In 430 BCE, and again in 427, a great pestilence broke out in Athens. At the time that city-state was at the height of its imperial grandeur, the acknowledged leader of much of the Greek world. Its leadership however was being challenged by Sparta and the Peloponnesian League whose invading armies had forced the Athenians on to the defensive behind their Long Walls: there they were pent up in insanitary conditions. In the course of its two outbreaks, the pestilence (we have no way of knowing what it was) killed off a third of the Athenians.
Given that medical doctors found themselves utterly powerless against the “plague” of Athens, their claims to competence in dealing with any illness were thrown further into doubt. Perhaps by coincidence, throughout the Greek world by the last third of the fifth century temples dedicated to the healing god, Asclepius, had became hugely popular. In Rome, symptomatic of growing Greek influence in metaphysical matters, a temple dedicated to the god was established in 291 BCE.
Throughout the Mediterranean world Asclepian temples continued to attract crowds until their functions were taken over by miracle-working Christian saints and shrines in the fourth and fifth centuries CE. Who then was Asclepius?
According to legend, Asclepius was the son of the Greek god Apollo, the same god who had hurtled the darts of killing pestilence against the Greeks around 1200 BCE when they were besieging the city of Troy (as recounted by “Homer” in the Iliad). Asclepius’ mother however was a mortal woman. Given that Asclepius had this link with humankind, after he had fallen out with Zeus and been killed because he had restored a dead man to life without permission, he was elevated into the ranks of the gods.
The still-extant walls of temples dedicated to Asclepius at Cos, Pergamum, Epidaurus and elsewhere contain plaques commemorating the miraculous cures effected in their precincts. The procedure was for a blind, or crippled, or mentally deranged, or hopelessly afflicted individual to sleep for a night or two in the temple. He or she then dreamed that Asclepius, in one or another of his forms, had appeared and given instructions. The next morning these instructions were interpreted by a priest. According to the commemorative plaques put up by the no longer blind, or the no longer crippled, these instructions had led to a cure. Some of those cured by these miraculous interventions claimed to have been medical practitioners.
In the Greek language, the word “iatros” has a variety of meanings. It might mean someone who had persuaded others that he was a medical doctor. At the time there were no teaching hospitals or standard ways of acquiring a medical education. Though some cities at the end of the classical period had taken to appointing a civic physician, the appointment was made after public disquisition between rival contestants. The man who spoke most logically won out, even though his actual ability to effect cures was possibly non-existent. There were no medical licensing institutions or regulatory bodies.
In addition to “medical doctor” the word “iatros” can also mean root-cutter, drug-provisioner, midwife, wise woman. People in all of these categories might take upon themselves the role of public curer. In normal circumstances of course, out in the Greek countryside or in the Roman Campagnia, the head of household or his wife served as the first line of defense against illness in the familia (the cellular social grouping consisting of the biological family and its slaves). Though specialists admit that they really know very little about the sorts of herbal remedies and drugs used by the common people in classical times, they assume that they were similar to those listed in the books on home remedies published in western Europe from the sixteenth century onwards.
Hints in various places in the literature of ancient Greece suggest that, in addition to herbs and drugs, another locally available avenue of relief from illness lay in the use of incantations. It seems that the words of the incantation itself were considered to be efficacious, rather than who said them or the purpose for which they were said. Thus, a head of household might send out a slave to repeat an incantation over a sick horse or a fellow slave in the expectation that it would have the desired effect. In contrast to the situation among the Persians and the Jews, it is thought that the ancient Greeks did not resort to curses to cause a disease to attack one of their enemies.
Critical research has clearly shown that the supernatural underlay Greek “rationalism” in medicine as in all other fields. Aside from two schools of thought which emerged late in the Hellenistic period, the Methodists and the Empiricists, all other Greek medical writers (including Galen) fully believed that elements of the Divine were to be found everywhere. The sun, the moon, the planets and the stars all contained or reflected aspects of the Divine, as did the everyday world of human experience.
According to the Greeks, and most prominently in the works of Plato (427-c. 347 BCE) and his highly erudite and prolific student Aristotle (384-322 BCE), the cosmos and the world of everyday experience could be likened to a ship at anchor in heavy seas. Though the ship veered violently around from one direction to another as it was hit first by one wind and then by another coming in from another side, there was a limit to how far it would move (held fast by its sheet-anchor). Similarly in the cosmos, despite apparent changes, there was underlying stability and order. It was, of course, the duty of the philosopher to discover what this actual reality was (hence Plato’s posited World of Perfect Forms).
Now it was, of course, essential to the creation of “science” (as we understand it) to hold that there were rules undergirding the workings of the universe. If all humankind had believed that disorder and chaos was what actual reality was all about, not only would the development of “science” have been impossible, so too would the development of ethics and concepts such as virtue, civic duty and restraint. As it was, these concepts – together with the notion of an underlying rule-bound cosmos and world of the everyday – won through to become the dominant element in the Great Tradition. Fittingly enough, Galen (the great medical synthesizer living in the time of the Emperor Marcus Aurelius) wrote an essay entitled, “The best physician is also a philosopher.”
Yet, even in the writings of Galen there were three minor mentions of a disturbing concept which had the potential to throw a spanner into the comfortable picture of a rule-governed universe in which a well-endowed person could keep himself in good health by maintaining a proper balance among the “humors” at work within his body. The troublesome concept involved the notion that disease was caused by invisible entities coming in from the outside to attack a person and cause his death. This invisible agency was posited to be an independent force which could strike down anyone whatever his or her status, mode of living or life-style. If the logic of this position were followed through, there would be no need for medical doctors or indeed for any curers. The disease itself would always be master of the situation: Hesiod (in his “Works and Days”) had stated as much in the sixth century BCE.
Yet, by the fifth century BCE, this idea (a disease universe of chaos) had been rejected and been replaced by the dictates of philosophy. The self-proclaimed role of the philosopher and the philosopher of medicine was to prove that thinking men who allowed themselves to be governed by sensible rules could maintain themselves in good health. The recommended regimen was essentially preventive: they were to “do nothing in extreme.” Only in this way would their humors be kept in balance.
As goes without saying, humoralism was intensely individualistic. Only a rich man could afford to employ a personal physician who could advise him from day to day on dietary intake, the sexual and exercise requirements appropriate to his temperament and his time of life, and the season of the year, the sign of the zodiac under which he had been born, and the rest.
Philosophical medicine (as synthesized by Galen and later Muslim thinkers) was designed to answer every question. With its multiplicity of answers it could not readily be falsified: in this, doubtless, lay its longevity. It may also be suggested that the doctrine of humoralism provided medical doctors with a distinctive role in society. If, through the accidents of history, they had happened to be deprived of their role as interpreters, they might have permanently disappeared.
Indeed, during the last years of the Roman Empire in the West, hard-faced local secular rulers, most of them recruited from the ranks of provincial armies, decided that Greek-style humoralism and medicine was effete and unmanly, hence unnecessary. By the sixth century CE, except for the tiny Byzantine outpost at Ravenna, the medical profession in the West had ceased to exist.
For the next five hundred years, the future of formal medicine in the Great Tradition lay to the south and east of the Mediterranean, in the world of Islam. To this region we now turn.
The Islamic world drew on the medical achievements of the ancient Greco-Roman world and subtly transformed them to fit its own purposes. In this form, they were transmitted to the primitive West and served as the starting point for later Western medicine in the Great Tradition. But equally important in World History, Islamic medicine also built on medical traditions coming from ancient Persian, Arabian and Egyptian sources and created a lasting new synthesis.
The years immediately after the death of the Prophet Muhammad in 632 CEhad seen the rapid expansion of Islam beyond the Arabian Peninsula to encompass the whole of the territory of the old Persian Empire in the east, and the Christian provinces of greater Syria and Egypt in the west. To the east, Islam continued its advance and, by the 670s, it had come to incorporate much of what is now Afghanistan and the Indian province known as Sind. Islam’s advance also continued in the west, and by 720 it had come to include the whole of North Africa (bringing it to the shores of the Atlantic and the Mediterranean). It had also come to include Sicily and the Iberian Peninsula.
Within two or three generations of their incorporation into the world of Islam, the new provinces sent the most talented of their young men and women to the rapidly growing urban centers of the empire. Beginning first in Baghdad (now in Iraq) until it was wrecked by the Mongols in 1258, and then in Damascus (Syria) and Cairo (Egypt), immigrant and locally born scholars mingled together, exchanging ideas. Coming out of this were new systems of thought about illness that contained elements from several provinces, mixed together in new ways.
Today (in its Islamic form rather than in its popular variant) the “Medicine of the Prophet” continues strong among Muslim immigrant populations in the West.
In the early Islamic centuries, the technological innovation that greatly assisted in building up new syntheses in medicine, natural philosophy, theology and in other areas of scholarly concern was the making of paper. Brought in from China, by 750 paper was being produced in all the great cities of the Islamic world. Books made up of sheets of paper bound together around a single spine were much more convenient to use, to carry around, and to store in great libraries, than were old-fashioned scrolls made of sheep-skin or papyri.
They were, of course, produced by hand. A master would slowly read out a scholarly work and scribes would copy down what he said. Depending on how many scribes he employed, ten or fifteen or more copies of a 300-page book could be produced in a few weeks. It was in this way that, by 1236, (when it was burnt by crusading Christians) the great Library in Islamic Cordoba (in Andalusia, Spain) had built up a collection said to number 400,000 books.
It is now generally accepted that, by the early tenth century, leading Islamic physicians had gone far beyond the ancient Greeks in the study and practice of medicine. One of the greatest of their number was undoubtedly Abu Bakr Muhammad al-Razi (865-925 CE). Born in the city of Rayy in northern Persia during the period of weakening Abbasid rule, al-Razi spent part of his adult career in Baghdad (the Caliph’s seat of government) and the remainder in Rayy (where he was on good terms with the local governor). In both cities he served as director of a local hospital.
In his studies al-Razi was able to bring together what he regarded as the best of the traditions of the ancient world: Greek, Syriac, Persian, with a bit of ancient Egyptian thrown in. But unlike most of his predecessors, al-Razi did not allow himself to be overwhelmed by the grandeur of the book-learning of the past. Instead, in his day-to-day interaction with patients, he made it a practice to note down the specifics of each case and to draw up conclusions which very often were at odds with the conclusions of earlier masters.
Several of the clinical observations al-Razi made in Baghdad have been translated into Western languages. These show that his patients came from the neighborhood around the Muqtadiri Hospital where he taught. They included door-keepers and craftsmen and their wives and other quite ordinary people. The diseases and conditions al-Razi dealt with included perforated kidneys (leading to symptoms of fever), diarrheal diseases, inflammation of a man’s sexual organs, a woman’s miscarriage, and eye diseases. In the case of al-Husain Ibn ‘Abdawaih’s daughter, al-Razi found that she was suffering from a mild case of smallpox and, through appropriate treatment (doubtless much aided by the healing processes of nature), he was able to save her eyesight.
In his clinical practice, al-Razi had several assistants who seem to have dealt with routine cases. Yet he kept himself immensely busy with seeing patients, with reading and discussing ancient texts with students, and with writing, writing, writing. Specialists tell us that al-Razi wrote a total of 61 medical treatises. Of these, only 32 are still preserved in one or another of the world’s archives and only nine have been translated from the Arabic into a western European language. In other words, much of what al-Razi wrote has been lost or has not been critically studied in the West. As a result, while awaiting translations from Arabic, current English-language assessments of his achievements can only be provisional.
The most recent of the Greeks on whose works al-Razi drew was the great synthesizer, Galen (129-200/210 CE) who lived near Rome in the time of the Emperor Marcus Aurelius. We now know that Galen had been extremely selective in his choice of the Hippocratic works and other ancient Greek sources from which he chose to quote.
At its full-blown best in the fifth and fourth centuries BCE, as we saw in Chapter 3, ancient Greek medicine had accepted the importance of open intellectual inquiry and of medical pluralism. It had not cared that some groups of medical writers utterly contradicted other writers. Galen on the other hand, coming much later as synthesizer and simplifier, had picked up only certain threads from the ancient Greek medical past, and by so doing he had all but closed the door of intellectual inquiry. Only in our own time – when in practical terms Hippocrates, the other ancient Greeks, and Galen have all become irrelevant to actual medical research – have historians of medicine finally discovered how instrumental Galen was in skewing the long-term development of the medical profession.
Galen, as systemizer and simplifier had worked within a complex paradigm that posited a balanced constitution as equivalent to good health, and an unbalanced constitution as equivalent to some sort of disease condition. Galen was also very much aware of the need to keep the medical profession in being by providing it with fee-paying patrons/clients. Accordingly, he had argued that each individual client had his/her own particular balance: this balance gradually changed as the client progressed from childhood to youth to adulthood and on to old-age. Within this schema, the role of a physician was to understand the particular characteristics of his client and (for a fee) to prescribe a proper regimen for him to follow. Improper foods and excessive eating were obviously to be warned against, as were insufficient exercise or too much exercise of the wrong sort. According to Galen, moderation in all things and a worry-free existence was the key to health.
Yet, going far beyond what an intelligent layman might have been able to figure out for himself (without the expense of paying a consultant physician) Galen’s paradigm also posited the division of the theory of medicine into three parts. These were the theory of the “natural” causes of disease as a deviation from the normal, the theory of “causes” and the theory of “signs.”
There were seven “natural” things: the four elements (earth, air, fire, water): complexions (nine in number, a combination of hot and cold, wet and dry); the four humors (phlegm, yellow bile, black bile and blood); the four members (the brain, the heart, the liver, the testicles – two in number but counted as one); the three forces; the two actions (i.e. unconscious digestive processes and conscious movement); the three spirits; the three types of sickness. In addition, there were the six “non-naturals.” The first five, according to Galen, were climate, motion and rest, diet, sleeping patterns, evacuation and sexuality; the sixth consisted of afflictions of the soul. Even a quick scan of this listing of categories of things and forces (each of which had a complex meaning) will convince the reader that for Galen and his followers “medicine” was really a branch of philosophy: only a well-educated specialist could begin to understand it.
Bibliography
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