by Sean Martin
As the body was understood to be the microcosm of the great world, so environmental factors also had to be considered. In the tract On Airs, Waters and Places, Hippocrates stresses the importance of seasonal influences such as the strength, direction and temperature of winds. What kinds of waters flow? Are they marshy and soft, hard and rocky, or salty and unsuitable for human consumption? And what about the position of the locality itself: is the land high or low, secluded or exposed? What are people’s habits like there? Do they eat and drink to excess? Are they idle or industrious?
Health was understood to be a balance of the four humours; this was the natural state of life. Illness only resulted when the humours were out of balance, usually due to a deficiency in one humour, an excess in another, or some unfavourable influence arising from the airs, waters and places. Despite the stress Hippocrates laid on observation and experience, the humoural theory dominated western medical thinking until the Renaissance.
Disease in Ancient China
Records from China about disease are amongst the oldest in the world: the last 3,000 or so years are covered in various forms – historical chronicles, oracle-bones and grave goods. However, like their ancient western counterparts, the Chinese records suffer from the same problems of interpretation, in that the terminology of traditional Chinese medicine is ‘based on a system hardly translatable into modern Western terms.’74 Not only that, but early Chinese script itself poses another problem. As Angela Ki Che Leung notes in the Cambridge World History of Human Disease, Chinese writing didn’t reach its modern form until around the third century BC, so these early texts on oracle bones and the like are written in pictograms, and an imprecision in the terminology is inevitably present: ‘For example, chi, which subsequently invariably meant “epidemic disease in general,” shows a man alone or lying on a bed with the arrow of the disease shooting into him.’75 (Disease as an arrow also recurs in Anglo-Saxon ideas about disease – see the next chapter – while the ancient Egyptians also conceptualised disease as being ‘something from outside’, as we saw earlier in this chapter.)
Furthermore, not only have the concepts of disease changed, but so have the diseases themselves, ‘so much so that it is impossible to determine whether an ancient classical term meant the same thing when used in premodern texts, or to find the exact modern counterpart of a disease discussed in old texts.’76 The term ‘fever’, for instance, was as vague as it was in western records, where it could stand for any number of conditions.
William McNeill listed 99 epidemics in China between 243 BC and the time of the Black Death in the fourteenth century, based on two earlier compilations, one from the Sung Dynasty (960–1279) and the other put together in the eighteenth century.77 These are, as we might expect of old sources, rather vague. In 243 BC, for instance, there was ‘epidemic throughout the empire’, while in 48 BC there was ‘Epidemic, flood and famine east of the pass’, which O’Neill tentatively identifies as Honan, Shansi and Shantung provinces. Even this scant information is better than that for the late second and early third centuries AD, where a number of epidemics are recorded, but their location and mortality rates seem to have escaped the original compilers completely.
The oldest Chinese records are oracle bones, dating from the Shang Dynasty (c. 1600–1046 BC). Written on scapulae and pieces of tortoise shell, they were used for divination. From the oracle bones, we can deduce that the ancient Chinese suffered from diseases of the eyes and ears; had dental problems and speech defects; abdominal diseases; dysuria; beriberi (or something like it); obstetric and paediatric problems; and, in addition, various lethal seasonal epidemics. Scholars are also fairly certain schistosomiasis was known.
Seals from excavated tombs provide another useful source of information about the diseases of the late Chou Dynasty (c. 1046–256 BC) and Warring States period (c. 475–221 BC). These seals reveal how disease had come to be seen as a field with many different aspects, rather than simply a general notion of ill health. The seal of the physician Wang indicates that he specialised in speech impediments; physician Chang’s seal reveals that his speciality was the cure of external lesions; physician Kao treated ulcers; physician Kuo dealt with beriberi and other similar conditions; physician Thu specialised in removing nasal polyps; and physician Chao seems to have been a kind of early psychologist.
Medical texts become an increasingly valuable source of data in the late Chou Dynasty, the so-called Spring and Autumn period (c. 771–c. 476 BC). The Yueh Ling (Monthly Ordinances) discusses seasonal diseases. An unseasonally warm or cold spring, autumnal summer or mild winter would spell epidemics. Epidemics in the spring could have been scabies; in summer, bronchitis and pneumonia; in autumn, ‘fever’ might have meant malaria, and in winter, typhus and tetanus could have developed. Texts written or compiled after the Yueh Ling began to differentiate clearly between tertian and quartan malaria. Tuberculosis was also recorded for the first time, as was leprosy.
The Chou Li (Record of Institutions of the Chou Dynasty, probably compiled in the early Han Dynasty, second century BC) also notes that each of the four seasons has its particular epidemics. Spring has feverish aches and headaches; summer, ‘itching scabies-like epidemics’; autumn brings malaria and other fevers; while in winter, respiratory diseases dominate.
A concept of ‘airs, waters and places’ becomes evident in many of the texts. Another book from the late Warring States period, the Lu Shih Chun Chiu, asserts that, in places where there is too much ‘light’ or clear water, diseases of the scalp (alopecia, ringworm, psoriasis) and goitre will occur. In places where there is an excess of ‘heavy’ or turbid water, people suffering from swellings and leg ulcers are commonly found, and there will be some who are completely lame (suggestive of beriberi). Acrid water will produce skin lesions, such as abscesses and boils; and where ‘bitter’ water flows, there will be many people with bent bones (rickets). Only in places where there is ‘sweet’ water, will people be free of problems. (Indeed, they are said to be ‘healthy and handsome’.)
Chinese thinking about disease was not entirely free of superstition. The chronicle known as the Tso Chuan, compiled during the Warring States period and covering the years 722 to 468 BC, records some bizarre magical remedies. In the year 638 BC, a deformed witch, probably suffering from rickets, was to be burnt as a remedy for drought until a sceptical official intervened and saved her. The Shan Hai Ching records less extreme forms of magic, detailing the medicinal value of certain plants, animals, herbs and minerals.
The Nei Ching (also known as The Yellow Emperor’s Inner Canon), which probably dates from the late Warring States period, was arguably the most important ancient Chinese medical text. It attempted to take the supernatural out of disease, much as Hippocrates did in Greece. No longer were diseases sent by gods, demons or troublemaking ancestors, but were seen to be imbalances of natural processes. Six ‘humours’ were identified: wind, humid heat, dry heat, damp, cold and aridity. The Nei Ching developed an elaborate classificatory system that utilised the concept of Yin and Yang (the two fundamental forces in the universe), the five elements of fire, water, earth, wood and metal, Pa Kang (or the eight diagnostic principles), and the concept of chi, or energy.
Galen & Disease in Rome
The history of disease in ancient Rome is patchy. Livy (59 BC – AD 17) records various epidemics in his History of Rome. Between 490 and 292 BC, and especially in the years 212–174 BC, ‘a mortality crisis is mentioned on average every 4.3 years’.78 Rome’s health appears to improve after that: from the mid second century BC to the late second century AD, only five epidemics are mentioned (142 BC, 23–22 BC, AD 65, AD 79/80 and 189). However, this could be a result of authorial bias, in that writers often ‘paid less attention to inauspicious events’.79 Epidemics were auspicious, endemic diseases were not, and therefore less liable to be recorded. Late Antiquity is a bit better – that is, worse – with ten epidemics listed between AD 285 and 750. As Walter Scheidel notes, ‘This paucity i
s undoubtedly a function of the nature of the evidence, rather than a reflection of dramatic improvement.’80
The most important medical figure in ancient Rome was Galen (129–c.216 AD), a polymath – doctor, writer, philosopher, surgeon – who hailed from Pergamon, site of one of the most well-known Asclepions in the ancient world. He is the most important medical figure of the Roman period, and, with Hippocrates, the most important medical authority before the Renaissance. He also wrote voluminously: we have more books by Galen than any other writer from antiquity. He practised in Rome, a city where competition among doctors was far more intense than Athens, and just as deregulated. Rome was a city that, according to the sophist Polemo of Laodicea (c.90–144), was the ‘epitome of the world’. If so, then it was certainly an unhealthy world: Galen wrote that every day, ten thousand people could be found suffering from jaundice, and an equal number from dropsy.81
Despite Polemo’s claim, Rome might be atypical of the ancient world. Its huge population of around a million82 meant that it probably suffered from more diseases than any other city of the time; and cities are fertile breeding grounds for disease, much more so than villages. Some of the city’s most persistent health problems were due to a combination of overcrowding, environmental issues and architectural innovation. As Walter Scheidel noted, ‘Rome’s nodal position encouraged the introduction of new strains of the disease while its exceptionally large population would have made it easier for such arrivals to become endemic and contribute permanently to the metropolitan disease pool.’83 Susan Mattern sees ancient Rome as rife with disease vectors: ‘Rome was, then, an ideal environment for any disease spread by vermin, flies, mosquitoes, feces, dogs, or (because of its densely packed population) through the air, as well as for respiratory illnesses caused by indoor air pollution. One of its most dangerous, pervasive, and characteristic illnesses was malaria.’84
The city had always suffered from malaria, due to the proximity of the Pontine Marshes. No one knows the date at which it became endemic in the city, but it was certainly there by the first century BC, when the poet Horace (65 BC – 8 BC) and Livy both made references to it. The disease was worst in late summer, turning all places where stagnant water formed – the impluvia or cisterns that caught rainwater, ponds, overflow from fountains and baths – into potential death traps, as this is where the female anopheles mosquito would lay her eggs. Susan Mattern notes that ‘cases of malaria may have spiked in flood years’.85 P. falciparum is the most lethal form of malaria. This may be the disease that is referred to in ancient writings as the ‘semitertian fever’. Writers noted that the fever was periodic, returning every two days. It is this aspect of the fever – the other main one being ‘quartan fever’, returning every three days – that gives us fairly concrete assurances that the disease in question was indeed malaria. Galen notes that ‘we see it every day, especially at Rome.’86 But one mistake made by Galen, and the Hippocratic writers before him, was thinking fever was the disease, not the symptom. (The Hippocratic Corpus abounds with fevers.) Galen believed that the sickness was created by ‘bad air’ – which led to the eventual coining of the name ‘malaria’ (from the Latin, mal’ aria), in the eighteenth century. Until then, it lurked under a variety of names: semitertian fever, quartan fever, Roman fever, ague.
Since the time of Hippocrates, ‘bad air’, or miasma, had been commonly thought to either cause or spread disease. While this was incorrect in the case of malaria, it was not too far wide of the mark in others, such as in the case of airborne diseases, like pneumonic plague (see below), which could be transmitted from person to person by coughing – a form of ‘bad air’, as it were. The miasma theory could also be said to be partially correct in that it intuited the importance of environmental factors in the spread of disease. Dirt, for instance, could spread typhoid (again, this is something we’ll come back to later). In the case of ancient Rome, one kind of ‘bad air’ that led to disease was poor ventilation in the home. The second century AD mummified body of a girl found in Grottarossa on the Cassian Way near Rome showed signs of anthracosis, caused by carbon accumulation in the lungs, a disease more commonly associated with coal miners. But in the case of the girl from Grottarossa, her symptoms were probably caused by smoke from lamps, cooking and fires. She was only around eight years old.87
Water supplies in the city also had an unwitting role in the spread of other diseases. The city’s aqueducts may have brought fresh water into Rome, but when they overflowed, potentially major health hazards were created. Water from an overflowing fountain would turn the mud of the street into a rich breeding ground for germs. E. coli was known to have flourished in such conditions, as did gastrointestinal diseases. Like the ancient Egyptians before them, the citizens of ancient Rome were afflicted by worms; dysentery and diarrhoea could be fatal (especially in children). Animals ran freely: dogs, pigs, goats, even cattle, could be seen in Rome’s public thoroughfares on a daily basis. Horace mentions a muddy sow running down the middle of the street in one of his poems, and while the sow herself might have been perfectly happy on her daily round of rooting, animals could act as vectors for rabies, malaria, and also for zoonotic (animal to human) diseases, such as bovine tuberculosis and later, plague. Add muddy feet and unwashed hands to the equation, and you have a direct – and very busy – link between the street and people’s homes.
Suetonius (c. 69 – after 122) records gruesome confirmation of this. One day ‘a stray dog picked up a human hand at the cross-roads, which it brought into the room where [the emperor-to-be] Vespasian was breakfasting and dropped it under the table’.88 Although the anecdote was no doubt included for its symbolic aspect – the hand was a symbol of power – it illustrates the hazards presented by people dying in the streets and going unburied; unclaimed corpses were usually buried in common pits, or thrown into the Tiber. Suetonius notes that Vespasian, when working as an aedile, or public official responsible for the upkeep of public buildings, sewers, and streets, fell foul of the emperor Caligula, who was ‘furious because Vespasian had not kept the streets clean, as was his duty, [and] ordered some soldiers to load him with mud; they obeyed by stuffing into the fold of his senatorial gown as much as it could hold’.89
Rome’s public baths were another hazard. Like the aqueducts and the city’s sewers, they were the envy of other cities, and should have gone a fair way to maintaining good standards of hygiene. But in reality they were extremely unhygienic. The Romans had a tradition of ‘medicinal bathing’ that took place in public baths; both Celsus (c. 25 BC – c. 50 AD) and Pliny the Elder (23 AD – 79 AD) wrote of its benefits. Bathing was used as a treatment for many diseases, including those known to be infectious, such as leprosy, dysentery and respiratory ailments. However, the potential for spreading disease by way of infected bathwater was high, given that people could be exposing open wounds in the water, while Celsus advised patients suffering from bowel problems ‘to bathe their anuses in the hot pools located at these venues but (not unreasonably) warns those with infected wounds not to expose them to the filthy contents of these facilities.’90 Posterior problems notwithstanding, Galen noted that people urinated in the baths. The hot, smoky atmosphere of the bathhouses likewise could cause people to faint when it wasn’t aggravating respiratory problems. The dirty water and humid atmosphere did nothing to keep the cockroaches away. According to Pliny the Elder, they liked the damp warmth (Natural History, 11.34).
The combination of dirt, vermin, dead bodies, free range animals, overcrowding – including a permanent influx of population from rural areas, either seeking a livelihood or escaping war – meant that the Eternal City was an eternal crucible of disease. (Despite this, it was, ironically, still one of the more healthy cities of the ancient world; seventeenth century London was dirtier.) Evidence from skeletal remains, and a certain amount of educated guesswork, suggests that Romans also suffered tuberculosis, leprosy, typhoid, all manner of diarrhoeal and gastrointestinal diseases, worms, jaundice, gout, salmonell
a, anthrax, rabies, epilepsy, hepatitis, elephantiasis and tetanus. Confronted with such a list, it is not surprising to find that most of Galen’s patients did not reach old age.
There were other diseases, too. Pliny the Elder devoted the beginning of Book 26 of the Natural History to what he termed ‘new forms of disease, unknown in ancient times’.91 One of these was a skin condition Pliny termed mentagra, which ‘spreads over the interior of the mouth, and takes possession of the whole face, with the sole exception of the eyes; after which, it passes downwards to the neck, breast, and hands, covering them with foul furfuraceous eruptions.’ It is ‘painless and not life-threatening, but so disgusting that any sort of death is preferable.’92 Mentagra was transmitted by kissing, and seemed to afflict only upper class males. All of this suggests some sort of sexually transmitted disease, but what it was, we do not know.
The most deadly unknown disease, however, was something Galen himself lived to see. The Antonine Plague – sometimes known as the Plague of Galen’s time – broke out during a military campaign in Seleucia in Mesopotamia during the winter of 165–6. By the end of the following year, returning troops had brought it to Rome; it continued to spread throughout the empire and returned regularly until the late 180s or early 190s. Galen’s descriptions of the plague are vague, and don’t allow us to say with any certainty what it was. He describes it as ‘great’, and that it lasted a long time; however, Galen did go into some detail about the symptoms. Sufferers developed an eruptive skin rash, sometimes spreading over the whole body, which could become ‘rough and scabby’ and fall off ‘like some husk’.93 Accompanying this was fever; diarrhoea – including the passing of black and bloody stools; vomiting (in some but not all cases); an upset stomach; fetid breath; and a cough – which sometimes included the regurgitation of blood and scabs. Galen notes ‘that the plague was similar to the Thucydidean plague and quotes a passage which includes Thucydides’ words about the rash being blistery… in another passage Galen again says the plague was very close in form to the one described by Thucydides.’94 A rash like the one Galen describes discounts the Antonine Plague being plague in the bubonic sense, where the rashes tend to appear around the buboes in the armpit and groin. Similarly, the rash produced by typhus doesn’t behave in quite the same way as the one described by Galen.
