Greek medicine after Hippocrates reached a peak in Alexandria and shortly afterward began to infiltrate Rome, which exercised hegemony over the Greek world after 146 B.C. The various medical sects growing out of developments in Alexandria were taken to Rome by Greek practitioners and subsequently underwent their principal development there.
Roman medicine had had a long history of its own, inherited from the Etruscans in both secular and religious aspects, but it was the religious healing that had the more lasting influence. The Etruscan inheritance is shown in the early Roman reliance on divination from the entrails of animals, the use of Etruscan prognostic charts, and the propitiation of the gods to stop epidemics (religious processions to ward off plague continued well into the Middle Ages). As early as the seventh century B.C. there was a College of Augurs, and for virtually each disease or symptom there was a special divinity. According to legend, the Greek medical deity Asclepios (Aesculapius in Latin) was introduced to Rome in 295 B.C. in the form of a snake sent from the temple of Epidaurus.
Over the years, theurgy and superstition gradually gave way to more rational attitudes. In the Roman Aesculapian temples the suppliants were bent on receiving more than just treatment by the god and his snakes; they often insisted on prescriptions for drugs to carry away with them. As Rome came more and more to dominate Greece politically, Greek culture ironically became the predominant force in the intellectual life of the Romans. Greek was the language of the rich and educated, who had their children taught by Greek tutors and derived their literature from Greek models. Especially in medicine the attitudes, methods, and practices were almost entirely Greek.
Healers and Their Methods
In the first century A.D., Pliny wrote, “The Roman people for more than six hundred years were not without medical art but were without physicians.” However, the Aquilian Law of the third century B.C. made a medical practitioner liable for his neglect of a slave treated by operation, so at least someone was publicly practicing the healing arts. For the most part each family was ministered to by the head of the household himself, but no citizen would think of practicing outside his home. The Roman upper class had the same aversion to manual work as did the early Greeks and felt that practicing medicine was unworthy of cultured men. With the influx of Greek practitioners over an extended period, Roman contempt for Greeks in general and healers in particular varied with the political scene, internal changes in the profession, and the needs of rulers and the populace for medical attention.
Cato, the censor (234-149 B.C.), was especially incensed at the virtual control over Roman intellectual life of Greek ideas, which he considered effete and dishonest. According to Pliny, he railed particularly against the physicians, endeavoring to reinstitute what he considered pragmatic Roman methods. Cato advised the use of cabbage and wine for maintaining health and treating illness, but he accompanied his treatments with magic formulas and incantations.
An increasing number of Greeks and other foreigners continued to pour into the rich, exciting, and powerful city of Rome. In 46 B.C. Julius Caesar, in an attempt to limit a famine, temporarily banished all foreigners from the city except for physicians, to whom he granted citizenship. Many early healers were probably incompetent and unscrupulous, and their social status was low (most were slaves), but more and more freedmen and even citizens began to enter practice. Thus Greek and Roman attitudes and methods gradually merged.
The first well-known Greek physician to come to Rome was Archagathos of Sparta, about 219 B.C., and his career illustrates the swings in the Roman attitude toward physicians. Initially he was hailed by the populace and the Senate, receiving the honor of citizenship, and his brilliant surgical procedures earned him the appellation vulnerarius (wound healer). Either because of overenthusiasm for operating or because of failures, he was later repudiated and called carnifex (butcher). It is also possible that people’s unreasonable expectations (possibly heightened by the physician’s own estimate of his talents) could not be matched by the effectiveness of contemporary medicine.
An important impetus to acceptance of Greek practitioners in the first century B.C. came from Asclepiades of Bithynia (c. 120-c. 70 B.C.), who was influenced by teachings originally advanced by Erasistratus in the third century B.C. He was apparently a man of immense personal charm and dynamism, with a brilliant mind. Some of his contemporaries and also later writers, notably Galen, counted him a near-charlatan, but a majority of people in high place and low considered him “a messenger from heaven.” Probably the poet-scientist Lucretius and the political leader and orator Cicero were among his admiring close friends. The general populace was impressed by his personality, methods, and results, which he was quick to exploit, for Asclepiades sought to cure tuto, celerites ac jucunde (safely, quickly, and pleasantly). His reputation was also advanced by the report that he had restored a dead man to life.
His teachings were a deliberate repudiation of Hippocrates, for he believed that the physician, not nature, cured disease. He abandoned the doctrine of the four humors totally. Instead he erected an elaborate solidistic system (an extension of the earlier theories of Democritus and Heraclides) which regarded the body as composed of an almost infinite number of atoms of different sizes always in motion, between which flowed the body liquids. Health depended on the smooth activity of the atoms; sickness occurred when the motions were disordered. Themison, a pupil of Asclepiades, developed these ideas further in founding the system of Methodism, which became one of the most influential systems for centuries afterward.
In practice Asclepiades used mild methods, such as diet, exercise, massage, soothing medications, enemas, music, and singing. One of his most successful procedures was tracheostomy (making an opening in the windpipe) for obstruction to breathing. For “phrenitis,” a term he applied to mental illness, he employed opium, wine, and hygienic measures. His principle was to avoid wherever possible drastic and weakening procedures. Yet he did employ bleeding and in fevers continued the debilitating and dehydrating custom of markedly restricting both food and drink.
The overthrow of authority, rejection of the four humors, avoidance of teleological explanations, and promulgation of a materialistic approach to body mechanisms were steps toward rationalism. However, over two hundred years later Galen railed at Asclepiades and also against the more ancient Erasistratus for repudiating Hippocrates and the four humors. He was particularly incensed at Asclepiades for rejecting the principle of assisting nature and for downplaying anatomy. Indeed so damning were Galen’s writings that the name of Asclepiades almost disappeared during medieval times and was virtually forgotten until the Renaissance. Nevertheless, through his practices, principles, and reputation, Asclepiades improved the standing of physicians in Rome, especially that of the Greek doctors.
Although free citizens probably did eventually practice medicine, most Roman practitioners were mainly freedmen and slaves. Physicians were usually of Greek origin, but immigrant Egyptians and Jews also practiced. The upper-class Roman often had a private slave-physician for his own family, but sometimes he was hired out to others. There were also municipal or government slave-physicians to minister to sick slaves and slave-physicians who were assistants to free and freedmen physicians. These slaves could buy their freedom, but they were so valuable to their professional masters that a law had to be passed setting the manumission price according to the worth of the slave as an assistant rather than as a practicing physician.
Many healers who were not considered physicians indulged in medical care, usually in special places, as for example in the baths, barber shops, and theaters. Again the problem of determining what was outright quackery and what merely empiric medicine is difficult to resolve. Thessalus of Tralles was an uneducated practitioner who achieved great popularity. He repudiated all teachings of the past, scorned science of any kind, and used showmanship to advance his reputation. Calling himself the “Conqueror of Physicians,” Thessalus announced that he could impart the knowledge of all medicine in half a year. One wonders how far off he may have been.
Each military unit had a specific number of physicians according to the size of the force, who may have been but simple soldiers with special experience in medical lore. Even here foreigners (especially Greeks) rather than Roman freedmen may have been the medical practitioners.
As in earlier times in Greece, midwives actively practiced obstetrics. Their standing in Rome appears to have been much higher than in Greece, and some women were even looked upon as female doctors. But women in some respects found themselves in approximately the same position as in Greece, for the head of the household had total power of life and death over his daughter, and few women were included in the discussions and activities of men. On the other hand, women were better off legally in Roman society than in Greek, for increasingly they were able to marry and divorce independently.
The regulation of medical practice was at first nonexistent. Anyone could call himself a physician. Even under Augustus, who in A.D. 10 granted physicians exemption from taxes (in grateful recognition of the successful treatment of his rheumatism by Antoninus Musa), neither licensure nor definition determined who could practice. The privileges were further extended by Vespasian (A.D. 69-79) and Hadrian (A.D. 117-138) in relieving doctors of military service and other public duties. So desirable had the self-proclaimed position of physician become that Antoninus Pius (A.D. 138-161) restricted the privileged exemptions to a limited number and to those who remained in their native villages. Finally, Emperor Severus Alexander (A.D. 222-235) passed comprehensive laws regulating training, certification, and control.
The training of physicians changed from unregulated individual instruction for a fee to supervision by the Collegium Archiatri (a sort of guild) to salaried teachers in a school that included courses other than medicine. Bedside teaching was required, an activity not always popular among patients, as indicated by these lines from Martial:
I was getting sick and you came at once,
Together with a hundred students, O Symmachus;
A hundred frosty fingers probed me;
I had no fever, O Symmachus; now I have.
Public Health and Hygiene
In some respects, Roman attitudes about health and disease were similar to the Greek. The hopelessly ill and deformed were little cared for. The same disdain extended to unwanted newborns and led to their disposal. The poor of both countries lived in mean, crowded housing, but Roman multiple dwellings, though they were still slums, seem to have been better constructed and better provided with drainage, water supply, and paved streets. Certainly the homes of the rich Romans were far more opulent than the houses of their counterparts in Greek times, and the Roman emphasis on agriculture led to a larger and more varied supply of food. Not that famine was unknown, but in general the sometimes elaborate Roman meals were a contrast to the frugal diet of the Greeks.
The greatest glories of Roman hygiene were the water supply and the sanitation system. By the end of the first century A.D. nine aqueducts were channeling water to Rome, and later there were more. (Purification was achieved mainly through settling basins and intermediate reservoirs along the route, and drinking water was kept separate from the rest.) Destined principally for the public baths and fountains, water was available for private use at a fee, thus enabling the rich and influential to obtain as much as they desired. Although the less wealthy could also afford enough water, many of the poor still relied on wells and water carriers. In some far-flung Roman cities pure water was even more widely available to all classes of society than in Rome.
Along with supplying water into the city there was a system of draining used water and sewage out of the city (that is, into the Tiber). The famous Cloaca Maxima was only one part of a great complex of sewers and conduits running beneath buildings and streets. In some dwellings, people still emptied refuse and chamber pots directly into streets, but for the most part streets, roads, and alleys were kept clean, abundant pure water was available, and swamps and stagnant pools were regularly drained. The association of marshy land with disease was long recognized, and in the first century B.C. Marcus Varro had advised against building near swamps “because there are bred certain minute creatures which cannot be seen by the eyes, which float in the air and enter the body through the mouth and nose and there cause serious disease.”
Apparently the Roman talent for organization did not extend as readily to institutional care of the sick and injured. Nevertheless, infirmaries for sick slaves were established, and Seneca said that even free Romans sometimes used them. There were really no other places except the offices and perhaps homes of physicians where the ill and wounded could be domiciled, treated, and cared for.
Only among the military legions was a system for hospitalization developed. At first wounded soldiers had been quartered in the homes of the rich, especially during a serious battle. Then field tents were set up separate from the barracks. Later, infirmaries (valetudinaria) were erected in all the garrisons along the frontiers. Apparently these stone and wooden structures were carefully planned and also stocked with instruments, supplies, and medications. However, it was not until the fourth century A.D. that hospitals for civilians appeared in the cities. The first was founded in Rome around the year 394 by the Christian benefactress Fabiola.
Pedanius Dioscorides (fl. c. 41-68) was probably a military physician who, traveling with the army to many lands, had the opportunity to study and record the medical uses of hundreds of plants and to write what is probably the first thorough, systematic materia medica. Diocles of Carystus in the fourth century B.C. was an earlier source of information on medicinal plants, and Aristotle’s pupil Theophrastus presumably also made extensive contributions to botany and medicinal herbs. Crateuas in the first century B.C. had written the first illustrated herbal with colored plates, but from subsequent descriptions it is doubtful that the treatment was thorough or systematic. It was the work of Dioscorides which was to become the basis for all subsequent studies and writings on pharmacology and materia medica.
Celsus and Pliny
Much of the information on Alexandrian and on Roman medicine is based on the writings of two encyclopedists: Cornelius Celsus and Caius Pliny, the Elder, both of the first century A.D.
Celsus (fl. 14-37) was apparently a patrician layman who tried to summarize most of the knowledge available at the time, including agriculture, law, military science, philosophy, rhetoric, and medicine. Only the eight books comprising his De Medicina and a few additional fragments on the other subjects have survived. These extensive works had some influence in his own time, but were lost until the Renaissance, when reborn interest in the ancients led to their discovery by Pope Nicholas. Celsus was the first medical author to be printed (1478) in movable type after Gutenberg’s invention. Part of the reason for the earlier neglect of Celsus was probably his use of Latin. Since scientific and medical treatises of his time were written in Greek, apparently no one would expect to find an intellectual contribution in Latin.
In the opinion of most scholars, Celsus was not a medical practitioner, but so perceptive are his detailed descriptions and judgments that surgeons will especially appreciate his writings on hernia, wounds, and amputations. “Now the laying open is to be done boldly, until the outer tunic, that of the scrotum itself, is cut through, and the middle tunic reached. When an incision has been made, an opening presents leading deeper. Into this the index finger of the left hand is introduced, in order that by the separation of the intervening little membranes the hernial sac may be freed.”
He made a particularly outstanding, perhaps the first (Heliodorus may have preceded him), description of ligating and dividing bleeding vessels. “The blood vessels that are pouring out blood are to be grasped, and about the wounded spot they are to be tied in two places, and cut across in between, so that each may retract and yet have its opening closed.”
The internist may also be impressed by his good sense. “The failings of those who practice medicine are not to be charged to the art itself… The physician of experience is recognized by his not at once seizing the arm of his patient as soon as he comes to his side, but he looks upon him and as it were sifts him first with a serene look, to discover how he really is; and if the sick man manifests fear, he soothes him with suitable words before proceeding to a manual examination.”
The De Medicina of Celsus covered a wide range of topics: the history of medicine, the preservation of health, and derangements of almost every organ system of the body. Celsus approached each therapeutic maneuver with understanding. His description of cosmetic surgery included restoration of the prepuce, for evidently some Jews in Rome sought to obtain positions and social acceptance by hiding their origins.
Celsus advised mild methods, relying much on exercise and rest, measures for which he gave credit to Asclepiades. Perhaps he has been best remembered for his description of the characteristics of inflammation: redness and swelling with heat and pain (rubor et tumor cum calor et dolor). Today these are still called the four cardinal signs of inflammation.
Whereas Celsus was selective in what he reported and approved, Caius Pliny (23-79) had a voracious and omnivorous intellectual appetite. His monumental Historia Naturalis contained every bit of information he could gather from the past or present. Virtually every waking hour for two years was devoted to collecting and recording. Indeed, Pliny is reported to have died satisfying his curiosity about volcanoes during the same eruption of Vesuvius that buried Pompeii and Herculaneum.
Owing to his extensive writings on history, physics, biology, chemistry, geography, food, philosophy, magic, folklore, plants, and medicine, subsequent generations were able to obtain voluminous information about the past—some of it fanciful. Pliny stated that light travels faster than sound and that the world rotates rapidly, but he also mistakenly concluded that every liquid becomes smaller when frozen. He recognized that some additives to wine were poisonous, but he was probably not aware that lead in water vessels and pipes was more noxious. Many of his descriptions of plants and drugs were correct, but others were superstitious and inaccurate. He had a horror of menstruation, reporting that dogs went mad if they licked the fluid, that even ants discarded their food if a menstruating woman came near.
Pliny did not believe in an afterlife. “I deem it a work of human weakness to seek to discover the shape and form of God. Whoever God is—provided there is a God—and wherever he is, he consists wholly of sense, sight, and hearing, wholly of soul, wholly of mind, wholly of himself.” Yet he accepted as truth many fantastic marvels, such as one-footed people who used the giant foot to shelter themselves from the rain. Pliny also believed that there had been “rains of milk, blood, flesh, iron, sponges, wool, and baked bricks.”
He reserved most of his ire for Greeks, especially the physicians. “And there is no doubt that they all busy themselves with our lives, in order by the discovery of some new thing or another to win reputations for themselves.” “There is alas no law against incompetency; no striking example is made. They learn by our bodily jeopardy and make experiments until the death of the patients, and the doctor is the only person not punished for murder.”
Despite their extraordinary variety of facts and opinions, Pliny’s works were regarded as authoritative throughout the Middle Ages and are still a valuable source of information about the ideas and customs of antiquity.
There were a number of other outstanding contributors to medicine in Rome in the second century A.D., notably Soranus (fl. c. 98-138) who came from Ephesus in Asia Minor. Although he wrote on injuries and diseases, his principal field of work was obstetrics and the diseases of women. He was a popular practitioner, and his works served as a textbook in the Middle Ages. Soranus showed an understanding of menstruation and parturition and their difficulties, including the interference of genital tract inflammation with both menstruation and conception. He also noted the complications in delivery due to pelvic abnormalities and the improper presentation of the baby. His methods of correcting abnormal positions were sound, as were his measures to prevent tearing of the pelvic soft parts during delivery.
His instructions extended to the care of infants and the management of diseases of later childhood. Soranus clearly differentiated the uterus from the vagina, proved that the uterus could be removed without fatality, cautioned that manual removal of the placenta (afterbirth) could produce inversion of the uterus, advised emptying the bladder with a catheter before delivery, suggested psychological methods in difficult menstruation, and favored rupture of the membranes to hasten delivery in delayed labor. He also explained how to reduce the vagina to virginal size by inserting a tampon saturated with an astringent.
Rufus of Ephesus (c. 110-180) made important anatomical observations while in Rome. He described clearly the correct course of the optic nerves and the parts of the eye including the capsule of the lens. He confirmed some anatomical information earlier reported but not fully appreciated; for instance, that nerves originate from the brain, that some nerves direct movement and others sensation. He also recognized the heartbeat as the cause of the pulse and discussed its many properties. Rufus also subscribed to the theory of the pneuma (the Stoics’ idea of a vital force borne in the air), as did most of his contemporaries, but he apparently belonged to no particular medical sect. Not only was Rufus an investigator but also a highly respected physician. His recognition of the psychological import of dreams is an example of his astuteness.
But of all the practitioners, contributors, medical writers, and teachers of Roman times, one gigantic personality, Galen, towered above all, not only in his own period but also in many succeeding centuries.