400-1300 CE: The Middle Ages

Aristotle’s philosophy and Galenic medicine was taken up by mediaeval Muslim Jewish and later, Christian philosophers who, unlike Aristotle, set man’s limited understanding of the order of the physical world against divine knowledge. Only God as its creator could understand the world completely and our human limitation meant that aspects of the world would forever remain mysterious to us. Thus for the mediaeval, understanding the natural world was linked to God’s grace in allowing us to gain knowledge. While some aspects of the underlying divine order could be revealed through human observation and reason, others emerged by divine revelation through scripture and miracles.

Sporadic epidemics of small pox, measles and other infectious diseases continued to kill large numbers during the middle Ages, and infections increased as the population multiplied and became denser. Academic medicine in the mediaeval period elaborated and expanded on Galen. Much Galenic medicine came to mediaeval Europe from Arabic sources. The writings of Arabic physician scholars like Avicenna and Averroes were filtered through Christian theological beliefs to continue the Galenic tradition in the Christian world. Because at the time there existed a central belief in divine purpose, God’s lessons appeared in such diverse areas as biology and metallurgy as well as medicine. Moral values were attributed to physical characteristics: the whiteness of a swan was an indication of its purity; the gold colour of a lion was associated with its regal nature and with the sun.

Sun Lion

When in the late renaissance Galileo found spots on the sun using his telescope that cardinals knew that the telescope must be faulty, because the sun like the lion was pure gold and without blemishes as a divine lesson for all of us.

The biblical idea that diseases, especially plagues, were the result of god’s wrath or punishment for sinful behaviour and that cure was largely a function of god’s grace, was accepted without question by the mediaeval. A central and widespread notion of health in the mediaeval period derives from the story of Eve and the apple in Genesis, and connects God’s will to human health.

During this period the distinction between academically trained doctors and other healers remained. All continued to practice, and the distinctions between different kinds and levels of practitioners remained. The wide range of practitioners incorporated not only the collected medical knowledge that went back to Egypt and Mesopotamia, but also incorporated local oral traditions of herbal remedies as well as catholic teachings.

Galen and the Humours


Galen’s (c.129-210) theory of medicine was developed from Aristotle and closely linked to the four elements of air earth fire and water. The four humours, blood, black bile, yellow bile, and phlegm corresponded to the elements in that order. Galen located the humours in appropriate organs, associated them with a developmental process, and connected them to the seasons of the year and to astrology.

The stability and power of the Aristotelian world view was mirrored in the astonishing longevity of its medical offshoot, Galenic medicine. Like Aristotle’s physics, Galenic humoral medicine remained the dominant western medical framework for almost 1600 years. The figure below has been included in medical text books in various forms and with different degrees of elaboration up to and including the nineteenth century.


According to Galen, a healthy person is someone whose four humours are in equilibrium. When they are out of kilter, medical interventions are meant to rebalance them. Diseases can be hot or cold, wet or dry, and cures prescribed hot remedies for cold diseases, wet remedies for dry diseases and so on. I was startled when I realized that, however unconsciously, we still make use of these ideas when we provide “hot” chicken soup as a remedy for the common “cold.”

The humours are not merely bodily fluids. They refer to people’s character and identity and are also connected to their social and physical environments. Because temperament and physiology are considered by Galen to be interactive, being angry, for example, might increase the flow of black bile or vice versa: the environment might stimulate the flow of black bile and make someone angry.

Thus illnesses were called “distempers” and regimens were prescribed to “temper” or harmonize the humours. Many rebalancing interventions commonly part of Galen’s prescriptions for regaining health, continue to be prescribed today: for example, changes in climate and adjustments of lifestyle such as diet and exercise. Galenic medications remain a large part of the naturopathic medicine cabinet. Other direct interventions like cupping, purges and bleeds continue to be used. When Gwyneth Paltrow, the movie star, was asked about the four brownish circles on her back, she declared that applying hot cups to create a vacuum and extract poisonous humours, made her feel significantly better. Sir William Osler one of the founders of modern medicine continued to bleed patients into the 1920s.

Finally the humors were connected to the world in a very particular way so that every person’s temperament is different and linked to the state of the universe at their time of birth. Medicine was highly individualized. In order to balance someone’s humours it was necessary to know the date and time of their birth and an astrological chart would identify what a properly balanced set of humours would be for each person. It would also provide an initial analysis of their character. (This must bring to mind the ideas being floated these days about individualized medicine through DNA.) The reason for this is that the exact time of one’s entry into the universe gave them a different set of humoral characteristics. The link to the stars was a link to the Gods who were visible as planets and stars in the heavens.

Melancholy, black bile and Earth are under the sway of Saturn. Water and phlegm are categorized under the moon and Venus. Fire, choleric, yellow bile are listed under the sun and Mars; and air, together with sanguine blood are under Jupiter. This meant that each person’s balance was different depending on their time of birth and hence your horoscope was part of a complete medical diagnosis: it ascertains your innate tendencies.

Since the Seventeenth Century it has been fashionable for scientific researchers to attack Galen for his bad medicine. Indeed a whole book called Bad Medicine points out all the outlandish practices attributed to Galen. One of the major elements of Galen’s practice was the development of dietary regimens for his patients and a nutritionist who reviewed one of them said that if someone stayed on such a diet for six months they would be dead. As far as I can tell this just goes to show that compliance was as much a problem for physicians in Galen’s day as it is today: there are few records of patients dying as a result of Galen’s regimens.

Perhaps at this point it may be useful to point out, as most general practitioners know, most minor conditions will improve in time without any intervention at all; many conditions are time bound and heal themselves, large numbers of patients are the worried well and finally the course of chronic diseases remains uncertain and in many cases does not easily respond to treatment.  So we can accept that Galenic physicians, despite a non-scientific theoretical frame, remained the most revered academic professionals for over 1500 years. Their patients respected and returned to them for ongoing treatment and kept them close during the decline and death of a family member. Galenic medicine stood the test of time and remained the basis of medical textbook well into the 19th Century.

2000 Years Ago: The Roman Empire

As the Roman Empire expanded over Europe the Romans brought with them an attitude to maintaining and improving health through environmental controls, exercise and early versions of public health. Their precise engineering and public health measures drained swamps, brought clean water to cities, and built baths and gymnasia to help maintain the health of their populations. Medical practices for the ill were largely of Greek origin and delivered by the by now familiar range of physicians, priests, bone setters, herbalists and midwives.


Pedanus Dioscorides (around 40 to 90 AD)

He wrote Materia Medica, a five volume encyclopedic account of herbs and other medicines that recorded the knowledge from earlier oral traditions. This pharmacopoeia contained descriptions of almost 5,000 medical uses for about 1,000 medications made from over 600 plants. His classification system was crude by modern standards, but usable by generations of herbalists. It was transmitted widely, and translated into many languages, and appears to have remained a source of information for over 1500 years that was consulted by all literate healers and a major accompaniment to Galenic medicine. It has recently been translated yet again.

Publius Aelius Aristides Theodorus (117-181 AD)


Aelius Aristides is perhaps the most famous patient of antiquity. He was so ill that he could not continue to work as an orator and first placed himself in the care of the Egyptian God Serapis. Later he became a devotee of Asclepius in Pergamum. He spent some years in the temple where he slept on the temple grounds, recorded all his dreams to learn what the gods wanted of him, and taking their instruction, fasted, was bled, took enemas, induced vomiting, and either did not bathe at all or bathed in very cold waters. After some years he was cured and began to write and speak again. He remained an orator and writer and continued to work through ongoing sickness. Galen said of him, “As to them whose souls are naturally strong and whose bodies are weak, I have seen only a few of them. One of them was Aristides… [who] belonged to the most prominent rank of orators. Thus it happened to him, since he was active in teaching and speaking throughout his life that his whole body wasted away.

Aristotle and Virtues


According to Aristotle, the virtues were the capacity to make choices and provided ways of achieving ends through action.  They were dispositions of the individual, and required various goods as resources to allow for their execution.  Fitness and strength, for example, are goods of the body for the virtue of courage: a weak or unhealthy person has less capacity to act courageously. Education in the science of politics is an external good to the end of engagement in government. Some virtues are not available to everyone. An excellent example is munificence, which is the virtue of giving very large gifts to the state, such as museums or universities. This virtue is accessible only to those with large financial resources. Virtues themselves stand in relation to the ultimate end of eudaimonia. This term has been variously translated as well being, living a good life, being a virtuous person, excellence, or happiness.

When we apply this picture to a particular virtue such as courage, the goods associated with it might be presented as follows:

Goods of the body Goods of the soul                  External Goods

Health                               Capacity to assess risk                     Training

Strength                           Intelligence                                          Social position

Agility                                Rationality                                           Right to bear arms

Endurance                       Inclination to act                               Possession of arms

The ways in which people use the goods at their disposal is particularly important for Aristotle. Wellbeing for him was not a state, but an activity.[1] He believed that the good life involved action and engagement with one’s social environment. Thus, one measure of goodness was how people act in relation to their social context. At every level one’s actions have consequence, but those of a full citizen are the most directly consequential while those of the natural slave are the most instrumental and circumscribed. At the same time one can act well or badly at every level. The arena of living well is the interaction between the individual and her social context.

People at all social levels could be courageous or cowardly. Further, possession of goods of the body did not guarantee that someone would be courageous. Thus, a full citizen could be cowardly despite the resources available to him. Similarly, having fewer goods did not necessarily bar someone lower on the social scale from courage. A woman could be courageous in a limited way, despite her lack of strength. But the courage of a woman involved different actions from that of a man. Because of differences in strength, a rather cowardly but strong man would be able to perform actions that would require great courage for a (weak) woman.[2] Courage involved different actions for different individuals, because it depended on the physical, mental and external resources one could bring to an action. This example does not show that courage is a relative concept. It points to the question of understanding the concept in the context to which it is applied and especially considering the resources that are available. Importantly for us it underlines that the hierarchy of society is mirrored in the hierarchy of virtues and how they are applied.

Aristotle did not confuse the possession of goods with the good life. The good lyre player, noted Aristotle, uses a good lyre to play well. However, “[t]his makes men fancy that external goods are the cause of happiness, yet we might as well say that a brilliant performance on the lyre was to be attributed to the instrument and not the skill of the performer.”[3] The quality of the lyre is no guarantee of good playing. Similarly, being a full citizen with all the external goods provides no guarantee of the good life.

Close relationships, contemplation (or understanding), and fortune all play critical parts in Aristotle’s views on the active good life, or eudaimonia. He argues, for example, that friendship contributes to our resiliency in times of misfortune.[4] He also suggests that understanding is a mode for achieving eudaimonia.

For Aristotle there is a fundamental human inclination to try to understand the nature of the world. However even the goods required to exercise this inclination are distributed by level of civil status. The role of the intelligent and insightful observer requires many resources, and is thus more available to those who have had sufficient life experience, the appropriate resources of body and mind, and whose level in society provides them with necessary external goods.[5]

Finally, fortune also plays a part in contributing to the good life. Good luck, for Aristotle, is not a sufficient condition for the good life, as the good life must be one of active engagement. Instead he argues that the absence of bad luck is a necessary condition for living well.[6] It is nonsense to think that someone who suffers from great misfortune can still lead the good life. If one’s life ends in terrible pain and suffering one did not live well. Aristotle concluded, “The fine man on the rack does not live well.”

How Aristotle’s Ideas Can Help Us Understand More about Patients and Health

This is a good time to look at the World Health Organization’s definition of health. It is an excellent example of what one can see as “health imperialism.” It mistakenly defines “health” as “a complete state of physical, mental and spiritual wellbeing.” For Aristotle, few can have all the resource to achieve a complete state of well-being or eudaimonia. I used to ask audiences how many of them felt healthy using the WHO definition and very few put their hands up. One woman with MS was feeling particularly good and argued that having a condition like multiple sclerosis does not stop someone from developing a sense of well being. It becomes clear that the WHO definition confuses health with well-being, perhaps for the well-intentioned purpose of making well-being the object of its efforts rather than just health. It seems that this mistake has become widespread. The healthcare industry perpetuates the confusion by arguing that health is an end in itself and many of us have come to accept this. The enormous percentage of GDP spent on healthcare in developed countries suggests that policy makers have also accepted this. Perhaps this is an easy confusion to make despite Aristotelian warnings.

Aristotle was not a health imperialist: he certainly did not think that being healthy was a sufficient condition for leading the good life. In fact, he rarely discussed the notion of health directly. Rather, he saw health as a resource for well-being and he recognized over 2000 years ago that inequalities in well-being were related to the difference in resources available to different social levels. Aristotle may help us to moderate the current confusion which tends to conflate health and wellbeing.

[1] NE, x, 6, 13, 1176a 33-35.

[2] Politics, iii, 4, 1277b 23-25.

[3] Politics, vii, 3, 13, 1332a 19-27.

[4] See NE, viii & ix.

[5] NE, x, 8, 1178b 33 – 1179a 9.

[6] NE,  1, x, 1100b 24-30

400 BC Aristotle And the Good Life

Rafael Plato and Aristotle

Aristotle was Plato’s prize student, but he disagreed with his teacher in many and important ways. Unlike Plato he believed that the physical world was stable and knowable – it was not chaotic. This makes it possible to gain practical knowledge based on observation. Rafael painted Plato pointing to the heavens where true knowledge was to be found and Aristotle stretches his hand to the world around us.

Aristotle was a habitual and careful observer of nature. He identified and grouped large numbers of animals. His views of the physical world formed the basis for the longest lasting theoretical frame for physics and biology that remained dominant for over 2,000 years. His views and observations also deeply influenced academic medicine and Galen’s articulation of the humoral theory five centuries later. We should never underestimate his intellectual capacity.

Aristotle’s theories were closely tied to his observations and to the general Greek intellectual orientation of his day. For example, he accepted the four elements of the pre-Socratics, air, earth, fire and water, which provided a metaphysical framework for thinking about matter in general as well as a background for more specific areas such as medicine. He identified four kinds of causes, material cause (what something is made of), formal cause (its design), efficient cause (what or who makes it) and final cause (its purpose). These causes are also easy to apply to health and medicine and Aristotle is fond of using medical examples to explain them. “Health,” he says, “is the final cause of walking.”

This orderly sense of the world that is a critical part of Aristotle’s view extends to the place of humans in nature. Aristotle believed that there is a hierarchy in the natural world with human beings at the top of it. He explained this by asking us to recognize that all living things have something in them that makes them alive. We might call this their “life force” or their “soul.” Plants only have vegetative souls that make them living things, and allow them to grow take on nourishment and reproduce. Animals have vegetative souls but also have animal souls with the added capacity of being able to move about, and have sensations and appetites. Finally there are human beings who have in addition to the vegetative and animal souls, rational souls which allow them to be conscious and engage in intellectual activity. This hierarchy in nature puts humans at the top. Although we now know this to be false since all existing creatures are equally evolved, it continues to affect our understanding of, and relationship with, the natural world.

In the Nicomachean Ethics and the Politics, Aristotle considered many issues related to healthcare and the place of patients in it. The hierarchy in the natural world extended to the social environment. Athenian society had strong social gradients, and he thought about the connection between these gradients and different levels of wellbeing. His discussion of “goods” or resources sheds light on our understanding of what can make people healthy and give them a sense of well-being, and his thoughts about misfortune can help us to think about risks to well being. His consideration of the status of individuals and their relation to each other can help us understand more about the history of medicine from the patient’s point of view. Health though it is the end of exercise is not an end in itself. It is the end of various resources such as a clean environment, exercise and good nutrition, but it is also contributes to the ultimate end of living a good life.

For Aristotle, the good person lives well. Importantly, this notion of goodness is not limited to Judeo-Christian notions of moral well-being. People have different capacities for living well. In the Politics and Ethics, Aristotle wrote that one’s relation to one’s society or state identified one’s civil status. And status came with resources for living well. The range of civil status in Athens at that time was much more like that in Mesopotamian society than ours. An overview is worthwhile: the upper class included full citizens (always male) with the greatest capacity to engage in the workings of the state and possessing the material and educational resources to live well. The middle classes consisted of artisans, doctors and merchants, who were trained in their work roles, but did not fully participate in the decisions of the state. Then came foreign political prisoners who were captured in war, often with great expertise that helped them function as teachers or advisers on a variety of topics including health, but without any political rights. Women had even less civil status because at the time they were not educated and could not hold property or engage in political decision making. Finally, there were labourers and natural slaves who were tied to their masters in a variety of forms of bondage. They did menial work, had the fewest rights and obligations and the lowest capacity to live a good life.

Social gradients made it clear that living well required resources, which Aristotle called “goods” and which provided the means to live well. He distinguished between three types of goods: goods of the body, goods of the soul, and external goods.[1] Goods of the body included health, fitness, strength, suppleness and so on; goods of the soul included such things as virtues, intelligence and wit; external goods comprised wealth, property, training etcetera. A person’s capacities were said to be dependent on their external goods as well as their internal ones.

The distribution of these resources followed levels of civil status and, consequently, the capacity to live well. An individual was seen to be a part of the state- one of its elements.[2] The nature of the state and the individual’s place in it determined much about the goods at his or her disposal. Thus, a full citizen had the means to live well. He was in the highest class, with the greatest economic capacity, was trained in the science of politics, which gave him the skills to participate in government and the capacity to make decisions with consequences to the wellbeing of the state. A middle class person – an artisan or doctor – had training for his work, less right to govern, fewer economic resources, and hence a more limited capacity for living well than a full upper class citizen. Though he may be well educated and participate in training and education, a foreign political prisoner had no civil status: this limited his capacity to engage in society and to live well. In Aristotle’s day, women were given almost no education and had no rights to property or resources that would enable them to govern. In this patriarchal society, women’s range of moral action was severely limited, although there were female physicians, midwives and other healers. Finally, a natural slave had limited intellectual capacity, no training and functions only in response to his master’s orders; hence the natural slave had the most limited capacity for living a good life.[3]

Just as there were different levels of citizens, so there were different levels of healers: philosopher doctors who were well literate, well-trained and close to the upper classes, priests and other healers who interpreted sacrificial livers, cast spells and prepared magical amulets, barber doctors who could cut out dangerous growths, set bones and heal wounds but might also be illiterate, people with a traditional understanding of medications to deal with particular conditions. Similarly ancient midwives might include the upper class wives and children of philosopher clinicians, all the way down to illiterate relatives of patients who had some experience helping women give birth. Their fees were set according to these levels – all the way from very expensive to free.

[1] Aristotle. The Politics of Aristotle. Translated by Peter L. Phillips Simpson. Chapel Hillq: The University of North Carolina Press, 1997. [Politics], vii, 1, 1323a  24-27.

[2] Politics, i, 2, 1053a 19f.

[3] See generally the Politics, especially Book I.

Ancient Greece and Hippocrates 400 BC

Herodotus saw Egypt as a major source of medical knowledge that could contribute to healthcare in Greece. But Greece ended up as the central birthplace of the western medical tradition. Ancient Greek n=medicine, like other traditions was founded in earlier cosmologies – myths in which the gods created the world, and humans, and introduced disease as a punishment for bad behaviour.

Keeping the gods happy was a major element in many early health strategies. The need for intermediaries was part and parcel of ancient Greek medicine as it was in its precursor in Egypt and Mesopotamia. The range of practitioners already present in Mesopotamia continued in Egypt and later in Greece. There were priestly interpreters of the livers of sacrificed animals and priests who intervened with the gods through prayer. There were herbalists who learned from their elders and transmitted prehistoric knowledge in the oral tradition. There were bonesetters and wound healers who learned from earlier practitioners and received the skills that were centuries in the making. There were magical curers who recited incantations and cast spells. There were astrological diagnosticians who linked diseases to the place of the gods in the sky. And, of course, there were doctors who were especially adept at dealing with particular diseases or particular organs.

Hippocrates circa 460 BC-circa 370 BC

Hippocrates is called the father of western medicine. He is credited with collecting older medical interventions, identifying many health conditions and with giving sage advice about others. A goodly number of his observations and diagnoses have stood the test of time over 2400 years. Roy Porter notes that “The sixty or so works which comprise the so-called Hippocratic corpus were penned by him only in the sense that the Iliad is credited to Homer or the Pentateuch to Moses.” His massive written work is now believed to have been produced over more than a century by many different people, but today he is mostly remembered for making explicit early versions of humoral medicine and his swearing in ceremony for new doctors.

Humoral medicine links the four elements of the pre-Socratics, air, earth, fire and water, to four humours present in every human body: blood, black bile, yellow bile, and phlegm. A good balance of these humours is an indication of health and when someone becomes ill, the doctor’s objective is to rebalance the humours. The theory which was quite ancient was enunciated by Hippocrates is later developed using Aristotle’s metaphysics and becomes the central medical theoretical frame taught in medical schools until the late nineteenth century. We will look at Galen’s version more carefully.

Hippocrates’ Oath is quoted below in its earliest known form.

I swear by Apollo the physician, and Aesculapius the surgeon, likewise Hygeia and Panacea, and call all the gods and goddesses to witness, that I will observe and keep this underwritten oath, to the utmost of my power and judgment.

I will reverence my master who taught me the art. Equally with my parents, will I allow him things necessary for his support, and will consider his sons as brothers. I will teach them my art without reward or agreement; and I will impart all my acquirement, instructions, and whatever I know, to my master’s children, as to my own; and likewise to all my pupils, who shall bind and tie themselves by a professional oath, but to none else.

With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurt or damage.

Nor shall any man’s entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so. Moreover, I will give no sort of medicine to any pregnant woman, with a view to destroy the child.

Further, I will comport myself and use my knowledge in a godly manner.

I will not cut for the stone, but will commit that affair entirely to the surgeons.

Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient; and I will willingly refrain from doing any injury or wrong from falsehood, and (in an especial manner) from acts of an amorous nature, whatever may be the rank of those who it may be my duty to cure, whether mistress or servant, bond or free.

Whatever, in the course of my practice, I may see or hear (even when not invited), whatever I may happen to obtain knowledge of, if it be not proper to repeat it, I will keep sacred and secret within my own breast.

If I faithfully observe this oath, may I thrive and prosper in my fortune and profession, and live in the estimation of posterity; or on breach thereof, may the reverse be my fate![4]

At the beginning of the oath its related Gods are mentioned. Apollo was a god who could bring healing, but was also, when angry, a deliverer of illness and even plagues. Aesculepius is the Greek physician who was transformed into a God by the other Greek gods. Panacea and Hydieia were two of his daughters. Panacea was the goddess of universal healing, and Hygieia was the personification of health, cleanliness, and sanitation. Panacea later was linked to idea of the Philosopher’s Stone which was not only said to transmute base metals into gold but to act as a cure for all diseases.

The oath is certainly doctor friendly. It presupposes a kind of apprenticeship system of training and a strong bond between the doctor and his teacher as well as an obligation to his teacher’s family. Professional courtesy remains a somewhat diminished part of medical practice in those parts of the world with government funded universal health coverage. But in places where there is private healthcare, many doctors still extend this courtesy to their colleagues and do not charge them for their services. And have not since ancient Greece. (Many doctors do not appreciate being free patients because they believe that they are treated less well than paying patients, but the circumstance they are in can make it impossible to pay.)

The patient related parts of the oath have stood up for a very long time. In fact the oath only began to be questioned and revised in the last century, just after the time that humoral medicine was expunged from medical text books. The ban on physician induced abortions and on medically supported euthanasia has become quite controversial in recent years, and it looks like doctors will not only be called upon to perform abortions, but will also be asked to offer their assistance to those terminally ill patient who want to die. These and other changes have led to substantial rewrites of the oath.

Ancient Egyptian Patients and their doctors 5000-2000 Years Ago

Ancient Egypt grew and prospered for centuries without a written language. It produced highly skilled craftsmen who could work with metal and stone and other materials. It bred sophisticated architects to design and build the pyramids and other funerary structures. The practice of preparing bodies for mummification was very intricate and required highly specialized knowledge. All functioned in an oral tradition. This long history predates the written word and is a critical source of the material which eventually appeared as hieroglyphic texts.

Some texts speak of secret information with ancient religious sources including humans who were deified. “Most famous was Imhotep, chief vizier to Pharaoh Zozer (2980 -2900 BC) renowned as a physician astrologer, priest sage and pyramid designer.” (Porter page 23). Some texts were accessible only to doctors who had trained in the temple medical schools. The idea that doctors have secret knowledge that can be applied to treatment, but kept from patients probably began well before this period. Secrecy has been an ongoing aspect of the doctor patient relationship as everything from secret diagnostic procedures to secret formulae for medications. It seems that some elements of the relationship between doctors and patients were forged several thousand years ago.

The decoding of papyri displayed the richness of Egyptian medical knowledge with a wide range of treatments, using herbal, as well as mineral remedies and employing a growing set of medical tools. Advanced medicine was for royalty and the wealthy as it continued to be for much of history. A papyrus depicts the richness and range of goods given to an Egyptian doctor who has treated a foreign king.

Egyptian Doctor receiving fees

If in Mesopotamia there were gods for each of the organs, in Egypt the doctors themselves began to specialize in particular parts of the body. Herodotus in reviewing Egyptian medicine makes special note of this when he points out that “the whole country is full of physicians of the eyes: others of the head; others of the teeth; others of the belly and others of obscure diseases.”  Herodotus on Egyptian Medicine.

Among the physicians in ancient Egypt were a fair number of women – there was a medical school for women that focused on birth practices and in women’s health. Unlike the Greeks who later conquered them, the Egyptians apparently did not believe that women were genetically weaker and less intelligent than men.

5000-4000 Years Ago Mesopotamian Patients

Written texts dramatically improved the recording, preservation and transmission, of information. Mesopotamia and the surrounding area was the cradle of written language  This was the first major western technological revolution. The introduction of the printing press was the second and some have argued that the World Wide Web is the third. Each marked great changes and made an enormous difference to the advancement and accumulation of knowledge.

In ancient Mesopotamia the writing has been preserved on clay tablets and though some of it remains to be translated, there is quite a lot that tells us about the healthcare system of the time. According to Roy Porter three types of healers are mentioned in the tablets which are the earliest written records of medical care:

“Under a head physician, three types of healers practiced: a seer called (bârû) who was expert in divination [by inspecting the livers of sacrificed animals]; a priest (âshipu), who carried out exorcisms and incantations [to allay the anger of the gods of each organ], and a physician (âsû) who employed drugs and performed surgery and bandaging.”  (page 23)

But of course like most medical histories, Porter’s ignores the role of female healers called asâtus, who primarily cared for women but are rarely mentioned in the clay tablets. Most of the active treatments included herbal remedies that were passed down through an oral tradition and there were apparently a large number of female healers who were not part of the formal system but were major recipients of that oral learning.

Other Mesopotamian tablets that mention health care are records of fee structures and begin to distinguish the different kinds of healthcare practitioners as well as different groups of patients. Below are some of the rules and regulations for health practitioners taken from Hamurabi’s Code which can help us distinguish the levels of patients in Mesopotamia.

If a doctor has treated a freeman with a metal knife for a severe wound, and has cured the freeman, or has opened a freeman’s tumor with a metal knife, and cured a freeman’s eye, then he shall receive ten shekels of silver.

If the son of a plebeian, he shall receive five shekels of silver.

If a man’s slave, the owner of the slave shall give two shekels of silver to the doctor.

If a doctor has treated a man with a metal knife for a severe wound, and has caused the man to die, or has opened a man’s tumor with a metal knife and destroyed the man’s eye, his hands shall be cut off.

If a doctor has treated the slave of a plebeian with a metal knife for a severe wound and caused him to die, he shall render slave for slave.

If he has opened his tumor with a metal knife and destroyed his eye, he shall pay half his price in silver.

If a doctor has healed a freeman’s broken bone or has restored diseased flesh, the patient shall give the doctor five shekels of silver.

If he be the son of a plebeian, he shall give three shekels of silver.

If a man’s a slave, the owner of the slave shall give two shekels of silver to the doctor.

If a man has destroyed the eye of a patrician, his own eye shall be destroyed.

If a man has knocked out the teeth of a man of the same rank, his own teeth shall be knocked out.

If he has knocked out the teeth of a plebeian, he shall pay one-third of a mina of silver.

The accompanying text gives some idea of the value of these fees: the cost of renting a middle class dwelling at the time was about five shekels of silver yearly and the daily pay for an ordinary craftsman was about one-fiftieth of a silver shekel. Medical fees for the best doctors were high and seem to have remained high since antiquity.

We can use the information from the tablets to distinguish the different classes of patients in Mesopotamia: there are, in descending order, patricians, freemen, plebeians, and slaves. The fees set for each is scaled as is the punishment for failure. It is not clear what differences in care are provided to each of these groups, but more than likely there was a difference either in the number of physicians involved, the services provided, or the delay in treatment.

The only healers whose work is directly regulated in the code are the âsû because they are the only ones who actually provide hands on care. The âshipu and the bârû never operate on the patient: they only serve as intermediaries between patients and the relevant deities. This may be an indication of the class level of the healers. Because the âsû are the only healers whose work is directly mentioned in the code, they are the most vulnerable to punishment. The ashipu or priests doctors and the bârû presumably share the fee but not the responsibility.

The particular gods related to each organ brings to mind the current extent of specialization. Specialist doctors are increasingly associated with particular body parts – from retinas to knees and the first among them are revered much like the ancient gods of particular organs. Patients have been often warned not to anger the gods of the organs from Mesopotamian times on. Many patients continue to have such fears today.

10000 Year Ago Patients and Agriculture

It has been argued, most notably by Nathan Cohen, in Health and the Rise of Civilization, that the development of civilization is a function of the increased density of human population. As the number of people increased and open land became scarcer. It was less possible to live merely by foraging. It became necessary to develop a source of food that could sustain a larger number of people. Humans adapted by learning how to domesticate animals and to raise crops. Labour-intensive practices like herding, clearing forests, getting the earth ready for planting, harvesting and preparing food for storage, all required workers and organization.

In larger groups, it was more difficult to make decisions by consensus. Specialist roles emerged for leaders and for experts in hunting game, healing the sick, or deciding when and where to plant next. Manual farm workers were also needed. Towns grew up to support agriculture: local merchants and manufacturers helped the farmers by supplying them with equipment and services they needed to produce crops and helped them distribute their excess products more widely.

Agriculture came with more diseases. Animal germs evolved into germs that affected humans. We began to share diseases with animals: measles from dogs, influenzas from pigs and ducks, colds from horses, and small pox and other viruses from cattle. Today we remain susceptible to diseases from domestic animals. The SARs virus was found to come from bats which infected domestic cats and animals that were being sold in markets in the Quandong province in China.

Permanent settlement and reliance on agriculture had other effects. Human diet became less varied and had an

excessive reliance on starchy monoclutures such as maize, low in proteins, vitamins and minerals. Stunted people are more prone to illness, and poor nutritional levels in turn lead to pellagra, kwashkiorkor, scurvy and other deficiency diseases. (Porter page 5)

The result was that in the change from nomadic foraging to a more sedentary agricultural stage, humans actually became shorter and smaller. More critically the social relations between people began to change. Land owners acquired farm labourers as workers or slaves. Among the earliest written documents in the proto-Elamite tablets from around 3100 B.C. describe the meager rations of gruel and weak beer given to farm workers to keep them just above the starvation level. And so civilization by itself, as Cohen notes, does not guarantee a better diet for all – in the same tablets there are descriptions of the wealth of food choices available to the well off – things like yogurt, cheese and honey. From these earliest times and in many societies there were important distinctions in class levels, types of work and lifestyles. These differences extended to healthcare. There were different classes of patients that more or less correspond to the various social classes. The care given to slaves was no doubt different from that provided for the upper classes. Most medical history is about middle and upper class healthcare, because medical historians typically attach doctors to the higher levels of society. Throughout history these classes shift and their boundaries change: inequalities in patients tend to parallel inequalities in other aspects of society.


Father of Sickness

It might be a good idea to look at a story about healing taken from an unfamiliar tradition. This is a Siberian legend in which a sickness spirit becomes aware of his power to make people ill and a young shaman is needed to intervene with the sickness spirit so that he will leave the patient.


One of our kinsmen, Nya Nganas, went walking one day in the snow-clad taiga to look for game.  All of a sudden, however, the day turned foggy and he could not find his way home.

Although he searched this way and that he could not find the homeward path and eventually came upon a stream which seemed to have come from nowhere.  When he tried to jump across he lost his footing and plunged into the water.  Down and down he sank, far into the depths, until at last he came out on the other side, underneath the water.

The land there stretched to the horizon without a trace of snow; just the tips of the grass were slightly whitened as if touched by hoar frost.

He set out to cross this strange new land, looking to all sides for some sign of life.  At last he spotted a young girl travelling along a track in front of him.  She was riding a strangely coloured reindeer.  As he ran after her, he called out:

“Hello there, from what tribe are you?”

But the girl did not seem to hear him, for she paid no heed.  As he caught up with her he touched her lightly on the shoulder.

“Who are you?” he asked.

At his touch the girl cried out in pain.

“Why does my shoulder hurt so, as if someone is stabbing me?” she cried.

“What a strange girl,” Nya Nganas said.  “She certainly looks like a girl from our parts, yet whatever I say she doesn’t hear me.”

So again he tapped her on the shoulder and once more she let out a cry of pain:

“Oh, oh! An evil spirit sickness has pierced my shoulder.”

“What a strange thing,” thought Nya Nganas.  “I’ll travel behind her and see where she’s bound.”

On and on they went, with the girl constantly crying and groaning.  Finally, a camp of some five or six chooms came into view: they were of the Tungus people.  Arriving at the tents, the girl entered one of them, crying loudly:

“A sickness spirit struck me along the way.”

Nya Nganas followed the girl into the choom and sat down behind the tent pole some way from her.

“Where did the spirit strike you?” the girl was asked.

But she cried out in great pain and was too poorly to explain.  So sorry for her did our man feel that he tried to wrap her in his parka despite her shrieks of pain.

All the while the fire in the hearth crackled and hissed as if hostile to the visitor.

The people in the choom said:

“Why is the fire behaving so? Why does it crackle and hiss?  Something evil has entered our choom: the spirit sickness has come.  What shall we do?  Our poor maid will not last long unless we do something.”

One of the girl’s brothers then spoke up:

“Let us send for the old shaman who lives in the next camp; he may be able to cure our sister.”

It being agreed, he went off to fetch the shaman, returning with him that evening.  The shaman was a wizened old man who at once began to weave his shaman spells and to talk with the spirits.  Finally, he said:

“Three days will pass and the girl will get better.”

Thereupon, the shaman returned to his own choom.  But the girl continued to moan as one gravely ill: day and night she lay in a fever and at the end of three days was even worse than before.

All the time, our man sat uncomprehending in the corner unseen by all.

At last, the girl’s father spoke up:

“Our daughter is doomed, the old shaman could do nothing for her.  Somewhere I’ve heard there is a young orphan who has become a shaman; he even has his drum and powerful charms.  Let us summon him.”

The old man’s eldest son again went forth and this time brought back the young shaman.  Sitting alongside the girl, the orphan-shaman first took a bite to eat, then laid out his shaman’s attire and drum upon the floor ready for his work.  Having eaten, he began to pull on the shaman’s bakari, the long fur boots.  As he tied the laces of his boots, he stole a glance towards Nya Nganas.  Having put on the remainder of his attire, he began to do up the thongs of his robe and again stole a glance in the direction of our man.

And our man thought to himself:

“This shaman knows that I am here.”

The shaman finished his dressing and now took up the drum; yet he still refrained from playing it.  Nya Nganas meanwhile tried to hide behind the girl, pressing his face close to the girl’s back so that the shaman could not see it.  First from one side, then from the other, however, the shaman peered behind the girl as he beat the drum.

Beating the drum now very hard and fast, he chanted loudly:

“A sickness spirit has come.  It came to you on the road and pierced your left shoulder.  Do I speak truly?”

“You do,” whispered the girl.

“You have the sickness of koga nguo, the evil one,” continued the shaman; and turning to our man, he said,”How is it, Nya Nganas, that you cling so tightly to the girl?  You will tear out her soul.  Tell us what it is you want; she shall have it, but let the girl go free.”

“Give me the strangely coloured reindeer on which the girl rode here,” our man said. “Give me that and I shall depart at once.”

The shaman now addressed the girl’s father:

“The sickness spirit asks for the reindeer the girl rode.  Do you give your consent?”

“Yes, certainly, certainly,” said the old man quickly.

“Good, it is settled,” said the young shaman.”Now, brothers and sisters of the Tungus tribe, you must make a reindeer out of wood.”

So they set to making a reindeer out of wood; legs and horns and tail.  And with the charred wood from the fire they drew patterns on its body.  When the job was done, the shaman took up his drum and beat it loudly jumping up and down as if running fast.  Our man, Nya Nganas, quite lost his senses from the drumming and dancing; he thought to himself:

“They’ve prepared the reindeer for me, I must mount it and get away from here.”

And he climbed on the wooden reindeer’s back and galloped away like the wind across the plain.

All the while the shaman played his drum and danced round and round in circles until he dropped down exhausted.  At the same time, far, far away on the bank of a stream, our man came to a sudden halt on his reindeer.  When he looked about him, he found to his surprise that he was sitting on a wooden reindeer on the bank of the self-same stream upon which he had stumbled in the fog.

“What sort of shaman did this to me?” he wondered. “The old shaman was not powerful at all; he did not even see me.  But that young orphan-shaman was very strong; he made me lose my senses.”

Slipping down from the reindeer, he left it on the riverbank and walked home, soon coming to his choom.  Once there he told his kinsfolk of his adventures in that other world.

“So I learned that some of us really are sickness spirits,” he said in conclusion.  “One of you, my brothers, is a piercing sickness; another is a fever sickness, and another the terrible smallpox spirit.  One of us, it may be, will one day find himself in that other world, and then the same orphan-shaman will not let him go.  He is a very clever shaman.”

With these words, everyone present turned into sickness spirits.  No longer were they people, they had each and every one become a sickness.

Henceforth, when someone is ill, folk say it is one of our kind who has come.  And if the shaman cannot help, it is because he is like the weak old shaman.  But should our sickness spirit find itself in a choom visited by the young orphan-shaman then he will see it and the spirit won’t be able to steal a single soul.

This narrative like many others including those of the Judeo-Christian bible, Greek mythology and many eastern traditions emerge from oral traditions in which stories are told and retold over long periods of time before they finally are transcribed into written form.

A young girl is riding a beautiful multi-colored reindeer. She begins to feel terrible pain when touched by Nya Nganas who does not yet know that he is a sickness spirit. We can see that several aspects of the patient/caregiver/doctor relationship have already been established in this culture. The patient is too ill to do anything but express pain. She never sees the source of the pain but only feels the result of his touching her. Her father as a family caregiver recognizes that this illness is beyond his capacity to alleviate. And so he calls for the most experienced shaman – one from the next door community. This shaman, like the patient and her family caregivers, cannot see the sickness spirit in the room. He examines her and declares that the girl will be better in three days. It seems that a wait-and-see diagnosis was a widespread medical precept even then.

But in this case the girl does not get better because Nya Nganas does not leave the room. And so her father sends his son to get a second opinion from a younger shaman. New to the field, he is the only one who has the special ability to actually see and speak to the sickness spirit. He negotiates an agreement – an exchange of the multi-coloured reindeer for the departure of the spirit (and hence the illness.) The family does not give up the actual multi-coloured reindeer, but builds a replica of it: something like a rocking horse as an ikon of the reindeer. The spirit accepts this and leaves, riding on the wooden reindeer. The girl is cured.  When he gets home, the spirit informs the others in his village that he and they are all sickness spirits.

This tribe in Siberia had already identified the roles of shamans and patients. Their overall belief appears to be that sickness spirits, even though they might not be aware of their powers are the source of all diseases. According to the story, the objective of sickness spirits is to steal souls – by making people ill and taking their lives. Each spirit is responsible for a particular disease. That the tribe is a fairly large herding society is suggested by the presence of a spirit of small pox in their midst. The story, full of people not knowing who they are, what affects them and what can be done about, is yet another explanation of how sickness comes to the world and especially of how its cure needs the intermediary of especially sensitive healers.