The Greatest Benefit to Mankind: A Medical History of Humanity

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 £420. and laid up £540 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.

* 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

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 (bârû), specializing in divination; a priest (âshipu), who performed incantations and exorcisms; and a physician (âsû), 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.’