The eight books are introduced by a long preface tracing the story of medicine from the time of the Trojan war, and lamenting the rise of clashing sects: Dogmatists, who stressed the need to seek out unseen causes; Empirics, whose emphasis was on experience; and Methodists, wedded to ‘common conditions’. Medicine, in Celsus’ view, required not just experience but reason.
Celsus’ first book is on the preservation of health and on diet; Book 2 deals with signs the doctor should watch for, and remedies; Book 3 concerns diseases of the whole body – fevers, jaundice and so on; Book 4 lists the diseases of individual body parts in the top-to-toe order which was to become customary; and the lengthy Book 5 falls into two parts, a description of various drugs, and treatments for bites and ulcers. Book 6 handles treatments of diseases of the parts of the body, again from top to bottom. Subsequent books deal with surgery, opening with a brief history of the art, and moving on to a list of surgical conditions occurring anywhere in the body, before examining surgical techniques for individual parts, again from head to heel. The final book deals with fractures, ruptures and luxations, including such ambitious operations as removal of bone splinters from the skull. After surgery the physician must be alert to the four cardinal signs of inflammation – calor, rubor, dolor and tumor (heat, redness, pain and swelling). As the first major medical author writing in Latin and offering a summary of the whole of medicine in a single work, Celsus exercised a powerful influence.
The medical colossus of the Roman era is Galen (AD 129-c. 216), but he had significant contemporaries who stand in his shadow, in part because he belittled them, in part because their works, unlike his, survive only in fragments. One was Aretaeus of Cappadocia (fl. AD 140) who proclaimed his loyalties by writing in Greek and frequently alluding to Hippocrates. His work, known in Latin as De causis et signis acutorum et diuturnorum morborum [Acute and Chronic Diseases] provides the best disease descriptions of any surviving ancient author. A ‘rationalist’, he inclined to the pneumatic school, believing that in the universe and in man alike, pneuma (spirit) bound everything together, and any change in it led to illness.
Aretaeus made disease the hub of his inquiries, recording nothing about his patients – or himself for that matter. He gave fine descriptions, among other things, of dropsy and diabetes, mental disorders and epilepsy. Diabetes represented ‘a liquefaction of the flesh and bones into urine’, so much so that ‘the kidneys and bladder do not cease emitting urine’. His description of tetanus gives evidence of his clinical experience:
Tetanus consists of extremely painful spasms, which are a peril to life and very difficult to relieve. The attack begins in the jaw muscles and tendons, but spreads to the whole body, because all bodily parts suffer in sympathy with the one first affected.
There are three types of spasms. Either the body is stretched, or it is bent either backward or forward. With stretching the disease is called tetanus: the subject is so rigid that he cannot tarn or bend. The spasms are named according to the tension and the position of the forward and backward arching. When the posterior nerves are affected and the patient arches backward, we call the condition opisthotonus; when the anterior nerves are affected and the arching is forward, the condition is called emprosthotonus.
Another doctor then active was Soranus, practising in Ephesus AD C. IOO. His Gynaecology, the largest early treatment of that subject, should be understood in the context of traditional Hippocratic thinking on the diseases of women, which presumably reflected prevailing male prejudices. Children born at seven months were said, implausibly, to have a greater chance of surviving than those born at eight; the ‘wandering womb’ was blamed for hysteria-like illnesses; and the female constitution was an imperfect version of the male. Soranus, however, was sceptical of many of these traditions, and dismissive of the ‘wandering womb’. His Gynaecology, which enjoyed wide circulation, is divided into four sections. The first, dealing with conception and pregnancy, also discusses virginity and the right age for intercourse (not before menarche, at about fourteen). Advice was given on contraception, though Soranus disapproved of abortion by mechanical means. The next section treats labour, recommending the sitting position and the Roman birthing-chair. In case of difficult labour, he taught ‘podalic version’ – easing a hand into the uterus and pulling down one of the baby’s legs, so that it would be born feet-first. The third part examines women’s maladies, including uterine fluxes and womb-caused diseases, and the final section is concerned with problems in the birth itself: how to remove the placenta after birth and tie the umbilical cord.
Another physician associated with Ephesus was Rufus (AD 70–120), who learnt anatomy in Alexandria and spent some time in Rome. He wrote commentaries on several Hippocratic writings, accepting the doctrine of the four humours and of cure by opposites. His writings were praised by Galen. Galen’s sun, however, outshone his ideas, as it did everyone else’s.
GALEN
Galen’s dominion over medicine for more than a millennium was partly the consequence of his prolific pen. More of his opus survives than of any other ancient writer: some 350 authentic titles ranging from the soul to bloodletting polemics – about as much as all other Greek medical writings together. He had vast erudition and a matching ego.
Born in AD 129 in Pergamon (now Bergama, Turkey), one of the fairest cities in the Greek-speaking empire, Galen was the son of a wealthy architect, Nicon, and a shrewish woman (‘My mother … used to bite her serving maids, and was perpetually shouting at my father’). He enjoyed a long, lavish, liberal education; when he was sixteen, his father was visited in a dream by Asclepius, after which the son was piously steered towards medicine. He studied with Alexandrian teachers and travelled in Egypt, learning about drugs from India and Africa. Returning home in 157, he was appointed physician to the gladiators, a job which enlarged his anatomical and surgical expertise, since wounds afforded windows onto the body. But Pergamon was provincial, and in 162 he left for Rome, where public debates against Methodists and high-profile public anatomical displays spread his fame. One of his party tricks, revealing his genius for self-advertisement as well as experiment, was to sever the nerves in the neck of a pig. As these were severed, one by one, the pig continued to squeal; but when Galen cut one of the laryngeal nerves the squealing stopped, impressing the crowd. Leading senators and dignitaries began to employ him, and from AD 169 Galen was in imperial service, first with the emperor’s son, Commodus, and later a succession of emperors. He liked reminding readers that his patients were of the highest rank. ‘Something really amazing happened when the emperor [Marcus Aurelius] himself was my patient’, he wrote:
Just when the lamps were lit, a messenger came and brought me to the Emperor as he had bidden. Three doctors had watched over him since dawn, and two of them felt his pulse, and all three thought that a fever attack was coming. I stood alongside, but said nothing. The Emperor looked first at me and asked why I did not feel his pulse as the other two had. I answered: ‘These two colleagues of mine have already done so and, as they have followed you on the journey, they presumably know what your normal pulse is, so they can judge its present state better.’
When I said this, he bade me, too, to feel his pulse. My impression was that – considering his age and body constitution – the pulse was far from indicating a fever attack, but that his stomach was stuffed with the food he had eaten, and that the food had become a slimy excrement. The Emperor praised my diagnosis and said, three times in a row: ‘That is it. It is just as you say. I have eaten too much cold food.’
He then asked what measures should be taken. I replied what I knew of a similar case, saying: ‘If you were any plain citizen of this country, I would as usual prescribe wine with a little pepper. But to a royal patient as in this case, doctors usually recommend milder treatment. It is enough for a woollen cover to be put on your stomach, impregnated with warm spiced salve.’
Expert in one-upmanship, Galen couched an inflated sense of his importance in terms of the dignity of medicine, scolding colleagues as dimwits. He was invariably right; there is no denying that he was an erudite man and an accomplished philosopher, particularly in constructing an image of the organism as a teleological unity open to reasoning. For him, anatomy proved the truth