Bryn Mawr Classical Review 2005.07.74
Vivian Nutton, Ancient Medicine. London and New York: Routledge, 2004. Pp. xiv, 486; ills. 31, maps & plans 4. ISBN 0-415-08611-6. $105.00.
Reviewed by John Scarborough, School of Pharmacy & Department of Classics, University of Wisconsin (firstname.lastname@example.org)
Word count: 2477 words
To begin, I wish to express my admiration for this near-masterpiece of compression: Ancient Medicine, encompasses sources, texts, and modern scholarship ranging from Homer to some notes on medicine and the Christians in the seventh century, a span of 1500 years. In writing the book, Nutton has not merely summarized much current scholarship in ancient medical studies (exclusive of current work in the pre-Greek ancient Near East), but has also shown remarkable courage in setting forth his own views on disparate aspects, each of which will receive challenges from specialists. In many respects, Ancient Medicine represents the subspeciality very well, since we have a rare collegiality even as we heatedly dispute texts and interpretations, and what "medicine" was two millennia before Pasteur.
Nutton's book carries the marks of this continual debate. And since the practice of medicine in any culture consists distinctively of attributes labeled "disease," "health," and "therapeutics," and how certain authorities espoused particular theories on each facet, one must continually interweave multiple cordages: 'hard' data (plants and phytochemical principles, minerals and medicinal chemistry, technologies of agriculture (animals, bees and honey, etc.), basic human anatomy, and some comparative anatomy; 'soft' subjects (how various schools of philosophy influenced the medical 'sects' of classical antiquity, self-advertising by individual physicians [notoriously prominent is Galen of Pergamon], interpretation of papyri and inscriptions concomitant with what archaeology might or might not tells us, and what the Hippocratic-Galenic notions of a "humoral pathology" meant in terms of prognostics and diagnostics). Ancient Medicine attempts to incorporate all these particulars of medicine among Greeks and Romans, and does so with greater and lesser success, depending on the subtopic.
Nutton's volume is the first in English in a century to undertake this large task (the publisher's blurb is literally correct),1 since Sigerist's two volumes ended with an account of Hippocratic medicine.2 One will find fluid, detailed summaries of medicine in Ptolemaic Egypt, some bits on what is known about practitioners and practice in the Seleucid and Antigonid kingdoms, the coming of Rome to the Hellenistic world and the resultant cultural tussle, the often-debated nature of medicine in the Roman Republic and the first two centuries of the Roman Empire, ending with a gradually tapering narrative on 'later' Roman medicine and some pertinent details on what the new Christianity 'did' with the 'old' notions of a rational medicine.3 Nutton rejects (I think rightly) 'biomedical' presentation of individuals, concentrating on how known figures reflected the common intellectual milieu of their own times.4 By refusing to endow "Hippocrates" with the aura of superphysician (nowadays almost everyone in ancient medical studies accepts Hippocratic writings, no longer classed as 'Coan' or 'Cnidian'),5 or letting Galen be the absolute focus of medicine in the second century, Nutton illustrates how physicians, midwives, drugsellers and rootcutters, philosophers, patients, magic-workers, alchemists, spell-casters, and supposedly unlearned country-dwellers, all existed and plied "medicine," sometimes with no sense of rivalry,6 sometimes with bitter encounters on all intellectual levels, ranging from the vicious medico-philosophical disputes delineated in the writings of Galen to the presumptive dupes sold counterfeit pharmaceuticals in the infamous Seplasia of Naples .
This cacophony of approaches characterizes Greco-Roman medicine, though names provide milestones for the historical journey, including Plato, Hippocrates, Aristotle and Theophrastus, Herophilus and Erasistratus, Asclepiades, Cornelius Celsus, Pliny the Elder, Soranus, Rufus, Aretaeus, and Galen. Each authority signals an intellectual phase in the development of theoretical constructs in a fusion of empirical observations, clinical histories, surgical expertise, pharmacological explanations, and philosophical unities (or their lack) in an age long before legal definitions certified what medicine was and what it was not. In fact, Roman law is deliberately fuzzy about contraceptives, abortifacients, and the presumed liability of a physician, midwife, or surgeon;7 and anyone who learned the arts and skills of medicine did so as an apprentice to an individual who had years of raw experience, or in costly private instruction by a teacher who attracted would-be medical students (the 'curriculum' normally was study and commentary on the medico-philosophical classics), or the beginner simply began and accumulated his or her own raw experiences. Fluidity marks medicine, perhaps best understood as an unpredictability in the outcomes from physician to physician, but an internal paradox also defines medical practice on all levels: the occasionally rigid traditions of a very old folk medicine underpin much of what is present in our texts of pharmacology, medical magic, midwifery, diagnostics and prognostics (less so in surgery, since greater sophistication is apparent in comparing Hippocratic texts with similar tracts in the early Byzantine era). Added to the paradox is the nature of folk medicine as the most innovative aspect of medicine, since new drugs, new techniques, new explanations of good health and causes of illness, sometimes emerge first in so-called popular lore. Moderns need to reflect that the once-dominant "germ theory" is currently yielding to the seemingly arcane technologies of molecular genetics, even while we still rely on traditional remedies gained from an ancient folklore of dietetics, drugs ultimately derived from natural products (salicylates remain salicylates in the fanciest of aspirin tablets), and a self-care passed on from generation to generation.
Nutton is well aware of all these particulars, and, with topics that match his well-known abilities in classical philology,8 his narrative drips with controlled expertise, an ease of choosing just the right example from hundreds that speaks of the many years spent with Greek and Latin texts on medicine and related subjects. Especially strong chapters (among 20) in Ancient Medicine are 5. "Hippocratic Theories," 7. "Religion and Medicine in Fifth- and Fourth-Century Greece," 8. "From Plato to Praxagoras,"9 13. "The Rise of Methodism," 14. "Humoral Alternatives," 15. "The Life and Career of Galen," and 16. "Galenic Medicine." Variations in quality of presentation are mirrored by what Nutton does well, and what he does not do well: his assessment of evidence in the texts and in corollary materials from papyrology, epigraphy, and archaeology rests on what lawyers call 'reasonable tests' (in torts) and 'substantial evidence thresholds' (in private and administrative law),10 and consequently for him most ancient pharmacology fails both standards, and surgery generally lacks even the least of the substantial evidence thresholds required for pronouncement of 'success.' Portions of Ancient Medicine present the negative, the frothy, the argumentative, the basic futility of a Greco-Roman medicine, equipped with sophisticated notions of humoral balances and imbalances. Oddly, Nutton reasserts Whiggish medical history by denying that ancient medicine did few patients much good, stated explicitly on p. 316: "[My book] is an account that supplements, but does not abandon, the more heroic chronicle of medical progress as an accumulation of skills, ideas, and practices over the centuries from Early Greece to the triumph of Galenism."
By contrast, study of a Greek text with all of its shady nuances, emendation-history through the centuries, and peculiar methods and manners of expression (enclitics, particles, verb-forms, inflections, etc.) allows a modern philologist to state 'this is reasonable, this is not,' or 'this has internal evidence that marks it as threshold sufficient,' judgments admirably suited for theoretical constructs, philosophy, and the phases of a living Greek, whether it is the Sophistic Greek of the second century, or the flowing, homely illustrations replete in Platonic dialogues. Such standards, however, do not work well when one assesses medicine, or any of the linked sciences or pseudo-sciences: a physician does not evaluate evidence of an illness on the basis of what might be 'reasonable,' but on the basis of experience and history (his own or that gained through books and formal instruction), and a diagnosis generally takes the form of an historically-embedded terminology, frequently separate from a common speech or literature. Anyone working in the real world of medicine where patients appear and death is common, is struck by variations within a class of ailment, by sensations that enable one to heal the sick (odors, touch, vision, occasionally taste, certainly hearing) and how each patient presents his or her own modulation of a standard, textbook description. Medicine remains an Art, much as some Hippocratics proclaimed, and much as is loudly proclaimed by current medical educators when they institute courses in 'communication skills' for medical students.
Among the portraits penned by Nutton, Galen of Pergamon (A.D. 129-after 210) is the sharpest and most believable on all levels of textual and historical evidence, and students of medicine or Roman history will be richly rewarded by the two chapters that set Galen into a firmly Roman imperial context.11 Galen speaks as a self-professed medical genius unhappily competing with dolts and buffoons, those others practicing medicine ignorant of basic anatomy, pharmacology, the taking of case-histories, and a reverence for the sublime works of Hippocrates.12 He arrogantly parades his abilities in philosophy,13 and is securely wedded to classical maxims and forms derived from Plato, Aristotle, and particular Stoics;14 and even while enjoying use of syllogisms, he repeatedly notes that he is first a physician, then a philosopher.15 A paradox again lurks: the figures damned by Galen are often known only through the impeccable and logical sarcasm of Galen himself, and, 'biographical' details remain in the realm of 'autobiography,' even though Nutton argues that there are independent testimonials attesting to the life and times of Galen (all are late, and the one that might matter is easily questioned due to the nature of the source itself).16 Wisely Nutton has foregone writing that "biography" of the purported personal physician to Marcus Aurelius, since Galen alone tells us that is what he was. Nonetheless, by carefully piecing the autobiographical with separately documented events, people, and literature, in Chs. 15 and 16 (pp. 216-247), Nutton has produced the best narrative of Galen's "life and times" now available, even though there are strange errors that peep through from time to time.17
The writing style is occasionally irritating, as the author continually 'tests' the evidence at hand, and there are too many pages marred by negatives, 'maybe,' 'perhaps,' 'cannot be known,' 'seems,' passive constructions that any good barrister eliminates in revision, and qualifications that would merit warm approval of any practitioner of modern sociology. For example, p. 164, one reads about the cutesily-titled "Dr Asclapo of Patras, a man of kindness, learning and fidelity, [who] was recommended by Cicero to his friend Sulpicius Rufus as a valuable companion in Achaea in 46 B.C.," followed by " ... other doctors seemed to have come to Italy ...," then with the trailer of an inscription recording Q. Manneius Menodotus, "originally from Tralles in Asia Minor [who was] adopted by a Roman citizen at Atinum, Q. Manneius. Where and when the two men met can only be guessed at ...." "Precedents ... almost certainly lie behind the action of Julius Caesar, perhaps around 49 B.C., in conferring Roman citizenship on any doctor ... " " ... .following his dramatic cure by an ex-slave-doctor, Antonius Musa, the emperor Augustus is said to have granted tax immunity for ever to all practitioners of medicine." Then comes this wonderful, convoluted, qualified-out-of-existence sentence: "The number of immigrant doctors who took advantage of this generosity to become full citizens and the procedures whereby one proved one's qualifications as a doctor or a teacher are both unknown." This is tough going for a fellow-specialist, and certainly impossible for a student or someone generally acquainted with the history and culture of the late Roman Republic. Disturbing too are residues of biases not befitting the study of ancient medicine. In introducing the topic of Greek medicine and its transition or 'transplantation' in Rome, Nutton writes (p. 157): "Without this development it is possible that Greek medicine would have remained on the same level of importance to us as that of the Babylonians or Egyptians, an interesting, if somewhat tangential, object of historical study." Apparently Nutton rejects the widely accepted scholarship by Burkert who argues for heavy Near Eastern cultural influences on Greece.18
There is an overweening pride in 'privileged information,' since one often notes 'forthcoming' or 'unpub.' (by another individual) in a reference to a source that backs statements in the text,19 and citations of British doctoral dissertations (especially his own ) which cannot be borrowed without the authors' permissions20), sometimes accompanied by a gratuitous scholarly cruelty quite inappropriate from a prominent authority.21 For the uninitiated, the footnote references to primary sources are often misleading,22 perhaps the result of a too-rapid composition and lack of careful proofreading, and there are some strangely repetitive historical mistakes that any undergraduate in ancient history would immediately know to be incorrect.23
A talented philologist, trained in the finest analytical techniques applicable to Greek and Latin, easily misses the particulars that infest pharmacology, surgery, and the unexperienced if essential recollections of an everyday medical practice. Nutton's medical science is minimal, a shortcoming apparent in several chapters, exemplified by the summary of Scribonius Largus (pp. 172-174). This short section repeats much of an earlier publication,24 and suffers from the same faults: a total absence of specificity about drugs, what they do, and especially why Hellenistic and Roman pharmacology might value them enough to be recorded. Nutton displays his sure command of the interpersonal, historical, and sociological contexts, but he disdains to describe the "... antidotes against poisons, bites and stings [and] plasters, dressings, and soothing salves -- the typical drugs used by surgeons" (p. 172). Simply listing 'common names' (" ... the humble carrot to the exotic aloe, from fenugreek to ginger, from butter to the electric ray or torpedo fish ... "[ibid.]) reveals none of the complex pharmacological technology embedded in Scribonius Largus' intricately constructed recipes in the Compositiones set down sometime after A.D. 43 in Latin. The tidbits about remedies used by Octavia or Messalina call for specifics, especially how the compound drugs become tooth-cleaners, headache remedies, and analgesics for quinsy, details that would provide the slice-of-life in a royal household and the contents of an unusual medicine chest.25
The achievement of Ancient Medicine is striking in view of these numerous flaws. Nutton has accomplished a compaction of an enormous body of evidence, if occasionally jagged and overqualified. Graduate seminars in any aspect of Greek or Roman medicine will enjoy testing the evidence presented in this book, but will test the sources and render interpretations of those sources with techniques familiar to physicians who assess data emerging from controlled laboratory analyses. Given its prose that packs too many examples into too few sentences and paragraphs, the book is utterly unsuitable for the general reader or for undergraduates in ancient history, the Classics, or the History of Medicine. Nutton has -- to use a proper metaphor -- created a body of literary evidence that will be meticulously dissected for many generations, and doubtlessly future authors will use these collections of ancient medical organs, tissues, and cellular structures as foundations to create their own studies of Greek and Roman medicine. Ancient Medicine is a huge quarry, fit for mining and exploitation by those who have the proper equipment.
1. "Literally," since the last English-language textbook on ancient medicine (through the Byzantines) is Ernest Playfair's translation (from the German) of Max Neuberger, History of Medicine, Vol. I (London: Henry Frowde/Oxford University Press, 1910); "The Medicine of the East" (Mesopotamia, Egypt, Persia, Old Testament, ancient India, ancient China and Japan [pp. 11-82]) is woefully dated, but some sections of "Medicine in Classic Antiquity" (pp. 83-274) retain their value as clearly written summaries of major figures, Hippocrates most obviously excepted. In German, the 1902 T. Puschmann, Max Neuberger and Julius Pagel Handbuch der Geschichte der Medizin, Vol. I: Altertum und Mittelalter (Jena: Gustav Fischer; rptd. Hildesheim & New York: Georg Olms, 1971) remains useful in tracking texts especially in Roman and Byzantine medicine (Iwan Bloch's "Byzantinsche Medizin" [pp. 492-567] still is a standard account). Greek and Roman surgery has two excellent histories, one in German and one in English: E. Gurlt, Geschichte der Chirurgie und ihrer Ausübung, Vol. I: Volkschirurgie -- Alterthum -- Mittelalter -- Renaissance (Berlin: August Hirschwald, 1898), esp. pp. 314-592 (Rome and Byzantium); and Guido Majno, The Healing Hand: Man and Wound in the Ancient World (Cambridge, Mass.: Harvard University Press, 1975), esp. chs. 4, 8-10.
2. The assembly of material on Greek medicine in Henry Sigerist, A History of Medicine, Vol. II: Early Greek, Hindu, and Persian Medicine (New York: Oxford University Press, 1961), esp. chs. 1 ("Archaic Medicine in Greece") and 4 ("The Golden Age of Greek Medicine") reflects the progressive opinions of the day, but were written to be read, and one can do so today and derive much benefit (ignoring Hippocrates as superdoctor).
3. Nutton is heavily indebted to Owsei Temkin's fundamental Hippocrates in a World of Pagans and Christians (Baltimore: Johns Hopkins University Press, 1991).
4. Especially important in Nutton's interpretations of the welter of internally- and otherwise-contradictory theoretical constructs labeled Hippocratic; ch. 5, "Hippocratic Theories," is one of the best chapters in the entire book, with a full accounting of the papyrus text we know as the Anonymus Londinensis.
5. Two books undergird Nutton here: Wesley Smith, The Hippocratic Tradition (Ithaca, New York: Cornell University Press, 1979), and Antoine Thivel, Cnide et Cos? (Paris: Les Belles Lettres, 1981 [Publications de la Faculté des Lettres et des Sciences humaines de Nice, 21]).
6. This is the basic thesis argued in several books by G. E. R. Lloyd, including Magic Reason and Experience (Cambridge and New York: Cambridge University Press, 1979), Science, Folklore and Ideology (Cambridge, etc., 1983), and The Revolutions of Wisdom (Berkeley and London: University of California Press, 1987).
7. To the references in n. 138 (p. 327) should be added Marcian, Institutes, 14, quoted in Justinian's Digest, (ed. Mommsen-Krueger), 48, 3. 1-3.
8. Amply demonstrated in two essential texts, translations, and commentaries: Galen On Prognosis (Berlin: Akademie Verlag, 1979 [Corpus Medicorum Graecorum V 8, 1]), and Galen On My Own Opinions (Berlin: Akademie Verlag, 1999 [Corpus Medicorum Graecorum V 3, 2]).
9. Sometimes a British English confuses more than it clarifies, e.g. p. 124 where "savours" is used to designate Mnistheus' 'humors.' An American reader would have preferred 'a characteristic taste or flavor' (OED, s.v. def. 1), and 'savour' is archaic English for 'characteristic smell' (OED, s.v. def. 3). Which is it? And on p. 125, Nutton misunderstands the Latin of Caelius Aurelianus, Acute Diseases, III, 165 (ed. and trans. Drabkin, pp. 402-403). There is nothing "magnificent" about the death caused by Praxagoras' bungling use of emetics and cathartics (the drug is not named [no hellebore here]) to treat hernias. The Latin: quo probatur manificam mortem Praxagoras magis quam curationem voluisse scribere, rendered by Drabkin as "From this it would seem that Praxagoras wanted to describe a hand-inflicted murder rather than a cure."
10. Nutton indicates this mode of thinking in the "Preface" to his collected papers, published as From Democedes to Harvey: Studies in the History of Medicine (London: Variorum, 1988), p. ix: "The papers brought together in this volume mark an intellectual and personal transition from putative law student through Cambridge classics don to London medical historian."
11. In English, there had been only the jejune Galen of Pergamon by George Sarton (Lawrence: University of Kansas Press, 1954), and Luis Garcia Ballester's Galeno (Madrid: Guadarrama, 1972) is disfigured by hundreds of misprints. Recently, Heinrich Schlange-Schöningen, Die römische Gesellschaft bei Galen (Berlin and New York: Walter de Gruyter, 2003) in excruciating detail attempts a 'social biography' of Galen, but the old adage 'can't see the forest for the trees' sums this effort (some of the 'footnotes' consume an entire page).
12. If one analyzes carefully the basic thesis on Galen's Hippocrates as put forth by Wesley Smith (n. 5 above), Galen "invented" the Hippocrates he so pointedly respected.
13. Easily sampled now in English: R. J. Hankinson, trans., with introd. and commentary, Galen On the Therapeutic Method Books I and II (Oxford: Clarendon Press, 1991). Hankinson's commentary is easily one of the finest ever produced on Galen as a philosopher.
14. Galen's On the Doctrines of Hippocrates and Plato (ed., trans., with commentary by Phillip De Lacy, 3 vols. [Berlin: Akademie Verlag, 1978-1980: Corpus Medicorum Graecorum V 4, 1, 2]) quotes liberally from otherwise lost Stoics, in company with Plato and Aristotle, set beside his ideal Hippocrates.
15. And thus he composed "The Best Doctor is also a Philosopher," freshly translated by P. N. Singer in Galen: Selected Works (Oxford and New York: Oxford University Press, 1997 [in World's Classics series]), pp. 30-34.
16. Eusebius, Ecclesiastical History, V, 28. 13-14, with Epiphanius, Remedy for Heresies, LIV, 3. 1.
17. E.g. p. 183, with n. 79, p. 378: The text cited by Nutton from Galen (Kühn, X, 942) does not say that surgeons in Galen's day used 'catgut' for sutures; the Greek reads "threads that some call silk." The first recorded use of animal intestine as material for sutures is in the Surgery by Albucasis (Arabic, 11th century).
18. Although cited by Nutton, these ideas are implicitly dismissed. Esp. e.g. Walter Burkert, Die orientalisierende Epoche in der griechischen Religion und Literatur (Heidelberg: Carl Winter, 1984) = English translation by Margaret E. Pinder and the author as The Orientalizing Revolution (Cambridge, Mass. and London: Harvard University Press, 1994); of special interest is ch. 2, "A 'Seer or a Healer:' Magic and Medicine" (pp.41-87).
19. I tabulated about 30 of these "unpub.," "Camb. Diss.," "forthcoming," and other similar 'privileged' references. At least Kent Weeks' 1970 Yale PhD thesis (on Egyptian anatomy) is available for anyone to peruse.
20. E.g. Peter Green's 1954 Cambridge thesis on Pliny the Elder's use of magic, " ... still unmatched" (n. 95, p. 369). V. Nutton, The Medical Profession in the Roman Empire, PhD diss. Cambridge 1970, dir. A. H. M. Jones; requests have been refused several times over 25 years.
21. E.g. n. 66, p. 382 (on the recent Budé edition of Soranus as 'not philologically reliable'); n. 75, p. 383, n. 76 (a scholar places 'too much weight on the secret networks of women'); n. 18, p. 376 (two scholars have translated the "Preface" to the drug-manual of Scribonius Largus: neither is 'entirely reliable'); and many more. "Philologically insensitive" is Nutton's deepest insult, as exemplified in his "Asclepius Transformed" in C. J. Tuplin and T. E. Rihill, eds., Science and Mathematics in Ancient Greek Culture (Oxford and New York: Oxford University Press, 2002), pp. 242-255 (p. 253 with n. 31).
22. By mixing primary texts with secondary references in the bibliography, a beginner is hard-pressed to distinguish between the two, e.g. the edited texts of the fragments of Heracleides of Tarentum, listed simply as 'A. Guardasole, Eraclide di Taranto. Frammenti (Naples: D'Auria, 1997), when a much more informative manner (useful to beginners and veteran scholars alike) would be to let the reader know that this is the new edition of the fragments of Heracleides, with an Italian translation and commentary: Alessia Guardasole, ed., with introd., trans. and commentary, Eraclide di Taranto Frammenti (Naples: M. D'Auria, 1997) tells someone immediately that this is a primary text. And the writings and translations of Julius Hirschberg are reduced to impenetrable status (Nutton: Hirschberg, J. (1982) The History of Ophthalmology, Vol 1, Antiquity, Bonn: Wayenborgh). In English? Trans. from the original German? By whom? There are far too many of these in the notes and the bibliography.
23. E. g. (repeatedly) Nutton prints Mithridates V (pp. 131, 142, 246, several others, even making the index, p. 474). My students would know Mithridates VI of Pontus, whether he was the royal patron of the pharmacologist Crateuas or not. Computers sometimes make us careless, but proofreading still is necessary (spell-checks don't catch the odd numerical errors, or the foreign misspellings).
24. Vivian Nutton, "Scribonius Largus, the Unknown Pharmacologist," Pharmaceutical Historian, 25, no. 1 (March 1995), 5-8. Since this essay is only 'philologically sensitive' one available in English, I assign it as a required reading in my course, Greek and Roman Medicine & Pharmacy, here at the University of Wisconsin.
25. Here is a "slice of life" as given through Scribonius Largus, Compositiones, 70 (ed. Sconocchia, p. 39): "For Treatment of a Choking Quinsy: And the following has proven beneficial for many patients, and is certainly quite powerful and quite effective: 2 drachmas each of costus, celery seeds, anise seeds, oil of camel grass, and cinnamon-cassia, one-half drachma of cardamom, 2 drachmas of the wild rue (two-thirds of which is the seed), one-half ounce of fissile alum, 5 medium-sized ground-up oak galls, 2 drachmas of saffron, one-half drachma of the refined residue of the oil of saffron, one-half drachma of myrrh, 4 drachmas of Cretan birthwort, 3 drachmas of cinnamon, one ounce of the ashes of a young wild swallow, and one-half drachma of spikenard. All these ingredients are to be conjoined and either pounded or otherwise produced separately each having been skimmed in Attic honey. And whenever the compound is to be used, a sufficient amount of the same honey should be added to it. The Augusta always has this compound at hand" (my trans.). Antonia Minor, the mother of Claudius, is the 'Augusta' here, and she suffered from 'angina,' called quinsy in the 19th century, a swelling of the tonsils. Each of the ingredients has phytochemical principles, and collectively they make up a rather good analgesic. These are the sorts of details that make ancient medical studies so interesting. And yes, we can identify each of the plants through Linnaean, binomial nomenclatures.