Stifling and Suffocation: the Development of the Textual Tradition

In my discussion of the ways in which the Hippocratics classify disease, I have emphasized that the disease label hysteria, far from being applied in these texts for the first time, is a much later invention. The developing hysteria tradition uses only a selection of the Hippocratic texts on womb

movement; within this selection, it ignores the disagreement on such matters as the most susceptible category of woman, and the variation in symptoms according to the part of the body that the womb reaches in its quest for moisture. It also takes and merges distinctive images and therapies from these texts, regardless of their relative importance in Hippocratic medicine.

In the texts used to support this developing tradition, the symptom that stands out, and that is indeed sometimes used to introduce the Hippocratic disease description, is pnix , usually translated as suffocation. It is now necessary to consider the significance of this symptom in some detail. If we are to take seriously Shorter's suggestions that "the presentation of 'hysterical' symptoms tends to be molded by the surrounding culture" and that we should therefore be asking why "certain symptoms are selected in certain epochs,"^[130] we need to reject our fascination with womb movement—which was, after all, seen as unproblematic by classical Greek writers—and instead explore the implications of pnix in the very specific context of classical Greek medicine.

In his recent history of hysteria, Trillat poses a very pertinent question: is it the womb or the woman who suffocates in these texts?^[131] He suggests that this is not clear from the Hippocratic texts; however, unlike the Littré translation, the Greek text is often relatively straightforward on this issue, due partly to the convention by which Hippocratic writers often used plural terms for the womb. This enables us to see that, although in some cases it is the woman who suffers from the pnix ,^[132] it is generally the womb that is "stifled"; for example, "When the womb (sing.) stifles"; "If the womb (plural) arrives at the heart and stifles (plural)."^[133] I am proposing the translation "stifles" rather than "suffocates" for reasons that will shortly become clear.

In order to grasp the implications of pnix , the stifled womb that in turn stifles the woman, it is necessary to return to the question of what the Hippocratic writers—and the culture within which they practiced—understood to be the nature of woman. "Not only was the cause of hysteria rooted in the very nature of being female, but also in the belief that that nature was prone to disorder": thus W. Mitchinson, in a recent article on nineteenth-century Canadian medicine.^[134] This interest in nature takes on a different coloring in the key hysteria text of the early seventeenth century, Edward Jorden on "the suffocation of the mother," which was written to show that this disorder should not be "imputed to the Divell" but rather has "its true naturall causes."^[135]

In Jorden's sense, nature is also fundamental to the Hippocratic texts. One of the achievements of Hippocratic medicine which it is common-

place to admire is its movement away from explaining disease as divine in origin—the result of displeasing a deity, as in the opening of the Iliad , or of failing to fulfill a ritual obligation—in favor of natural explanations.^[136] The Hippocratic text usually quoted in this context is On the Sacred Disease , in which the alarming symptoms of epilepsy are shown to have a natural explanation, making it no more and no less sacred than any other disease. In the Hippocratic Diseases of Women 2.151^[137] an explicit comparison is drawn between a group of symptoms classified by Littré as hysteria and the sacred disease. It would be wrong to conclude from this that medical writers in the ancient world had correctly understood the similarity between the mechanisms by which these two disorders, as we define them, are produced; what is important is the suggestion that there is a natural explanation not only for the symptoms produced by womb movement but also for that movement itself.^[138]

For the history of medicine, it does not matter that the "natural" explanations given—the movement of the womb around the body, the constitution of the female—are ones in which we do not believe; what is important is that nature, not the gods, is thought to be responsible. There is however a further aspect of the production of the symptoms which explains why they naturally affect only women; women, by nature, have wombs, and "the womb"—implying both "not the gods" and "no other part of the body"—"is the origin of all diseases" according to the Hippocratic text Places in Man .^[139] Menstruation is, as the second-century A.D . writer Soranus puts it, "the first function" of the womb,^[140] and the writer of the Hippocratic text Nature of the Child describes as "simply a fact of her original constitution" the naturally wetter and more spongy flesh of the female which makes a woman produce excess blood.^[141] This blood moves to the womb every month prior to leaving the body in that flow that is, among other names, called he physis , "nature,"^[142] or ta kata physin , "the natural things."^[143]

For the Hippocratic writers, then, menstruation and nature are synonyms; all diseases of women come from the womb and thus from the nature of female flesh, the wet and spongy texture of which causes the accumulation of large amounts of blood, making menstruation necessary to female health. As Generation 4 puts it, "if the menses do not flow, the bodies of women become sick."^[144]

The symptom of pnix arises from the nature of woman. There is some disagreement in the ancient medical writers as to whether women are by nature hot or cold. For Aristotle, whose ideas on this point were historically more influential than those of the Hippocratics, women are cold, too cold to concoct blood into semen.^[145] Difficulties arise with this

position because, in humoral pathology, blood is hot and wet. If women have more blood than men, surely they should be hotter than men? In the debate given by Plutarch in Moralia ,^[146] a doctor takes up precisely this position in order to argue that women are the hotter sex; this is also the argument used to prove women's hot natures by "Parmenides and others," according to Aristotle,^[147] and a related argument appears in the Hippocratic Diseases of Women 1.1,^[148] which says that "the woman has hotter blood, and because of this she is hotter than the man."

It is however possible to argue that women are cold, despite their excess blood. Other speakers in the Plutarch passage claim that menstrual blood is not normal, "hot" blood, but a cold and corrupt form. The Hippocratic writer of Regimen 1.34 does not go this far; he accepts that menstrual blood is hot but argues that, since they purge the hot every month, women end up being cold!^[149]

There is also a third option; the womb, due to the way in which its role in conception and gestation is imagined, can be classed as hot, whether or not the menstrual blood or the woman herself is considered cold. Aristotle, for whom women are cold, can thus retain the traditional analogy by which the womb is compared to an oven.^[150] This analogy appears in a wide range of types of source material. By committing necrophilia, the tyrant Periander of Corinth was—in the words of the historian Herodotus—"putting his loaves into a cold oven."^[151] In the Dream Book of Artemidorus, an important source for ancient imagery, a hearth (hestia ) and a baking-oven (klibanos ) can represent women, because they receive things that produce life. Dreaming of seeing fire in a hearth means that your wife will become pregnant.^[152] In the Hippocratic texts Generation and Nature of the Child there are several occasions in which the womb is described in terms of the heat it generates, in one of which the embryo is compared to bread baking in an oven. Intercourse heats the blood and thus produces heat in the whole body, and the development of the seed in the womb is due to its being in "a warm environment."^[153] Whether women are classified as hot or cold, they have within them an oven to heat the seed.

How should this influence our understanding of pnix? The sensations of suffocation and stifling are not necessarily identical. Suffocation implies an obstacle preventing breathing; in this it resembles strangulation but, whereas the former suggests to us something over the mouth and nose, the latter suggests something around the neck. Stifling additionally implies heat, which is why it is to be preferred as a translation of pnix . Overlap is of course possible, since pressure around the neck or over the mouth may also cause a feeling of heat. Greek words related to pnix ,

such as pnigos and pnigmos , mean stifling heat, while a pnigeus is an oven. Support for the importance of heat in pnix in the period of the Hippocratic texts may be gained from Aristophanes' play Frogs , in which the god Dionysus asks the hero Heracles for a way to Hades which is neither too hot nor too cold. Heracles suggests "by rope and stool"—that is, to hang oneself. Dionysus replies, "No, that's stifling."^[154] Heracles goes on to suggest hemlock, which is rejected as "too cold." The use of a hot/cold opposition again associates pnix with heat.

It is thus because the Hippocratic writers have absorbed the traditional and powerful image of womb as oven that they associate its movement with the production of excess heat. This suggests a further aspect of the common recommendation of pregnancy as the best cure for many disorders of the womb; if nothing is cooking in a woman's oven, its heat will overwhelm her in some way unless something is done to use up that heat. The underlying image of womb as oven in these texts could account for other symptoms. Women with pnix feel cold at their extremities, perhaps because all their body heat moves toward the womb.

In the cultural context of Hippocratic medicine, pnix thus implies something more than "difficulty in breathing." It points us to something fundamental to that culture's image of the female, as an oven in which the seed is cooked. The supposed movement of that oven to other parts of the body in search of moisture to dampen down the fire can therefore be seen as causing heat in the affected part; the womb itself is stifled, and this can be transmitted to the woman sufferer. Being a woman, for the Greeks of this period, means having an oven inside you; an oven that is a natural—and socially acceptable—target when a physical cause is sought for dramatic somatic manifestations.^[155]

I have already demonstrated the variations within the Hippocratic corpus on such questions as the heat or coolness of the woman and the most likely category to suffer from womb movement. There is one Hippocratic passage in which pnix is explicitly linked to physical obstruction of breath. This is Diseases of Women 1.7, in which the womb, dried out by fatigue, moves to the liver because this organ is full of moisture. The result is sudden pnix , due to what is described as the interruption of the route of the breath through the belly. It is this etiology, rather than the general image of woman, or womb, as hot, which is taken up by later writers seeking to account for pnix . However, due to their general beliefs about the role of breath, heat still plays a part in such theories.

In later classical medicine pnix apparently becomes simply obstruction of respiration; however, nothing in the history of medicine is really simple. The implications of the shift in terminology require further explo-

ration of the conceptual universe of these writers, since respiration itself does not have the meaning we would most naturally assume.

The difficulty of using words such as respiration, veins, arteries, and pulse is that we regularly employ them within an anatomy and physiology completely different from those of ancient writers. Furthermore, theories of breathing, nutrition, and blood movement were themselves changed many times before William Harvey, and not necessarily as part of a linear process of experiment and discovery. To translate the Hippocratic phlebs (channel) as "vein" is to imply it is different from another sort of channel that is an "artery." The distinction between arteries and veins was probably first made by Praxagoras of Cos in the late fourth century B.C ., not in the context of an emerging theory of the circulation of the blood around the body, but instead because he believed blood and pneuma traveled through different systems.^[156]

Respiration is an excellent example of these difficulties, which also allows us to look at the presentation of hysteria in one of the immediately post-Hippocratic writers most relevant for the hysteria tradition: the fourth-century B.C . philosopher Heracleides of Pontus (ca. 390-310 B.C .). Although we may use respiration to mean breathing in general, behind the word inevitably lies our knowledge of the process by which oxygen is taken in and carbon dioxide given out. If we translate the title of a treatise by Galen, De usu respirationis , as "On the use of respiration," it may be difficult for us to appreciate the implications of the term within the science of the second century A.D . and before. A theory once widely held however is that of skin-breathing, discussed from before the time of Hippocrates to that of Galen. In the mid-fifth century B.C ., the philosopher Empedocles proposed that all living things breathe through the pores of their skin.^[157] Plato preserves a version of skin-breathing that also accounts for the movement of blood in the body; air enters through the skin to replace that exhaled through the nose and mouth, while also entering through the nose and mouth to replace that exhaled through the skin. The resulting movement, rather than the heart, is thought to be responsible for sending blood to those parts of the body requiring its nutriment.^[158] When Galen uses words for respiration, he includes within it skin-breathing.

Aristotle suggests that the function of respiration is to cool the innate heat generated in the body by food; Galen goes further, arguing that breathing occurs "for the sake of the innate heat" and, elsewhere, that "the use of breathing is the conservation of the innate heat."^[159] By this he means that breathing regulates the innate heat either by fanning it or by cooling it.

Skin-breathing and innate heat play an important role in Galen's theory of "hysterical suffocation," especially in relation to a story that becomes part of the hysteria tradition: the apparently dead woman whose revival is described in a lost work by Heracleides of Pontus. In his discussion of the most severe form of hysterical suffocation in On the Affected Parts 6.5 Galen refers to this story as follows:

For [Heracleides] says that that woman who had neither breath nor pulse could only be distinguished from a corpse in one way: that is, that she had a little warmth around the middle part of her body.^[160]

After Heracleides, Galen says, doctors developed tests for the presence of life: wool held at the nose, or a vessel of water on the navel. In the later tradition a deep concern remains over the ability of hysteria to mimic death—particularly since one of the symptoms is supposed to be the absence of any pulse—and stories are told of women mistaken for dead who revive on the edge of the grave.^[161] Although Apnous is lost, the story of the woman is repeated in several other writers of antiquity. The closest to Galen in both wording and time is Diogenes Laertius, a writer of the third century A.D ., who states that the woman's body was apnoun kai asphykton , "without breath or pulse," for thirty days. As well as this last detail, Diogenes Laertius adds further information about the circumstances, and this is duplicated in other writers.^[162] The story told by Heracleides apparently concerns Empedocles, who told his friend Pausanias how he had realized the woman was not dead from observing the innate heat. Clearly she was able to breathe through her skin, and eventually recovered, much to the amazement of the onlookers who attributed this to a miracle performed by Empedocles.

This story was very popular in the sixteenth century; one medical writer of that period who used it was Pieter van Foreest. Instead of following Diogenes Laertius, who said that the woman was without breath or pulse for thirty days, he uses the version given prior to Galen, by Pliny in the first century A.D .^[163] This sets the story within a discussion of souls that leave the body and return to it, which is in turn followed by accounts of people who recovered from apparent death. Pliny writes, "This topic is the subject of a book by Heracleides, well known in Greece, about a woman who was seven days without breath but was called back to life." Van Foreest repeats the "seven days" as well as Pliny's remark that "the female sex seems particularly liable to this disease, since it is subject to turning of the womb."^[164] In his scholia on this section, van Foreest follows Galen's theory on the innate heat, which is also used to account for the coldness of the extremities. He then states that learned authorities

all agree that patients with this condition should not be buried until the third day.^[165] Why should he give the third, rather than using seven or thirty? Perhaps the solution is to be found in the use of the story in early Christian writing. Origen (ca. A.D . 185-ca. A.D . 254) refers unbelievers to it in the context of Christ's resurrection from the dead: although Origen does not say how long the woman in the story in Heracleides lay dead, the figure of three days may come from this analogy.^[166]

Galen was thus not the only ancient writer to associate the story with a condition of the womb; however, where Pliny merely says that women are more likely to suffer in this way because their wombs move, Galen gives a full etiology accepting the theories of innate heat and skin-breathing.