By Tim Harding
‘By definition, alternative medicine has either not been proved to work or has been proved not to work. You know what they call alternative medicine that has been proved to work? Medicine.’ – Tim Minchin
A corollary of Tim Minchin’s rhetorical question might be ‘What should we call alternative medicine that has been proved not to work?’ I recently asked this question at my local Skeptics in the Pub meeting, eliciting an immediate and resounding chorus of ‘Quackery!’ (When you think about it, if the part of ‘alternative medicine’ that works is medicine, and the part that doesn’t work is quackery, there is nothing left in the category of ‘alternative medicine’).
On his Quackwatch web site, Dr. Stephen Barrett defines quackery as ‘the promotion of unsubstantiated methods that lack a scientifically plausible rationale’. This definition includes questionable ideas as well as questionable products and services, regardless of the sincerity of their promoters. In line with this definition, Barrett reserves the word ‘fraud’ only for situations in which deliberate deception is involved.
So where did quackery come from? The word ‘quack’ derives from the archaic word ‘quacksalver’, of Dutch origin, literally meaning ‘hawker of salve’. The quacksalvers sold their wares on the market by shouting in a loud voice. In the Middle Ages, the word ‘quack’ meant ‘shouting’. These days, we tend to associate quackery with dodgy products and practices from the nineteenth century such as snake oil, miracle hair tonics, magnetic bracelets and homeopathic remedies. But the origins of western quackery actually go back much further – to the cradle of western civilisation in ancient Greece and Rome.
In those ancient times, scientific experimental methods had not yet been developed – let alone clinical trials. Medical observations were largely confined to patients as individuals rather as a cohort or group. Ancient physicians were not much better than naturopaths when it came to empirical evidence. Without scientific data from treatment groups versus control groups, it was difficult to know which treatments worked and which didn’t. As a result, there was no clear dividing line between medicine and quackery. Ancient ‘medicine’ consisted of a mish-mash of well-meaning but misguided treatment by physicians and surgeons, faith healers, herbal remedies, aromotherapy, other superstitions – and even sorcery or magic. Sounds familiar? That’s right – many of these weird ancient beliefs have carried through to the quackery of today as a legacy of the vast Roman Empire.
Ancient Greek medicine
The first notable Greek physician may have been the poet Homer in the 7th or 8th centuries BCE. In his Iliad, Homer describes various medical techniques such as the extraction of arrows, the treatment of wounds, the application of dressings and the dispensing of soothing drugs. The Homeric poems provide a glimpse of ancient medical ideas and practices long before the formal documentation of medical literature. It is significant that practical medical treatment appears to have been provided in this early period, probably as a matter of military necessity, so that wounded soldiers could be saved to fight another day.
Reliance on the gods or faith healing seems to have come later, to some extent in parallel with advances in medical treatment. The god of healing, Asklepios, had a shrine at Epidaurus in southern Greece, where miraculous recoveries were said to have been made by the sick and lame by sleeping in the temple overnight. A Greek lyric poet from Thebes named Pindar (c.522– c.443 BCE) wrote:
‘[Asklepios] delivered all of them from their different pains, tending some of them with gentle incantations, others with soothing potions, or by wrapping remedies all around their limbs, and others he set right with surgery.’
The following picture is of a cast showing a physician examining a patient while Asklepios stands nearby holding the symbol of medicine, a snake coiled round a staff.
There were also apothecaries who harvested herbs and prepared drugs, accompanying their ministrations with important rituals and incantations. Theophrastus (c.371 – c.287 BCE), who was a student of Aristotle, described some of these weird rituals in his History of Plants:
‘They say that the peony, which some call glykyside, should be dug up at night, for, if a man does it in the day-time and is observed by a woodpecker while he is gathering the fruit, he risks the loss of his eyesight; and if he is cutting the root at the time, he gets a prolapsed anus’.
‘One should draw three circles around mandrake with a sword, and cut it with one’s face to the west; and at the cutting of the second piece one should dance around the plant and say as many things as possible about the mysteries of love’.
On the other hand, the medical literature subsequently found in Greece differs markedly from that found elsewhere. It includes reasoned arguments and debates, reflecting an intellectual openness consistent with Greek philosophy, rather than medicine as some sort of secret mystical art. The links between medicine and philosophy can be traced back to Parmenides, Empedocles and even Pythagoras, whose ideas on appropriate living included a ban on eating beans!
Athens was one of the first city states to employ a publicly funded physician as a more rational alternative to traditional folk medicine. Other Greek cities also maintained a public physician as well as several private practitioners.
The Greek historian Herodotus tells the tale of the early Greek physician Democedes of Croton, who started his career in the civil service of Athens and Aegina. In 522 BCE, Democedes was captured by the Persians and sent to Susa. The Persian King Darius once sprained his ankle while he was hunting, and his Egyptian doctors seemed to make it worse. Darius then summoned Democedes, who was able to heal the ankle using Greek remedies. Democedes was richly rewarded and hired as a physician of the Persian court. Darius’s wife, Atossa, later had a breast ulcer. When Democedes cured her ulcer, he was allowed to visit Greece as a reward.
Schools of medicine had existed for some time in various regions of Greece, most notably on the island of Kos, associated with the famous name of Hippokrates, a younger contemporary of Herodotus. Hippokrates’ contribution to medicine is best remembered today by the ethical oath bearing his name. Very little is known of Hippokrates himself, or how much of the Hippokrates medical treatises he personally wrote. Hippokrates is cited in later works by Aristotle and Plato; but the Greek habit of composing imaginary speeches or letters by famous people from the past gradually blurred the distinction between the genuine and the false. The following references to Hippokrates are actually references to the large body of medical literature bearing his name, the Hippokratic Corpus.
Hippokrates attempted to put medical diagnosis and treatment on a rational basis. He viewed the human body as an organism whose parts must be understand as a whole. Hippokrates thought that human physiology was comprised of four fluids or ‘humors’: blood, phlegm, black bile and yellow bile, corresponding to the four inanimate elements of earth, air, fire and water, as shown in the diagram below.
Disease was thought to result from an imbalance of these humors, resulting in a disturbance of the natural harmony and order of the world so important to Classical Greek thought. Hippokrates also placed emphasis on prognosis as well as diagnosis, so that the course of an illness could be predicted. The more familiarity a physician showed with a disease, the more confidence his patients would have in him. Prognosis also had practical benefits in planning the medical interventions that would be needed at different times.
In the absence of the modern germ theory of infectious disease, the danger to health from overcrowding within the Long Walls of Athens was not foreseen, resulting in a devastating plague in 430BCE. Thucydides did not attempt to explain the reasons for the plague, but in the prognostic tradition of Hippokrates, he tried to describe its symptoms and effects so that if it struck again it could be recognised.
Active medical interventions included cauterisation and blood-letting, as well as surgery, the rectification of dislocations and the setting of bone fractures. Other therapies included cupping, special diets, herbal remedies, potions, purgatives and exercises, consistent with the idea of ‘bringing the body back into balance’. One rather spectacular treatment often performed in public was succussion, where the patient would be tied upside down to a ladder and then repeatedly dropped from a height of several feet as illustrated below.
It is unclear what succussion was supposed to achieve, but it is worth noting that succussion is a word still used by homeopaths to describe a shaking step in the preparation of their water doses. The founder of homeopathy, Samuel Hahnemann falsely believed that succussion activated the ‘vital energy’ of the diluted substance and made it stronger.
The rise of quackery in Rome
Traditional Roman medicine was initially an amateur activity using simple home remedies based on easily available agricultural ingredients such as wool, eggs and the humble but miraculous cabbage. Cato the Elder wrote in his treatise On Agriculture:
‘For those who are troubled by colic, cabbage should be steeped in water…. ‘
‘Now as to patients for whom urination is painful or dribbling. Take cabbage, put in boiling water, boil briefly till half cooked…. ‘
‘If any sore or cancer develops in the breasts, apply ground cabbage …’
‘In case of dislocation, foment with hot water twice a day and apply ground cabbage: it will soon cure it…’
The Romans were a highly superstitious people. For instance, the Roman Senate only sat on ‘auspicious days’. In around 78 CE Pliny the Elder wrote in his Natural History:
‘I find that a bad cold in the head clears up if the sufferer kisses a mule on the nose.’
‘Some people keep a weasel’s heart in a small silver container, for swollen glands.’
The number three was regarded as a ‘lucky number’. An anonymous Roman inscription reads:
‘To Julian who was spitting up blood and had been despaired of by all men the god revealed that he should go and from the threefold altar take the seeds of a pine cone and eat them with honey for three days. And he was saved and went and publicly offered thanks before the people’
Later Roman culture was greatly influenced by the ancient Greeks in many things, including philosophy, literature, art, science and medicine.
Galen of Pergamon (c. 129-200 CE) was a leading surgeon, physician, and philosopher of Greek origin. In 162 CE, he established a large and successful practice in Rome, where he attended the Emperor Marcus Aurelias. Amongst his voluminous works was a short essay entitled That the Best Physician is also a Philosopher, where he urged physicians to emulate Hippokrates and to embrace logic and rationality:
‘What reason, then, remains why the doctor, who practises the Art in a manner worthy of Hippocrates, should not be a philosopher? For since, in order to discover the nature of the body, and the distinctions between diseases, and the indications for remedies, he must exercise his mind in rational thought, and since, so that he may persevere laboriously in the practice of these things, he must despise riches and exercise temperance, he must already possess all the parts of philosophy: the logical, the scientific, and the ethical’.
Consistent with this approach, Galen saw the bodies of living things and their various parts as designed and operated by a craftsman-like nature with a purpose in mind; thus an important key to anatomical and physiological knowledge is an understanding of nature’s purposes. This form of ‘intelligent design’ has been described as a teleological view of biology by modern reviewers of Galen’s writings. Galen held that nature rules the body from three anatomical centres – the liver, the heart and the brain (in contrast to the Aristotelian view that all faculties are centred in the heart). He claimed that human physiology can be explained by the principal activities of nature, which are genesis, growth and nutrition.
Like Hippokrates , Galen believed in the need for the ‘four humors’ to be in balance: blood, black bile, yellow bile and phlegm. He thought that the human body had three physiological spheres: the nutritive, the vital and the logical. According to Galen, stomach cooks food to what was called ‘chyle’ and sends it to the liver. The liver adds ‘natural spirit’ and sends it to other organs and the heart. The heart adds ‘vital spirit’ and sends it to the brain. The brain adds what was called ‘pneuma’ and sends to the body through nerves. Such views were the likely origin of the modern naturopathic belief in ‘vitalism’ that persists today. Naturopathy posits that a special energy called ‘vital energy’ or ‘vital force’ guides bodily processes such as metabolism, reproduction, growth, and adaptation. Such energies and forces are unknown to modern science.
For religious reasons, there was little or no dissection of human corpses in ancient Rome. Nevertheless, Galen believed in the supreme importance of anatomy, so he regularly performed dissections on animals. Although he was conscious of the limitations of extrapolating from animals to humans, he did express some erroneous views about human anatomy, such as the following description by Galen in his work On the Usefulness of Parts of the Body:
‘All the parts, then, that men have, women have too, the difference between them lying in only one thing, which must be kept in mind throughout the discussion, namely, that in women the parts are within [the body], whereas in men they are outside, in the region called the perineum. Consider first whichever ones you please, turn outward the woman’s, turn inward, so to speak and fold double the man’s, and you will find them the same in both in every respect’.
Women were treated by male physicians and the gynaecological treatises of the Hippokratic Corpus were almost certainly written by and for men. Part of the deficiency of observational evidence stems from the failure of male medical writers to speak to women about their illnesses. Women were traditionally presented as being incapable of knowing what was wrong with them or telling a doctor if they did know. Galen’s teleological view of biology also appears to have influenced his attitudes towards women:
‘So too the woman is less perfect than the man in respect to the generative parts. For the parts were formed within her when she was still a foetus, but could not because of the defect in the heart emerge and project on the outside, and this, though making the animal itself that was being formed less perfect than one that is complete in all respects, provided no small advantage for the race; for there needs must be a female. Indeed, you ought not to think that our creator would purposely make half the whole race imperfect and, as it were, mutilated, unless there was to be some great advantage in such a mutilation’.
These biased attitudes impacted wider Greek and Roman society. For example, it was believed, on false medical grounds, that a man’s seed was most potent when he was about 30 years of age; and a woman’s body best suited for childbirth when she was still a teenager.
The medical theories of ancient Greece and Rome formed the foundation of Western medicine for centuries, even if they were eventually rejected. The main reasons for this rejection were the development of empirical scientific methods after the Renaissance; coupled with advances such as the invention of the microscope and the germ theory of infectious disease. Whilst there were observations of individual patients, there is no evidence of any organised medical experiments being conducted in ancient Greece and Rome, let alone clinical trials. In some ways, the Greek philosophical traditions of logic and reasoning held back a more empirical scientific approach to medicine. Instead of conducting practical experiments on illnesses, ancient Greek and Roman physicians became diverted into a search for the underlying purposes of diseases – a relatively fruitless ‘search for meaning’ rather than for empirical evidence. This mystical and unscientific approach is one of the hallmarks of quackery today.
Aristotle On the Generation of Animals excerpt translated by A.L. Peck. Published online http://www.stoa.org/diotima/anthology/wlgr/wlgr-medicine339.shtml
(Accessed 20 September 2012)
Galen That the Best Physician is also a Philosopher translated by Brain, P., 1977, “Galen on the ideal of the physician”, South Africa Medical Journal, 52: 936–938.
Galen On the Usefulness of Parts of the Body excerpt translated by M.T. May. Published online http://www.stoa.org/diotima/anthology/wlgr/wlgr-medicine351.shtml
(Accessed 20 September 2012)
Herodotus The Histories R.B. Strassler (ed), The Landmark Herodotus, Quercus, London, 2008.
Thucydides A Comprehensive Guide to the Peloponnesian War, R.B. Strassler (ed), The Landmark Thucydides, Free Press, New York, 1996.
Brain, P., 1986 Galen on Bloodletting: A Study of the Origins, Development and Validity of his Opinions, with a Translation of the Three Works Cambridge University Press, Cambridge.
Flaceliere, R., 2002 Daily Life in Greece at the Time of Pericles. Phoenix Press, London.
King, H., 1995 ‘Medical texts as a source for women’s history ‘ in The Greek World Anton Powell (ed.) Routledge, London and New York.
Martin, T. R., 2000 Ancient Greece – From Prehistoric to Hellenistic Times, Yale University Press, New Haven and London.
Nutton, V., 2004 Ancient Medicine Routledge, London and New York.
Pagel, W., 1970 Book Review of Galen and the Usefulness of Parts of the Body in Medical History/ Volume14 / Issue04 / October 1970, 406-408. Published online: 16 August 2012
Roberts, J.W., 1998 City of Sokrates: An Introduction to Classical Athens (2nd edition), Routledge, London.
Roebuck, C., 1966 The World of Ancient Times Charles Scribner’s Sons, New York.
Waterfield, R., 2004 Athens – A History, Macmillan, London, Basingstoke and Oxford.
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