The history of the western part of ancient North Africa is to a great extent the history of foreign invaders who conquered the country and imposed their language and culture on the inhabitants. Apart from the Berbers, who were the indigenous inhabitants of North Africa west of the Nile Valley, the Phoenicians, Romans, Vandals, Byzantines, Arabs, Turks and French all made their presence felt in the centuries gone by. In modern times, independent states – Libya, Tunisia, Algeria, Morocco and Mauritania – have replaced the region known as North Africa in ancient times.

The period during which the Romans held sway over North Africa (146 BCE–439 CE) in particular interests us, since it presents a remarkable phenomenon: not only does this period encapsulate within some 500 years the rise and fall of a country, but equally amazing, in the aftermath it appears that not a trace of Rome's influence on the region remained, even after half a millennium of rule. Only ruins as a sad reminder of a remarkable period in world history.

A brief overview of the history of Roman North Africa

Approximately 3000 years ago the Phoenicians were the first to discern and exploit the strategic possibilities of a promontory in the Mediterranean Sea just across from Sicily. Ships crossing the sea from east to west and back all had to pass through the 320 km strait between the present-day Sharīk Peninsula and the western tip of Sicily, which made it a valuable strategic asset to the country controlling it. According to legend, the Phoenicians, Semitic colonists from Tyre (in modern Lebanon), founded a city on this promontory (near modern Tunis) in c. 800 BCE; they called it Quart-hadasht (‘Carthago’ in Latin), which means ‘New City’, implying that it was a ‘new Tyre’. By the sixth century BCE Carthage had grown to one of the most important Phoenician settlements on the North African coast, especially after the influx of immigrants from the mother city, Tyre, after it had been conquered by the Babylonian king, Nebuchadnezzar. Carthage now became a serious rival to the Greek settlers in Sicily and Corsica. This led to a long and bitter war in Sicily itself and also in North Africa.

Background

During the twilight years of the late Roman Empire in the West, the province of Africa Proconsularis, with Carthage as its administrative capital and centre, experienced a flowering of scientific and, in particular, medical activity. North Africa had, up to the Vandal invasion in the early fifth century, escaped the disasters that struck the eastern and western empires in the third century. Great parts of the empire had been ravaged by internal civil wars, Persian and Germanic invaders defeated Roman armies and the country experienced a financial crisis that reduced the coinage to almost nothing. In fact, in the late fourth century, the re-founded Carthage was the largest city in the western empire after Rome, and the province was peaceful and prosperous.

The tranquil circumstances in North Africa during the late fourth and early fifth centuries could have been one of the reasons for the amazing number of medical texts coming from this small but vibrant province. The French scholar Guy Sabbah pointed out that in the period from c. 370 to c. 450 CE the greatest number of medical works produced in the Roman world at large were written by four medical writers – Helvius Vindicianus, Theodorus Priscianus, Caelius Aurelianus and Cassius Felix – all of whom lived in or near Carthage. One of the main reasons advanced in the course of his article is North Africa's good school system. The fifth-century-CE Gallic monk Salvian wrote with admiration about the schools in North Africa where Greek, Latin and philosophy were taught. Sabbah even suggested the existence of an ‘African School’ of physicians and medical writers, but that is perhaps taking it a step too far. Still, that there were highly intellectual circles in Carthage where medical matters such as the urgency of translating Greek works into Latin for ordinary doctors, and the provision of text books for aspiring medical practitioners of whatever level of expertise, were discussed, cannot be denied. In fact, the works by the aforementioned authors give the impression that they were didactic, lecture notes, as it were, written for students who study medicine. Vindicianus’ Gynecology is a prime example, as will be seen below; his letter to his nephew Pentadius likewise; Theodorus Priscianus’ Gynecology is written for midwives or people assisting with births (see Chapter 6), Cassius Felix's On medicine would also have been useful for students studying medicine (see Chapter 7).

Background

In 1919, archaeological excavations at Thamugadi (now Timgad) in North Africa brought to light a fragment of an inscription containing an invocation to Christus Medicus – ‘Christ the Physician’. A second fragment completing the inscription was found nearby in 1923. This unique epigraphic evidence dating to the end of the fourth and beginning of the fifth century CE confirms numerous references to this concept in Christian literature. Arbesmann indicates that it was popular in Roman North Africa since the time of Tertullian (second and third centuries CE), and occurs very frequently in St. Augustine's works, especially in his sermons as priest and later Bishop at Hippo Regius. But before the reason for this African Church Father's use of the concept (which gives us an interesting glimpse of his personality) can be discussed, his life and his interest in the medical sciences have to be reviewed against the background of the era. The focus of this chapter is however not only Augustine himself; references to medicine in his voluminous writings allow us a wide-angle view of the whole medical scene in Roman North Africa in the late fourth and early fifth centuries CE.

Life

Augustine's childhood and his progress as a young man are well documented in what can, to some extent, be seen as his autobiography, the Confessions. Aurelius Augustinus was born in 354 in the small town of Thagaste (now Souk Ahras in Algeria) from middle-class parents. His father, Patricius, about whom he has very little to say, was a pagan, but his mother, Monica, who had a great influence on him, was a Christian. He had his first education in Thagaste, where he was, inter alia, taught Greek, but he himself states that he never properly mastered it. At age eleven he went to Madauros (now Mdaourouch) for further schooling; he hated his time in school there, but enjoyed Latin, and Cicero's Hortensius sparked his interest in philosophy. Cicero, however, did not tell him about God, and finding the Bible disappointing because of the unskilful Latin translations that could not compare with Cicero's grand style, Augustine turned to the Manichees because of their appeal to reason and their erudition in the ‘liberal arts’ (see below).

Dionysius of Halicarnassus, a first-century-CE Greek historian, made the following remark in his book Roman Antiquities: ‘The extraordinary greatness of the Roman Empire manifests itself above all in three things: the aqueducts, the paved roads, and the construction of drains.’ These may seem very mundane aspects to eulogize, but had it not been for the infrastructure provided by aqueducts, bath complexes and sewers, many of Rome's achievements, among them the provision of health care, would not have been possible. The necessary infrastructure was made possible by the amazing level of architectural and technological knowledge of Roman engineers and their expertise in implementing the building plans.

Aqueducts

Aqueducts are, arguably, one of the most distinctive features of Roman civilization. In his famous book, The decline and fall of the Roman Empire, the eighteenth-century historian Edward Gibbon described aqueducts as ‘the noblest monuments of Roman genius and power’. Not only were they a symbol for everything Rome represented, they were also ‘conducive to the health […] of the meanest citizen’. This was already emphasized in the first century CE by the Roman Water Commissioner, Frontinus, when he compared the vital Roman aqueduct network with the ‘useless pyramids and the good-for-nothing tourist attractions of the Greeks’.

However, before proceeding to discuss these technological masterpieces, the bubble must be pricked to deflate some of the glory of the aqueducts. Archaeological excavations in North Africa during the past few decades have brought to light the fact that not many cities had aqueducts, yet thrived on water from traditional sources, such as wells, cisterns, reservoirs, rainwater tanks, and also from water drawn from the quanat, a characteristically Middle Eastern way of supplying water. Furthermore, little of the aqueduct water reached the ordinary citizen for domestic purposes: pipes from the aqueduct served only a restricted section of the urban centre, since water was mainly used for luxury consumption in prestige projects such as public baths, ornate fountains and the houses of the rich. Aqueducts, contrary to the quanat, were not necessary precursors to town development, but were mostly built belatedly after the city had already been established, as an indication of civic pride and an urbane Roman lifestyle (aqueduct building was ruinously expensive).

In 175 CE Galen, then one of the court physicians of the emperor Marcus Aurelius (r. 161–180), gave a public lecture in Rome on the knowledge and competence of contemporary physicians. In the lecture he pointed out some serious problems in this regard and suggested a number of criteria by which the best doctors could be recognized. Although the standard set by this brilliant (but insufferably arrogant) physician was unrealistically high (he took himself as norm), there must have been some truth in his statement, since the information about the (in)competence of doctors described in another later source is equally negative. In a compilation of letters serving as introduction to a collection of medical recipes assembled by Marcellus (end of fourth and early fifth centuries), a Gallic nobleman of Burdigala (now Bordeaux in France), it appears that doctors were found lacking in many respects. In addition to this there is a letter from Vindicianus (late fourth century CE; proconsul of the province of Africa Proconsularis, but also renowned physician) to the emperor Valentinian I, in which Vindicianus fulminates against his colleagues who, because of ignorance, applied the wrong therapy to a seriously ill patient.

The problem

Criticism of doctors can be traced back to the earliest medical manuscripts and occur in practically every literary genre. The problem is that there was no official licensing by the state, or by a body such as a general medical council, to ensure that those presenting themselves as doctors have the necessary medical knowledge and competence. There was also no consensus about what the training of those aspiring to become doctors should comprise. People with little or no competence could thus practise as doctors, with the result that doctors acquired a bad reputation, as is reflected in the works of, inter alia, the satirist Martial, who remarks in one of his epigrams, ‘Diaulus was a doctor until recently, now he is an undertaker; what he does now he also did as doctor.’ And in the first century CE Pliny the Elder, in his encyclopedic work the Natural History, has much to say about the ignorance of doctors that put patients’ lives at risk. His remark that only a doctor can commit homicide with complete impunity speaks volumes.

North Africa was the most prosperous province during the late Roman Empire and experienced a flowering in all fields, but especially in science and medicine. A great number of medical texts produced in this period in the Roman Empire at large originated in North Africa. Four outstanding physicians/medical authors in late fourth- and early fifth-century North Africa immediately attract our attention: Helvius Vindicianus, Theodorus Priscianus, Caelius Aurelianus and Cassius Felix.

It is my intention to envision these four authors in their own environment and time frame. The first chapter thus deals with Roman North Africa in general – its rise and its fall after three waves of foreign invaders had swept across the country; the development and demise of some of the cities, especially Carthage, where Vindicianus would have had his seat as proconsul, and Cirta, the home town of Cassius Felix; the people who inhabited these cities, each with their own language and culture; and some famous contemporary Classical and Christian authors.

The health facilities available so many centuries ago are astounding. The aqueducts, the massive bath complexes and the Cloaca Maxima, a sewer in which an ox wagon could turn around, are only a few examples of the amazing level of architectural and technological knowledge of the Roman engineers. Yet the cities were deficient in disposing of human waste, which must have led to many diseases. Hospitals, a Christian initiative, were only established in the fourth century.

Various epidemics for which there were no cures swept through North Africa in the fourth and fifth centuries, killing thousands of people. It is interesting to note the changing views of the reasons for these epidemics in the course of centuries.

The question then arises what the standard of health services was. Not only was the lack of antibiotics and antiseptics, discovered some 1500 years later, a problem, but also the fact that diagnoses and operations were done with little knowledge since there was a veto on dissection. The absence of a health board to supervise the standard of physicians meant that any quack could present himself as a doctor.

Background

The late fourth and early fifth centuries CE were a remarkable period in the history of Roman North Africa. On the one hand there was the Vandal invasion of North Africa and the fall of Carthage in 439, with all that this disaster entailed on the social, economic and agricultural levels. On the other hand, in this very same period, we find an amazing productivity of medical texts, for which Vindicianus, proconsul and physician, his student Theodorus Priscianus, Caelius Aurelianus, the physician Cassius Felix and, somewhat later, Muscio were responsible.

If one were to look for an explanation for this interesting phenomenon, a few reasons come to mind. Rome was, in the first instance, no longer the official capital of the western Roman Empire (since 402 it was Ravenna), nor was it the intellectual and cultural centre that it had been in earlier times. The centre had gradually shifted south to Carthage, which had not been ravished by long drawn-out civil wars and invasions by barbarians during the previous two centuries. North Africa was peaceful and prosperous, at least until the Vandal invasion in 429. The social stability of the country meant that scholars had the opportunity to devote themselves to the study of the ancient Greek manuscripts, and the money to acquire the manuscripts. Travel was also still possible, retaining the possibility of contact with the medical school in Alexandria, which was still flourishing in the third and fourth centuries. A more immediate reason was the fact that, thanks to the good schooling that children received in North Africa, there were still scholars who understood Greek in the late fourth and early fifth centuries, something that was becoming an exception in the rest of the western Roman Empire.

The question arises whether the four medical writers mentioned above had anything in common, anything specifically ‘African’? Was there, for instance, something ‘African’ in the drugs they recommended that caused them to be different from those in the Greek East? That does not seem to be the case. Sabbah points out that the plants from which the materia medica (drug ingredients) recommended by the North African authors derived are basically the same as those in the Mediterranean basin.