Medicine and Health in the Ancient World

Introduction

To reconstruct ancient medicine and health, scholars depend primarily on three sources: human remains, artistic representations, and texts. For example, a spongelike porosity in a skeletal eye orbit may imply an anemia to the paleopathologist who specializes in ancient disease. On pre-Columbian human-shaped jars from Peru, furrowed areas around the mouths may suggest leishmaniasis, a disfiguring parasitic condition still found in the Andean highlands. A vague expression such as “jaguar-macaw seizure” in a curative incantation requires a Maya expert to find a modern equivalent.

In determining ancient medical and health practices, archaeology plays an important role, as does oral tradition, especially in conservative areas such as the Yucatán. In rare cases, surgical instruments survive, such as the scalpels, forceps, and needles of a physician who died in the eruption of Mount Vesuvius in 79 c.e. In Pompeii, archaeologists discovered a shop for the practice of medicine with residues of medicaments. Another source of information is fossilized excrement (coprolites), which, when analyzed, reveals much about parasitic infection and diet in an ancient population.

From a scientific perspective, disease is caused by living organisms, physical factors, chemicals, psychic factors, physiological changes, genetics, and nutritional deficiencies or excesses. A nonscientific model of disease locates causes in the individual, the natural world, social context, or the supernatural world. Many people and cultures attribute disease to both scientific and nonscientific factors, without sharply differentiating the two. For example, Mesopotamian medicine, often characterized as strictly supernatural, has at least a naturalistic side, if not a scientific aspect.

To ask who first practiced medicine and where is pointless. Primates in captivity have been observed practicing simple therapeutic procedures such as extracting splinters. One case, however, stands out. About 46,000 years ago, in the Shanidar cave in northern Iraq, there lived a Neanderthal whose skeleton reveals numerous problems including arthritis, trauma to the face and skull, and blindness in his left eye. His right arm, by one interpretation, had been amputated. Yet he had survived and been cared for by his group until he died at about age forty. In a nearby grave, the remains of flowers today recognized as medicinal have been hailed, prematurely, as evidence for proto-pharmacology.

Neolithic medicine

Beginning about 12,000 years ago, the Neolithic revolution ushered in fundamental changes that, contrary to the name, occurred gradually and irregularly at different rates in different locations. Ground and polished tools replaced tools formerly produced by chipping and flaking. Cultures that had once been hunter-gatherers now turned to agriculture and began to domesticate animals and make pottery.

The adoption of a sedentary lifestyle had profound health implications. Diseases of high infectivity and latency—arbovirus, chickenpox, rabies, tuberculosis, and herpes simplex—had probably already affected hunter-gatherers. As population densities increased as well as human-animal contacts, however, opportunities arose for other viruses and bacterial infections, especially in areas where sanitation and hygiene were minimal. For example, the use of unglazed pottery for storage would have easily led to outbreaks of food poisoning. Permanent structures would have quickly attracted vermin and insects carrying yellow and dengue fevers. As the landscape was cleared, stagnant irrigation pools would have become homes to snails that harbor schistosomiasis and malarial mosquitoes. Because the measles virus requires at least twenty-five to fifty new hosts annually, hunter-gatherer groups of less than one hundred would have suffered little if any exposure. By mathematical simulation, as densities increased to over 300,000, it would have become problematic. Although subject to individual variation and further analysis of skeletal evidence, studies of many different Neolithic locales suggest that, at least initially, there were some increases in physiological stress and mortality because of infectious diseases and diets lower in protein, vitamins, and minerals. Stature diminished from Upper Paleolithic and Mesolithic norms in the eastern Mediterranean. In South Asia, the adoption of vegetable food sources is associated with porotic hyperostosis, caries, abscess, rickets, and scurvy.

The Neolithic Age presents some of the earliest evidence for surgical intervention. In trepanation, holes were bored and sawed, scraped, or grooved into skulls of living people. In the absence of anaesthesia, antisepsis, and asepsis, the fact that many survived is extraordinary. The motivation is still debated: relief of fracture or headache, epilepsy, mental illness, demoniac possession, or some unrecoverable ritual because it was also practiced post-mortem. Sinicipital cauterization of the scalp, which leaves a characteristic T-shaped lesion on the skull, was practiced primarily on females and may have been a form of ritual branding rather than therapy.

Egyptian medicine

Later generations who venerated the wise men of the Pyramid age regarded the Egyptian Imhotep not only as their premier physician but also as a veritable god of healing. Even the conquering Greeks came to equate him with their god of medicine and continued to build temples in his honor. A Renaissance man, Imhotep may well have been the chief architect of the step pyramid built by King Djoser (r. c. 2687-2668 b.c.e.) at Saqqara, but no third millennium b.c.e. evidence exists to link him to the art of healing.

From the dynastic period, however, the names of some 150 physicians have been gathered from such sources as tombs, texts, and even mines and quarries where they plied their trade. In status, they range from high court physicians to commoners, and some were perhaps trained in a literate temple context. Hierarchal titles are often appended (for example, chief of physicians or inspector of physicians), but without context, their significance remains opaque. Two women physicians are attested, Peshet from the Old Kingdom and Tawe from the Ptolemaic period. The etymology of swnw (“physician”) is still debated. Drawn with an arrow, a pot, and the determinative for man, it sometimes is thought to represent an “arrow man,” one who extracts arrows in a military context, but this view is conjectural.

In the fifth century b.c.e., the Greek historian Herodotus described an unusual degree of medical specialization among the ancient Egyptians. To what extent this evidence may be extrapolated to the third millennium b.c.e. is unclear. Titles such as “physician of the eyes,” “shepherd of the anus,” “chief of dentists” are subject to interpretation. The semantic range of the word translated “anus” is wide and may include both small and large intestines. Also, given the common Egyptian notion that disease could arise from autointoxication brought on by intestinal stasis, the label may refer to someone who prepared and administered enemas. The translation “proctologist” would be too precise as well as anachronistic; equally inappropriate is the label of “ophthalmologist” for someone who may have treated eye infections with ointments. Even much of the evidence once adduced to prove dental intervention is now rejected. Holes, supposedly drilled in a mandible to relieve an abscess, today are interpreted as channels created by the abscess itself. A golden prosthesis could never have sustained its two teeth in a living, masticating mouth but was perhaps inserted post-mortem. Surgical therapies did include circumcision, trepanation, sutures, and treatment of fractures.

Although some diseases were attributed to naturalistic causes such as autointoxication, many were ascribed to magical and supernatural causes. Disease, it was believed, could arise from gods, demons, and ghosts and therefore could be combated with incantations, amulets, knotted hair, and even the eating of excrement (coprotherapy) to create an intolerable environment for an indwelling spirit. Troublesome cases might require the services of physician, magician, and priest of Sekhmet, the goddess of disease.

An essential source of information is the seventeen extant medical papyri. The earliest, the Kahun papyrus (1820 b.c.e.), deals in part with gynecology and ascribes many afflictions to a wandering uterus. The Edwin Smith papyrus, though extant only in a copy from about 1550 b.c.e., may date to the Old Kingdom. It sets out forty-eight cases, mostly of trauma, generally in a pattern of title, examination, diagnosis and prognosis, and treatment. Treatment often uses honey, which, from a biomedical point of view, would have antibacterial properties, and there is scarcely any resort to magic. The Ebers papyrus of 1500 b.c.e. is a compendium of different sources and focuses on internal medicine. It alludes to a basic notion of the circulatory system with the heart connected to different organs by channels. The notion of intestinal waste products as a cause of disease is mentioned here.

Another critical source of information are the mummified remains of the Egyptians themselves. Sophisticated CAT (computerized axial tomography) scans allow noninvasive examination, and DNA (deoxyribonucleic acid) analysis has added new information. Among some of the diseases that have been detected are schistosomiasis, tapeworm, tuberculosis, atherosclerosis, sand pneumoconiosis, joint disease, and possibly smallpox.

Mesopotamian medicine

Of the successive civilizations that controlled the land between the Tigris and Euphrates Rivers, two are especially important in the history of medicine: the Sumerians and the Akkadians. By the third millennium b.c.e., the Sumerians, who spoke a language unrelated to any known linguistic group, had established complex bureaucratic city-states in an area of 10,000 square miles (26,000 square kilometers) along the rivers and canals. By the end of the millennium, Semitic speakers, among whom were the Akkadians from Iraq, had assumed a rule that would last for fifteen hundred years. Just as Greek culture prevailed over the conquering Romans, so too did the high Sumerian culture overpower the Akkadians, who worshiped its gods and zealously studied its literature.

Drawing a picture of Mesopotamian medicine presents sometimes challenging difficulties. In contrast to Egypt, human remains are few, apart from skulls. Medical texts, though numerous, contain vague terminology translatable in various ways. A word rendered “leprosy” by one scholar, to another may mean “scurvy” or “diphtheria.” The orientation of the texts is not theoretical but pragmatic. Reconstructing the culture’s general notion of disease is therefore hard, and often what modern physicians would call a symptom, such as a cough, is treated more like an individual affliction. Behind a simple description like “the evil cough,” on the other hand, may lurk a condition as serious as pulmonary tuberculosis.

The earliest reference to a physician (Sumerian azu; Akkadian asu, from the Sumerian) occurs about 2500 b.c.e. A false etymology of this term as “he who knows the waters” led many scholars to assume physicians were originally priestly diviners. Mesopotamian disease causation was therefore largely characterized as magical and supernatural (stemming from witches, demoniac possession, and divine displeasure). In fact, complementary magical and naturalistic therapeutic traditions existed throughout Mesopotamia. Natural agents of disease included heat, cold, dryness, indigestion, and even love. One text seems to imply some idea of contagion.

The priestly ashipu (“conjurer”) employed magical incantations and rituals and, on occasion, herbal remedies, and the asu focused primarily on an elaborate pharmacopoeia specified in detailed herbal texts. In intractable cases, the services of both might be retained as well as the diagnostic skills of a seer (baru ). The status of the physician is uncertain. In the code of Hammurabi (r. 1792-1750 b.c.e.), a physician is treated as a craftsperson subject to monetary fines or even retaliatory capital punishment in the case of a noble patient’s death.

The world’s earliest medical text is Sumerian and comes from Nippur (c. 2000 b.c.e.). A fragmentary list of fifteen prescriptions, it probably draws on a long folk herbalistic tradition. The materia medica is based on plants, animals, and minerals. Instructions are given to pulverize and compound these in a mixture with beer to create poultices and internal remedies. Exactly what diseases are being treated is unclear.

A fundamental Akkadian text that survives in a late form is the Sakkiku (All Diseases ). Originally written on forty tablets with some three thousand entries, it contains some rudimentary diagnosis of symptoms. A yellow complexion is traced to the yellow disease, jaundice. Elsewhere, however, it often parallels omen texts. If on the way to a patient’s house, the conjurer sees a black dog or pig, the patient will die; if white, he will live.

The texts are almost silent about surgery, and to what extent it was practiced is controversial. The code of Hammurabi alludes to an eye operation. Cesarean section, probably post-mortem, was practiced but apparently only on slaves. Simple scalp abscesses were treated with pressure, incision, and scraping. Another text may refer to removal of a liver abscess.

One promising approach is to treat Mesopotamia as a chapter in the history of tropical medicine. Current Iraqi medical journals are quarried as much as ancient texts to set disease parameters. Some ancient conditions that continue to afflict the modern population are deficiency disorders (scurvy), helminthic disorders (worms), cutaneous leishmaniasis (a skin condition), typhoid, and pneumonia.

Greek medicine

The word “physician” (i-ja-te ) first occurs in a second millennium b.c.e. Linear B tablet from Pylos. Elsewhere there are references to an unguent boiler, female bath keeper, and medicinal plants. No specific diseases are mentioned. Skeletal evidence presents at least five cases of trepanation. A Mycenaean example on an aristocrat’s skull is sophisticated, but the patient appears to have died shortly afterward. Among diseases detected in bone is spinal osteoarthritis. In the classical period, malaria, tuberculosis, and chronic deficiency diseases are common.

The Homeric epics supply the earliest literary evidence. Disease arises from divine displeasure. In the Iliad (Homer) (c. 800 b.c.e.; English translation, 1616), Apollo, sometimes a god of healing, shoots arrows at the Greek camp to avenge Agamemnon’s insulting treatment of his priest. A plague ensues, striking the mules and dogs first, then humans. Apollo’s epithet here, Smintheus (“Mouser”), has been taken too readily as evidence that Homer recognized rodents as carriers. Description of 147 war wounds reveals a knowledge of anatomy that is at times precise and practical (for killing purposes) and at times fanciful. The sources of this knowledge were probably the battlefield and analogous inferences drawn from animal slaughter in cooking or sacrifice. Systematic dissection was not practiced until the third century b.c.e., primarily in Alexandria. Wounds are sometimes treated with a bitter root probably related to onion, an astringent. Some are dressed, others left open. Sucking is mentioned but whether therapeutically (to remove pus or poison) is unclear. In the Odyssey (c. 800 b.c.e.; English translation, 1616)Odyssey (Homer)>, Odysseus’s flow of blood is stanched by a magical incantation, an ancient Indo-European practice.

Hesiod’s slightly later Erga kai Emerai Erga kai Emerai (Hesiod)> (c. 700 b.c.e.; Works and Days, 1618) suggests that the countless plagues that escaped from Pandora’s jar attack humans “spontaneously.” Some have seen this passage as a movement to a more naturalistic explanation of disease, but the jar still did come from Zeus, to avenge Prometheus’s theft of fire.

By the fifth century b.c.e., the shift had occurred, catalyzed in part by the natural philosophers of the Ionian revolution who sought rational explanations for phenomena. To trace the change in detail is impossible because no pre-Hippocratic medical texts survive. One pivotal figure was Alcmaeon of Croton in southern Italy, a major medical center. Born about 510 b.c.e., Alcmaeon believed that disease arose in the blood, marrow, or brain from a lack of equilibrium (isonomia) of certain bodily qualities (wet, dry, cold, hot, bitter, sweet).

Combined with Empedocles’ theory of the four elements (fire, air, earth, water), Alcmaeon’s ideas proved instrumental in the development of Hippocratic medicine. The Corpus Hippocraticum (fifth to third century b.c.e.; “Hippocratic collection”) is a heterogeneous assemblage of more than sixty treatises, none of which predates the fifth century b.c.e. Which essays, if any, were actually composed by Hippocrates of Cos, the father of medicine, has been vainly debated since antiquity. Internal inconsistencies imply that it is not the work of one person or dogmatic group. The first essay in the Hippocratic corpus, Peri archaies ietrikes (fifth or fourth century b.c.e.; Ancient Medicine), stresses that medicine must depend on observation and not philosophical speculations. Peri ieres noysoy (fifth or fourth century b.c.e.; On the Sacred Disease, 1849) argues that epilepsy is not a divine affliction but may be naturally explained; phlegm blocking the veins that lead to the brain causes paralysis and seizure. Peri physios anthropou (fifth or fourth century b.c.e.; On the Nature of Man, 1968) contains the fundamental humoral theory that would prevail in Western medicine for more than two thousand years. In the human body, four fluid substances (blood, phlegm, yellow bile, and black bile) occur, an imbalance of which causes illness. In general, therapy is conservative and depends on dietetics, which stresses proper food, lifestyle, and environment. Commonly prescribed diets for the sick include barley soup as well as honey and water. Surgical intervention included trepanation and nephrotomy for kidney stones and bleeding.

Physicians initially were on the level of craftspeople and traveled from place to place to earn a living and gain experience. In contrast to modern practice, patients were often diagnosed and treated in a public context. A system of apprencticeship existed, and some of the duties of an apprenctice to his master are specified in the Hippocratic Oath. How generally applicable the oath was is debatable.

Remarkable advances in anatomy occurred in the third century b.c.e. in Alexandria under the authoritarian Ptolemies who allowed physicians such as Herophilus to engage in vivisection on condemned criminals. The voluminous works of Galen (129-c. 199 c.e.) codify and refine earlier medical concepts. Stoic mixture theory is applied to the humoral system, and in this influential form, Hippocratic concepts are transmitted down to the nineteenth century.

Together with this rational medicine there persisted a temple medicine connected with the cult of Asclepius, the son of Apollo. It involved incubation, sleeping at a temple to receive a cure or dream instruction. Evidence survives in actual temple accounts and in the literary narratives of Aristides.

Roman medicine

Roman medicine was a complex amalgam of Greek, Hellenistic, Etruscan, and native traditions. Unlike the Greek, the native tradition was nontheoretical and little concerned with diagnosis and prognosis. Instead, it was pragmatic and rooted in an agrarian lifestyle that espoused the view that the paterfamilias (head of the household) should possess sufficient medical knowledge to ensure the well-being of his family, slaves, and livestock.

In his treatise De agricultura (c. 160 b.c.e.; On Agriculture, 1913), Cato the Censor (234-149 b.c.e.) offers such knowledge to owners of middle-sized estates. Though well acquainted with things Greek, he poses as a skeptical xenophobe in his phihellenic environment and orders his son Marcus to have no dealings with physicians. His panacea was cabbage, administered internally or externally, for afflictions as diverse as sinusitis and cancer. Any slave whose condition did not respond to cabbage, he believed, should be disposed of promptly as an economic liability. Wool and honey figure prominently among his remedies. Washed ram’s wool soaked in oil is recommended for uterine inflammation. In the case of fracture, a magical incantation combining archaic Latin and gibberish is offered.

In general, the native healing tradition fell under the influence of magic and religion. Divine displeasure was the fundamental cause of disease. Major deities like Mars might be invoked to stave off pestilence, but there was also a multitude of minor deities linked to specific morbidities and physiological changes. Bone growth was the province of the goddess Ossipaga, and Carna protected organs made of flesh (caro). Fever, to the Romans, was not a symptom but an illness in its own right and was personified by a goddess Febris who could be invoked in temples. Among some of the common diseases suffered were tuberculosis, eye infections, osteoarthritis, and gout. Numerous epidemics have been debatably identified as bubonic plague, typhus, and smallpox.

Despite mistrust of foreign physicians, Greek medicine continuously made inroads into Roman culture. When a devastating plague stuck in 293 b.c.e., the cult of Aesculapius (Asclepius), the healing god and son of Apollo, was introduced. After the epidemic ceased, a temple was erected in his honor. In 219 b.c.e., the Greek physician Archagatus established a publicly funded practice in Rome. At first a popular wound healer, in time, because of his severity with the knife and cautery, he became known as the “butcher.” Far more illustrious was Asclepiades (first century b.c.e.), who subordinated Hippocratic humoral theory to a corpuscular theory. Disease, in his view, resulted from the clogging of interatomic spaces in the body, which inhibited the free movement of bodily substances. The major Hellenistic medical sects persisted, with the Dogmatists emphasizing philosophical speculation, the Empiricists, experience with individual patients, and the Methodists, nonhumoral dietetics. In this intellectual ferment, other sects developed, and dividing lines were always shifting.

In the early Republic and into the imperial period, many physicians were slaves or freedman of low social status. In 46 b.c.e., however, Julius Caesar granted citizenship to Greek physicians who had established practices in Rome. Like craftspeople, physicians could form their own collegia or guilds. Women were allowed to enter the profession. Although ordinary patients might be treated in the doctor’s own house or a streetside shop, the wealthy were usually seen in their own houses. Particularly skillful practitioners rose quickly into the upper echelons of society. Antonius Musa with his hydrotherapy counted the emperor Augustus among his patients. Galen progressed to become court physician to Marcus Aurelius. Medical training began under Asclepiades in the form of apprenticeships. Vespasian was the first emperor to establish a public salary for medical teachers. Civic posts with tax immunity were established in cities and towns.

In addition to Pliny the Elder (23-79 c.e.), a fundamental early imperial source is the encyclopedist, Aulus Cornelius Celsus, an aristocrat grounded in Greek medicine who divided medicine up into dietetics, pharmacology, and surgery. His regimen included a balanced diet without too many honeyed sweets, exercise, baths, and massage. His description of inflammation remained standard into the twentieth century (redness, swelling, heat, and pain). Surgeries included cataracts, bladder calculi, hip reduction, and cosmetic repairs. The surgical instruments found at Pompeii reveal the technological advances since the Hippocratics.

The Romans refined military medicine by valetudinaria (hospitals of a sort), though for the common soldier, there was little organized medical care. In hygiene, public sanitation, and waste disposal, the Romans showed their characteristic genius in the aqueducts and the draining of marshes. Under the Christians, in the sixth century c.e., doctor-saints were invoked in churches built over the temple of Asclepius.

Chinese medicine

Of the legendary cultural heroes and emperors of the third millennium b.c.e., tradition linked three to the healing arts. Fuxi established the eight diagrams of the Yijing (eighth to third century b.c.e.; English translation, 1876; also known as Book of Changes, 1986) and thus laid the foundations of medical philosophy. Shennong supposedly first taught people to cultivate the five grains and amassed knowledge of curative plant properties. Huangdi, the Yellow Emperor, acquired his remarkable therapeutic skills directly from the gods. Later generations would erroneously ascribe to these last two figures two of the fundamental works of Chinese medicine: Shennong bencao jin jizhu (c. 500 c.e.; The Divine Farmer’s Materia Medica, 1998, also known as Classic of Shennong or Divine Husbandman’s Materia Medica), an annotation or commentary on an earlier, lost work, Shennong bencao jing (late first or early second century c.e) and Neijing (also known as Huangdi beijing, c. 300 b.c.e.; Huang Ti nei ching su wˆn: The Yellow Emperor’s Classic of Internal Medicine, 1949).

Archaeological evidence for medical activities occurs first in the Shang Dynasty (1600-1066 b.c.e.). To the Shang elite, any misfortune, including illness, originated in the displeasure of ancestors who advised Di, the supreme ancestor. To communicate with the spiritual world, cattle bones and tortoise shells were perforated, inscribed with questions, and subjected to heat, which caused cracking. The king or his diviner “read” the cracks to resolve a question (for example, “Tooth illness. Is there a curse? Perhaps from father?”). Snow, wind, and possibly sorcery were also recognized as causes of disease. Wine jars depicted on the bones and found in the tombs are often assumed to have contained therapeutic concoctions but may simply have been sacrificial; tomb evidence does exist for medicinal herbs.

In the Zhou Dynasty (1066-256 b.c.e.), demons replaced ancestors as the primary agents of disease. The secretive therapies of this period are nearly impossible to reconstruct. Talismans and raucous parades in which weapons were thrust into the air were thought to aid in their expulsion. The notion of physician as demoniac exorcist persisted even after a naturalistic paradigm appeared. In the Mawangdui graves of 168 b.c.e., straightforward prescriptions appear as well as a magical incantation to stanch blood flow.

From the end of the Zhou Dynasty through the Han Dynasty (206 b.c.e.-220 c.e.), a new biological paradigm evolved under the influence of various natural philosophical conceptions as well as Confucianism and Daoism. One impetus for its holistic nature may have been the political unification of the empire itself. Inconsistent ideas, applied medically, are syncretized in the Classic of Internal Medicine, not the work of Huangdi, but originally a heterogeneous assemblage of eighty-one essays, the earliest of which may date to the second century b.c.e.

These foundational conceptions are complex and can be set forth here only in a drastically simplified way. The doctrine of systematic correspondences claims that everything in the universe, concrete and abstract, is interconnected. All phenomena exist in dualistic and complementary relationships (yin-yang). Everything can be reduced, symbolically speaking, to five elements or phases (fire, air, earth, water, and metal). To maintain health, the body must maintain a balance of yin and yang. Imbalance alters the interaction of the body’s five elements and impedes the movement of vital energy (qi ). Outside causes of disease include weather, seasons, temperature, and wind. The seven emotions and dietary irregularity may also be causative.

Given this holistic paradigm, not surprisingly the Chinese made little progress in surgery. There exist fanciful accounts of removal of a portion of necrotic spleen and development of anesthesia. Hard evidence exists for opening of abscesses, castration, and removal of cataracts. Other therapeutic practices included moxibustion (localized burning) and acupuncture, which, despite claims of antiquity, is first mentioned in a text of about 100 b.c.e. Needles were inserted to restore the movement of qi through the body’s channels or meridians. In dietetics, balance could be achieved by the five types of grain, fruits, vegetables, domesticated animals, and flavors.

In the first millennium c.e., the major achievement was the development of an elaborate drug therapy as exemplified in the Shennong bencao jin jizhu (c. 500 c.e.; The Divine Farmer’s Materia Medica, 1998, also known as Classic of Shennong or Divine Husbandman’s Materia Medica), an annotation or commentary on an earlier, lost work, Shennong bencao jing (late first or early second century c.e). Its materia medica was based on plants, animals, and minerals and included substances still used in traditional herbal medicine.

South Asian medicine

As early as the third millennium b.c.e., a concern for public hygiene manifests itself in the cities of the Indus Valley civilization. At Mohenjo-Daro, the town planners provided fresh water tanks and connected bathrooms in individual houses to drains that ran beneath the city’s streets. Removable brick covers allowed the main drains to be cleared periodically. In its sophistication, the system was unequalled until early Roman imperial times. The Great Bath west of the main street has sometimes been described as hydropathic, that is, designed for the treatment of diseases by means of water. In the absence of deciphered texts, uncertainty prevails, and it may instead be a prototype of the Pushkar, the ritual tank of a Hindu temple. In general, this emphasis on cleanliness probably arose more out of a concern with ritual rather than with hygiene.

For obscure reasons (perhaps partly a climate change), the Indus Valley civilization declined. By 1500 b.c.e., Aryans had emigrated eastward out of the passes of Afghanistan and hastened decline and subjugation with their powerful two-wheeled chariots. Their sacred oral literature, the Vedas, were collected and arranged shortly after 1000 b.c.e. Of these, the Atharvaveda (c. 1500-1100 b.c.e.; The Hymns of the Atharva-veda, 1895-1896) is a major source for their medical practices. The general perspective of these hymns, some virtually medicinal charms, is magico-religious, though trauma (for example, fracture) could be explained naturally.

Dropsy to the modern physician is a morbid accumulation of serous fluid in tissue that may be caused by kidney or heart problems. In the hymns, “water-belly” comes from the god Varuṇa as a punishment for perjurers who swear falsely by the divine waters. In jaundice, a demon is conjured to move to the yellow Sun, and water is sprinkled over the patient and over yellow parrots to transfer the visible symptom of yellowness into the birds. Certain other actions accompanied the incantations. In one case, primitive catheterization with a reed corrects blocked urine flow.

Despite apparent crudeness, already in this Vedic period there are advances that presage classical Hindu medicine. Intermittent fevers suggestive of malaria are carefully observed, plants are used in ways not simply magical, anatomy is being investigated, and a pneumatic notion of physiology is evolving.

By about the fifth century b.c.e., a confluence of Vedic practices, other forms of folk medicine, and above all Buddhism and Yoga lead to the development of Ayurveda, the science of longevity. Two classic texts are the compendia of the semi-legendary physicians Caraka and Susruta. The first stresses general medicine, the second, surgery. The compendia of Susruta suggest some remarkable surgical feats: removal of urinary calculi, cataract operations, treatment of inflammation, suturing with ant mandibles, and plastic surgery to repair ears and noses. Systemization occurs from this point to the tenth century c.e., and the Ayurvedic tradition remains vital to this day.

Ayurveda is a holistic approach that is both preventive and therapeutic. It encouraged physicians, private and state, to follow an ethic ensuring the patient’s privacy, much as the Hippocratic Oath does. Treatment emphasizes equally diet, lifestyle, medicines, and certain therapeutic purification procedures. Palpation and auscultation were two diagnostic tools. To simplify complex theory, the body is a microcosm of the universe and, like it, composed of five elements. These elements occur in the body as the three doshas, akin to the humors of Hippocratic medicine: wind (air and space) associated with the colon, bile (fire and water), with the stomach, and phlegm (earth and water), with the lungs. Improperly digested food and drink block the body’s channels with a sludgelike substance, ama. An imbalance of the doshas results, which causes disease. An elaborate pharmacopoeia was based primarily on plants but also on animals and metals. Magical elements persisted right through the seventeenth century. A testimony to Ayurveda is its vitality in modern India as well as Western medicine’s current interest in it as an alternative therapy.

Mesoamerican medicine

When the Spanish entered Central America in the sixteenth century c.e., they encountered a remarkable civilization that had been in decline for at least six hundred years. The Maya (1000 b.c.e.-900 c.e.) at their peak had numbered as many as perhaps 10 million people in an area with twelve major centers controlled by shamanistic kings. The complex society was highly stratified, and the division of labor was elaborate.

Near the end of the Classic period (300-900 c.e.), the civilization mysteriously collapsed. In less than 150 years, the population may have fallen to 1.8 million, and the great palaces and temples were abandoned. The exact reasons are elusive, though scholars have suggested such factors as internal strife, outside military intervention, and climate changes. One theory, directly related to health and medicine, surmises that the population carried within it a kind of biological time bomb. Skeletal and other evidence indicates that the pre-Columbian Maya were subject to such endemic diseases as yellow fever, malaria, nutritional diseases like scurvy, and Chagas’ disease, which can cause cardiomyopathy in children. When combined with some other stress such as agricultural crisis, what was endemic perhaps turned explosively epidemic.

The medical practices of the pre-Conquest Maya, to a certain extent, may be reconstructed from colonial sources, given the conservatism of the Yucatán natives. An example is the narrative of the Franciscan Diego de Landa. Also, though written in European script, some extant Maya texts of the seventeenth and eighteenth centuries may contain material based on hieroglyphic texts destroyed by the Spanish. Ethnobotanical medical texts present a wealth of information on plant remedies for respiratory diseases; gynecological problems; bites and stings; bowel, ear, and eye complaints; inflammation; and many other problems.

The mythological text Popul Vuh (n.d.; Popul Vuh: The Sacred Book of the Ancient Quich‚ Maya, 1950) presents supernatural notions of disease that may be pre-Conquest. Among the lords of Xibalba, the terrifying underworld, One Death and Seven Death assign the others rulers specific commissions. Scab Stripper and Blood Gatherer draw blood from people. Demon of Pus and Demon of Jaundice make people swell up, leak pus from their legs, and turn yellow from jaundice. Bone Scepter and Skull Scepter bring on edema and emaciation. Perhaps a survival of this notion is the practice of contemporary Maya shamans who magically (and maliciously) place dry or moist bones within someone’s body. The dry bones induce emaciation, the moist, fluid accumulation, dropsy. A worm, according to the text, causes toothache, and bonesetters also treat diseases of the eye, a combination still attested today, as in the Quich‚ dialect eyes are classified as bones.

The Rituals of the Bacabs (n.d.; English translation, 1965), perhaps likewise traceable to hieroglyphic texts, sets out magical incantations against various diseases, which are treated as personalized entities. In chanting, the shaman insultingly relates the personal history and lineage of the disease as if thus to assert his power over it. Threatening it with his fan and staff, he often seeks to consign it to Metnal, an odiferous region of the underworld. The modern Maya concept that disease arises from evil winds is also hinted at in the text. Elsewhere both natural and supernatural concepts occur, but whether they were sharply demarcated is uncertain. Sexual excess is mentioned as bringing on disease and required confession and penance to restore harmony with the gods. Sorcery and witchcraft play a role as well.

The Spanish distinguished three classes of healers: physicians, herbalists, and sorcerers, but there seems to have been some crossover in their functions. If the patient were lower class, a physician might conduct his own diagnostic divination. The profession, it seems, was hereditary.

Dental filing and inlay reached high levels but were essentially ornamental and not therapeutic. In general, surgery appears to have been primitive, but phlebotomy was practiced with special lancets and possibly circumcision.

North American medicine

One of the earliest sources for Native American medicine is an illustrated Latin narrative by Jacques LeMoyne, an artist who recorded the French attempt to establish a Huguenot base in Florida in 1564-1565. A captioned plate reveals how the Temacua tribe treated their sick. One patient lying on a bench has his forehead cut with a shell and then has his blood sucked out and spit into a jar. Another lies face down on a bench as seeds are thrown over burning coals below him. The smoke induces vomiting and thus supposedly expels the cause of the illness. A third inhales a plant called “tobaco” to draw out morbid fluids. Finally, the text alludes to natural remedies for venereal disease.

Subject to ethnological evaluation, there is much here that parallels techniques common to many North American tribes and possibly predates contact with Europeans. Sucking a wound is well attested geographically and temporally. The Kansas Potawatamis in the 1930’s and the Wisconsin Ojibwas in the 1940’s were still employing this technique. Its purpose is variable: simple therapy to remove pus or venom; providing blood from a brave warrior to nursing women so that their own male infants might be empowered; and allowing the shaman, the intermediary between the human and spirit world, to extract the etiological agent, sometimes conceived as an object or animal. Bloodletting itself was probably learned from Europeans. Much evidence also exists for fumigation, especially in the treatment of respiratory or rheumatic diseases. Well documented also is the use of tobacco to cure disease, assist in exorcism, and, among the Seminoles, even ward off natural elements such as lightning.

Another common therapy was moxibustion (localized burning) in which reeds were placed on the skin and kindled, especially in cases of gout or sciatica. Trepanation occurs, but there is no evidence for elaborate surgery. Scarification was practiced over a pain site as a form of counterirritant and to create an exit point for the pain. Amputation was sometimes employed but ritually and punitively. Treatment of fractures and dislocations was highly skilled with the use of form-fitting splints molded with clay or rawhide. The treatment of wounds with boiling water has sometimes been interpreted as primitive asepsis. Perhaps the greatest achievement was the use of plants in the treatment of various illnessses. Sassafras and prickly pear were used in diuretic remedies, jimsonweed, a bronchodilator, for asthma. Unlike Europeans, the Native Americans knew how to treat scurvy.

Not merely an assemblage of therapies, medicine implied mystery and drew on religion and often rituals and incantations. Disease, viewed as a disruption in balance between the sick person and the surrounding natural environment, might arise from witchcraft, sorcery, spirit intrusion, soul loss, taboo violation, and intrusion by a foreign object or animal. To outsiders, a shamanistic medicine-man (sometimes woman) appeared as the stereotypical healer. In fact, in some tribes, naturally and supernaturally caused diseases were distinguished. In one case, the medicine-man, as a religious leader and communicator with the spirit world, might be employed, in another, a healer possessed of straightforward remedies. The Lakota, for example, made use of both the wakan witshaska “mystery man” and the pejihuta witshaska “grass-roots man.” Medicine societies also occurred, dedicated to animal spirits whom they could invoke to cure disease, repel withcraft, and ward off natural disasters.

European colonization with its dense-population diseases such as smallpox, measles, typhus, and scarlet fever exacted a devastating toll on the Native American populace. By one estimate, a population of 18 million was reduced to only 500,000 by 1900. The notion that precontact Native Americans were paragons of health, however, has been slowly disproved by paleopathological evidence. Amoebic dysentery, influenza, and pneumonia, complicated by overpopulation and competition for resources, were major problems before the arrival of Europeans. Skeletal studies of Archaic and Woodland populations in the Northern Plains do, however, reveal a generally healthy population apart from arthritis and dental disease.

Sub-Saharan African medicine

Historical study of African therapeutics is a recent phenomenon. In the absence of native written sources, reconstruction depends largely on oral tradition and, to a limited extent, archaeology. Fundamental is the notion that many modern therapies, especially herbalism, are traceable back over three millennia to the practices of ancient hunter-gatherers. Historical linguistics by comparative analysis of vocabulary in Bantu-speaking areas provides some insight into earlier phases of the languages and so also into ancient culturally shared ideas of medicine and disease. Examples of reconstructed roots in proto-Bantu are gidu, referring to taboos, the violation of which may lead to disease, and dok, also an etiological concept related to angry words, blows, or poisons. Traditionally, the three major diseases have been sleeping sickness, malaria, and smallpox, in cases of which the Yoruba made sacrifices to the god Ipoona.

Complicating the picture are the various foreign influences that over the centuries have acted on local traditions, whether directly or indirectly: Egyptian, Greek, Christian, and Islamic. Medical pluralism remains characteristic of African healing and, in a modern context, has created problems for governments struggling to impose Western concepts of licensing.

Also, scholars have begun to recognize economic, environmental, and social structural factors generating diverse approaches even within certain tribes or among speakers of the same language. As elsewhere, disease conditions and responses to them would have altered with the historical context. The health problems of hunter-gatherers would have been less complex than sedentary agriculturists of the first millennium b.c.e. In addition, even more infectious diseases and viruses must have developed in the urban centers of the first and second millennia c.e. as trade grew with the Mediterranean and Europe. A more specific example are the two distinctive West and East-Central African lifestyles and medicines dictated by the presence or absence of the tsetse fly, the vector of sleeping sickness: agriculturalism versus pastoralism.

Despite these cautions about overgeneralizing, studies have revealed certain common ideas about health and disease. These include notions of purity; balance with one’s environment and social context; ideal bodily structure, which includes color coding ideas (white = health, black = chaos, red = perilous transition); coolness versus heat, which is associated with disease; flow and blockage; and contagion. In the past, pus from smallpox victims was introduced into scratches of the uninfected, but the modern conception of immunization was not operative here.

The causes of disease may be personal (deities, spirits, ancestors, sorcerers, witches), in which case, the services of a diviner are required to determine the agent’s identity. In other instances, especially where the cause is clear, as in accidental trauma, the problem may be naturalistically explained. Among the physical agents of disease are heat, cold, and dampness. In some cases, both forms of explanation may be invoked.

One form of traditional ritualized therapy found throughout Central and South Africa is ngoma, named after the long drum used in its practice. Reputedly at least two millennia old, it is often a final resort in cases of debilitating chronic disease. The patient is initiated into a sort of corporation of fellow sufferers and is then treated psychotherapeutically by a range of activities that include drumming, dancing, dream visions, and the establishment of a new identity. A cured patient may progress from initiate to healer within the corporation. Perhaps the most striking aspect of traditional therapy is the extraordinary variety of medicinal plants. Their use runs the gamut from markers to determine if an illness is spiritually induced to biomedically efficacious medicaments for diarrhea and diabetes.

One area where archaeological excavation has revealed historical evidence about disease is lower Nubia, especially during the times of intensive agriculture, the Meroitic, Ballana, and Christian periods (350 b.c.e.-1300 c.e.). Skeletons show signifcant decline in stature from earlier periods, nutritional deficiences, developmental stress, dental caries, and premature osteoporosis. Too much reliance on a single crop, millet, probably caused much of the deficiencies. Surprisingly low rates of infectious disease are perhaps explained by the ingestion of tetracycline, an antibiotic produced by a bacterium that might have flourished in the mud bins used to store grain.

Bibliography

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Longrigg, James. Greek Rational Medicine. London: Routledge, 1993.

Majno, Guido. The Healing Hand. Cambridge, Mass.: Harvard University Press, 1975.

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Prioreschi, Plinio. A History of Medicine. 3 vols. Omaha, Neb.: Horatius Press, 1996-1998.

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