Book Review by Pertinax
This is a dense and wide ranging work, with heavy annotation and a formidable bibliography. The earnest scholarship is to be expected from titles published by Routledge.
This is not a work for casual reading, though its structure allows one to move between major subject areas without reading all of the text. This is a work of considered scholarship and makes great efforts to give the reader intellectual and social bearings in the classical world,. The essence of the book is that it is the first large scale history of ancient medicine in a single volume since the Victorian era. The work has a broad range, charting the place and nature of medicine in the ancient world , most particularly we see the actuality of the physicians work and how technical knowledge was accumulated and disseminated . The overlap between medicine and magical religious ceremonial behaviour is also explored. The transmission of medical knowledge from Attic to Roman civilisation (and hence as an underpinning to modern medical ideas and ethics) is a central issue.
Firstly the survivability of written records is considered, and one suffers a cold chill realizing how little precious scholarly work has filtered through to influence contemporary medicine . The inadvertent survivals, the persistence of isolated scholars , the requirements of Church and State in Medieval times for the most basic useful instructional works and the chance of physical survival of scroll and manuscript, all these factors are gravely enumerated and rehearsed to make one feel the weight of responsibility that the historian has.
The “scene setting “ is one where the reader has to re-imagine the limits of the known world considering the Mediterranean World of Attic and Roman civilisations, firstly we must realise that the subject area was subjected to a much more circumscribed inflow of pathogens( harmful disease vectors) than our own modern Europe: the idea of the “inland sea” is a good psychological and physical imagining tool. Although goods and persons might travel considerable distances to Rome this movement was of a very restricted number of persons, in much more constrained and truncated routes than in the modern era. The possible “target” populations for pathogens were also limited in scope (pre 330BC Athens, Corinth, Syracuse and Corinth alone exceeded populations of 15000) with limited low density hinterlands . Any “plague” might hit one locality hard, but fail to disseminate lacking sufficient host organisms. The 65AD plague in Rome is a good example, 30000 died in the City but very few elsewhere. The upshot is that our modern view of a disease transmission model is inapplicable.
The pathocoenosis of localities was also very variable, as an extreme example malarial lowlands would have especially morbid low density populations, cities would tend to have “long lived” age cohorts of a near modern type, If one managed to survive infancy in a n urban area (and as a citizen or freedman) then a life expectancy of near modern normality was possible. So life expectancy was heavily skewed, and the delivery of medicinal care likewise biased toward urban centres...
What of reconstructing disease profiles in antiquity? The conceptualisation of disease has changed, the Ancients considered that disease was a “state of motion” ie: an active aggressing of the person whereas health was a state of “stillness” or rest, not as we might say now an excess of physiological reserves to hold off morbid vectors .However we do have vivid descriptions of disease that can be recognized , pneumonia, pleurisy, scabies, herpes and parasitic infections in particular are vividly reported in antiquity. Ulcers were remarked upon as being a mainstay of doctoring by Galen , this makes good sense as they are one category of affliction dealt with in short order by the (correct) use of antibiotics. The specialisation of physicians dealing with fistulae probably has much to do with the parasitic infections mentioned above. Interestingly only minor forms of STD are reported paleopathologiy for syphillis is very scarce. Eye diseases are another solid commonplace, and Galen was insistent that any decent surgeon should be capable of operating on a diseased cornea (hence the reasonable commonplace of eye surgery tools as survivals).
It is as regards “fevers” that the link and the possible understanding of total disease profile is broken, a fever is now recognized as a symptomatic occurrence (healing crisis) rather than being considered the disease itself. .However, certain well reported and geographically mappable fevers can be interpreted as malarial outbreaksin the Classical world. The strength of the Authors work rests particularly in the well constructed arguments relating to possible disease profiles.
It is posited that Homer was a Deputy chief of Medical staff at the siege of Troy, his (or her-apologies to Andrew Dalby) description of the Plague caused by Apollo being a very early instance of disease as engendered by sinfulness or inappropriate behaviour toward a Deity. This theme of disease as an unknown scourge for moral shortcomings reappears as a motif in Biblical writings and as a major presence in the Western psyche today. The personalized idea of “sin” being presented in a pre-Christian context.
A major topic in written works and as a generalized commonplace is that distinct geographical schools of medicine can be discerned in this epoch, Nutton argues cogently that such a position is untenable based as is suggested on a later re-arguing of context caused by the general standardisation on an intellectualy defined “Greek” medicine. Hippocrates and the Hippocratic oath get useful analysis, suffice to say Hippocrates probably didn’t write the Oath, has virtually no extant writings and certainly didn’t behave in a very Hippocratic manner.
There is a detailed discussion of practical experiment (pharmacological and anatomical) in the Hellenistic world as the Author moves to the crucial transition of Greek medicine refined, technically re-defined and advanced by Rome. The critical historical passage is the Romans cheerful assimilation of a “foreign” technology and its wholehearted recapitualtion and expansion, it is indeed the bedrock of all our present day ethical/moral /empirical notions of what medicine should be .The single most powerful tool in this process being the development of the Latin technical vocabulary that allowed “worldwide” dissemination of ideas, though interestingly the first strong contact of Greek to Roman ideas was the Roman adoption of Greek deities deemed particularly effective in giving enhanced protection against plague, Asclepius in his sacred serpentine form being the most popular with writers.
The transformation of the Roman world under Augustus had far reaching impact on medicine. The dynamic of expansion coupled with the universality of “Greek” Romanised medicine made medicine within the Empire a universal standard (not always attained , but as clear in its evolving goals as any modern medical establishment in that ideas of anatomy, pharmacology and conduct had achieved definitive everyday standards). Pharmacology was an area of intense study. Not least for those desirous of fame and fortune. The key enabling factor of this period is the desire to expand versus the need to keep trained combatants alive as a valuable resource and as a reciprocal sign of Augustinian “care” for loyal men, interestingly the history of Legionary hospital construction parallels this reciprocal compact. When more settled frontiers are being guarded by auxiliary troops the evidence of best case healthcare diminishes .The doctrine of cleansing, rapid binding and stitching of wounds was vigorously propounded by Celsus and Galen, this incisive speed is the key to any effective combat medicine ancient or modern . I particularly enjoyed the palopathology regarding the analysis of fecal remains from drainage ditches in Germania showing a high level of worm infestation from spoiled pork (trichonosis) , the dried larval segments of worms and flagellate bacteria being easily interpreted by microscopic analysis.
The evolution of medicine from availability to the wealthier person to dissemination downward in social rank followed the Augustinian expansion and the great increase in population., both in absolute terms and in expansion of the Empire. This is also the moment when physicians started to explore the possibility of mineral medicines beyond the basic plant pharmacopia. The rise of the “Methodists” accompanies this expansion , inded this school was denigrated as “popular” medicine , though it dominated for the first two centuries of the Christian era. The essence of Methodism was in fact skeptical , pragmatic healing ie: if a technique or drug cured a visible condition then theoretical debate about underlying causation was secondary,. To those who sought explanation via the “humours” (like Galen) this was a plebian non-intellectual approach. Soranus’ work on gynecology has survived from the Methodists and would serve as a text book in the modern era , its pragmatic and sympathetic approach to problems of midwifery is unequalled.
The dominant personality of Roman medicine is Galen of Pergamum, and the chapter on his life explores his privileged ,serious minded upbringing; his vast , direct practical knowledge, his vast output of written information and his stunningly self assured self publicity.Galen is the epitome of the “cultured Greek” at the centre of The World (Rome). His education befitted him to become a man of belles lettres , but his earnest desire to be a physician took his writing, observational and rhetorical skills into medicine. His work in anatomy alone, using only naked eye dissection /vivisection techniques is startlingly excellent., but he reached into all spheres of medicine. His written work received praise and attention from Christian copyists due to its conscice nature and analytical excellence. Galen certainly as a bit “flash” , but his showmanship has an unassailable bedrock of practical work behind it.
Not a lighthearted work , but a solid scholarly dissection of an area that now seems much closer in time (and methodology) than when I started to read the text. I shall be looking out for Nutton’s work in future.