(2) History of the Medicine

Wider Hippocratic reverberations

The humours provided a theoretical framework that lasted. We still use the idea of the temperaments in casual speech (‘a naturally sanguine person’, ‘generally melancholic’), and the hot-cold, wet-dry axes of the humours regulate how we see common acute complaints. Popular belief has it that we catch colds by going out without our hats on, or getting our feet wet. Doctors, who ought to know better, fall in with popular disease conceptions about the nature and treatment of colds, partly because that is what patients expect, partly because it saves time in the patient–doctor encounter, partly because doctors, too, are all too human. More recently, Darwinian medicine has used the Hippocratic vix medicatrix naturae to question the treatment of symptoms. Is it better to suppress the cough, or dry up the nasal secretions, when they are part of a naturally evolved defence?

Much of the Hippocratic legacy was actually transmitted to the West through the writings of Galen, who dominated medical thinking for more than a millennium. Galen saw himself as extending and completing the framework of the Hippocratics. We know much more about him than any other doctor of antiquity: more words of his survive than any other ancient writer, medical or otherwise, and his works are laced with autobiographical snippets. He wrote about all aspects of medicine: diagnosis, therapy, regimen, and the philosophy of medicine. He codified the Hippocratic doctrine of the humours, but also consolidated an experimental dimension to medicine. Whereas the Hippocratics were content with careful observation, Galen went much further, offering anatomical and physiological accounts of what happened in health and disease. He was big on ego-strength and seemed to assume that his was the last word on virtually everything. He cannot be blamed that most doctors for more than a thousand years agreed with him.

Humoralism served Galen very well at the bedside, explaining disease, but he also developed a complicated physiology to explain normal bodily function, which relied on spirits (pneuma) rather than humours. Within his model, food was taken into the stomach, whence it was turned into chyle. This chyle went to the liver via the portal vein, where it was converted into blood suffused with natural pneuma. Some of this blood then was conveyed to the heart. Part of the blood from the heart went to the lungs to nourish this essential organ. Other portions of the heart’s blood passed through invisible pores from the right to the left ventricle, where it mixed with vital pneuma, acquired from the lungs and ultimately through breathing air. This vital blood then went via the aorta and carotid artery to the brain, where it had its last refinement, with animal pneuma, and then via the nerves to initiate motion and sensation.

This model of human physiology became gospel for more than a millennium. So, too, did Galen’s comments on anatomy, often (through no fault of his own) performed on pigs, apes, and other animals.

The prohibition on human dissection was out of Galen’s control, and his only mistake was not to tell his readers where he got his anatomical knowledge from. This omission encouraged later worshippers of Galen to assume that the human body must have changed since the master dissected, but eventually left him a sitting target for progressives who believed their own eyes.

More than 500 years separated Hippocrates and Galen, and there were of course many doctors and systems of treatment afoot between them. One group of doctors in Rome emphasized massage, warm or cool baths, and other therapies to relax or constrict the body’s pores, their preternatural state of tension posited as the cause of disease. Other doctors adopted their own approach to diagnosis and treatment. Some of these alternative systems survived Galen’s dominance, but Galen bestrode the millennium after his death far more comprehensively than Hippocrates had done in the centuries after his followers stopped writing. These medical dimensions are worth studying for their own sake, but Greek medicine as a whole left three basic principles that formed medicine until the modern period.

The first principle, as we have already seen, was humoralism. The second was the botanical basis of most drugs. Doctors looked to the botanical kingdom for medicines to combat disease. One doctor in particular organized the ancient pharmacopoeia into a form that others found useful for centuries.

Dioscorides (fl. c. 40–80) wrote a treatise on Materia Medica which incorporated the medicalbotanical writings of earlier authors but also included much that he himself had discovered about plants and their medicinal qualities. Although he described a few animal products, plants dominated, as they did for most other doctors in antiquity and beyond. Plants could yield substances that would bring on a sweat, induce vomiting or a purge, produce sleep, or control pain. Many botanical preparations, such as opium and hellebore, had great staying power, but unlike the core theoretical content of ancient medicine, plants have definite geographical distributions, and the search for them meant that later doctors had to do their own hunting, in their local forests and hedgerows. If you have a particular plant in your area, you can supply it to others who don’t, and importing and exporting drugs became an active business in later centuries. Galen incorporated much of Dioscorides’ work in his own voluminous writings, and the latter’s Materia

Medica was still prized in the Renaissance

The third legacy – a secular approach to disease – was more elusive but just as important for all that. Both religion and magic continued to influence thinking about health and disease by doctors and laymen. They still do. But the ancient healers whose writings survived and were prized believed that disease could be understood in natural terms. This is not to say that ancient doctors were not religious: Galen had a notion of monotheism that later commentators turned into a kind of recognition of the religious movement that was gaining ground during his lifetime – Christianity. But when Hippocrates or Galen was confronted with a sick patient, they drew on their own knowledge and skills in an attempt to bring about an act of healing at the bedside. For all this, disease still frequently was and is experienced within a religious or moral framework, seen as a result of sin, punishment, or, like Job, trial – why me?

These glosses do not negate the fact that the framework of ancient medicine was a naturalistic one. Physician and physics derive from the same Greek root, meaning ‘nature’, and attempting to understand the way the body functions in health and disease has ever been a spur for the curious doctor and worried patient.

Medicine in the library

The miracle of survival

When one stops to think about it, it is a miracle that anything written survives from antiquity. How is it that we can enjoy Homer’s epic poems, Plato’s and Aristotle’s works, or the 20 volumes (in their incomplete modern edition) of Galen’s writings? Manuscripts were laboriously copied by hand, on parchment or other mediums, were scarce and expensive commodities, and were then subjected to the ravages of time, the destruction of war, natural decay, or simple carelessness. The items that survive today are usually later copies, made centuries after the original text, prepared because someone wanted a version for himself. In general, the more prized a text was, the greater the chance of survival, simply because there were more versions of it made. But far more words written in antiquity have perished than have come down to us. The largest library and museum in the ancient world was in Alexandria, Egypt. It housed tens of thousands of scrolls and parchments, but suffered serial destruction and continuous decay from the 2nd century and was nothing but ruins by the 7th.

Thus, we are indebted to the anonymous scribes in great households, religious establishments, and royal courts for much of what we know of the thoughts of people who lived two millennia and more ago. The writings of Hippocrates, Galen, and other doctors of antiquity provided the formal foundations of medical practice into the 18th century. Consequently, the period of appreciation, preservation, and commentaries upon their works that characterizes the millennium between the fall of Rome in 455 and the movement we call the Renaissance deserves its own place in the history of medicine. It has been called the period of ‘library medicine’. In this chapter, I shall make little distinction between the Latin West and the polyglot East, which includes Byzantium, the Islamic Empire, and Jewish and Christian contributions to medical life in the areas in which Islam came to dominate. Doctors in these widely separated geographical and cultural milieus all shared one characteristic: a veneration of the medical wisdom of the Greeks, and a desire to base their own medical theories and practices on these ancient precepts. Of course, they added much along the way.

Along with this essential contribution of preserving and adding to the Greek medical heritage, this epoch, from the 5th century to the invention of the printing press, also fundamentally changed the nature of medical structures. It bequeathed to us three important things: the hospital, the hierarchical division of medical practitioners, and the university, where the elites of medicine were educated.

Preservation, transmission, adaptation

In late antiquity Europe, medical care was mostly in the hands of individuals without access to any of the writings of the classical period. Local traditions, including informal care, magico-religious remedies, and superstitions dominated, but the prevailing world view of the Christian era encouraged individuals to wait for the end of the world, and in any case, to see disease as a part of a wider providence, and trivial compared to the potential joys of the world to come. The few literate doctors would have had access to some 4th- and 5th-century writings within the classical tradition. Caelius Aurelianus (fl. 4th or early 5th century) produced a compilation on acute and chronic diseases, based largely on the works of an earlier physician, Soranus. Caelius’s work was rational, full of medical insights, and survived throughout the medieval period as a summary of diseases and their treatments.

For example, he described migraine, sciatica, and a number of common diseases. His treatments were mostly gentle, suggesting massage, bed rest, heat, and passive exercise for dealing with sciatica. A few other medical works were also around in the Latin West: some minor works of Galen, including spurious treatises attributed to him, the Hippocratic Aphorisms, as well as bits of other ancient authors. The centre of gravity had shifted east, however, to the Byzantine Empire, the capital of which was Constantinople, now Istanbul. A lot of ancient manuscripts had already found their way east, and physicians in the Christian East preserved, translated, and commented on them. The rise of Islam saw Byzantium decline in influence and territory, but those same lands, now within Islamic dominion, were also significant for the transmission of the ancient corpus of medicine.

Islam was a wonderfully polyglot culture, and a number of Greek manuscripts survived only in the languages of the area of Islamic conquest, especially Arabic, Persian, and Syriac. A major translation movement was underway by the late 8th century, and this continued for three centuries. The medieval Islamic medical tradition is often seen primarily as a conduit for the preservation and transmission of ancient Greek texts, which were translated into the Middle Eastern languages, then in turn rendered back into Latin, and finally into modern European languages.

Medieval Islamic medicine was more than an interlude, however. There was also a vigorous learned medical culture which not only reformulated Greek medical ideas to its own context but also added new observations, medicaments, and procedures. Three of the great names of Islamic medicine, Rhazes (c. 865–925/32), Avicenna (980–1037), and Averroes (1126–98), span almost four centuries, and between them produced a corpus of work that assimilated Greek ideas and passed them, properly transformed, back to the West. All of them were men of wide interests. Rhazes active in what is modern-day Iran, wrote on alchemy, music, and philosophy, but his actual medical practice was extensive, and his diagnostic acumen was much admired during his lifetime. He distinguished smallpox from measles for the first time (measles he judged the graver illness), and offered shrewd medical advice for travellers.

Like Rhazes, Avicenna (Ibn Sina) was a man with many interests outside of medicine. Aristotle was the dominant philosophical influence on him, and infused his medical writings. A precocious youth, Avicenna produced more than 250 titles in the course of an adventurous life. His Canon of Medicine (Al-Qanum fi l-tibb) has been described as the most studied medical treatise of all time, and its five Books cover the whole of medical theory, treatment, and hygiene, as well as associated surgical and pharmacological dimensions of medical practice. Like Galen, Avicenna was a clever man who did not hesitate to tell his readers about his talents, but the Canon brilliantly assimilates and packages Greek medical wisdom and Islamic medical experience, in a logical and well-ordered form.

It was ideal as a complete medical textbook, for which it was long used in Europe, in Latin translation, and continues to be assigned to students of unani tibb (traditional Islamic) medicine. Averroes (Ibn Rushd), like Avicenna well versed in Aristotelian philosophy, worked in Islamic Spain and in Morocco. His major medical work (he also published on philosophy, astronomy, and jurisprudence) was an encyclopaedic one, in the style of Avicenna’s Canon. Variously rendered in English as ‘The Book of Universals’, or ‘Generalities of Medicine’, Averroes’ textbook in seven sections covered the whole gamut of medicine, from anatomy to therapy. Its Latin translations presented a Galenic-Aristotelian synthesis to generations of doctors in late medieval Europe.

Just as the Islamic doctors had instituted a programme of translation of ancient texts into Middle Eastern languages, so the process of translating these translations back into Latin was initiated by Constantine the African (d. before 1098), and continued by many other scholars. These newly available Latin texts formed the basis of the curriculum of the earliest European medical schools, beginning with the famous one at Salerno, southern Italy, established about 1080, and adopted by medieval university medical faculties during the following centuries.

Hospitals, universities, doctors

Depending on what counts as a ‘hospital’, this central institution of modernity can be traced to various beginnings. The Romans used special buildings called Valetudinaria (from the same root as our word for someone who is worried well, a valetudinarian) to house and care for wounded and sick soldiers. There is one known to date from about CE 9. Slightly earlier, slaves were also being housed together when they were sick, a reflection of their value. These structures were pragmatically designed to contain a number of beds and related facilities, but they were also generally related to the necessity of a particular campaign or outbreak of illness and were not conceived of as permanent institutions in the modern sense.

Our word ‘hospital’ comes from the same root word as do hospitality, hostel, and hotel. In Christendom, early ‘hospitals’ were religious establishments, maintained by religious orders and available as places of refuge or hospitality for pilgrims, but also for the needy. Their function was not explicitly medical, although (like monasteries or nunneries) the ‘hospital’ might also contain an ‘infirmary’ (place for the sick or infirm), where those with specific medical needs could be looked after. More common and larger in the Near East (Jerusalem contained one with 200 beds by 550) than in the Latin West, they gradually began to dot the landscape of present-day Europe. Many of the famous European hospitals of the present date back to medieval times and their names testify to their religious origins: Hôtel Dieu in Paris, St Bartholomew’s Hospital in London, Sta Maria Nuova in Florence.

Within the Islamic lands, hospitals also attained considerable size and importance by the 11th century. They sometimes had special divisions, such as wards for patients suffering from eye diseases, or the insane, and attracted students wishing to learn how to practise medicine. They were probably more overtly ‘medical’ than their Christian counterparts, but they shared the same range of philanthropic or charitable funding, and, in times of epidemic, the same function of isolation and segregation. Community leaders made use of hospitals for two diseases in particular: plague and leprosy. Often called ‘lazarettos’ – from Lazarus, the poor man whose sores the dogs licked in Jesus’ parable in Luke’s Gospel – these isolation hospitals were adapted for plague after the Black Death, from their earlier use for people diagnosed as lepers. No disease better than leprosy captures the combination of brutality and love infusing medieval Christendom. The diagnosis itself, often for conditions that modern doctors would give another name, carried with it total social ostracism and legal death, with divorce by the leper’s spouse permitted. It condemned its victim to a life of isolation and begging, generally confined to a lazaretto and needing to carry the familiar leper’s rattle when going outside, so that passers-by were alerted to the oncoming source of physical (and moral) contagion. At the same time, some monks, nuns, and other religiously motivated individuals freely lived among these outcasts and devoted their lives to them.

The leprosy diagnosis was common from the 12th to the 14th centuries, in most parts of Europe, and leprosy’s decline may have been catalysed by the fact that people living together in closely confined quarters were particularly vulnerable to the Black Death and the repeated plague epidemics that followed. Certainly a number of leper hospitals were turned into plague hospitals, for many of the same reasons, save that plague was an acute disease, from which some individuals recovered, and leprosy was a chronic disease and generally a life-long sentence. Plague hospitals, especially in southern Europe, were converted to other medical uses after that disease disappeared from Europe in the 17th century; in the Middle East, where plague continued, they were kept as places for quarantining travellers and others on the move when plague was near. Another medieval institution important for medicine was the university. The medical school at Salerno from the late 11th century was simply that: a school to train doctors. A university followed there a couple of centuries later. In the meantime, many others were founded throughout Europe, beginning with Bologna (founded c. 1180), and followed by those in Paris (1200), Oxford (1200), and Salamanca (c. 1218). By the late 15th century, there were 50 in Europe, dotting the north and south, east and west. A university has different faculties, and most of these either had from the beginning or developed medical faculties, to complement those of arts, philosophy (including what we would call science), theology, and law. Although many of the medical faculties were very small, and the number of graduates miniscule, the movement gave birth to learned medicine, and the university-educated physician. It represented the quintessence of ‘library medicine’, since the teaching was initially based on texts, of classical and Islamic authors, and disputation ather than practical training or experiment was the key.

One consequence of the newly graduated physician was the formalization of the occupational hierarchy within medicine that persisted until the 19th century. With an expensive and lengthy education that the universities offered came the gentlemanly status that physicians long prided themselves on. (Until a decade ago, Fellows of the Royal College of Physicians of London could not sue for the recovery of fees.) As gentlemen, manual work was beneath them. That was the job of the surgeon and apothecary, both occupational niches that already existed but was more formally fixed with the coming of the university. Surgeons and apothecaries were trained by apprenticeships, or by informally learning their craft by associating themselves with an older practitioner. It was the Hippocratic way, but it began to acquire a lower social (and, generally, economic) status when compared with physicians who could read Latin and dispute the niceties of Galen and Avicenna.

There were, to be sure, a few surgeons with university exposure, and among both surgeons and apothecaries, individuals with learning and wealth. The boundaries were not always fixed and, in the countryside, many physicians compounded their own drugs and performed surgery. In other words, they acted as general practitioners. In urban areas, however, the divisions were retained and regulated by colleges and companies of physicians, or by the university faculty. Surgeons in urban areas often established guilds, on a par with those regulating other manual occupations, such as butchering, baking, or candlestick making. The medical regulation was patchy, but the image of the three occupational hierarchies remained part of public perception until later developments in medical knowledge also changed what doctors could do.