By AD 650 ancient medicine had taken on the form in which it was to dominate the theory and practice of medicine in the Greek East, and subsequently in the Muslim world and the Latin West, for a millennium – namely, Galenism. Learned doctors and other intellectuals were now agreed that the human body, organised anatomically and physiologically into three almost separate systems based on the brain, heart and liver, depended for its health ultimately on a balance between its four constituent humours, blood, bile, black bile and phlegm. This balance varied according to the individual’s age and diet (in the broadest sense of the term), the season of the year and the environment, and determined not only physical but also mental well-being. It was a system standing firmly on the twin pillars of observation and logic, and gained added authority from the longevity of the theories on which it was based and from the ease with which it could be co-ordinated with other systems of thought, such as Aristotelianism, Platonism and monotheism. It was not entirely immune to change, although its rhetoric of certainty did not allow for radical developments or more than a circumscribed area of disagreement. Such a theory, backed up by centuries of observations and apparently effective therapies, had deservedly triumphed. The vigorous debates of fifthcentury BC Greece or second-century Rome were long gone: arguments over the interpretation of Galen had replaced disputes over alternatives to Galen.1 How the pluralism of earlier medicine developed into this near-monolithic system and how it interacted with an increasingly desecularised world are the main themes of this chapter. Any answer to the first question runs into an immediate difficulty. The century and a half that follows the death of Galen is a black hole in the history of medicine. No completely surviving text can be assigned with confidence to this period, except for Gargilius Martialis’ book on Medicines from Fruits and Vegetables and a strongly Neoplatonist essay, preserved under the name of Galen, on the way in which the foetus receives its soul.2 Several recipes for both animals and humans, as well as magical tricks and useful hints on everything from archery to surveying, were included by the Greek writer Julius Africanus in his Tapestries (Cestoi), written about 225.3 A few scattered fragments of

veterinary authors such as Theomnestus, writing around 326, and his slightly earlier source, Apsyrtus, remind us of a once-flourishing literature on animal medicine, in Greek as well as in Latin.4 The inscriptional record of doctors also drops away substantially after the middle of the third century (although the geographically restricted evidence of the papyri continues). There is likewise a diminution in the quantity of literary and historical material available, with the exception of Christian writers, who focus on medical matters only incidentally or in the context of the miracles of saints. But hagiography is an elusive genre, and the modern historian must work hard to win nuggets from even so apparently informative a source as the life of St Gregory Thaumaturgus (‘the wonder-worker’, c.220-72), bishop of Pontus.5 Tracking medical developments in this period is thus an act of faith, not of history. When our information reappears in quantity, from the 340s onwards, the picture that emerges has altered greatly since the second century. The Roman Empire has gained a second capital, Constantinople, and a newly authorised religion, Christianity, and in law, literature and astronomy as well as in medicine the codification of earlier learning has taken over from original thought. Compendia, commentaries, large collections of extracts from earlier authors and short guides to self-help medicine replace the wide-ranging discussions of Galen; systematic anatomical investigation (‘Hippocratic butchery’, as one Christian author called it) has disappeared;6 and belief in demons, chants, charms and magical herbs obtrudes into the rationalities of natural philosophy. Although the name of Hippocrates has now come to stand for medicine itself, the Hippocratic physician appears an endangered species in a world increasingly dominated, and divided, by religion.7 It is a situation that continued at least into the seventh century. One explanation for this new medical landscape puts the emphasis on social, political and economic changes in society at large. The invasions and civil wars of the middle years of the third century and the first quarter of the fourth disrupted the prosperity of the Empire and its institutions. The response of emperors such as Diocletian (reigned 284-305) and Constantine (reigned 307-37) was to cling more closely to the past for justification, even as they imposed radical changes on society. Although it would be going far too far to see this as a decline, patterns of behaviour and thought, as well as political and social priorities, altered in reaction to altered circumstances. An inhabitant of the new eastern capital, Constantinople, massively enlarged from a town to a megalopolis within a few decades, was bound to have a different outlook from that of an aristocrat in Rome.8 Linguistic, cultural, military and political circumstances also combined to break the unity of the Roman Empire. From 364 onwards the two halves of the Empire were ruled by separate, although initially related, emperors and gradually drew apart. The city of Rome progressively lost political importance, even as it asserted its ecclesiastical pre-eminence. By 600 the Latin West, under the impact of a series of barbarian invasions, had split into a

number of independently developing kingdoms or regions. Their economic foundations were no longer as strong as those in the East; towns were fewer and their urban institutions weaker. Medici can be found, even in areas as remote as the Lleyn peninsula in N. Wales, but they appear in isolation.9 Learning, where it existed, was mainly under the protection, and for the purposes, of the church: the syntheses of medicine and of anatomy in Books 4 and 11 of the Etymologies of Bishop Isidore of Seville (d. 640) were intended to be studied as words, by grammarians.10 Medical practice thus developed in different ways to cope with different societies. However, the emphasis of this sociological explanation on change underestimates the continuities and the distorting effect of Galen and the Galenic Corpus. If we did not have the many volumes of the garrulous Pergamene, the pattern of medical life would scarcely seem to alter over the centuries, especially in the Greek half of the Empire. Civic doctors in small towns in Late Antiquity still assert their right to tax immunity in the face of demands from needy tax-payers. Public regulations, extended in 368 to Rome and its new college of doctors, still urge the merits of medical education and emphasise the need for honest practice – and continue to be evaded.11 Law codes continue to lay down the exact price for a slave trained in medicine, just as if this was the Rome of Augustus.12 Handbooks, drug collections, guides such as Celsus or Rufus’ For the Layman, compilations of information from other writers, such as the Introduction to Medicine, medical catechisms and summaries are found in both the High and the Later Empire. A belief in the powers of chants, amulets and spells is not confined to Late Antiquity.13 What was unusual was Galen, with his philosophical disquisitions, his insistence on anatomy and his long-winded theoretical expositions of causes or symptoms. To take Galen as typical, one might argue, results in a historically flawed perspective that plays down the similarities between the centuries and creates the impression of a catastrophic decline the moment Galen disappears from the scene. To decide between the validity of an approach that stresses the continuities and one that emphasises the differences between the centuries is far from easy. And even if one opts for change, the superiority does not always lie with the authors of the earlier period. Caelius Aurelianus’ massive Latin treatise On Acute and Chronic Diseases, written around AD 400, is fuller and at times clearer than the similar one of Aretaeus two centuries or more before. Pelagonius, writing his substantial Latin treatise on veterinary medicine at the end of the fourth century, shows no concern about a medical decline: true, while on a journey it might prove difficult to find assistance immediately, and any owner of horses should acquaint himself with at least the basics of horse medicine, but that had always been the case.14 By contrast, it is more often the information in our non-medical sources that suggests a difference in tone, a reduction in overt speculation, a closing in of horizons, perhaps even a growing split between a tiny elite and the rest of society. A passing

comment of the church historian Philostorgius neatly exemplifies this shift. Posidonius, a learned doctor at the end of the fourth century and an expert on mental diseases, was regarded as unusual for maintaining that madness was not the result of attacks by demons but had a physical cause in the imbalance of humours.15 This ambiguity in our sources’ characterisation of medicine in Late Antiquity was neatly summarised by Owsei Temkin in 1962 when he argued that Byzantine medicine ‘represents the formation as well as the continuation of a tradition, broken and unbroken’.16 In other words, one can detect important changes taking place, even as the participants themselves claim to be maintaining past tradition, and these changes in turn come to be seen as part of that tradition. Very rarely can one point to a specific individual as the agent of change – there is no Herophilus, no Asclepiades, for instance – or to any one decisive moment. Often these developments can be seen only over the long term, by comparison with what went before or as laying the foundations for others yet to come – for example the development of Galenism, the growing split between theory and practice, the role of translation and bilingualism and, above all, the accommodation of medicine to the new institutions of Christianity. All these developments, as we shall see, give the lie to any interpretation of the medicine of Late Antiquity in terms of stagnation and uncomprehending decline. Rather, they show new, and at times vigorous, responses on the part of doctors, of all kinds, to the society around them, even as they assert continuities with their own heritage. These responses took a variety of forms. For example, the general surveys by the three most substantial Greek medical writers to survive from Late Antiquity, Oribasius of Pergamum (c.325-400), Aetius of Amida (S.E. Turkey, fl. 530) and Paul of Aegina (active in Alexandria c.630), differ substantially from anything found earlier.17 Celsus and Pliny may have derived most of their material from what they had read, but they imposed on it their own individual emphases and style. By contrast, in the later syntheses extracts from earlier writers are assembled, often verbatim and duly acknowledged, into a coherent mosaic of opinions, ideas and remedies. Comments by the compiler himself are almost non-existent. These encyclopaedias varied greatly in size; Oribasius produced one for his patron, the Emperor Julian, in seventy books, of which over thirty survive, another in nine books for his son Eustathius, one in four books for his friend and biographer Eunapius (340-c.414) and a further single volume (now lost) of Galenic extracts, the fruit of midnight discussion with Julian while on campaign in Gaul c.358.18 These medical encyclopaedias display learning, elegant organisation and practicality, virtues not to be despised or dismissed in favour of novelty. They are more than mere repertories of the past, valuable though they are for that reason. Paul’s Book 6 is by far the most informative (and most practically minded) Greek surgical text extant, covering everything from hernias and fistulae to sprained ankles and varicose veins, and from the removal of missiles from battlefield wounds to the

surgical reduction of over-large breasts in a man, ‘which bring the reproach of femininity’.19 Paul’s text is also a tribute to an ongoing Alexandrian surgical tradition, in which complicated operations continued to be performed, with apparent success and with a more than local fame, at least until the seventh century. The procedure he recommends for removing a severely damaged rib could well be followed today, while his comments, based on Antyllus, about the dangers involved in an emergency trachaeotomy imply that that operation had been attempted, and may well have succeeded.20 One can see why the Scottish physician and translator Francis Adams of Banchory should have chosen in the 1820s to embark on a translation of Paul, furnished with an extensive commentary, because of its practical relevance to contemporary therapeutics.21 But, at the same time, much was lost in this process of redaction. As these encyclopaedias developed, they became more and more brusque. Alternatives became irrelevant luxuries, and the word of Galen came to dominate over all others. The long citations in Oribasius were often amalgamated, and the names of the different authors omitted or lumped together under that of Galen, to form a coherent and succinct account of a particular topic. Galen’s hesitations and qualifications (and even self-contradictions) were edited out, and the practical and empirical side of his work was replaced by the dogmatic. Galen was becoming Galenism. This process was assisted by Galen’s own rhetoric. More than once he had claimed to be perfecting medicine, or to be transmitting what Hippocrates had already completed. Hence it was easy to believe that all medical knowledge was contained in his many volumes, if one did but look closely. ‘Hippocrates sowed the seed, Galen reaped the harvest’, said one resigned author, with the implication that only unprofitable stubble remained.22 The sheer size of Galen’s achievement was also daunting. Few believed that they could now master the whole of medicine as he had done, and they preferred either to summarise or to concentrate on only one part of the medicine that he had unified. Nevertheless, the spread of Galenism was neither universal nor immediate. There were still Asclepiadeans in Asia Minor in the fourth century, and Methodists flourished in the Latin world for some time after that.23 Even among followers of Galen, there were rival interpretations and arguments between pragmatists and rigorists. Alexander of Tralles, writing around 560, contrasted his own willingness to employ a variety of therapies with the reluctance of the book-bound, ineffective and even murderous Galenist to depart from his master’s words, even when common sense demanded it. Alexander was no backwoodsman relying on a few books and herbal remedies, but a cosmopolitan Greek, the brother of both the Emperor Justinian’s legal adviser and the architect of Hagia Sophia, the greatest church of Byzantium. He had travelled widely, to N. Africa, Italy and further west with the emperor’s troops, and he had sought out remedies from peasants, more galenico, in

Figure 19.1 The great doctors of Antiquity, Hippocrates, Galen, Paul, Oribasius, Asclepiades and Dioscorides. Frontispiece to Thomas Linacre’s Latin version of Galen’s Method of Healing, Paris, S. de Colines, 1530. The artist depicts the dissection of a human body, perhaps alluding to Galen, although the book itself has nothing to do with anatomy. Courtesy of Wellcome Library, London.