly distinguished from leprosy; treponemal infections (pinta, yaws, endemic and venereal syphilis) had, it is suggested, initially presented as mild childhood illnesses, spread by casual contact and producing a measure of immunity. With improved European living standards, treponemes dependent on skin contact had become disadvantaged, being replaced by hardier, sexually transmitted strains. Thus an initially mild disorder grew more serious. A related theory holds that the spirochete had long been present in both the Old World and the New; what would explain the sixteenth-century explosion were the social disruptions of the time, especially warfare.

Like the pox itself, the debate raged – and remains unresolved to this day. But whatever the precise epidemiology, syphilis, like typhus, should be regarded as typical of the new plagues of an age of conquest and turbulence, one spread by international warfare, rising population density, changed lifestyles and sexual behaviour, the migrations of soldiers and traders, and the ebb and flow of refugees and peasants. While Europeans were establishing their empires and exporting death to aboriginal peoples, they were caught in microbial civil wars at home. Bubonic plague bounced from the Balkans to Britain, malaria was on the increase, smallpox grew more virulent, while typhus and the �bloody flux’ (dysentery) became camp-followers of every army. Influenza epidemics raged, especially lethal being the �English sweat’ (sudor Anglicus) which struck in 1485 (delaying Henry VII’s coronation), 1507, 1528, 1551 and 1578, and was described by Polydore Vergil, an Italian diplomat in London, as �a pestilence horrible indeed, and before which no age could endure’. John Caius’s (1510–73) A Boke of Conseill against the Disease Commonly Called the Sweat or Sweating Sickness (1552) noted the copious sweating, shivering, fever, nausea, headache, cramps, back pain, delirium and stupor. It came to crisis within twenty-four hours, with very high mortality. It was thought even worse than the plague, for plague:

commonly giveth three or four, often seven, sometimes nine … sometimes eleven, and sometimes fourteen days’ respect to whom it vexeth. But that [the sweating sickness] immediately killed some in opening their windows, some in playing with children in their street doors, some in one hour, many in two it destroyed, and at the longest, to they that merrily dined, it gave a sorrowful supper.

The �English sweat’ remains a riddle. Such calamities form a doleful backdrop to the Renaissance.




THE MEDICAL RENAISSANCE


From the fourteenth century Europe’s cultural and intellectual life was undergoing a mighty rebirth. First in the bustling commercial cities of Italy and later in transalpine courts, the arts and humanities were being restored to a brilliance unknown for centuries. Glory would be achieved, enthusiasts proclaimed, by burying the immediate past and emulating the ancients. New inventions were changing material culture: gunpowder, the compass and Gutenberg’s printing press. Books multiplied, and were cheered on by propagandists and educators.

Among these was the monk who quit his monastery, Desiderius Erasmus (1466–1536), who led European scholarship and culture for more than three decades. A supreme stylist, it was he who established Greek as the basis for literary and theological studies, not least through production of a restored Greek text for the New Testament. His example prompted others to produce the first Greek editions of the ancient medical authors, and he inspired young scholars and physicians to bring out the great Aldine edition of Galen (1525). He also took a keen personal interest in medicine, both as patient (he suffered from gout, kidney stone and hypochondria) and as author. His Latin versions of three of Galen’s works, The Protrepticus, The Best Method of Teaching, and The Best Doctor is also a Philosopher, were the first to be based on the Greek of the Aldine edition, and enjoyed huge success. Yet, if Erasmus promoted medical learning, he was dubious about doctors, echoing that earlier humanist, Petrarch (1304–74), who had written, �I have never believed in doctors nor ever will.’

Painters, philosophers and poets commended the beauty of the human form and the nobility of the human spirit, using the emblem of Vitruvian man, in which the idealized naked male human form was superimposed upon the cosmos at large. Above all perhaps, after centuries when the Church had taught mankind to renounce worldly goods for the sake of eternity, Renaissance man showed an insatiable curiosity for the materiality of the here and now, a Faustian itch to explore, know and possess every nook and cranny of creation. No wonder they became inquisitive about human bodies, which were judged to occupy a privileged status. According to the Venetian surgeon Alessandro Benedetti (c. 1450–1512),

The human body was created for the sake of the soul and stands erect among other animals, as established by divine nature and reason so that it might look upward more comfortably.… The heart was first created since it contains the principle of life and sense. Next came the brain and liver. Then nature, performing like a painter, sketched out the other members with a life-giving fluid; they gradually receive their colours from the blood, which is very abundant in man and stirs up very much heat.

Art and nature thus both drew attention to the body, and in an intellectual climate that revered the classics, no wonder there was a revival of ancient medicine. For centuries, of course, Galen had been god: the Arabs had synthesized his works and the medieval West had translated these into Latin. So why was there a need for a Galen revival?

Admiration for all things Greek was in the air. Spurred by the fall of Constantinople in 1453, Greeks like Theodore Gaza (fl. 1430–80) and his student Demetrius Chalcondylas (d. 1511) went to Italy, taking manuscripts with them and passing their knowledge to Italian humanists eager to believe that truth was at its purest in Greek sources: Plato, Aristotle, the poets and orators. These ideas were obviously applicable to medicine too, for were not its first oracles Greek?

�Back to the sources’ (ad fontes) acquired a further incentive. From 1517 Luther and his fellow Protestants were reforming the Church by returning to the Bible as the well-spring of true religion. Every doctrinal formulation of the Catholic Church was to be rejected unless sanctioned by the Bible, and the study of Greek manuscripts, it was argued, would purify the understanding of scripture. A return to the sources promised the key to progress, and philology (the study of language) was vital to rescue truth before it was engulfed in oblivion and error. This awakening prompted a medical parallel.

The first priority for medical humanists lay in sound new translations of original Greek texts, since the Arabic and medieval Latin editions were now judged incorrect and inelegant. Technical terms had been especially susceptible to adulteration. In 1492 Nicolaus Leoniceno (1428–1524), the doyen of Greek medical scholars at Ferrara, drew attention to this in his De Plinii et aliorum in medicina erroribus [On the Errors of Pliny and of Many Others in Medicine]. Criticizing Pliny’s muddling of plant names, Leoniceno ordered a critical re-examination of medical knowledge through revitalized study of the classics. He urged the recovery and editing of ancient Greek medical texts, and promoted scholarly yet stylish new Latin versions. Scornful of the folios used in medical teaching, he criticized Arabic works such as Avicenna’s Canon for corrupting the Greek treatises they purported to honour. It was he who provided the texts for the first Galenic works to be printed in Greek, and who published Latin versions of Galenic treatises, including the Ars medica.

Leoniceno delighted in exposing howlers resulting from inept scholarship, showing how mistranslations had clouded the terminology of diseases, plants and anatomy, with dangerous consequences – people would be prescribed the wrong drugs. One of the first treatises on syphilis, his De epidemia quam vulgo morbum gallicum vocant (1497) [On the Epidemic Vulgarly Called the French Disease] predictably denied it was new: he claimed classical texts should be scrutinized and provided a philological survey of Greek terminology for skin diseases.

In later years, much was done on texts and terms as part of a wider humanist attempt to dispel the medieval murk. Terminological exactitude was, for instance, crucial in a blood-letting controversy initiated by Pierre Brissot (d. 1522), who taught that the Greek texts of Hippocrates and Galen showed blood-letting was meant to be carried out on the same side as the source of illness rather than the opposite side, as in Avicenna’s corrupt versions.

In 1525 the Aldine Press in Venice, Europe’s leading printing house, published the complete works of Galen in Greek, a landmark in the retrieval of the pure word of the ancients. For workaday practitioners, it had little relevance, for few could read Greek; but they could use the new Latin translations, which after 1525 were mainly based upon the Aldine Greek. Galen’s On the Natural Faculties was published in 1523 in a new translation by Thomas Linacre (c. 1460–1524), physician to Henry VII, and in 1531 Johann Guinther von Andernach (1487–1574) published the newly discovered text of Galen’s On Anatomical Procedures, which sparked a reappraisal of dissection. During the sixteenth century an astonishing 590 editions of Galenic treatises appeared, the main publishing centres being Paris, Lyons, Venice and Basel. There was also a Hippocrates retrieval, the first humanist Latin edition appearing in 1525, and the first Greek edition, from the Aldine Press, a year later. In 1531 Guinther von Andernach, who was also one of Vesalius’s teachers, praised the times as those when �medicine has been raised from the dead’, because Hippocrates and Galen – until recently �almost utterly corrupt’ – had �at last been rescued from perpetual darkness’.

Greek texts were recovered: how did that affect medicine? It boosted the idea that ancient medicine was the true one and scholars its rightful guardians and interpreters. In Paris, the medical humanist Jacobus Sylvius (1478–1555) approached Hippocrates and Galen with religious awe, declaring �they had never written anything in physiology or other parts of medicine that was not entirely true’. His pedantry and Galen worship culminated in an Introduction to Anatomy (1555), vindicating Galen against Vesalius. If what the eye saw at dissections did not correspond with what Galen had reported, the fault lay not with Galen but with the corpse! Puny moderns could not be expected to show so perfect a body structure as that displayed by the ancients.

Like many contemporary physicians, Sylvius was a bookworm. His Order and Way of Reading Hippocrates and Galen (1539) was one of the earliest attempts to evaluate the authenticity of the Hippocratic Corpus, as well as suggesting the best way for students to approach Galen. His enthusiasm for recovering the true Galen was widely shared. He marks the shift from Arabic to Greek Galenism, notably in his treatises on pharmacology, where he demanded a return to Galenic purity. Galen’s remedies, he argued, were mainly composed of simples; the proliferation of compound medicines (ironically called Galenicals) was an Arab error. Not everyone, however, wanted to throw overboard the medical works of the Arabs and the medievals. Avicenna and Rhazes continued to be taught in most universities, and the tradition of medieval practica – handbooks listing disorders from head to toe with a description of symptoms and treatment – was too useful to be abandoned.

Scholarly study did not just give medical writings a classical authority and style; humanism spurred innovation as well. With the proliferation of medical discourse created by print culture, questions arose as to how medicine should be structured, taught and practised. Fifteenth-century medical teaching had become centred on the �affections’ (the ill happenings) of the body in terms of symptoms and cures, usually in a head-to-heels order; and the tried and tested practica supplied guides to diagnosis and remedies. But that hardly passed the crucial Galenic test: the conviction that therapy had to be rationally connected to aetiology. The practica contained little on disease causation, and failed to satisfy another Galenic requirement: the view that therapy should take into consideration the distinctive characteristics of each patient – constitution, temperament, strength, age and environment. Galen’s Methodus medendi [Method of Healing], extremely influential once it was available in Thomas Linacre’s translation (1519), declared that physicians had to assess not only the cause of the illness but all aspects of the patient.

Attempts were made to overcome this problem through that characteristic Renaissance solution, the application of method, an idea dear to the French philosopher Peter Ramus (1515–72). Scholars set about reducing Galenic medicine to �method’ and therefore certainty. The logical approach, they insisted, would help the physician to choose the correct �indications’ and so get the therapies right. The humanist faith in printed texts and academic methodologies encouraged encyclopaedic systematization, which could descend into the vain and verbose pedantry satirized by playwrights; Ben Jonson has one of his characters complain:

When he discourseth of dissection,

Or any point of Anatomy: that hee tells you,

Of Vena cava, and of vena portam,

The Meseraicks, and the Mesenterium,

What does hee else but cant? … Who here does understand him?

Giambatista da Monte (1498–1552), professor of the practice of medicine at Padua, was a pioneer of the new methodology. His �universal method’ involved proceeding, by systematic division and elimination, from the general to the particular, from broad disease classifications to specific disorder. His book helped the doctor to run through all possibilities until a full account of the indications for cure was reached.

The idea of a foolproof method for applying Galenic medicine to the individual (the parallel with computer diagnosis comes to mind) was taken further by Sanctorius Sanctorius (Santorio: 1561–1636), professor at Padua. In his Methodi vitandorum errorum (1603) [Methods for Avoiding Errors], he urged, echoing da Monte, that medicine should not begin with particulars; one had to work from general concepts, which were to be divided and divided again. What was being promoted was a teaching device exalting learning above empiricism.

Academic medicine was not totally conservative and in thrall to Galen, however; some new ideas were proposed about disease causation and remedies. Debates flared as to whether the traditional humours and temperaments could explain all sorts of illness. New diseases like the pox and the English sweat seemed to call for something beyond the old model of temperamental imbalance. And what of the influences of the heavens, or magic? Astrological powers, like the stars or moon, were �occult’, and thus by definition lay outside the Aristotelian-Galenic philosophy which addressed the natural, sensory world; they gained intellectual credit, however, from the neo-Platonic, Hermetic and magical currents popularized through such authors as Marsilio Ficino (1433–99) and Pico de la Mirandola (1463–94). Hidden qualities and sympathies which defied Aristotelian categories might be at work, such as magnetism and the electric discharge of the torpedo fish. These were explained by recourse to �occult qualities’ or to the action of what was known as the �whole substance’.

Occult qualities were suspect in the eyes of many learned physicians, for they were the stock in trade of quacks, magicians and heretics. Nevertheless, thanks in part to the Platonic revival with its edifying vision of grand cosmic spiritual powers – and the undeniable fact that Plato preceded Aristotle and so was more �pristine’ and pure – they took hold.

Consider the career of Jean Fernel (1497–1558), one of the ornaments of the Paris medical faculty, who vowed there were some things �beyond the power of the elements’ (i.e., beyond Galen). Fernel devoted himself to philosophy, mathematics and classical writers such as Cicero, and wrote two major works of theoretical medicine. One was published in 1542 as De naturali parte medicinae [On the Natural Part of Medicine], reappearing in 1554 as the first book, Physiologia, of a general treatise, Medicina, which also included sections on pathology and therapeutics (Fernel introduced the terms �physiology’ and �pathology’). The other was a speculative dialogue, De abditis rerum causis (1548) [On the Hidden Causes of Things], in which two friends, Brutus and Philiatros, question the physician Eudoxus on the �hidden causes’ of certain diseases. In particular they ask: Is there not something in disease which is divine? The discussion ranges widely over the philosophical basis of medicine.

Fernel was a reformer of Galenic medicine who interwove other philosophical and Christian strands. His physiology had recourse to the four elements; to the qualities; to the action of innate heat, found only in living things; and to a subtle substance, mediating soul and matter, which he called spiritus (spirit), present only where there was life; his emphasis upon the workings of spirit owed much to Platonists. Fernel’s Medicina synthesized classical, medieval and Renaissance medical thought. By integrating Galenic medicine into wider Renaissance visions, his work achieved phenomenal popularity: ninety-seven complete editions or translations appeared between 1554 and 1680.

The problems posed by �new diseases’ forced Galenic theory to adapt. Debate raged about the nature and cause of syphilis. In his Tractado contra el mal serpentina (1539) [Treatise on the Serpentine Malady], the Spanish physician Ruy Diaz de Isla (1462–1542) judged that the great pox had been brought back from the New World, claiming he had treated Columbus’s pilot in 1493. In 1530 the Veronese physician and humanist Girolamo Fracastoro (Hieronymus Fracastorus: 14781553) published his Syphilis sive morbus gallicus [Syphilis or the French Disease], describing in verse the disgusting symptoms and treatment of the disease to which he gave the modern name. The poem tells the story of a shepherd named Syphilis who, for insulting Apollo, was punished by a �pestilence unknown’, which brought out �foul sores’ upon his body that could be washed away only with quicksilver. Fracastoro offered a clear if poetical diagnostic portrait. While the disease �arose in the generative organs’, it would then �eat away the groin’ or race through the whole body. Severe pain arose in the bones; eruptions appeared, and �unsightly scabs break forth, and foully defile the face and breast’.

In his more theoretical De contagione et contagiosis morbis curatione (1546) [On Contagion and the Cure of Contagious Disease], Fracastoro developed the ideas of the Greek atomist Epicurus and the Roman philosopher-poet, Lucretius, to explain contagious diseases in general by the presence of �seeds’, which could infect by contact at a distance, or by �fomites’, substances such as textiles which harboured and transmitted �disease seeds’. It is not likely that he thought of the seminaria (imperceptibly small particles) as micro-organisms – rather he imagined something more like a leaven or spores. A contagious disease like syphilis was, however, specific, retaining its character in person-to-person transmission.


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Whatever the cause, syphilis had to be treated – but how? Quacks offered nostrums, but the basic therapy, as recommended by Fracastoro, was the classically impeccable bleeding, together with the application to the sores of unguentum Saracenicum, a mercurial ointment long used for skin eruptions like scabies and leprosy (�a night with Venus, a lifetime with mercury’, people quipped). Controversy raged as to how mercury cured – or rather seemed to bring improvement – but most agreed that by means of the copious salivation and sweating it raised, aided by fires and much �rubbing and tubbing’ in special heated barrels, the poison would be expelled. Humoralists argued that the pox produced an excess of phlegm; hence, mercury, which provoked evacuant drooling, seemed the right intervention. Therapeutic hyperthermia (induced fever) long remained popular.

Mercury treatment involved the isolation, tubbing and sweating of the patient for up to one month, though in that process the �cure’ might become almost indistinguishable from the disease, as mercury produced drastic side-effects, including gum ulcerations, tooth loss and bone deterioration. Given the lethality of syphilis, these side-effects could be viewed in a favourable light: had not Hippocrates taught that desperate diseases needed desperate cures? For those wary of mercury and seeking gentler specifics, sarsaparilla was recommended, as was guaiacum bark (see below). But nothing was truly effective against a frightening new disease associated with sex and partly responsible for the bleak, puritanical and often misogynistic mood pervading contemporary sermons and plays. �How long will a man lie i’ the earth ere he rot?’, asks Hamlet: �Faith,’ replies the grave-digger, �if he be not rotten before he die, as we have many pocky corpses now-a-days.’ The syphilis threat led authorities to close bath-houses and brothels and to victimize prostitutes; Henry VIII shut down the London �stews’. Many believed that it was God’s will that a disease due to vice should wreak great havoc – a view which has surfaced again today with AIDS.




ANATOMY


The theory and practice of Galenic medicine were under debate, but in essentials Galenism remained intact, queried by some, defied by quacks and mavericks, but challenged head-on only occasionally, notably by the Swiss iconoclast, Paracelsus (see Chapter 9 (#ulink_2caebec9-cfb2-58ac-98f8-bf5a947e26ad)). Substantial change did, however, occur in anatomy. For long but an antechamber in the palace of medicine, anatomy’s rise owed much to Renaissance artists who grew fascinated with body form and developed the representational, naturalistic techniques so conspicuous in the magnificent illustrations of sixteenth-century anatomy texts.

In his De statua (c. 1435) [On the Statue], the humanist Leon Battista Alberti (1404–1472) argued that knowledge of the bodily parts was vital for the artist, providing him with insight into human proportion which echoed the harmonies of nature and art. Lorenzo Ghiberti (d. 1455) claimed that the artist had to be proficient in the �liberal arts’, including perspective, drawing-theory and anatomy. Knowledge of the skeleton conferred insight into proportion in both microcosm and macrocosm. Art theory and practice emphasized the value of anatomical knowledge and hence of dissecting experience. Underlying this was a naturalistic impulse, though one with its eye on the ideal beauty glimpsed in Graeco-Roman statues. Like the literary humanists, Renaissance artists believed the ancients had observed nature best.

Painters were soon pursuing anatomy as a matter of course. Leonardo da Vinci’s teacher Andrea Verrocchio (1435—88), Andrea Mantegna (d. 1506) and Luca Signorelli (c. 1444–1524) all showed some knowledge of muscular and perhaps of deeper anatomy: Verrocchio had his pupils study flayed bodies. It was, however, da Vinci (1452–1519), Albrecht Durer (1471–1528) and Michelangelo (1475–1564) who most clearly applied the knowledge gained from anatomy.

A brilliant anatomical illustrator, Leonardo was also a perceptive investigator of the mechanics of the human body. Ironically, given the humanist creed, he had no medical education, stumbled over Latin and knew no Greek. His anatomical notebooks show him comparing anatomy with architecture, and using it to probe the mysteries of the microcosm. Although it was never fully realized, from 1489 he planned an anatomical atlas of the stages of man from womb to tomb. His earliest investigations in the late 1480s centred upon a series of skull drawings, which outclassed all previous descriptions. He prized �experience’, but retained a traditional view of brain functions, attributing mental activity to three ventricles governing respectively sensation, intellect, and memory. The nervous system was rendered as a series of passages through which sensations and signals ebbed and flowed.

�Passing the night hours in the company of these corpses, quartered and flayed and horrible to behold’, it was after 1506 that Leonardo made his main anatomical contributions, devoting his attention to embryonic development, the muscles, and the nervous, vascular, respiratory and urino-genital systems. The vessels and respiratory passages were compared to the branching of trees and river valleys, and the workings of the heart explained in terms of hydrodynamics and mechanics. Leonardo executed about 750 anatomical drawings, which in some respects are superior to those in Vesalius’s Fabrica (1543), yet his thinking remained traditional. He continued to accept the Galenic doctrine that blood passed between the ventricles through invisible pores in the septum; and his drawings of the embryo were set within a �traditional’ womb. His career reflects the new involvement of artists with anatomy, though his work had no influence on contemporary medicine, since none of his anatomical manuscripts was published until the late eighteenth century.

As well as artists, medical men also anatomized. Among Renaissance anatomists the desire to see for oneself (the literal meaning of �autopsy’) arose from a variety of traditions. Berengario da Carpi (c. 1460–1530) studied at Bologna, the cradle of dissection, and in 1502 became lecturer in surgery there. He made the basis for his lectures the Anatomy of his Bolognese predecessor, Mondino, and his Introduction follows earlier procedures for public dissection. Berengario was no slavish imitator. While often using Galen to disprove Mondino, he was prepared to criticize him on the basis of personal observations, denying the existence in humans of Galen’s rete mirabile, that �marvellous network’ of blood vessels supposedly lying at the base of the brain (it is found in some animals but not in humans). Insisting on the need for frequent dissections, including humans, he gained a knowledge of female internal anatomy on the basis of postmortem examinations, including one of an executed pregnant woman.

The earliest truly Greek anatomical text was that of Alessandro Benedetti (d. 1512), who lived for sixteen years in Greece and Crete before returning to Padua in 1490 as professor of practical anatomy. In his Historia corporis humani; sive anatomice (1502) [The Account of the Human Body: Or Anatomy], the Greek anatomice in the title highlighted his hellenism. As a good humanist, Benedetti, like Leoniceno, weeded out Arabic terminology and self-consciously used Greek anatomical terms. Though his book was philological rather than substantive, it did provide an account of a well-ordered anatomy theatre.

Humanist anatomy was given a boost by the discovery of the first part of Galen’s On Anatomical Procedures (his treatise on how to carry out a dissection) translated into Latin by Guinther von Andernach in 1531. Mondino had started with the internal organs, since these putrefied first. His procedures were rejected by humanists in favour of Galen, who had begun in a more logical fashion with the bones – they were like the walls of houses, he wrote, everything else took shape from the skeleton – next proceeding to the muscles, nerves, veins and arteries, before reaching the cavities of the belly, the chest and the brain, and the internal organs.

But if Galen’s dissection strategy was more rational and the quality of his descriptions superior, its flaw was that it was animal not human. A challenge was thus thrown down to anatomists to outdo the master through hands-on investigation of the human corpse. The Liber introductorius anatomiae (1536) [Introductory Book of Anatomy] of the Venetian physician Niccolò Massa (c. 1485–1569) scolded those who pronounced on anatomy without having applied the knife to the things they wrote about.

By the 1520s increasing numbers of anatomical texts were being published, and Johannes Dryander (1500–60), professor of medicine at Marburg, carried out some of the first public dissections in Germany, writing these up in a treatise on the anatomy of the head. Andreas Vesalius (1514–64), however, restored Galenic anatomy in such a way as to transcend it. A true Galenic anatomist, in the sense of following the master’s advice to see for oneself, Vesalius also presented himself in his De humani corporis fabrica (1543) [On the Fabric of the Human Body] as a critic who had no compunction about exposing Galen’s errors: �How much has been attributed to Galen, easily leader of the professors of dissection, by those physicians and anatomists who have followed him, and often against reason!’

Born Andreas van Wesele in Brussels, where his father was pharmacist to Emperor Charles V, Vesalius learned Latin and Greek and enrolled in the Paris Faculty of Medicine, studying under the conservative humanist Sylvius, then Galen’s great champion. (In later years Sylvius became a scourge of Vesalius, wittily calling him vesanus: madman.) Vesalius learnt his dissecting skills from Guinther von Andernach, and when in 1536 war forced him to flee Paris, he returned to Louvain where he introduced dissection. He showed his anatomical zeal by robbing a wayside gibbet, smuggling the bones back home and reconstructing the skeleton.

In 1537 he moved to Padua, where he made his anatomical name. Dissection had previously been demonstrated there by surgeons, and had never been mandatory for physicians. The rediscovery of Galen’s On Anatomical Procedures and the wider dissemination of his On the Use of Parts meant that humanists were beating the drum for the subject, and the appointment of the young physician was one consequence. Vesalius’s Tabulae anatomicae sex (1538) [Six Anatomical Pictures] were among the first anatomical illustrations specifically designed for students. The first three sheets were drawn by Vesalius himself and represented the liver and its blood vessels, together with the male and female reproductive organs, the venous and the arterial system. He was still viewing the body through Galenic eyes: despite Berengario, he drew the rete mirabile; the liver was still five-lobed, and the heart an ape’s.

Thereafter Vesalius grew more critical. Familiarity with human anatomy drove him to the unsettling conclusion that Galen had dissected only animals, and forced him to see that animal anatomy was no substitute for human. He now began to challenge the master on points of detail: for instance, the lower jaw comprised a single bone not two, as Galen, relying on animals, had stated. Evidently, human anatomy had to be learned from dead bodies not dead languages.

In 1539 he acquired a larger supply of cadavers of executed criminals and worked on his great masterpiece, the De humani corporis fabrica. Finishing it in 1542, he took it to Basel where the press of Joannes Oporinus published it in 1543 as one of the pearls of Renaissance printing. It presents exact descriptions of the skeleton and muscles, the nervous system, blood vessels and viscera. Though it contains no shattering discoveries, it marks a watershed in the medical understanding of bodily structures, for Vesalius interrogated Galen by reference to the human corpse. Others had criticized odds and ends of Galenic anatomy, but Vesalius was the first to do this systematically. The Fabrica gained immensely from the contribution of the artist, Jan Stephan van Calcar (1499–c. 1546), also from the Netherlands, who provided the text with technically accurate drawings displaying the dissected body in graceful lifelike poses. The work also enunciated clear methodological principles: the anatomist-lecturer must perform the dissection himself, the eye was preferable to authority, and anatomy was the skeleton key to medicine.

Book I of the Fabrica began in Galenic fashion with the bones rather than the internal organs. Various Galenic lapses were corrected: for example, the human sternum has three, not seven, segments. Book II dealt with the muscles and included the famous suite of illustrations showing �muscle-men’ at different stages of corporeal �undress’. Book III, on the vascular system, was less accurate because Vesalius still based his descriptions partly on animal material. Book IV described the nervous system, following the Galenic classification of the cranial nerves into seven pairs.

Book V dealt with the abdominal and reproductive organs, where he corrected Galen’s belief in the five-lobed human liver. He nevertheless still accepted the Galenic physiological tenet that the liver produced blood from chyle, while denying that the vena cava originated in the liver – an observation which, had Vesalius been more physiologically-minded, might have begun the erosion of the Galenic belief in two distinct vascular systems, the venous originating in the liver and the arterial stemming from the heart.

Book VI was devoted to the thorax. Examining the heart, Vesalius cast doubt on the permeability of the interventricular septum: �We are driven to wonder at the handiwork of the Almighty by means of which the blood sweats from the right into the left ventricle through passages which escape the human vision.’ In the second edition (1555), this implicit denial of the septum’s permeability was made direct. Here lay a milestone of Renaissance anatomy, for it encouraged anatomists like Realdo Colombo (c. 1515–59) to conceive of the pulmonary transit, later used by William Harvey as evidence of the circulation of the blood. Another crucial correction of Galen came in Book VII, on the brain, where Vesalius denied the existence of the rete mirabile in humans.

In the end, Vesalius’s importance lay in daring to think the unthinkable: that Galen might actually be wrong, and Galen worship with it:

How much has been attributed to Galen, easily leader of the professors of dissection, by those physicians and anatomists who have followed him, and often against reason! … Indeed, I myself cannot wonder enough at my own stupidity and too great trust in the writings of Galen and other anatomists.

The Fabrica thus laid the groundwork for observation-based anatomy, announcing a new principle of fact-finding and truth-testing: all anatomical statements were to be subjected to the test of human cadavers.

Later anatomists corrected Vesalius as he had corrected Galen, and independent observation thus became sovereign. Anatomists also grew impatient to establish personal priority in discovering new structures. Amerigo Vespucci had his name immortalized in a continent; for an anatomist, naming a bodily part could be crucial for making his name.


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The frontispiece of the Fabrica presents the dreams, the programme, the agenda, of the new medicine. The cadaver is the central figure. Its abdomen has been opened so that everyone can peer in; it is as if death itself had been put on display. A faceless skeleton points towards the open abdomen. Then there is Vesalius, who looks out as if extending an invitation to anatomy. Medicine would thenceforth be about looking inside bodies for the truth of disease. The violation of the body would be the revelation of its truth.

By transference, the idea of anatomizing became a potent medical metaphor during the next couple of centuries, as in Robert Burton’s Anatomy of Melancholy (1621) or John Donne’s poem �An Anatomy of the World’ (1611), and modern medicine adopted the anatomy lesson as its signature: medicine was represented as a probe into nature’s secrets, peeling away layer upon layer in the hunt for truth; nothing would resist its gaze. The knife also suggested other modes of mastery, not least sexual conquest, as when Donne likens the lover’s caress to a surgeon’s knife:

And such in searching wounds the surgeon is

As wee, when wee embrace, or touch, or kiss.

A new genre came into fashion: self-anatomy, introspection into one’s own soul, a kind of spiritual or psychological dissection. �I have cut up mine owne Anatomy,’ declared Donne, �dissected myselfe, and they are got to read upon me.’

Practical anatomy advanced on a broad front after the Fabrica. Accounts of the whole body continued to be published, for instance Charles Estienne’s (1504–64) De dissectione partium corporis humani (1545) [On the Dissection of the Human Body]. Realdo Colombo, an apothecary’s son who studied surgery at Padua, succeeding Vesalius there in 1544, corrected some of his errors in his De re anatomica [On Anatomy], published posthumously in 1559. He accused Vesalius of passing off descriptions of animal anatomy as human – precisely Vesalius’s charge against Galen. Colombo’s discovery of the pulmonary transit and elucidation of the heartbeat were momentous. Vivisection experiments showed that blood went from the right side of the heart through the lungs to the left side; that the pulmonary vein did not, as Galen had thought, contain air but blood; and that blood was mixed with air not in the left ventricle of the heart but in the lungs, where it took on the bright red hue of arterial blood. Describing the heartbeat, Colombo held, opposing former views, that the heart acted with greater force in systole (contraction) than in diastole (dilation); this too was crucial for Harvey.

Gabriele Falloppia (1523–63) was appointed in 1551 to perform the annual anatomies at Padua, and he produced more criticism of the Fabrica in his Observationes anatomicae (1561) [Anatomical Observations]. The tremendous kudos of the new anatomical teaching is illustrated by an incident in 1555, when the university authorities sought to revive the old style of anatomizing as ordained by the statutes. A junior lecturer was to read out Mondino’s Anatomia, and the senior professor, Vettor Trincavella (1490–1563), was to deliver theoretical lectures. Falloppia’s role as anatomist would thereby have been demeaned. In the event, Trincavella’s orations were broken up by rowdy students chanting vogliamo il Falloppio (�we want Falloppia’), after which anatomy was entirely in his hands.

Falloppia’s Observationes may be regarded as a coda to the Fabrica, adding new observations and correcting errors in both Galenic and Visalia anatomy. Though not a systematic textbook, it covered a wide range of subjects, with emphasis on the skeleton, especially the skull, and the muscles. Particularly important were his descriptions of the structure of the inner ear, the carotid arteries, the head and neck muscles, and the orbital muscles of the eye. It also contains the famous description of the uterine tubes bearing his name. Falloppia meanwhile kept up a huge practice, claiming to have examined the genitals of 10,000 syphilitics.

Unlike Vesalius, later anatomists produced specialized studies of body parts, such as the treatises on the kidney, the ear and the venous system published by Bartolomeo Eustachio (c. 1500–74) in his Opusula anatomica (1564) [Anatomical Studies]. He scolded Vesalius for depicting a dog’s kidney instead of a human one, and produced figures of the ear ossicles and the tensor tympani in man and in dogs. The Eustachian tube from the throat to the middle ear was described, though priority really belonged to Giovanni Ingrassia (1510–80), who had discovered it in 1546.

Study of specific structures encouraged comparative anatomy, in which different animals were correlated in a self-consciously Aristotelian manner; Aristotle had been keen to compare animal anatomy for classification purposes and to discover essential structural/functional correlations. The greatest comparative anatomist was one of Falloppia’s pupils, Hieronymus Fabricius ab Aquapendente (Fabrizio or Fabrici: c. 1533–1619), who succeeded to his Padua chair in 1565. Fabricius’s aim was to produce a work to be called Totius animalis fabricae theatrum [The Theatre of the Entire Animal Structure], but only small sections emerged. As an anatomist he was less interested in Visalia structural architecture than a comparative approach which stressed three aspects of anatomy: the description, action, and use of body parts. Although Vesalius had surpassed the ancients in descriptive accuracy, he had written little on the action and use of the parts; this was what Fabricius aimed to remedy.

Fabricius’s most significant work was De venarum ostiolis (1603) [On the Valves of the Veins], for the venous valves were to be crucial for William Harvey’s demonstration of the blood circulation. It was not Fabricius who discovered them, but he was the first to discuss them at any length. The valves, he maintained, were designed to prevent the extremities from being flooded with blood and to ensure that the other body parts would get their fair share. This theory tallied with the Galenic view that blood was attracted from the liver, the blood-making organ, by each part of the body when it needed nourishment. The valves thus helped the central and upper parts to get blood by preventing its tendency to gather at the extremities.

Fabricius’s embryological treatises also influenced Harvey. De formatione ovi et pulli (1621) deals with the development of the egg and the generation of the chick, while De formatu foetu (1604) [On the Formation of the Foetus] describes how nature provides the means for foetal growth, nourishment and birth. His descriptions of foetal development lay within the Aristotelian theoretical framework of the female contributing the matter and the male the form.

A more idiosyncratic challenge to Galenic physiology had meanwhile come from the polymath Michael Servetus (1511–53). Sickened by the corruption of the Roman Church, Servetus went further than Luther along the road of heresy and developed anti-Trinitarian views, leading to condemnation by Catholics and Protestants alike. In Lyons he had met the medical humanist Symphorien Champier (c. 1471–1539), who advised him to study in Paris, where he worked with the cream of the faculty: Sylvius, Fernel and Guinther von Andernacht. But he soon fell under suspicion, and was condemned in 1538 by the Parlement of Paris for lecturing on astrology. In 1553 he anonymously published his major work, the 700-page Christianismi restitutio [The Restoration of Christianity], which was denounced by Calvin as heretical. Escaping the Inquisition, Servetus was nevertheless condemned for heresy on entering Calvin’s Geneva, and burnt at the stake.

It was in The Restoration of Christianity that Servetus announced the pulmonary transit of the blood, within the framework of an heretical account of how the Holy Spirit entered man. The Bible taught that the blood was the seat of the soul and that the soul was breathed into man by God: there had therefore to be a contact point between air and blood. This led Servetus to denounce Galen’s whole scheme. Blood did not go through the septum; he proposed instead a path from the right to the left heart through the lungs. Blood was mixed with air (that is, spirit) in the lungs, rather than in the left ventricle. Confirmation lay in the size of the pulmonary artery – its design was too large to transmit blood for the lungs alone. Servetus’s views had no influence on the development of anatomy, not least because almost all copies of his book were burnt with their author.

Renaissance dissections increased knowledge of the structure of man and other animals. But while precipitating an anti-Galen reaction, Vesalian anatomy followed his precepts: without Galen no Fabrica. Humanist anatomy was conservative in theory. No anatomist opposed the traditional Galenic tripartite division of physiologic function (venous, centered on the liver; arterial, centered on the heart; and sensory/motor, centered on the brain), even when anatomical structures and vascular connections crucial to the scheme were being discredited (for instance, the rete mirabile). For all their radical rhetoric, Vesalius’s generation shored up ancient medicine and philosophy even as they exposed its factual errors. All the same, Renaissance anatomists enormously elevated the standing of their subject. Its status had been low; it was not listed among the ancient major divisions of medicine, and was stigmatized by its surgical connexions; but the appointment of the physician Vesalius at Padua served notice that anatomy and surgery were to be incorporated into the wider humanist medical movement. The Fabrica’s preface argued for the unity of the different medical arts; physicians should not disdain to use their hands, an adage equally dear to contemporary experimental natural philosophers.

Anatomy became integrated into learned medicine – even in backward England, thanks to John Caius (1510–73). Caius was a Galenist physician and protégé of Thomas Linacre, who had been largely responsible for the founding of the College of Physicians in 1518, and for the medical lectureships at Oxford and Cambridge.

Educated at Gonville Hall in Cambridge, from 1539 Caius studied at Padua, teaching Greek and collecting manuscripts, particularly those of Galen, whom he idolized. On his return, he settled in the capital, being admitted Fellow of the College of Physicians in 1547. In his nine terms as president, Caius attempted to mould the college along continental lines, regulating medicine according to the best Galenic standards. He reorganized its statutes, and introduced formal anatomies into its lectures, also demonstrating anatomy before the Barber-Surgeons Company. In Cambridge he refounded his old hall in 1557 as Gonville and Caius College, serving as its master from 1559 and fostering a strong medical tradition, from which William Harvey (1578–1657) was to benefit. Through enthusiasts like Caius and his equivalent in Leiden, Pieter Pauw (1564–1617), anatomy became incorporated throughout Europe into the humanist revival.

Anatomists presented their subject as the cutting edge; the way to certain knowledge was through the senses, especially by �autopsia’, seeing for oneself. Though the Paduan Aristotelian philosopher Cesare Cremonini (1552–1631) was still insisting in 1627 that anatomy could never be the foundation of medicine (only causes, the domain of philosophy, and not observation could lead to certainty), the sheer success of anatomy swept this dogma aside. Dissections became public events: at Bologna they were staged during the annual carnival, the macabre fascination of the memento mori, juxtaposing life and death, contributing to the appeal. Rembrandt’s �The Anatomy Lesson of Dr Nicolaes Tulp’ (1632), shows that anatomy had become one of the spectacles and symbols of the age. Not only the method of medicine, anatomy became accepted as a window onto the human condition.




SURGERY


Surgery saw fewer significant changes, and still played second fiddle to physic, being relatively unaffected by the new anatomy. Restricted largely to the body’s surface, surgeons dealt with the many accidents of life. They set fractures, treated burns, contusions, knife wounds and the increasingly common gunshot wounds, tumours and swellings, ulcers and various skin diseases; syphilis was usually handled as a surgical condition. Surgery was seen as a skilled craft: �A chirurgien should have three divers properties in his person,’ judged John Halle (1529–68), �that is to say, a heart as the heart of a lion, his eye like the eyes of an hawk, and his hands as the hands of a woman.’

Through most of Europe, surgery continued to be taught by apprenticeship and organized in guilds. In London a master surgeons’ guild had been founded in 1368; the Mystery or Guild of the Barbers of London received its charter from Edward IV in 1462; and in 1540, by Act of Parliament, the Guild of Surgeons merged with the Barbers to form the Barber-Surgeons Company, its first master being Thomas Vicary (c. 1490–1561); Holbein painted Henry VIII chartering the company, which continued until 1745. An active member was William Clowes (1544–1603), who worked as a naval surgeon before setting up in practice in London and being appointed surgeon at St Bartholomew’s Hospital in 1575. Military operations in the Low Countries (1586) gave him ample experience, and in 1588 he was appointed surgeon to the fleet. Clowes’s treatises on wounds, venereal disease and scrofula were written in racy vernacular, with young surgeons in mind, presenting personal case histories.

Clowes was one of a line of able common-or-garden surgeons: John Woodall’s (1556–1643) The Surgeon’s Mate (1617) served as a manual of naval surgery, attacking the bad habits of �blaspheming the name of the Almighty’ and the �dedication to the pot and Tobacco-pipe’ which were all too common among apprentices; Richard Wiseman (1621–76) was honoured as the �father of English surgery’. His Several Chirurgical Treatises (1676) dwelt on military and naval problems, while his Treatise of Wounds (16 j 2), jocularly known as Wiseman’s Book of Martyrs, advertised itself as specially for ships’ doctors �who seldom burden their cabin with many books’. He picked up much of his experience during the English Civil War, and his account of military surgery reveals its horrors: cannonballs and gunshot caused horrifying wounds, and amputation and trepanation were often the only remedies, conducted on the battlefield or on a storm-tossed vessel.

Fabricius left a graphic description of a sixteenth-century amputation:

I was about to cut off the thigh of a man of forty yeares of age, and ready to use the saw, and Cauteries. For the sick man no sooner began to roare out, but all ranne away, except only my eldest Sonne, who was then but little, and to whom I had committed the holding of his thigh, for forme only; and but that my wife then great with child, came running out of the next chamber, and clapt hold of the Patient’s Thorax, both he and myselfe had been in extreme danger.

This may not have been an uncommon scene before anaesthesia was available.

�He who wishes to be a surgeon should go to war,’ Hippocrates had advised, and the battlefield became accepted as the school of surgery. Growing use of gunpowder had worsened the injuries confronting field-surgeons, because cannonballs and lead shot destroyed far more tissue than arrows or swords and left gaping wounds prone to infection. Many of the most popular vernacular handbooks, such as the Buch der Wund-Artzney (1497) [Book of Wound Dressing] of Hieronymus Brunschwig (1450–1533) and the Feldbuch der Wundartzney (1517) [Fieldbook of Wound Dressing] of Hans von Gersdorff (c. 1455–1529), were based on field experience. Brunschwig’s work contains the earliest printed illustrations of surgical instruments, and endorsed the view that shot wounds were poisoned by gunpowder and so required cautery. Gersdorff explained how to extract bullets with special instruments and dress wounds with hot oil. Amputated stumps were to be enclosed in an animal bladder, after controlling haemorrhage by pressure and styptics. Thomas Gale (1507–87) published An Excellent Treatise of Wounds made with Gonneshot (1563) – the first English work on the subject.

The most acclaimed Renaissance surgeon, Ambroise Paré (1510–90), also learned his craft through war. In 1533 he served as aide-chirurgien to the chief Paris hospital, the Hôtel Dieu; and from 1537, for almost thirty years, he divided his time between tending the Paris sick and following the army. Enrolled in 1554 into the confraternity of St Côme, the surgeons’ college, five years later Paré attempted in vain to save the life of Henri II after he had been wounded in a jousting tournament.

Paré gave a conventional account of the �five duties’ of his art: �to remove what is superfluous, to restore what has been dislocated, to separate what has grown together, to reunite what has been divided and to redress the defects of nature’. His prime innovation lay in rejection of the standard treatments for gunshot wounds: the use of cautery (the burning iron) or scalding oil (�potential cautery’) to destroy poison and forestall putrefaction before beginning restorative therapy. In his La methode de traicter leys playes faictes par hacquebutes et aultres bastonsàfeu (1545) [Treatise on Gunshot Wounds], he described how, as a greenhorn on campaign in Italy in 1537, he had been forced to innovate. Initially, as taught, he had used boiling oil on what were considered to be poisonous gunpowder wounds:

But my oil ran out and I had to apply a healing salve made of egg-white, rose-oil and turpentine. The next night I slept badly, plagued by the thought that I would find the men dead whose wounds I had failed to burn, so I got up early to visit them. To my great surprise, those treated with salve felt little pain, showed no inflammation or swelling, and had passed the night rather calmly – while the ones on which seething oil had been used lay in high fever with aches, swelling and inflammation around the wound.

At this, I resolved never again cruelly to burn poor people who had suffered shot wounds.

Thenceforth he relied on restorative methods, using a digestive (wound-dressing) made of egg, oil of roses and turpentine, justifying this on the supposition that the gunpowder and shot were not, after all, poisonous. Piously, he always said that he had dressed the wound but God had healed the patient: Je le pansay; Dieu le guarit.

Another innovation mentioned in his Dix livres de la chirurgie (1564) [Ten Books of Surgery] was the use of ligatures in conducting amputations. Other writers had recommended tying off the veins and arteries so as to stop the blood, but Paré worked out the practical details. This made successful thigh amputations possible – William Clowes reported performing one in 1588, as did Fabricius a little later. There was, however, one drawback. No fewer than fifty-three ligatures were necessary in a thigh amputation, and this required trained assistance. Consequently, ligatures could come into general use only after a method had been found to control blood flow until the surgeon could tie the blood vessels, something accomplished in eighteenth-century France when J. L. Petit invented the first effective tourniquet.

Paré’s Cinq livres de chirurgie (1572) [Five Books of Surgery] dealt at length with fractures and dislocations, while in the Deux livres de chirurgie (1572) [Two Books of Surgery] he addressed the study of obstetrics, showing the art of podalic version (turning a baby in the womb, to facilitate feet-first delivery, as earlier described by Soranus) – and also seeking to explain monstrous births. His successes, however, did not go unchallenged. In 1575, the Paris faculty condemned him for publishing on �medical’ topics – an affront reflecting the tetchiness of physicians towards surgeons’ encroachments on their turf.

The practice of early modern surgeons challenges the myth that before anaesthesia and antisepsis their craft was crude and often lethal. The case notes of the London surgeon Joseph Binns (d. 1664) present a different picture. In a career stretching from 1633 to 1663 he recorded 616 cases. Of these no fewer than 196 related to gonorrhoea or syphilis; 77 were of swellings and 61 were more properly medical – including ague, stomach-ache, headache, insomnia, diarrhoea and epilepsy. Fifteen individuals suffered battle wounds, 14 were hurt at work, 19 suffered from falls from horses and 41 were injured in fights. Of the 402 outcomes recorded, 265 were cured and 62 improved; 22 showed no improvement and 53 died.

As Binns’s cases show, surgeons’ work remained mainly routine, small-scale and fairly safe – if often agonizing. Next to dressing wounds, drawing teeth, dealing with venereal sores and chancres, treating skin abrasions and so forth, the most common surgical procedure (indeed the profession’s badge) was blood-letting, often performed at the patient’s request. Galenic medicine had warned about the dangers posed by a �plethora’, believing that fevers, apoplexy and headache followed from excessive build-up of blood. Venesection was the obvious corrective. The normal method for phlebotomy was to tie a bandage around the arm to make the forearm veins swell up, and then open the exposed vein with a lancet: this was popularly called �breathing a vein’. Cupping with scarification was another procedure for drawing blood.

A few surgeons came up with ambitious new operations. In Italy Gaspare Tagliacozzi (1545–99) described in his De curtorum chirurgia per insitionem (1597) [On the Surgery of the Mutilated by Grafting] the procedure of rhinoplasty or nose reconstruction, which was obviously attractive in the era of syphilis. Rhinoplasty had been known in India since ancient times; in southern Italy the operation was apparently practised by empirics. Tagliacozzi was thus far from the technique’s inventor, but he published and claimed to have perfected it. In his rhinoplastic procedure, a skin flap was partially detached from the flesh of the upper arm, and allowed to establish itself as a viable tissue. Then the flap, still attached to the arm, was shaped and sewn to the remains of the nose. The patient remained with his arm thus attached to his nose for fourteen days, before the flap was severed from its original site. After a further period, the process began of reshaping the flap to form the new nose. The whole business took from three to five months.

Overall, however, with its deep-seated craft basis, surgery remained rather traditional. ParГ© concluded:

A Chirurgion must have a strong, stable and intrepide hand, and a minde resolute and mercilesse, so that to heale him he taketh in hand, he be not moved to make more haste than the thing requires; or to cut lesse than is needfull; but which doth all things as if he were nothing affected with their cries; not giving heed to the judgement of the common people, who speake ill of Chirurgions because of their ignorance.

Whether surgeons were ignorant or not, there remained severe limits upon what they could achieve.




PHARMACY


Pharmacy underwent significant change as the range of remedies was extended, thanks to the retrieval of classical drugs, the discovery of new vegetable products from America and the Indies, and the increasing use of chemical substances. Herbs – understood in the widest sense as the leaves, seeds or fruits, bark and roots of plants, shrubs and trees – had always been the prime ingredients of medical remedies. If used individually, apothecaries called them �simples’; combined into a compound drug, perhaps with animal and mineral ingredients, they would be called �Galenicals’. Herb gathering (simpling) and preparation of remedies were domestic skills practised in the family, but there was also a commercial side to herbal medicine.

With the Greek revival, physicians became concerned that the remedies then in use were inferior, and sought to recover the original materia medica used by the ancients. This required the reform of botany, since there was no uniform nomenclature, leaving plant identification chancy. Botany enjoyed its own humanist renaissance: medieval authors were denounced for their barbaric language and for corrupting ancient texts, and there was a call for pure editions of classical botanical works. The great scourge of the pharmacists was the Paris humanist Symphorien Champier. About 1513 he issued his Myroel des Apothecaires, whose subtitle reveals his position: The Mirror of the Apothecaries and Druggists in Which is Demonstrated How the Apothecaries Commonly Make Mistakes in Several Medicines Contrary to the Intention of the Greeks … on the Basis of the Wicked and Faulty Teachings of the Arabs.

Around the mid fifteenth century manuscripts of Theophrastus’ Historia plantarum [The History of Plants] and De causis plantarum [On the Causes of Plants] were brought from Constantinople and translated into Latin by Theodore Gaza. Galen’s De simplicium medicamentorum facultatibus [On the Powers of Simple Remedies] had been used in the medieval universities, but in 1530 a new Latin translation was published, corrected by reference to �old manuscripts’. More important, however, as a vehicle for medical botany was the De materia medica of Dioscorides (fl. AD 50–70), which galvanized the botanical revival. The work had been known in Latin to the Middle Ages, but humanists collected Greek manuscripts, and the Aldine Press published a Greek edition in 1499.

With the Dioscorides revival, herbals themselves changed. The earliest printed ones were compiled from medieval sources, but later works by William Turner (c. 1510–68), Leonhart Fuchs (1501–66) and others became more naturalistic, both verbally and pictorially, mirroring the Renaissance anatomy atlases. The first to abandon the old stylized pictures was the Herbarum vivae eicones (1530) [Living Images of Plants] of Otto Brunfels (d. 1534), town physician of Bern. The artist Hans Weiditz (d. c. 1536) (school of Durer) gave this herbal its innovative look. When his plants did not tally with Dioscorides’, Brunfels tried to force identifications.

He described 258 different plants; ninety-seven years later, Caspar Bauhin’s (1560–1624) Pinax theatri botanici (1627) [A Catalogue of Botanical Theatre] included around 6,000 specimens. This stupendous increase was achieved through individual and collaborative efforts. The first chair in botany was established in Padua in 1533; botanical gardens were created in Pisa and Padua in 1544–5, with other universities following: Bologna, Leiden, Leipzig, Basel and Montpellier. Plants, however, were not always available and altered with the seasons; this made the artificial or dry garden (hortus siccus) an invaluable invention, allowing rare plants to be preserved or exchanged, and providing teaching material and draughtsmen’s models.

A great boost was provided by Pier Andrea Mattioli (1500–77), who in 1542 became physician to the province of Gorizia, where he worked on a commentary of Dioscorides. Published in 1544, his edition of De materia medica became the spur for botanical and pharmacological research, earning its author European celebrity. Like Linnaeus later, Mattioli had a gift for inspiring collaborators to travel, collect and send him specimens. Expanding with each edition, the work culminated in the version of 1565, a lavishly illustrated Latin folio running to nearly 1500 pages, bejewelled with full-page illustrations.

As the entrepôt of the Mediterranean, enjoying close links with the Middle East and the overland spice trade from the Indies, Venice was the natural centre for the humanist goal of recovering classical medicaments. Not least, the Venetian Republic controlled Crete and Cyprus, the herb gardens of the ancients. Drugs unknown to the latin West – balsam and myrrh for instance – were rediscovered. Famous for its purging powers, rhubarb had entered Europe through the overland trade routes from the East; by the early seventeenth century, seeds from Bulgaria allowed one medically valuable type of rhubarb (Rhaponticum, from the Pontus or Black Sea) to be grown in Europe, while search continued for the �true’ rhubarb which Marco Polo had reported in 1295 as deriving from China. Theriac, that panacea of the ancients, composed of up to a hundred herbal, animal and mineral ingredients, seemed in the 1540s quite impossible to compound; many of its ingredients were unknown and more than twenty substitutes were needed. But by 1566 the Veronese botanist-pharmacist Francesco Calzolari (1522–1609) was using only three proxies. Physicians grew confident that the remedies of the ancients had been recovered.

Thanks to Iberian voyages of discovery, new drugs filtered in, together with foodstuffs like potatoes. Cocoa came back with Cortés in 1529, becoming a favourite drink, a specific for �wasting diseases’, a stimulant, and even the basis of cocoa-butter suppositories. Meanwhile the Portuguese had rounded the Cape of Good Hope in 1487–8 and reached India in 1499. By 1512–13 they landed in the legendary Spice Islands, the Moluccas, whose spices had traditionally arrived in Europe via the overland route.

Remedies from distant parts entered into scholarship, particularly through the writings of Nicolas Monardes (c. 1493–1588) and Garcia d’Orta (1501–68). Educated at Seville, Monardes commented that New World drugs were inferior to those of Spain (pharmaceutical chauvinism was strong), but he later changed his mind, enthusiastically praising their powers in his Dos Libros (1565–74). The book followed a standard format, giving for each plant its place of origin, appearance, colour, properties and uses. New World plants posed problems, for their virtues were uncertain. This led him to concentrate on the distinguishing marks of the new plants and to describe how they were processed by the American Indians. Together with coca, jalap, sarsaparilla and sassafras (these latter famed for blood-cleansing), one of his best-known descriptions was that of tobacco, which he praised for curing head pains, toothaches, bad breath, chilblains, worms, joint pains, swellings, poisoned wounds, kidney stones, carbuncles and fatigue. Its efficacy derived from its heating and drying qualities. Despite King James I’s strictures against �this filthy custom’, tobacco enjoyed a high medicinal reputation in the seventeenth century.

In the face of the terrifying syphilis epidemic, imported plant remedies might appear godsends, for treatment with mercury was almost worse than the disease. In the Caribbean the Spaniards saw syphilis (more probably yaws) treated by decoctions made from guaiac wood (Guaiacum officinalis); by 1508 this was being imported into Spain and its use became widespread. Also known as �holy wood’, guaiac was obtained from evergreens indigenous to the West Indies and South America. The folk belief that God planted cures where diseases arose reinforced the conjectural New World origin for syphilis. Shiploads of guaiac were imported into Europe, organized by the Fuggers of Augsburg, the mercantile and banking family who monopolized the trade and profited mightily. The German humanist and soldier Ulrich von Hutten (1488–1523) experienced the horrors of the mercury treatment; he went through eleven mercury cures in nine years, then he heard of guaiac, and after repeated infusions believed he was cured. Von Hutten’s De guaiaci medicina et morbo gallico (1519) [On the Guaiac Remedy and the French Disease] was translated into German and French, but by the time Monardes wrote in 1565 guaiac was losing support.

One key remedy from the East was opium, largely imported from Turkey. It had been in use in Egypt in the second millennium BC, and Avicenna called it �the most powerful of stupefacients’. Ever the queen of drugs, it was profusely used in western medicine from the sixteenth century, and Thomas Sydenham (1624–89) later proclaimed that �among the remedies which it has pleased the Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.’ It seemed the wonder drug; not just a pain-deadener, it also stopped dysentery and relieved respiratory disorders.

India supplied new remedies. In 1563 Garcia D’Orta published Coloquios dos simples, e drogas he cousas mediçinais da India [Dialogues on Simples and Drugs and Medical Matters from India] which described such eastern products as aloes, camphor, sandalwood, ginger, asafoetida and betel, and new fruits such as mangoes. Like the Italian humanist botanists, he had to confront identification problems. (Was modern cinnamon the �canella’, �cinnamon’ or �cassia’ of the ancients?) Other eastern drugs filtered to the West later, including Chinese rhubarb and ginseng, introduced in the eighteenth century by the Jesuits.

Thanks in part to the labours of the botanists and the importation of new drugs, the apothecary’s trade boomed, though for many (witness Romeo’s remarks) the apothecary remained a wretch vending poisons:

I do remember an apothecary

And hereabouts he dwells – whom late I noted

In tatter’d weeds, with overwhelming brows,

Culling of simples; meagre were his looks,

Sharp misery had worn him to the bones;

And in his needy shop a tortoise hung,

An alligator stuff’d and other skins,

Of ill-shap’d fishes …

Like other branches of medicine, apothecaries organized themselves. In England, James I recognized them as a special body in the Grocers’ Company in 1607, and ten years later they gained their independence, organizing as the Masters, Wardens, and Society of the Art and Mystery of the Apothecaries of the City of London.




THE MIND


Renaissance humanism, mysticism, hermeticism and astrology fostered interest in the human soul, the spiritual fulcrum in a cosmos governed by supernatural forces – good and evil. It is not surprising, therefore, that one field in which Renaissance philosophy made a contribution to medicine was mental disorder. Theories remained complex, however. The neo-Platonist Ficino related melancholia to the sway of Saturn, but also to the action of black bile, the humour of genius and of depression.

Humanist moralists explored the mind, notably the French essayist, Michel de Montaigne (1533–92), twice mayor of Bordeaux. Suffering agony from a bladder stone


(#ulink_37074bda-95cb-55f4-9431-d221513632a5) and sickened by religious and dynastic bloodshed, he retired from the world to compose his mind in tranquillity, only to find himself haunted by �monsters’ and �chimeras’. Solitude sparked �melancholy adust’, a sick humour disposing his melancholic temperament towards madness. Composing his Essais (1580) was an antidote, a writing cure aimed at restoring balance through anatomizing his mind in quest of self-knowledge.

Montaigne kept his soul �at home’ in the body, studying both, hoping to grasp how man should live wisely and face death well. Yet in response to the old Socratic injunction of self-knowledge (�nosce te ipsum’), he was sceptical: Quesçay-je? (What do I know?), he asked. Such themes were relentlessly pursued, not least by Shakespeare, whose contemporary, Robert Burton (1557–1640), described himself as �fatally driven’ upon the rock of melancholy and mixed philosophy and medicine. His Anatomy of Melancholy (1621) was a satirical flagellation of folly but also a serious medical inquiry which included the following causes of depression: �idleness, solitariness, overmuch study, passions, perturbations, discontents, cares, miseries, vehement desires, ambitions’, and hundreds more.

Philosophical medicine explored sickness of the mind and its synergy with the body. Mingling suspicion with sympathy, paintings and plays made much of fools, melancholies and madmen. �Bedlam’ acquired its notoriety, and Tom o’ Bedlam became a well-known figure, wandering the lanes, singing and begging. The period also brought the wave of mass hysteria and persecution known as the witch-craze. Despite the biblical injunction, �thou shalt not suffer a witch to live’ (Exodus 22:18), the medieval Church had long remained little concerned about witchcraft, but by the late fifteenth century this had changed, and a Papal Bull of 1484 condemned its spread and authorized a crackdown on its practitioners. Two years later, the Malleus maleficarum [Hammer of the Witches] of the Dominicans, Institoris and Sprenger, created a witchfinders’ handbook that passed through more than twenty editions and translations. Accusations spread, especially where religious conflict and social tension were rife, and trials and executions mounted till around 1650. As late as 1692 the Salem, Massachusetts, trials resulted in thirty executions, and witches were still occasionally being executed in parts of Europe on the eve of the French Revolution.

Nineteenth-century psychiatrists retrospectively diagnosed witches as mentally disturbed, their confessions of compacts with the Devil being the progeny of delusions and hysterical personalities. More recently, such charges have been levelled primarily at the witch-hunters, for whipping up mass hysteria. Though most early-modern doctors supported the prosecution of witches, a few were sceptical, and doubts were particularly expressed in the De praestigiis daemonum (1563) [On the Conjuring Tricks of Demons] of Johannes Weyer (1515 – 88). Weyer was the town medical officer of Arnhem in the Netherlands, and he warned against mistaking sickness for Satan. The Devil had no power over the body; so-called witches imagined the enormities they confessed, perhaps in the throes of fever. He insisted that the deeds of which they were accused – causing sudden death, impotence or crop failure – were natural occurrences. Witches were to be pitied and healed rather than harried and punished.

Felix Platter (1536–1614), dean of the medical faculty at the University of Basel, left extensive accounts of psychiatric disorders in his Praxis medica (1602) [The Practice of Medicine] and Observationum (1614) [Observations]. From a medical viewpoint he downplayed diabolical agency, though advising the use of amulets in cases of madness. He discussed hysteria and sexual disorders, described cretinism (then common in Switzerland), and advocated a basket of psychological, pharmacological and physical therapies. Occasionally at witch trials, medical and theological interpretations of insanity clashed. Yet it was not until the triumph of the mechanical philosophy that a naturalistic theory of mind gained ground, ruling out the supernatural element in mental illness.

A window is offered onto the deranged by the case notes of the Revd Richard Napier (1559–1634), a contemporary of Shakespeare’s who specialized in healing those afflicted in mind and spirit. A high proportion of the afflicted visiting him suffered family troubles, financial insecurities and religious torments, and many believed they were bewitched. Of the 134 cases of deep depression this Anglican clergyman handled, fifty-eight were attributed to deep grief following children’s deaths (�Much grief for the death of two children’, one parent related). Of Agnys Morton, who had murdered her illegitimate baby, evidently suffering from puerperal fever, Napier recorded,

This woman is distracted of her wits … went to make herself away, being tempted as she sayeth thereunto by the Tempter. Will not in any case say her prayers … Very ravenous and greedy, and will say the foul Fiend lyeth at her heart, that she cannot feed him fast enough.

Napier cast horoscopes in forming his diagnoses, and healed with a mixture of herbal remedies, prayer and counsel, often giving patients sigils and talismans. He may be regarded as one of the last Renaissance magi.




MEDICINE IN SOCIETY


Renaissance humanism benefited the doctor more than the patient. The new learning hardly helped physicians to cure diseases. But it gave the medical profession an elevated sense of its proper dignity, and though playwrights loved poking fun at the pedantic pomposities of costly and useless physicians, medicine grew more status-conscious, and more dismissive of its rivals. �All that falsely usurp this Title of Physitian’, declared Richard Whitlock, �take off their Visards, and underneath appeare Wicked Jewes, Murtherers of Christians, Monks, abdicant of their orders, &c. Unlearned Chymists, conceited Paedagogues, dull Mechanicks, Pragmaticall Barbers, wandring Mountebancks, Cashiered Souldiers … Toothlesse-women, fudling Gossips, and Chare-women, talkative Midwives, &c. In summe … the scum of Mankind.’

This heightened sense of dignity was marked in public recognition. Earlier tendencies towards the public employment of physicians continued. The code of criminal procedure promulgated for the Habsburg empire by Charles V in 1532, known as the Carolina, required judges to consult surgeons in cases of suspected homicide, and midwives in infanticide. A landmark in forensic medicine, the Code was adopted in much of continental Europe. Medical authors were keen to display their expertise in the courtroom. Paré explained how to recognize the signs of virginity in women – important because under ecclesiastical law non-consummation was one of the very few grounds for annulment of marriage – and the indications of death by lightning, smothering, drowning, apoplexy, poison and infanticide; he also showed how to distinguish between wounds given to a body when dead and alive.

Medical institutions continued to develop under royal and municipal patronage. In 1518 Henry VIII chartered the College of Physicians, granting it examining, licensing and policing powers over medical practice in London. (It became �Royal’ from the time of Charles II.) Unlike some European counterparts, however, the college did not succeed in extending its jurisdiction to a wider region, nor did it have control over the licensing of surgeons and apothecaries.

In health care provision in England, the sixteenth century brought a major setback. The dissolution of the monasteries and chantries (rapacious asset-stripping carried out in the name of religious reform by Henry VIII and Edward VI) resulted in the closure of almost all the medieval hospitals, which, even if they had provided little treatment, at least had afforded shelter to the aged, sick and incapacitated. A few institutions survived the Reformation, being re-established on a new, secular basis. St Bartholomew’s and St Thomas’s passed to the City of London after the Dissolution, as did Bethlem for treating lunatics. Despite its burgeoning population, rising to 200,000 by 1600, London long possessed only these three hospitals, not in themselves very large (in 1569 St Thomas’s housed 203 patients); beyond the capital, scarcely any medical institutions survived Henry VIII’s destructive greed.

Shortcomings in institutional medical provision in England and elsewhere may have been counterbalanced, thanks to the development of printing, by the growth of writings popularizing health advice. These sprang largely from the regimen and hygiene traditions incorporated within the Salernitan Regime. Such works, stressing the non-naturals, instructed readers to monitor their constitutions. Andrewe Boorde (c. 1490–1549), an ex-monk turned physician, offered rules in his Compendyous Regyment or a Dyetary of Healthe (1547). He began by prescribing where to situate a house, how to organize a household, what to eat and drink and what to avoid, and what exercise to take, before moving on to more detailed physical methods of preserving and restoring health. The non-naturals were also stressed by Andre du Laurens (1558–1609), physician to Henri IV and professor at Montpellier. In 1597 he published a book translated as Discourse of the Preservation of the Sight; of Melancholic Diseases; of Rheumes and of Old Age, which contended that the causes of ageing were mental as well as physical: �Nothing hastens old age more than idleness.’ Early in the seventeenth century, Sir John Harington (1561–1612) brought out a popular English translation of the Regimen sanitatis Salernitanum. Addressed to King James, The Englishman’s Doctor (1608) provided health advice to all:

Salerne Schoole doth by these lines impart

All health to England’s King, and doth advise

From care his head to keepe, from wrath his heart,

Drinke not much wine, sup light, and soon arise,

When meate is gone, long sitting breedeth smart:

And after-noone still waking keepe your eyes.

When mov’d you find your selfe to Natures Needs,

Forbeare them not, for that much danger breeds,

Use three Physicians still; first Doctor Quiet,

Next Doctor Merry-man, and Doctor Dyet.

Temperance was the message of the highly successful Discorsi della vita sobria (1558–65) [Discourses on the Temperate Life] of Luigi Cornaro (c. 1464–1566), which he wrote in his eighties. Cornaro maintained that a temperate life would enable the body’s finite supply of vital spirits to last until life ebbed peacefully away between the ages of five and six score. Practising what he preached, he attributed his longevity to moderation, exercise, keeping his mind occupied and heeding his diet. Old age aroused great interest. In 1635, William Harvey performed a postmortem on Thomas Parr (c. 1483–1635), supposedly the oldest man in England. Brought to London, he was presented to Charles I and exhibited at taverns, but the smoky London atmosphere proved too much and he expired, allegedly at the ripe age of 152.

Printing made other sorts of health literature more widely available. Obstetrics and babycare books began to appear in many languages. The earliest published midwives’ textbook written in the vernacular, Eucharius Rösslin’s (d. 1526) Der Swangern Frawen under Hebammen Rosengarten (1513) [Garden of Roses for Pregnant Women and Midwives] appeared in English as the Byrth of Mankynde (1540) and was still in use in the eighteenth century. Its frontispiece pictures the mother in labour among relatives and midwives, groaning on a birth stool, while the attendant astrologer gazes through the window to cast the baby’s horoscope.

Thanks to printing, stronger links were forged between medicine, learning and culture. Humanism’s preoccupation with recovering the learned medicine of the ancients proved, however, a mixed blessing, and scepticism towards the profession remained deep-seated: �Trust not the physician, his antidotes are poison,’ warns Shakespeare’s Timon of Athens. During the following century medicine was to build a new scientific basis.

* (#ulink_17b62cc0-e3cc-576d-8f96-32db67f7d9cd) Unlike syphilis, gonorrhoea is an ancient disease. An Assyrian tablet speaks of thick or cloudy urine, and the Hippocratic writers refer to �strangury’, that is, blockage of the urethra. There was no effective cure until sulfonamides became available in the 1930s.

* (#ulink_71dca62b-422c-5a36-b138-6527c990ceff) The ontological view of disease as produced by distinct entities had a few classical antecedents. In Timaeus Plato had compared diseases to creatures, and Varro (116–27 BC) had spoken of animals too small to be seen by the eye, �which by mouth and nose through the air enter the body and cause severe diseases’.

* (#ulink_bf74a795-11ac-59ef-807a-d998b00190ee) The heyday of eponyms was the seventeenth century, with Aselli’s pancreas, Graafian follicles, Haversian canals, the circle of Willis, Tulp’s valve, Bartholin’s duct and glands, and many lesser ones.

* (#ulink_75e675d3-61d8-51c9-8473-0362380ac8ea) Montaigne wrote, �I am in the grip of one of the worst diseases – painful, dreadful, and incurable. Yet even the pain itself, I find, is not so intolerable as to plunge a man of understanding into frenzy or despair. At least I have one advantage over the stone. It will gradually reconcile me to what I have always been loath to accept – the inevitable end. The more it presses and importunes me, the less I will fear to die.’

Self-possession in the face of sickness, he believed, was crucial. Physicians were of little use: �no doctor takes pleasure in the health even of his friends,’ he remarked; this was a long-standing humanist jibe.





CHAPTER IX THE NEW SCIENCE (#ulink_300d18db-26d2-5f43-8aa4-c28de577b13c)


THE DREAM OF RENAISSANCE HUMANISTS was to restore medicine to its Greek purity, but a counter-view gained ground in the seventeenth century as the �moderns’ confronted the �ancients’: medicine could thrive only if the deadweight of the past were cast off. After centuries of stultifying homage to antiquity, a fresh start was needed. This was a subversive doctrine indeed, but support could be drawn from the Reformation: if Luther could break with Rome, how could it be impious to demand the reformation of medicine? Such revolutionary impulses first found expression in the work of the iconoclastic Paracelsus.




PARACELSUS


Meaning �surpassing Celsus’, Paracelsus was the cocksure name adopted in his early thirties by Theophrastus Philippus Aureolus Bombastus von Hohenheim (c. 1493–1542), a medical protestant if ever there was one – though, ironically, he never formally abandoned his native Catholicism. Paracelsus was born in Einsiedeln, Switzerland and educated by his physician father in botany, medicine and natural philosophy. Around the age of twenty he briefly studied medicine in Italy but subsequently led the life of a wandering student. All the while he picked up knowledge from artisans and miners (�I have not been ashamed to learn from tramps, butchers and barbers’), observed and thought for himself, and acquired a taste for the esoteric. The writings of Trithemius (1462–1516), an occultist who aspired to the wisdom of the mythic Hermes Trismegistus, convinced him of the workings of invisible powers as spiritual intercessors between God and man in an enchanted cosmos.

Paracelsus’s off-beat education marked a drastic break with the orthodox university medical curriculum built on canonical texts; it helps explain how he repudiated Galenism and came up with new disease concepts in a twenty-year career that made him the scourge of the medical Establishment: �When I saw that nothing resulted from [doctors’] practice but killing and laming, I determined to abandon such a miserable art and seek truth elsewhere.’ But while there is no denying Paracelsus’s break with the past, the common portrayal of him as the founder of scientific medicine is misleading, for his creed always involved mystical and esoteric doctrines quite alien to today’s science. He thus appears a paradox. For while subscribing to popular beliefs and folk remedies, and lapping up the lore he heard from peasants about the nymphs and gnomes haunting mines and mountains, he also championed new chemical theories, dividing all substances into �sulphur’, �mercury’ and �salt’. Yet these must be understood not as material elements but as hidden powers.

Paracelsus’s fundamental conviction was that nature was sovereign, and the healer’s prime duty was to know and obey her. Nature was illegible to proud professors, but clear to pious adepts. His teachings on remedies thus drew on the popular doctrine of signatures to identify curative powers: the orchid looked like a testicle to show it would heal venereal maladies, the plant eyebright (Euphrasia officinalis) had been made to resemble a blue eye to show it was good for eye diseases. Paracelsus was perhaps influenced by radical Protestantism and its faith in a priesthood of all believers: truth was to be found not in musty folios but in the fields, and in one’s heart. Yet though he displayed a fiercely independent temper, kowtowing to none, unlike Servetus he cannily avoided getting ensnared in Reformation politics.

His fisticuffs mentality comes out clearly in his sublime contempt for academic pomposity: �I tell you, one hair on my neck knows more than all you authors, and my shoe-buckles contain more wisdom than both Galen and Avicenna.’ In 1526 he was appointed town physician and professor of medicine in Basel, a post requiring him to lecture to the medical faculty. This he did not in the customary Latin but in German, wearing not academic robes but the alchemist’s leather apron, and his manifesto pronounced that he would not teach Hippocrates and Galen, since experience alone (which included his intuitive flights) would disclose the secrets of disease. Jeering at orthodox physicians, and taking his cue from Luther, he then publicly burned Avicenna’s Canon, the Bible of learned medicine, along with various Galenic texts on St John’s day (24 June 1527). All this was quite unheard of.

Bloody-mindedness aside, Paracelsus’s significance lay in pioneering a natural philosophy based on chemical principles. Salt, sulphur and mercury were for him the primary substances. These did not completely replace the Aristotelian – Galenic system of qualities, elements and humours, but he considered them superior because they were in alchemical terminology �male’ – that is active and spiritual – whereas the elements were �female’ and passive. His �tria prima’ are to be understood not as material substances but as principles: solidity or consistency were represented by salt; inflammability or combustibility by sulphur; and spirituousness or volatility by mercury. Drawing on the occult, he associated diseases with the spirits of particular minerals and metals: �When you see erysipelas, say there is vitriol. When you see cancer, say there is colcothar’ (peroxide of iron). But he also boldly deployed metals and minerals – mercury, antimony (stibium), iron, arsenic, lead, copper and sulphur – for therapeutic purposes, together with laudanum (tincture of opium).

Embodying spiritual and vital forces, Paracelsus’s chemical principles explained living processes. These depended upon what he called archei, the internal living properties controlling processes like digestion; and also semina or seeds deriving from God, the great magus (magician) who orchestrated nature. The agents of disease, on the other hand, might be poisonous emanations from the stars or minerals from the earth, especially salts. His belief that there were as �many diseases as pears, apples, nuts’, and that each disease had a specific external cause sounds like an anticipation of ontological doctrines, but it must be remembered that he saw the essence of disease as spiritual.

Paracelsus ridiculed hidebound practices. Sickness was to be understood not by conventional urine inspection (uroscopy) but by chemical analysis using distillation and coagulation tests. He also enjoyed mocking innovations championed by others. Dissection, for instance, was worthless �dead anatomy’, for it could not reveal how the living body functioned. He died before Vesalius published his Fabrica, but he would probably have deemed it not worth a sausage. True physiology had to discover the nourishment each body part needed, while to fathom pathology stellar influences had to be probed and the presence of abnormal quantities of salt, sulphur and mercury tested. By disparaging humoral balance and stressing the prime role of particular organs in health and disease, he countered Galenist constitutionalism with a new notion of specificity and a pathology of disease as invasion from outside.


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He interpreted familiar diseases in new ways. Take gout, regarded by Hippocratic medicine as a classic humoral imbalance involving defluxion into the foot (�gutta’ means �flowing’). Paracelsus read gout not constitutionally but chemically, seeing it in terms of the wider category of �tartaric disease’ (diseases of incrustations). In De morbis tartareis (1531) [On Diseases of Tartar], he proposed that some local external factor, such as water supply, might produce the characteristic chemical deposits in the joints. He boasted patriotically that in Switzerland, �the most healthy land, superior to Germany, Italy and France, nay all Western and Eastern Europe, there is no gout, no colic, no rheumatism and no stone’. Gouty nodules, he maintained, consisted of calcined synovia or an excremental salt (tartar) coagulated in a joint. Since the tartar coating wine casks was a product of fermentation, such material could be compared to bodily deposits like gallstones, kidney stones, and the dental incrustations still known as tartar. Bodily tartar was thus derived from food and released through digestion. In some individuals it failed to be excreted, tending instead to be transformed by �spirit of salt’ into stony substances like calculi or gouty tophi. This theory of �tartarous disease’ was one of the earliest attempts to advance a chemical aetiology for a malady.

Paracelsus sneered at bookworms (�not even a dog-killer can learn his trade from books’), and his copious writings taught that truth was to be found not in libraries but in the Book of Nature, and issued a health warning: �the more learned, the more perverted’. Personal experience was what counted – �he who would explore nature must tread her books with his feet.’

However ambivalent such views – Paracelsus was the classic dogmatic anti-dogmatist, the humble chap convinced everyone else was wrong, the inveterate scribbler who told readers to close their books – his commitment to the discovery of truth through observation and experiment was a breath of fresh air. And it became the inspiration of the new medicine emerging in the �scientific revolution’ stirring at about the time of his death: 1543 brought not just Vesalius’s De fabrica but also Copernicus’s De revolutionibus orbium coelestium [On the Revolutions of the Heavenly Spheres] with its revolutionary heliocentric astronomy.




MEDICAL CHEMISTRY


Few of Paracelsus’s medical writings were published before his death in 1542, but by the 1550s they were spreading in a blaze of controversy. His followers made an odd bunch. His writings appealed, as would be expected, to radical reformers, such as the Danish Lutheran Peter Severinus, whose Idea medicinae philosophicae (1571) [The Idea of Philosophical Medicine] mocked Galenism, and in true Paracelsan fashion told readers to burn their books (though presumably not the Idea!), sell their houses and go on their travels, studying plants and learning from peasants. But his teachings also found favour in more select circles.

Cold-shouldered by universities, followers sought friends in high places; princely patronage would give Paracelsanism its imprimatur, while royal largesse could equip the laboratories chemical medicine required. In any case, many Renaissance rulers had intellectual aspirations of their own. The elector of the palatinate, Otto Heinrich Duke of Neuburg, was probably the first German noble to favour Paracelsans, and they also found support alongside the astrologers and magicians at the Prague court of the mystically-minded Holy Roman emperor, Rudolf II.




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