Medicine of the Ancient World (5000 B. C. – V cent. A. D.)
Lecture Plan
1. The Egyptian Medicine
2. Medicine of the Peoples of Mesopotamia. Babylon and Assyria
3. Medicine in India
4. Medicine in China
The ancient Middle East and Egypt
The establishment of the calendar and the invention of writing marked the dawn of recorded history. The clues to early knowledge are scanty, consisting of clay tablets bearing cuneiform signs and seals that were used by physicians of ancient Mesopotamia. In the Louvre there is preserved a stone pillar on which is inscribed the Code of Hammurabi, who was a Babylonian king of the 18th century BC.
The Code of Hammurabi
This code includes laws relating to the practice of medicine, and the penalties for failure were severe. For example, “If the doctor, in opening an abscess, shall kill the patient, his hands shall be cut off”; if, however, the patient was a slave, the doctor was simply obliged to supply another slave.
The Greek historian Herodotus stated that every Babylonian was an amateur physician, since it was the custom to lay the sick in the street so that anyone passing by might offer advice. Divination, from the inspection of the liver of a sacrificed animal, was widely practiced to foretell the course of a disease. Little else is known regarding Babylonian medicine, and the name of not a single physician has survived.
Egypt
Magic and religion
Magic and religion were part of everyday life in ancient Egypt. Gods and demons were thought to be responsible for many ailments, so the treatments often involved some supernatural element. Often the first recourse would be an appeal to a deity. Often priests and magicians were called on to treat disease instead of, or in addition to a physician. Physicians themselves often used incantations and magical ingredients as part of their treatments.
Since the belief in magic and religion was so commonplace in Egypt, it is as though the use of magic and religion would have contributed to a powerful placebo effect. Since many medicines appeared to lack active ingredients, the perceived validity of the cure, including the authoritativeness of the magical incantations, would have contributed to its effectiveness.
The impact of the emphasis on magic is seen in the selection of remedies, or the ingredients for those remedies. Ingredients were sometimes selected seemingly because they were derived from a substance, plant or animal the had characteristics which in some way corresponded to the symptoms of the patient. This is known as the principle of simila similibus (similar with similar) and is found throughout the history of medicine up to the modern practice of homeopathy. Thus an ostrich egg is included in the treatment of a broken skull, and an amulet portraying a hedgehog might be used against baldness.
Sources of knowledge Ancient Egyptian Medicine
Amulets in general were enormously popular with ancient Egyptians, being worn for many magical purposes. Health related amulets are classified as homopoeic, phylactic and theophoric. Homopoeic amulets portray an animal or a part of an animal from which the wearer hopes to assimilate positive attributes (like strength or speed). Phylactic amulates were protective, warding off harmful gods and demons. The famous Eye of Horus was often used on a phylactic amulet. Theophoric amulets represented the Egyptian gods, such as one representing the girdle of Isis, used to stem the flow of blood at miscarriage.
Doctors and healing
The first physician to emerge in Egypt is Imhotep, chief minister to King Djoser in the 3rd millennium BC, who designed one of the earliest pyramids, and who was later regarded as the Egyptian god of medicine and identified with the Greek god Asclepius. Knowledge on ancient Egyptian medicine comes from three main sources. The first is the study of Egyptian papyri, especially the Ebers and Edwin Smith papyri discovered in the 19th century. The former is a list of remedies, with appropriate spells or incantations, while the latter is a surgical treatise on the treatment of wounds and other injuries. The second is the study of the artistic representation of disease in the Nile Valley. The Egyptian’s predilection to portrayl life in a relatively realistic manner offers an excellent opportunity for the study of disease. The third, and perhaps most obvious, is the study of human remains of ancient Egyptians. With the advent of increasingly sophisticated medical techniques at the beginning of the 20th century, as well as those complex medical techniques in use today, the analysis of Egypt’s veritable wealth of human remains provided a tremendous boost to the study of the state of disease and health in the ancient Nile Valley.
Contrary to what might be expected, the widespread practice of embalming the dead body did not stimulate study of human anatomy. Yet the Egyptians had a lot of knowledge about the anatomy of the human body even though they never dissected the body. For example, in the classic mummification process, they cleanly removed the brain out of the body via the nose using a long hook.
Mummification process
The Egyptian physicians also were aware of the importance of the pulse, and of a connection between pulse and heart. Author of the Smith Papyrus had even some vague idea of a cardiac system, though not of course of a circulation. Still, he was not able to distinguish between blood vessels, tendons, and nerves.
Medical knowledge in ancient Egypt was so advanced that other kings and emperors from different empires would write to the Egyptian pharaoh to send them their best surgeon to perform operations.
Mostly the Egyptian physician’s advice for staying healthy was to wash and shave the body, including under the arms. This would have worked because cleaning would prevent microbes and viruses. The physicians would also advise their patients to look after their diet, and avoid foods such as raw fish or other animals which would not be clean.
The preservation of mummies has, however, revealed some of the diseases suffered at that time, including arthritis, tuberculosis of the bone, gout, tooth decay, bladder stones, and gallstones; there is evidence too of the parasitic disease schistosomiasis, which remains a scourge still. There seems to have beeo syphilis or rickets.
There were many ranks and specializations in the doctors. Royalty had their own doctors, even their own specialists. There were inspectors of doctors, overseers and chief doctors. Known ancient Egyptian specialists are ophthalmologist, gastroenterologist, proctologist, dentist, “doctor who supervises butchers” and an unspecified “inspector of liquids”. The ancient Egyptian term for proctologist, neru phuyt, literally translates as “shepherd of the anus”.
Medical institutions are known to have been established in ancient Egypt since as early as the 1st Dynasty. By the time of the 19th Dynasty their employees enjoyed such benefits as medical insurance, pensions and sick leave. Employees worked 8 hours per day.
India
Indian medicine has a long history. Its earliest concepts are set out in the sacred writings called the Vedas, especially in the metrical passages of the Atharvaveda, which may possibly date as far back as the 2nd millennium BC. According to a later writer, the system of medicine called Āyurveda was received by a certain Dhanvantari from Brahma, and Dhanvantari was deified as the god of medicine. In later times his status was gradually reduced, until he was credited with having been an earthly king who died of snakebite.
The period of Vedic medicine lasted until about 800 BC. The Vedas are rich in magical practices for the treatment of diseases and in charms for the expulsion of the demons traditionally supposed to cause diseases. The chief conditions mentioned are fever (takman), cough, consumption, diarrhoea, dropsy, abscesses, seizures, tumours, and skin diseases (including leprosy). The herbs recommended for treatment are numerous.
The golden age of Indian medicine, from 800 BC until about AD 1000, was marked especially by the production of the medical treatises known as the Caraka-saṃhitā and Suśruta-saṃhitā, attributed, respectively, to Caraka, a physician, and Suśruta, a surgeon. Estimates place the Caraka-saṃhitā in its present form as dating from the 1st century AD, although there were earlier versions. The Suśruta-saṃhitā probably originated in the last centuries BC and had become fixed in its present form by the 7th century AD. Of somewhat lesser importance are the treatises attributed to Vagbhata. All later writings on Indian medicine were based on these works.
Because Hindus were prohibited by their religion from cutting the dead body, their knowledge of anatomy was limited. The Suśruta-saṃhitā recommends that a body be placed in a basket and sunk in a river for seven days. On its removal the parts could be easily separated without cutting. As a result of these crude methods, the emphasis in Hindu anatomy was given first to the bones and then to the muscles, ligaments, and joints. The nerves, blood vessels, and internal organs were very imperfectly known.
The Hindus believed that the body contains three elementary substances, microcosmic representatives of the three divine universal forces, which they called spirit (air), phlegm, and bile (comparable to the humours of the Greeks). Health depends on the normal balance of these three elementary substances. The seven primary constituents of the body—blood, flesh, fat, bone, marrow, chyle, and semen—are produced by the action of the elementary substances. Semen was thought to be produced from all parts of the body and not from any individual part or organ.
Both Caraka and Suśruta state the existence of a large number of diseases (Suśruta says 1,120). Rough classifications of diseases are given. In all texts “fever,” of which numerous types are described, is regarded as important. Phthisis (wasting disease, especially pulmonary tuberculosis) was apparently prevalent, and the Hindu physicians knew the symptoms of cases likely to terminate fatally. Smallpox was common, and it is probable that smallpox inoculation was practiced.
Hindu physicians employed all five senses in diagnosis. Hearing was used to distinguish the nature of the breathing, alteration in voice, and the grinding sound produced by the rubbing together of broken ends of bones. They appear to have had a good clinical sense, and their discourses on prognosis contain acute references to symptoms that have grave import. Magical beliefs still persisted, however, until late in the classical period; thus, the prognosis could be affected by such fortuitous factors as the cleanliness of the messenger sent to fetch the physician, the nature of his conveyance, or the types of persons the physician met on his journey to the patient.
Dietetic treatment was important and preceded any medicinal treatment. Fats were much used, internally and externally. The most important methods of active treatment were referred to as the “five procedures”: the administration of emetics, purgatives, water enemas, oil enemas, and sneezing powders. Inhalations were frequently administered, as were leeching, cupping, and bleeding.
The Indian materia medica was extensive and consisted mainly of vegetable drugs, all of which were from indigenous plants. Caraka knew 500 medicinal plants, and Suśruta knew 760. But animal remedies (such as the milk of various animals, bones, gallstones) and minerals (sulphur, arsenic, lead, copper sulphate, gold) were also employed. The physicians collected and prepared their own vegetable drugs. Among those that eventually appeared in Western pharmacopoeias were cardamom and cinnamon.
As a result of the strict religious beliefs of the Hindus, hygienic measures were important in treatment. Two meals a day were decreed, with indications of the nature of the diet, the amount of water to be drunk before and after the meal, and the use of condiments. Bathing and care of the skin were carefully prescribed, as were cleansing of the teeth with twigs from named trees, anointing of the body with oil, and the use of eyewashes.
In surgery, ancient Hindu medicine reached its zenith. Operations performed by Hindu surgeons included excision of tumours, incision and draining of abscesses, punctures to release fluid in the abdomen, extraction of foreign bodies, repair of anal fistulas, splinting of fractures, amputations, caesarean sections, and stitching of wounds.
A broad array of surgical instruments were used. According to Suśruta the surgeon should be equipped with 20 sharp and 101 blunt instruments of various descriptions. The instruments were largely of steel. Alcohol seems to have been used as a narcotic during operations, and bleeding was stopped by hot oils and tar.
In two types of operations especially, the Hindus were outstanding. Stone in the bladder (vesical calculus) was common in ancient India, and the surgeons frequently removed the stones by lateral lithotomy.
They also introduced plastic surgery. Amputation of the nose was one of the prescribed punishments for adultery, and repair was carried out by cutting from the patient’s cheek or forehead a piece of tissue of the required size and shape and applying it to the stump of the nose. The results appear to have been tolerably satisfactory, and the modern operation is certainly derived indirectly from this ancient source. Hindu surgeons also operated on cataracts by couching, or displacing the lens to improve vision.
China
The Chinese system of medicine is of great antiquity and is independent of any recorded external influences. According to legend, Emperor Huang Ti (the Yellow Emperor) wrote the canon of internal medicine called the Nei ching in the 3rd millennium BC; but there is some evidence that in its present form it dates from no earlier than the 3rd century BC. Most of the Chinese medical literature is founded on the Nei ching, and it is still regarded as a great authority. Other famous works are the Mo ching (known in the West as the “Pulse Classic”), composed about AD 300; and the Golden Mirror, a compilation, made about AD 1700, of medical writings of the Han dynasty (202 BC–AD 220). European medicine began to obtain a footing in China early in the 19th century, but the native system is still widely practiced.
Basic to traditional Chinese medicine is the dualistic cosmic theory of the yin and the yang.
The yang, the male principle, is active and light and is represented by the heavens; the yin, the female principle, is passive and dark and is represented by the earth. The human body, like matter in general, is made up of five elements: wood, fire, earth, metal, and water. With these are associated other groups of five, such as the five planets, the five conditions of the atmosphere, the five colours, and the five tones. Health, character, and the success of all political and private ventures are determined by the preponderance, at the time, of the yin or the yang; and the great aim of ancient Chinese medicine is to control their proportions in the body.
The teachings of the religious sects forbade the mutilation of the dead human body; hence traditional anatomy rests oo sure scientific foundation. One of the most important writers on anatomy, Wang Ch’ing-jen, gained his knowledge from the inspection of dog-torn children who had died in a plague epidemic in AD 1798. Traditional Chinese anatomy is based on the cosmic system, which postulates the presence of such hypothetical structures as the 12 channels and the three so-called burning spaces. The body contains five organs (heart, lungs, liver, spleen, and kidneys), which store up but do not eliminate; and five viscera (such as the stomach, intestines, gallbladder, and bladder), which eliminate but do not store up. Each organ is associated with one of the planets, colours, tones, smells, and tastes. There are 365 bones and 365 joints in the body.
According to the physiology of traditional Chinese medicine, the blood vessels contain blood and air, in proportions varying with those of the yin and the yang. These two cosmic principles circulate in the 12 channels and control the blood vessels and hence the pulse. The Nei ching says that “the blood current flows continuously in a circle and never stops. It may be compared to a circle without beginning or end.” On this insubstantial evidence it has been claimed that the Chinese anticipated Harvey’s discovery of the circulation of the blood. Traditional Chinese pathology is also dependent on the theory of the yin and the yang; this led to an elaborate classification of diseases in which most of the types listed are without scientific foundation.
In diagnosis, detailed questions are asked about the history of the illness and about such things as the patient’s taste, smell, and dreams. Conclusions are drawn from the quality of the voice, and note is made of the colour of the face and of the tongue. The most important part of the investigation, however, is the examination of the pulse. Wang Shu-ho, who wrote the “Pulse Classic,” lived in the 3rd century BC, and innumerable commentaries were written on his work. The pulse is examined in several places, at different times, and with varying degrees of pressure. The operation may take as long as three hours. It is often the only examination made, and it is used both for diagnosis and for prognosis. Not only are the diseased organs ascertainedbut the time of death or recovery may be foretold.
The Chinese materia medica has always been extensive and consists of vegetable, animal (including human), and mineral remedies. There were famous herbals from ancient times; but all these, to the number of about 1,000, were embodied by Li Shih-chen in the compilation of Pen-ts’ao kang-mu (the “Great Pharmacopoeia”) in the 16th century AD. This work, in 52 volumes, has been frequently revised and reprinted and is still authoritative. The use of drugs is mainly to restore the harmony of the yin and the yang and is also related to such matters as the five organs, the five planets, and the five colours. The art of prescribing is therefore complex.
Among the drugs taken over by Western medicine from the Chinese are rhubarb, iron (for anaemia), castor oil, kaolin, aconite, camphor, and Cannabis sativa (Indian hemp). Chaulmoogra oil was used by the Chinese for leprosy from at least the 14th century, and about a century ago it began to be used for this purpose by Western physicians. The herb mahuang (Ephedra vulgaris) has been used in China for at least 4,000 years, and the isolation of the alkaloid ephedrine from it has greatly improved the Western treatment of asthma and similar conditions.
The most famous and expensive of Chinese remedies is ginseng. Western analysis has shown that it has diuretic and other properties but is of doubtful value. In recent years reserpine, the active principle of the Chinese plant Rauwolfia, has been isolated; it is now effectively used in the treatment of high blood pressure and some emotional and mental conditions.
Hydrotherapy is probably of Chinese origin, since cold baths were used for fevers as early as 180 BC. The inoculation of smallpox matter, in order to produce a mild but immunizing attack of the disease, was practiced in China from ancient times and came to Europe about 1720. Another treatment is moxibustion, which consists in making a small, moistened cone (moxa) of powdered leaves of mugwort, or wormwood (Artemisia species), applying it to the skin, igniting it, and then crushing it into the blister so formed. Other substances are also used for the moxa. Dozens of these are sometimes applied at one sitting. The practice is often associated with acupuncture.
Acupuncture consists of the insertion into the skin and underlying tissues of a metal needle, either hot or cold.
The theory is that the needle affects the distribution of the yin and the yang in the hypothetical channels and burning spaces of the body. The site of the insertion is chosen to affect a particular organ or organs. The practice of acupuncture dates from before 2500 BC and is peculiarly Chinese.
Little of practical importance has been added since that date, although there have been many well-known treatises on the subject.
A bronze model, c. AD 860, shows the hundreds of specified points for the insertion of the needle; this was the forerunner of countless later models and diagrams. The needles used are three to 24 centimetres (about one to nine inches) in length. They are often inserted with considerable force and after insertion may be agitated or screwed to the left or right. Acupuncture, often combined with moxibustion, is still widely used for many diseases, including fractures. Recently people in the Western world have turned to acupuncturists for relief from pain and other symptoms. There is some speculation that the treatment may trigger the brain to release morphine like substances called endorphins, which presumably reduce the feeling of pain and its concomitant emotions.
Greece
The transition from magic to science was a gradual process that lasted for centuries, and there is little doubt that ancient Greece inherited much from Babylonia and Egypt, and even India and China. Twentieth-century readers of the Homeric tales the Iliad and the Odyssey may well be bewildered by the narrow distinction between gods and men among the characters and between historical fact and poetic fancy in the story. Two characters, the military surgeons Podaleirius and Machaon, are said to have been sons of Asclepius, the god of medicine. The divine Asclepius may have originated in a human Asclepius who lived about 1200 BC and is said to have performed many miracles of healing.
Asclepius was worshiped in hundreds of temples throughout Greece, the remains of which may still be seen at Epidaurus, Cos, Athens, and elsewhere. To these resorts, or hospitals, sick persons went for the healing ritual known as incubation, or temple sleep. They lay down to sleep in the dormitory, or abaton, and were visited in their dreams by Asclepius or by one of his priests, who gave advice. In the morning the patient often is said to have departed cured. There are at Epidaurus many inscriptions recording cures, though there is no mention of failures or deaths.
Diet, baths, and exercises played their part in the treatment, and it would appear that these temples were the prototype of modern health resorts. Situated in a peaceful spot, with gardens and fountains, each had its theatre for amusements and its stadium for athletic contests. The cult of incubation continued far into the Christian Era. In Greece, some of the Aegean islands, Sardinia, and Sicily, sick persons are still taken to spend a night in certain churches in the hope of a cure.
It was, however, the work of the early philosophers, rather than that of the priests of Asclepius, that impelled Greeks to refuse to be guided solely by supernatural influence and moved them to seek out for themselves the causes and reasons for the strange ways of nature. The 6th-century philosopher Pythagoras, whose chief discovery was the importance of numbers, also investigated the physics of sound, and his views influenced the medical thought of his time. In the 5th century BC Empedocles set forth the view that the universe is composed of four elements—fire, air, earth, and water; this conception led to the doctrine of the four bodily humours: blood; phlegm; choler, or yellow bile; and melancholy, or black bile. The maintenance of health was held to depend upon the harmony of the four humours.
Hippocrates
Medical thought had reached this stage and had partially discarded the conceptions based upon magic and religion by 460 BC, the year that Hippocrates is said to have been born. Although he has been called the father of medicine, little is known of his life, and there may, in fact, have been several men of this name; or Hippocrates may have been the author of only some, or none, of the books that make up the Hippocratic Collection (Corpus Hippocraticum). Ancient writers held that Hippocrates taught and practiced medicine in Cos, the island of his birth, and in other parts of Greece, including Athens, and that he died at an advanced age.
Whether Hippocrates was one man or several, the works attributed to him mark the stage in Western medicine where disease was coming to be regarded as a natural rather than a supernatural phenomenon and doctors were encouraged to look for physical causes of illness. Some of the works, notably the Aphorismi (Aphorisms), were used as textbooks until the 19th century. The first and best-known aphorism is, “Life is Short, Art long, Occasion sudden and dangerous, Experience deceitful, and Judgment difficult” (often shortened to the Latin tag, “Ars longa, vita brevis”). This is followed by brief comments on diseases and symptoms, many of which remain valid.
The thermometer and the stethoscope were not then known; nor, indeed, did Hippocrates employ any aid to diagnosis beyond his own powers of observation and logical reasoning. He had an extraordinary ability to foretell the course of a malady, and he laid more stress upon the expected outcome, or prognosis, of a disease than upon its identification, or diagnosis. He had no patience with the idea that disease was a punishment sent by the gods. Writing of epilepsy, then called “the sacred disease,” he said, “It is not any more sacred than other diseases, but has a natural cause, and its supposed divine origin is due to man’s inexperience. Every disease,” he continued, “has its owature, and arises from external causes.”
Hippocrates noted the effect of food, of occupation, and especially of climate in causing disease, and one of his most interesting books, entitled De aëre, aquis et locis (Air, Waters and Places ), would today be classed as a treatise on human ecology. Pursuing this line of thought, Hippocrates stated that “our natures are the physicians of our diseases” and advocated that this tendency to natural cure should be fostered. He laid much stress on diet and the use of few drugs. He knew well how to describe illness clearly and concisely and recorded failures as well as successes; he viewed disease with the eye of the naturalist and studied the entire patient in his environment.
Perhaps the greatest legacy of Hippocrates is the charter of medical conduct embodied in the so-called Hippocratic oath, which has been adopted as a pattern by physicians throughout the ages. (oath). Not strictly an oath, it was, rather, an ethical code or ideal, an appeal for right conduct. In one or other of its many versions, it has guided the practice of medicine throughout the world for more than 2,000 years.
Roman medicine
In the following century the work of Aristotle, regarded as the first great biologist, was of inestimable value to medicine. A pupil of Plato at Athens and tutor to Alexander the Great, Aristotle studied the entire world of living things. He laid what can be identified as the foundations of comparative anatomy and embryology, and his views influenced scientific thinking for the next 2,000 years.
After the time of Aristotle, the centre of Greek culture shifted to Alexandria, where a famous medical school was established in about 300 BC. There, the two best medical teachers were Herophilus, whose treatise on anatomy may have been the first of its kind, and Erasistratus, regarded by some as the founder of physiology. Erasistratus noted the difference between sensory and motor nerves but thought that the nerves were hollow tubes containing fluid and that air entered the lungs and heart and was carried through the body in the arteries. Alexandria continued as a centre of medical teaching even after the Roman Empire had attained supremacy over the Greek world, and medical knowledge remained predominantly Greek.
Asclepiades of Bithynia (born 124 BC) differed from Hippocrates in that he denied the healing power of nature and insisted that disease should be treated safely, speedily, and agreeably. An opponent of the humoral theory, he drew upon the atomic theory of the 5th-century Greek philosopher Democritus in advocating a doctrine of strictum et laxum—the attribution of disease to the contracted or relaxed condition of the solid particles that he believed make up the body. To restore harmony among the particles and thus effect cures, Asclepiades used typically Greek remedies: massage, poultices, occasional tonics, fresh air, and corrective diet. He gave particular attention to mental disease, clearly distinguishing hallucinations from delusions. He released the insane from confinement in dark cellars and prescribed a regimen of occupational therapy, soothing music, soporifics (especially wine), and exercises to improve the attention and memory.
Asclepiades did much to win acceptance for Greek medicine in Rome. Aulus Cornelius Celsus, the Romaobleman who wrote De medicina about AD 30, gave a classic account of Greek medicine of the time, including descriptions of elaborate surgical operations. His book, overlooked in his day, enjoyed a wide reputation during the Renaissance.
During the early centuries of the Christian Era, Greek doctors thronged to Rome. The most illustrious of them was Galen, who began practicing there in AD 161. He acknowledged his debt to Hippocrates and followed the Hippocratic method, accepting the doctrine of the humours. He laid stress on the value of anatomy, and he virtually founded experimental physiology. Galen recognized that the arteries contain blood and not merely air. He showed how the heart sets the blood in motion in an ebb and flow fashion, but he had no idea that the blood circulates. Dissection of the human body was at that time illegal, so that he was forced to base his knowledge upon the examination of animals, particularly apes. A voluminous writer who stated his views forcibly and with confidence, he remained for centuries the undisputed authority from whom no one dared to differ.
Another influential physician of the 2nd century AD was Soranus of Ephesus, who wrote authoritatively on childbirth, infant care, and women’s diseases. An opponent of abortion, he advocated numerous means of contraception. He also described how to assist a difficult delivery by turning the foetus in the uterus (podalic version), a life-saving technique that was subsequently lost sight of until it was revived in the 16th century.
Although the contribution of Rome to the practice of medicine was negligible compared with that of Greece, in matters of public health the Romans set the world a great example. The city of Rome had an unrivalled water supply. Gymnasiums and public baths were provided, and there was even domestic sanitation and adequate disposal of sewage. The army had its medical officers, public physicians were appointed to attend the poor, and hospitals were built; a Roman hospital excavated near Düsseldorf, Ger., was found to be strikingly modern in design.