Tuesday, August 4, 2015

2015.08.05

Ido Israelowich, Patients and Healers in the High Roman Empire. Baltimore: Johns Hopkins Press, 2015. Pp. ix, 191. ISBN 9781421416281. $59.95.

Reviewed by Lawrence J. Bliquez, University of Washington, Seattle (lbliquez@u.washington.edu)

Version at BMCR home site

In his Introduction the author acknowledges the theoretical concepts and methods of medical anthropology underlying the approach reflected in his book's title: to wit, the collective experience of patient and provider in Roman health care. He also states his intention to analyze the range of healing activities offered under the High Empire. Then follows the meat of the book: five chapters investigating those activities and how they were regarded.

The first ("The Identity of Physicians during the High Roman Empire") traces the establishment of medicine in its Hellenized form in the Roman world, and specifically in the city of Rome, from the arrival of the surgeon Archagathus in 219 BCE. Israelowich describes as background how Greek health care included not only therapeutic methods but also institutions and official positions. The latter included that of "royal physician" to Hellenistic monarchs and that of "public physician," i.e., a doctor who was induced to stay in the community, thus insuring readily available professional care. The role played in the preference for Greek medicine by the aristocracy of the Republic and the subsequent elevation and regulation of its status in law by imperial personalities such as Julius Caesar, Augustus, Vespasian, and Antoninus Pius is explored. Detailed too are the privileges, such as citizenship and freedom from taxes, that raised the Greek, or at least Greek-trained physician, from a foreigner regarded with suspicion to a sometimes elite figure in society and at court by the time of the High Empire. As there was no universally acknowledged system of training or licensing, a physician owed his station to public opinion and patient choice. This process of legitimization is detailed in a particular case recorded on papyrus, that of an Egyptian doctor, Psasnis.

The second chapter ("Patient's Understanding of Health and Illness") enlarges on the patient's perceptions and power to choose. Israelowich persuasively maintains that, while physicians might be granted authority and titles, in the eyes of patients as consumers in what he calls "the medical marketplace," physicians and the priests of healing cults were viewed as equally competent in combating disease. Equal competence was reflected in a common medical language used in both "scientific" and temple medicine, as well as in application of common procedures, such as diagnosis and therapy via dreams. This fits with passages in Galen showing that patients were not much interested in the reasons for prescriptions and treatment offered them and were not discouraged from viewing them in religious terms. The "Sacred Tales" of Aelius Aristeides also reflects these sentiments, as does the epigraphic evidence brought to bear in the discussion. Inscriptions often attest to the simultaneous gratitude of those afflicted to both the physicians who attended them and to the gods beseeched for cures, especially Asclepius and Hygieia. They even record dedications to healing gods by doctors, and show instances where a priest also functioned as a physician.

Chapters three through five bring us to particular locales where health care was provided. In the case of chapter three ("The Domus and Reproduction"), Israelowich's focus is on the home and childbirth. He notes that childbirth, involving all members of the household, was the most common occasion for consultation of and treatment by a medical authority, first and foremost, a midwife. Both Greek and Roman authors demonstrate that male practitioners too might be involved, especially in cases of dystocia. For Israelowich, the home "acted as a microcosm of the medical marketplace;" that is, it reflects common themes explored throughout the book, such as the acceptability of scientific and religious approaches mixed together and the importance of "visible expertise" in legitimizing the status of midwives when there was no professional means of licensing. Israelowich uses inscriptions and citations from Roman jurists to argue that the healing activities of females might extend beyond midwifery, though their patients must have been predominantly females being treated for female complaints.

The obvious locale discussed in chapter four ("Health Care in the Roman Army") is the Roman military camp. Next to the home, Israelowich considers the camp the most significant arena for health care. Perhaps not everyone will agree that in this respect the Imperial army was everywhere as formally organized and well provided for as Israelowich would have it. But the picture he draws seems reasonable enough. In his view, as the advent of the Principate featured a professional army, military physicians were required, not just to care for soldiers, but to approve recruits, to exempt the wounded and sick from camp tasks, to facilitate the "honorable discharge" of those incapable of continuing in service, to staff and administer valitudinaria and, most likely, to apprise a commander of the number of soldiers fit to fight. Practitioners with Hellenistic medical training were preferred from the age of Augustus on. Adoption of the Greek system in so large an organization as the Imperial army, and the fact that units of the army were stationed on the far reaches of the Empire, fostered the dissemination of Greek inspired medicine and sanitary infrastructure. In turn, military doctors became acquainted with local means of healing, especially pharmaceutical, which were then disseminated over the efficient transportation system of the Empire and incorporated into the treatises of authorities like Dioscorides and Scribonius Largus. The nature of their service also presented surgeons the opportunity to develop new procedures, in particular for wounds. Once again, we find in the numerous dedications of military doctors no either/or as regards religion and science. Israelowich does find an exception, however, between the army and civil society when it came to professional legitimacy and status: in the latter patients chose their physicians; in contrast, military doctors were "appointed by the army, bestowed with a privileged legal position, and sanctioned to care for the soldiers."

The fifth chapter ("Medical Tourism during the High Roman Empire") walks the reader through the sanctuaries/temples, spas and cities frequently visited by "tourists" in search of cures. Featured among sanctuaries is the Asclepieion at Pergamum and the priests and physicians (some individuals assuming both roles) associated with it. Featured too is hydrotherapy, based on and developed from Hippocratic principles as practiced at many Asclepieia and at sites associated with different types of water for healing and maintaining health, such as at Baiae. The popularity of bathing among Romans will also have promoted the rise of hydrotherapy. The primary locus in this chapter is the urban center in which these sanctuaries/temples, waters, and prominent healers were combined. Israelowich argues that the very civic landscape promoted health and healing. He singles out and discusses aqueducts, fountains, sewers, bathhouses, and gymnasia, in addition to holy places and medical personnel. The chapter concludes by focusing on Pergamum and the career of Galen. Stressed is the ease of access to all of these locales by the efficient and secure transportation system provided under the Pax Romana.

To cut to the quick: Patients and Healers is a substantial piece of scholarship, worthy of careful study for anyone interested the subject. Its focus on the perceptions and motives of the patient with emphasis on inscriptions and ex-voto dedications distinguishes this book from other general studies on health care under the Empire. Israelowich's most striking finding, that "scientific" and temple medicine shared a common language and, in some cases, common procedures, creates a picture of health care in which there was more cooperation than contention, even though Roman institutions saw doctors as distinct professionals. It had long ago occurred to this reviewer that, given the limits to what a physician might do when confronted with an incurable condition, a "faith healer" might be an attractive option. But for Israelowich health care was never an "either/or" situation: under the High Empire many approaches were always simultaneously available and attractive, trainers in the gymnasium, pharmacists and root cutters, for example, also being part of this cooperative nexus. All in all, Israelowich has made a positive case in his effort, stated in the Introduction, "to identify whether a shared belief system underpinned the various instances in which health care was sought and administered during the High Empire."

Commendable too is the organization of the book: each chapter is conveniently broken into sub-chapters, and each terminates in a handy summary, with a concluding summary supplied at the end of the volume. Repeated points of emphasis keep the reader focused, such as the coexistence of religious and "scientific" approaches to health care, the preference for Greek medicine by the Emperors, the efficient and secure transportation system of the Empire and, reflecting contemporary health care, the empowerment of the patient in making choices and in conferring legitimacy in the medical marketplace. One special merit of this book is that it puts between two covers relevant votives, papyri and inscriptions, a good deal of them unfamiliar to this reviewer. Important texts are cited in the original as well as in translation. Finally, the book is reasonably priced.

I append a few quibbles and comments:

pp. 58-59: I am dubious that serious surgery was ever performed in an Asclepieion. "Instruments" found in any of these sanctuaries, insofar as I know, are merely common multipurpose spoons and spatulas having no specific association with medicine. Polluting bloodshed and the possibility of a patient dying on the premises seem out of keeping with such locales. The occasional cupping vessels, forceps or surgical knives mentioned in their inscribed inventories are, therefore, unlikely to be actively used tools, but just dedications, like the Athenian relief depicting such instruments from the Asclepieion on the Acropolis.1 The miraculous Epidaurian iama cited in support (the cure of Ambrosia's blindness by cutting into her sick eye and pouring medicine over it) has no parallel in classical surgical literature.

p. 73n: Celsus 5.23.5 and 25.13 cited for abortion are slightly misleading: the recipes given are for expelling a dead fetus, not a live one.

p. 79: Does the undocumented statement "other sources portraying a crescent shaped opening in the seat of the midwife's chair" refer to an unprovenanced relief in Basel? This is surely modern.2

p. 81: Re the citation of the fragmentary CILVI 8926: [Anonyma] Caesaris medica [ex familia c]asterni coiugi… f]ecit. The word casterni makes no sense. The online Clauss Slaby Datenbank prints medica(tor) / [3 c]astrensi coniugi / [3 f]ecit. Do we really have a female doctor in the Imperial household here?

pp. 6, 83: Were midwives really "expected" to be able to perform caesarean section? Pace the author, Digesta 28.2.12 does not so attest. Soranus, Gyn. 4.7-8 has doctors take over in cases of dystocia. This fits with descriptions of gynecological/obstetrical interventions in Hippocrates, Celsus, Aëtius, and Paul, where male attendance is the rule.

p. 96: The midwife's forceps emerges with the Chamberlens in the 17th century. There was no such instrument in classical antiquity.3

p. 97: The "Scoop of Diocles" cited in the Meyer-Steineg collection is not ancient. There may be a genuine specimen, however, in the rich instrumentarium recovered of late in Ravenna.4

The bibliography is full and up to date, though I miss an apropos essay paralleling the topics covered in chapter two: Cécile Nissen, "Asclépios et les Médecins d' après les Inscriptions Grecques: des Relations Cultuelles," Medicina nei Secoli, 19/3: 2007, 721-744. Also, Ernst Künzl's Medica, Die Ärztin, Mainz am Rhein: Nunnerich-Asmus Verlag & Media, 2013, would have been useful to the treatment of midwives/female practitioners in chapter three.



Notes:


1.   See John St. Milne, Surgical Instruments in Greek and Roman Times, Oxford: Clarendon Press, 1907, repr. New York: Augustus M. Kelley, 1970, Pl. IV.
2.   Quite apart from my own leanings, see Mirko Grmek and Danielle Gourevitch, Les maladies dans l'art antique, Paris: Fayard, 1998, 339.
3.   The relief depicting one in the Baglioni collection is not classical; Ernst Künzl, "Die Geburt des Kaisers Augustus? Zu den Hintergründen einer medizinhistorischen Fälschung," Archäologisches Korrespondenzblatt, 24: 1994, 403-5.
4.   E. Künzl, "Die Instrumenten aus Ephesos und Kos," in S. Zimmermann, E. Künzl, Die Antiken der Sammlung Meyer-Steineg in Jena, I, Sonderdruck aus Jahrbuch des Römisch-Germanischen Zentralmuseums Mainz, 38: 1991, 522-525; S. De Carolis, "Un nuovo strumento dalla domus Riminese 'del chirurgo'," Rivista Storica dell' Antichitá, 37: 2007, 119-22.

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