Medicine In The Roman World

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The Roman Empire was a complex and vigorous combination of Greek and Roman cultural elements, forged through centuries of war. Originally a republic of yeoman farmers, rather than merchants and adventurers like the Greeks, Roman citizens retained a preference for the practical over the abstract and a tendency to idealize the pastoral life even as they constructed cities unprecedented in size and complexity. They excelled in the arts of warfare and administration, as well as architecture, engineering, public health, and hygiene. Roman writers boasted that their ancestors had lived without physicians, though not without medicine, being well endowed with folk remedies, healing deities, and diviners. Presumably, the remarkable sanitary engineering achievements that are associated with Republican and Imperial Rome played an important role in maintaining public health.

When comparing Rome to Greece, critics characterized the Romans as a people without art, literature, science, or philosophy. However, they certainly could not be called a people without gods. Like the Egyptians, the Romans accumulated deities for all major organs and functions of the body. Nevertheless, they still had room in their hearts for new deities, especially when the old ones seemed unwilling or unable to do their duty. In 293 b.c.e., when their traditional gods were unable to stop a pestilence that was decimating Rome, the elders consulted Asclepius at the Temple of Epidaurus. While the Asclepiads conferred with the Roman delegation, a sacred snake emerged from the temple and boarded the Roman ship; this was taken as an omen that the Greek god of medicine intended to help Rome. A temple for Asclepius was constructed at a site selected by the snake, the epidemic ended, and the cult of Asclepius was established in Rome. Greek physicians were as eager to come to the aid of Rome as the sacred snake, but the reception they received was not always quite as warm as that awarded to Asclepius.

Originally, Romans were very skeptical of professional physicians. They did not condemn the practice of medicine per se, but they considered it was unethical to charge fees for treating the sick. Cato the Elder (234-149 b.c.e.) denounced Greek physicians as the worst enemies of Rome and accused them of poisoning and murdering their clients. Indeed, some of the most ambitious practitioners were actually greedy quacks, incompetents, and adventurers who used their knowledge to mislead patients, manufacture poisons, and enter into conspiracies.

Cato was fighting a losing battle, for Rome had been increasingly susceptible to Greek influences since the fourth-century b.c.e.. The introduction of the cult of Asclepius and the influx of Greek physicians were indicative of this trend.

Traditionally, the head of the Roman household was expected to supervise the medical affairs of his family, slaves, and animals. The actual practice of medicine, however, was regarded as a menial task suitable only for slaves and women. Most Romans relied on a combination of magic and folklore to fight disease. Each home had its special shrine and stock of herbal remedies. Appropriate rituals accompanied the administration of all drugs and the performance of any operation. It was an economical arrangement in which the same remedies, charms, and prayers served both man and beast. Cato, for example, was aware of many traditional remedies, but his favorite was cabbage, which might even be superior to chicken soup because, in addition to being harmless, it is a good source of vitamin C. In any case, Cato lived to the ripe old age of 84 during an era when the average life expectancy was about 25 years.

The writings of other Romans, almost by definition nonphysicians, reflect valuable insights into problems of hygiene, sanitation, and public health, especially the importance of water supplies and sewage disposal. Rome obtained its water from a variety of supply systems, but the aqueducts that were bringing millions of gallons of water into Rome by the second century b.c.e. are generally thought of as the quintessentially Roman solution to one of the major problems faced by urban planners. Lower quality water was considered acceptable for the bathing establishments found in every Roman city and almost every town. Admission fees for the public baths were generally minimal, but the Romans should be credited with the establishment of the pay toilet. While public latrines were generally incorporated into the bathing establishments, independent public latrines were usually sited in the busiest sections of cities and towns.

An admirable concern for the purity of water and the sanitary location of dwelling places is found in the text On Achitecture (ca. 27 b.c.e.) by the Roman architect and engineer Vitruvius. Also of interest is the suggestion by Marcus Terentius Varro (117-27 b.c.e.) that swampy places might be inhabited by extremely minute animals that could enter the body through the mouth and nose and cause serious illnesses. While wealthy Romans could take advantage of the architectural and engineering skills for which Roman civilization is justly famous, and retreat to peaceful, quiet country villas, most people lived in crowded, unsanitary houses lacking proper kitchens and heating systems, piped water, private baths, or latrines.

Despite Cato's warnings, as Roman society became more refined and prosperous, or, as critics might say, less virtuous and self-sufficient,

Roman citizens were soon eagerly consulting Greek physicians who offered them a medical regimen more sophisticated than cabbages and incantations. The career of Asclepiades (ca. 124-50 b.c.e.) provides an instructive example of how Greek medicine was adapted to a Roman clientele. Originally Asclepiades came to Rome as a rhetorician, but he quickly realized that the practice of medicine offered better prospects. Asclepiades offered treatments that were guaranteed to work ''swiftly, safely, and sweetly.'' While his theoretical approach was mechanistic, in practice Asclepiades advised a sensible regimen, with individualized attention to diet, rest, and exercise, along with simple remedies, such as wine, water, and cold baths, rather than bleeding and purging. Although Asclepiades provided a form of medical practice that could be successful in the framework of Roman expectations, suspicion and skepticism remained, as seen in the writings of Pliny the Elder (23-79).

Like Cato before him, Pliny the Elder, exemplary Roman gentleman and author of one of the major encyclopedic works of antiquity, was suspicious of professional physicians. According to Pliny, physicians were incompetent, greedy, superfluous, and dangerous. Greek physicians, he warned, had seduced Roman citizens away from their traditional herbal remedies and had contributed to the decay of Roman society. Pliny complained that physicians learned their craft by experimenting on patients and denounced them as the only men who could kill with impunity and then blame death on the victim for having failed to obey professional advice.

Pliny's Natural History provides an invaluable, far-ranging, if unsystematic survey of science, medicine, agriculture, industry, and the arts of the late republic and early empire. In lauding the virtues of Rome's traditional herbal remedies, Pliny claimed that everything had been created for the sake of man, making the whole world an apothecary shop for those who understood nature's simple prescriptions, such as wound dressings made of wine, vinegar, eggs, honey, powdered earthworms, and pig dung, and ferns used in the treatment of parasitic worms. Among the remedies suggested by Pliny are some that contain pharmacologically active components, such as ephedron for asthma, cough, and hemorrhage.

A more systematic approach to the search for remedies can be found in the work of Dioscorides (ca. 40-80), compiler of the text now known as De materia medica (The Materials of Medicine), one of the first Western herbals. Dioscorides exemplifies the generalization that Roman medicine was usually carried out by Greek physicians. Little is known about his life, except that he may have studied at Alexandria before serving as medicus to Nero's armies. ''Military doctor'' is probably too modern a translation for this term, because it is unlikely that an organized medical or surgical staff accompanied the Roman legions of this period. The Roman army may have had more formal provisions for the care of sick horses than sick soldiers. Nevertheless, throughout the existence of the Roman Empire, the activities of its armies and its medical personnel diffused Greco-Roman medicine throughout Europe, North Africa, and the eastern Mediterranean world.

Serving the Roman legions gave Dioscorides the opportunity to travel widely and study many novel plant species, hundreds of which were not known to Hippocrates. An acute observer and keen naturalist, Dioscorides provided valuable information about medically useful plants, their place of origin, habitat, growth characteristics, and proper uses. He also described remedies made from minerals and animals. Pharmacologists who have examined the text have found recipes for valuable therapeutic agents, including analgesics, antiseptics, emetics, laxatives, strong purgatives, and so forth.

Many of the herbal remedies identified and classified by Dioscor-ides can be found on the spice shelf of the average modern kitchen. The medical properties assigned to various herbs and spices would, however, surprise modern cooks. For example, cinnamon and cassia were said to be valuable in the treatment of internal inflammations, venomous bites, poisons, runny noses, and menstrual disorders. When properly prepared, such herbs and spices were said to induce abortion. A decoction made from asparagus was recommended as a means of inducing sterility; wearing the stalk as an amulet was said to increase the effectiveness of this prescription. Victims of bites by mad dogs might try a remedy made from river crabs, Gentian root, and wine. Then, to prevent complications, the patient should eat the liver of the dog in question and wear its tooth as an amulet. De materia medica includes many bizarre and unpleasant recipes, such as a remedy for malaria made of bedbugs mixed with meat and beans, but recent studies of the text suggest that Dioscorides classified his remedies according to subtle and sophisticated criteria. That is, Dioscorides appears to have based his classification on a drug affinity system rather than on traditional methods such as plant morphology or habitat. This required precise knowledge of growth characteristics of the plants, proper harvesting and preparation, and the effect that particular medicinal herbs exerted when given to a significant number of patients.

In contrast to the herbal of Dioscorides, which was frequently copied and widely used, the writings of Aulus Cornelius Celsus (ca. 14-37) were essentially forgotten until the rediscovery of his De re medicina (On Medicine) in 1426 presented Renaissance scholars with a source of pure classical Latin. De medicina became one of the first medical texts to be reproduced by Europe's new printing presses. Celsus had undertaken an ambitious encyclopedic work in four parts: agriculture, medicine, rhetoric, and warfare, but On Medicine is the only part that survived. Almost nothing is known about the life of Celsus except for the fact that

Dioscorides examining medicinal plants.

his contemporaries considered him a man of only mediocre intellect. Although Celsus was clearly a master of organization, clarity, and style, the question of whether he composed, compiled, or plagiarized On Medicine remains obscure.

In his historical introduction to the discussion of medicine, Celsus noted that the Greeks had cultivated the art of medicine more than any other people. The ancient Romans had enjoyed natural health, without medicine, he asserted, because of their good habits. When they turned to lives of indolence and luxury, presumably under the malign influence of Greek culture, illness appeared and medicine became a necessity.

After the death of Hippocrates, Greek medicine, which was never a monolithic enterprise, fragmented into various disputatious sects, some named after individuals and others, such as the Dogmatists, Empiricists, and Methodists, for their special approach to medical theory. Much about the origins, members, and practices of these sects remains unclear, but, thanks to Celsus, a fairly good account of the medical sects that flourished in his time can be reconstructed.

The Dogmatists emphasized the study of anatomy and claimed Erasistratus, Herophilus, and Hippocrates as their ancestors. Seeing medicine as a composite of practice, theory, and philosophy, the Dogmatists taught that physicians must study anatomy and physiology as well as the evident, immediate, and obscure causes of disease. Members of other sects might differ about many points, but they generally agreed that the Dogmatists were guilty of undue attention to speculative theories and a neglect of the practical goals of medicine.

Holding a more limited or more pragmatic view of the domain of medicine, the Empiricists believed it was necessary to understand evident or immediate causes, but that inquiry into obscure or ultimate causes was superfluous, because nature was ultimately incomprehensible to human beings. In medicine, the physicians should be guided only by the test of experience as it answered the question: does the patient get well? Some Empiricists claimed that the study of anatomy was totally useless for understanding living beings. They regarded human vivisection with horror and held it a crime to cause death in the name of the healing art. However, their emphasis on action was reflected in the excellent reputation of Empiric surgeons.

The Methodists believed that the body was composed of atoms and pores. Disease was the result of abnormal states of the pores due to excess tension or relaxation. Thus, knowledge of the three common conditions of the human body—the constricted, the lax, and the mixed—provided all the guidance the physician needed to treat his patients. Appropriate remedies relaxed or tightened the pores as needed. The Methodists claimed that, because their system was so complete, no further research into the causes of disease and therapeutics was necessary. But Juvenal, a Roman satirist, said that Methodist practitioners had killed more patients than they could count.

Celsus concluded that no sect was wholly right or wrong. In seeking impartially for the truth, it was necessary to recognize that some things that were not strictly pertinent to medical practice were valuable in stimulating and improving the mind of the practitioner. In dealing with cattle, horses, foreigners, and in the aftermath of disasters, it was sometimes necessary to look only at the simplest characteristics of disease. Under normal conditions, a superior physician had to consider geography, climate, and the unique reactions of different patients.

Properly considered, the art of medicine could be divided into three parts: cure by diet (which in this context might better be translated by the term ''lifestyle''); cure by medications; and cure by surgery. Experience taught the physician that standard medical practices were not equally appropriate to all patients. The art of medicine should be rational, Celsus concluded, and based on immediate causes, but ultimately medicine was an art that entailed a great deal of informed guesswork. Anatomy was an important part of medical knowledge, but Celsus declared that vivisection was cruel and unnecessary. Students of medicine could learn about the positions and relations of the internal organs from dead bodies, but the practitioner should be alert to the possibility of gaining anatomical knowledge when ''windows of opportunity'' occurred during the treatment of wounds.

Even though he rejected the Greek concept of the physician as a necessary guide to proper regimen throughout life, Celsus considered it essential for every individual to acquire an understanding of the relationship between disease and the stages of life. Moreover, in explaining this relationship, he offered as much advice as any modern guru of ''lifestyles.'' Acute illnesses, those that ''finish a man quickly, or finish quickly themselves,'' were the greatest threat to the young. The elderly were most threatened by chronic diseases. The middle years were the safest, but disease could strike human beings at any age, in any season. Little could be added to Celsus' conclusion that the best prescription for a healthy life was one of variety and balance, proper rest and exercise, and avoidance of a self-indulgent obsession with medical advice.

Surgery, according to Celsus, should be the most satisfying field for the practitioner, because it brought results that were more certain than treatment by drugs and diets. Physicians knew that some patients recovered without medicine, while some were not cured by the best medical treatment. In contrast, a cure brought about by surgery was clearly the result of skill, not the result of supernatural forces or luck. A surgeon must be filled with the desire to cure his patient and strong enough to perform his necessary work in spite of the patient's pain and suffering. After surgery, the physician must be ready to protect his patient from hemorrhage and the infections associated with the four cardinal signs of inflammation—calor, rubor, dolor, and tumor (heat, redness, pain, and swelling). The Roman surgeon had mastered tools and techniques that were unknown to his Hippocratic predecessors, such as the use of the ligature for torn blood vessels and special spoons and dilators to remove barbed arrows from wounds. Roman surgeons could perform amputations and plastic surgery, as well as operations for bladder stones, goiter, hernia, cataract, and snakebites.

De medicina provides a valuable survey of the medical and surgical practices of first-century Rome. However, during the European Middle Ages, Celsus and all the medical writers of antiquity, except Hippocrates, were eclipsed by the works of the great Galen of Pergamum (130-200 or 210).

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