Galen and His Influence: Winners and Losers in the Textual Tradition

Thus far, this chapter has covered the Hippocratic origins of the hysteria tradition in detail, while also mentioning the distinctive contributions of a small group of other writers: notably Plato and the second-century A.D . medical writers Aretaeus, Soranus, and Galen. It is however important to consider the question of the significant period between the fifth/fourth century B.C ., when the Hippocratic texts used here were being written, and the second century A.D . This is not an easy question to address. For the period immediately after the Hippocratics, literary medical sources are sparse. Works cited in later writers have not survived; we often read the extant fragments through the hostile eyes of an opponent, so that it is difficult not only to trace and date significant changes, but even to know what exactly was written.

Heracleides of Pontus (390-310 B.C .), whose lost work Apnous —mentioned by Pliny, Galen, and Diogenes Laertius among others—has already been discussed, is the only fourth-century writer other than Plato who is incorporated into the hysteria tradition. Other writers of the period are briefly introduced to the tradition, only to be rejected. Thus, for example, Soranus describes and criticizes the therapy used for hysterical pnix by Diocles of Carystos, who also worked in the fourth century B.C .; he "pinches the nostrils, but opens the mouth and applies a sternutative; moreover, with the hand he presses the uterus toward the lower parts by pressing upon the hypochondriac region; and applies warm fomentations to the legs."^[167]

In the third century B.C . important advances in anatomy were made in association with the medical school of Alexandria; the work of He-

rophilus of Chalcedon in particular is said to have included dissection of animal and human subjects, neither of which was practiced by the Hippocratics. For the history of hysteria, even more important than the fact that Herophilus is credited with being the first to identify the Fallopian tubes and ovaries is the attribution to him of the first description of the ligaments (which he called membranes) anchoring the womb in the abdominal cavity, a discovery which, in a positivist science, would have proved false the theory that the womb is capable of movement around the body.^[168]

No discussion by Herophilus of suffocation caused by the womb survives. His follower Mantias, who lived from around 165 to 90 B.C ., wrote on pharmacology, and one of the two surviving fragments of his work with a gynecological theme concerns hysterical suffocation. This fragment too is transmitted in the work of Soranus, who tells us that Mantias recommended playing flutes and drums when an attack was imminent, and giving castoreum and bitumen with wine when an attack was over. It is interesting that the discovery of the "membranes" does not appear to have significantly changed the therapy.^[169]

A further source for the period from the third to the first centuries B.C . consists of the surviving papyrus fragments from Greco-Roman Egypt, giving recipes, some of which may be identified as originating in the Hippocratic corpus. One very ancient collection of recipes, largely based on Diseases of Women and dating to the third or second century B.C ., mentions "suffocation from the womb" but recommends dried otters' kidneys in sweet wine—the only time this recipe occurs in Greek literature.^[170] A further recipe is given for a cough after the suffocation. Another papyrus dated to around 260-230 B.C . is too fragmentary for any reconstruction of the recipe, but it concerns a "hysterical woman" (gyne hysterike ); in the following line it is possible to read the word pnigmos .^[171] A papyrus from the early first century B.C . is even less legible, but the editor's reconstruction includes the words hysterikai and hysterikais .^[172] Papyri therefore show that Hippocratic recipes and variations on them continued to circulate in the ancient world; taken with the fragment of Mantias, they give further support to the proposal that the disease category hysterike pnix existed as a diagnosis in the second century B.C .

The next significant literary source comes from the Roman world: Celsus, writing in the early first century A.D . Book 4 of his work is arranged according to the parts of the body, and includes a chapter on diseases of the womb.^[173] This begins with a description of an unnamed but violent (vehemens ) illness that comes from the womb, an organ Celsus regarded as second only to the stomach in its influence on the rest of

the body. The condition he describes takes away the breath, so that the woman falls down as if she had epilepsy; however, unlike in epilepsy, the eyes are not "turned," there is no frothing at the mouth, and the sinews are not stretched. Instead, the patient sleeps. Some women suffer from this throughout their lives. Celsus does not investigate the etiology of the condition, but he gives recommendations for treatment: venesection, cupping-glasses, an extinguished lamp wick or other strong-smelling material held to the nostrils, cold water poured over the patient, hot wet poultices, and massage of the hips and knees. To prevent further attacks he recommends that the woman should abstain from wine for a year, be massaged regularly, and put mustard on her lower abdomen daily so that the skin reddens. He adds some suggestions for emollients, drinks (including castoreum), purges, and fumigations.

Some of this material is familiar; the cold water, lamp wick, and castoreum, for example, are no different from the Hippocratic recommendations, nor is the concern to distinguish the condition from epilepsy. Other suggestions are new; in particular, venesection, although used in the Hippocratic corpus, has not previously been discussed in association with this condition. As P. Brain has recently shown, although Galen gives the impression that venesection was a common therapy in the Hippocratic texts, it is in fact found only about seventy times in the entire corpus, and Diseases of Women contributes only one example.^[174] In Soranus it is recommended for hysterical suffocation, while for Galen it is the remedy of choice for menstrual suppression.^[175]

In the second century A.D . three medical descriptions of hysterical suffocation were produced, of differing importance to the growth of the hysteria tradition. By far the most influential in subsequent centuries was the work of Galen of Pergamum, although his triumph was not complete until after the eleventh century A.D ., when the translation of Arabic texts into Latin returned Galenic theory to the West. Until that time, although Arabic physicians were heavily influenced by Galenism, the many short gynecological treatises produced in the West were largely based on Soranus's Gynecology . However, this work was also disseminated in the East, through the Byzantine encyclopedists who used Soranus for their gynecological summaries. Its subsequent fortunes have been influenced by the fact that, although writers such as the sixth-century Aetius used it extensively, it survives in just one manuscript: the late fifteenth-century Paris BN gr. 2153 (Paris, Bibliothéque National, Greek manuscript number 2153), only discovered and identified by Dietz in 1830. The second-century writer most heavily influenced by Hippocratic sources was however neither Galen nor Soranus, but Aretaeus of Cap-

padocia, who had considerably less impact than either of the others on the later history of hysteria. Neither Soranus nor Aretaeus was translated into Arabic; nor, however, were the Hippocratic Diseases of Women and Nature of Woman , so that the Arabic descriptions of uterine suffocation derive from the Galenic version and its later interpreters: Oribasius, Aetius of Amida, and Paul of Aegina. The triumph of Hippocrates over Galen was delayed until the availability of printed Latin editions of the Hippocratic texts in the late sixteenth century.^[176] I now propose to look in turn at the texts of Aretaeus, Soranus, and Galen, establishing their contribution to the tradition, before turning to their use in late antiquity and beyond.

As has been discussed above, the description of hysterike pnix in Aretaeus's Of the Causes and Symptoms of Acute Diseases is today best known for its description of the womb as being "like an animal inside an animal," less emotively rendered as "like one living thing inside another." Like the Hippocratic writers, Aretaeus not only believes that the womb can move within the body but also advocates scent therapy, in which foul odors such as pitch, burned hair, an extinguished lamp, or castoreum are applied to the nose and fragrant substances rubbed into the external genitalia; unlike them, however, he knows of the membranes anchoring the womb in place.^[177] To us, the children of the "scientific method," these points may seem contradictory, but Aretaeus manages to combine them.

He describes the womb—"the seat of womanhood itself"—as being "all but alive," moving of its own volition upward to the thorax, or to left or right within the lower abdomen. It is when it moves upward and remains there for a long time, pressing violently on the intestines, that the patient experiences pnix , described as being like epilepsy^[178] without the spasms. Pressure is put on the liver, diaphragm, lungs, and heart, causing loss of breath and voice, while the carotid arteries are squeezed as a result of "sympathy" with the heart, causing a heavy head, loss of sensation, and deep sleep. Aretaeus then mentions a similar condition, characterized by pnix and loss of voice, which does not arise from the womb; the two differ in that only in cases arising in the womb will scent therapy help, and only in these cases do the limbs move.

When the womb moves up the body there will be "hesitation in doing her tasks, exhaustion, loss of control of the knees, dizziness, and her limbs are weakened; headache, heaviness of the head; and the woman feels pain in the channels at either side of her nose."^[179] The pulse will be weak and irregular, the breathing imperceptible, and death follows suddenly; it is difficult to believe that it has occurred, since the patient

has such a lifelike appearance. Recovery, too, happens suddenly; the womb rises up very easily, and just as easily returns to its place. Here Aretaeus uses another image, as vivid as that of the "living thing inside another living thing": the womb sails high in the water like a tree trunk floating, but it is pulled back by its membranes, of which those joining the neck of the womb to the loins are particularly capable of distending and contracting in a way that is likened to the sails of a ship.^[180] The condition is more likely to affect young women, since their way of life and understanding are "wandering," less firmly based.

Aretaeus thus combines womb movement with anchoring membranes, while continuing the exploration of a number of key themes in the hysteria tradition; for example, the difficulty in telling whether a sufferer from this condition is dead or alive, and the resemblance to epilepsy. Although much of the therapeutic material is Hippocratic, in particular the use of scent therapy, fumigation, and sneezing,^[181] he follows Celsus rather than the Hippocratics in recommending venesection from the ankle, while adding that one should pull out hairs from the patient in order to rouse her.^[182] He introduces the idea of "sympathy" in order to explain how the highest parts of the body can be affected by the womb; although the membranes prevent it from traveling that far, the womb can nevertheless exert an influence on these parts.

The survival of such Hippocratic ideas in the late antique and medieval worlds will be discussed later. However, as I have already mentioned, the main influence on late antiquity came from Soranus, the Hippocratics being read largely through the eyes of Galen until the mid-sixteenth century and beyond.^[183] Sections of Soranus's work were translated from Greek into Latin by Caelius Aurelianus in the fifth century, and—more important in terms of his later influence—by Muscio in the sixth century, thus making his ideas available in the Latin-speaking West. As for the Greek East, Soranus was the main source for the gynecological sections of the encyclopedias of Aetius of Amida in the mid-sixth century and Paul of Aegina in the seventh century, becoming in the East "la bible de la gynécologie et de l'obstétrique jusqu'à la Renaissance."^[184] What did Soranus contribute to the textual reservoir drawn on by the hysteria tradition?

The ideas of Soranus, in contrast to those of Aretaeus, are set in the context of the theories of the "methodist" medical sect. This arose in the first century A.D . in response to the dogmatist and empiricist positions. The fundamental difference between the latter two sects lay in their beliefs concerning the best way of acquiring knowledge. Where the dogmatists, despite some differences of opinion, agreed on the use of obser-

vation, dissection, and experiments in order to speculate on the "hidden causes" of diseases, the empiricists believed that no form of research could ever lead to an understanding of nature, and thus that the only route to knowledge was through the accumulated experience of past cases, which the practitioner could combine with his own experience in order to choose the correct therapy. Where the dogmatist was interested in causes, the empiricist looked for cures.

Methodism, in contrast to these sects, was based on a strict division of causes of symptoms into three conditions of the body: status laxus , in which the body or affected part is lax and wet, leading for example to a flux; status strictus , a constricted and dry state, of which amenorrhea was seen as a case in point; and status mixtus , a combination in which some parts of the body are constricted and others lax. Treatment characteristically began with a three-day fast, then built up the patient through diet and exercise, before moving on to aggressive treatments such as vomiting, shaking, or sneezing.^[185]

While Soranus is never a slave to the "method,"^[186] it is methodist theory that leads him to reject some commonplaces of Hippocratic medicine. For example, there is no place in the method for Hippocratic ideas of the superiority of right over left. Nor does Soranus accept the theory that the female body is qualitatively different from the male in terms of the porosity of its flesh; women are the same as men, except that they have some different organs, but even these organs are made of the same substance and subject to the same conditions. As a result of this reasoning, there is no place in Soranus's gynecology for the Hippocratic theory that menstruation is essential to female health as a means of purging the excess blood that naturally accumulates due to the wet and spongy consistency of female flesh. On the contrary, Soranus goes so far as to say that menstruation is bad for a woman's health, except insofar as it is necessary to conception. Intercourse is harmful, and permanent virginity is best for both men and women. Pregnancy, thought by earlier writers to relieve certain gynecological disorders, is in fact bad for women; it leads to exhaustion and premature old age.

Soranus also rejects the Hippocratic idea that the womb moves to other parts of the body. The womb cannot move; although he rejects dissection in principle, he quotes Herophilus of Chalcedon's research as proof that it is held in place by membranes.^[187] Soranus nevertheless accepts that there is a condition in which the major symptom is pnix , but he attributes it to inflammation of the membranes around the womb causing a status strictus .^[188] In particular he rejects any idea that the womb is an animal; it "does not issue forth like a wild animal from the lair,

delighted by fragrant odors and fleeing bad odors,"^[189] and he attributes this misunderstanding to its ability to respond to certain agents by stricture or relaxation. In treating the condition, he completely rejects the usual list of substances employed in scent therapy (they cause torpor and upset the stomach), together with sneezing (too violent) and intercourse; sexual intercourse cannot cure disease, since it has such bad effects on even a healthy body. Venesection is acceptable, however, after the patient has been warmed and rubbed with olive oil in order to relax her. The condition exists in both an acute and a chronic form, and treatment should take account of this.^[190]

While the gynecological theories of Soranus continued to circulate widely in both East and West through their use by the encyclopedists, the dominant influence on medicine as a whole in the Greek East was not Soranus but Galen. Where suffocation of the womb is concerned, Galen's descriptions eclipsed those of Soranus; writing as late as 1937, P. Diepgen describes Galen's picture of the hysterical attack as still being recognizable.^[191]

In his treatise On the Affected Parts , Galen himself calls the condition either hysterike pnix or apnoia hysterike , "absence of breath caused by the womb." Aretaeus had managed to combine the anchoring membranes with movement of the womb, while Soranus rejected womb movement and attributed the symptoms to inflammation of the membranes; Galen's new etiology was, however, to prove the most influential in the history of hysteria. He accepts that the womb is indeed the origin of the condition, but in place of movement to another part of the body, or inflammation, he blames retention of substances within the womb. The disorder manifests itself in a number of different forms—sometimes through lying motionless with an almost imperceptible pulse, sometimes through weakness while the patient remains conscious, and sometimes through contracture of the limbs.^[192]

A much-quoted section of On the Affected Parts reads: "I myself have seen many hysterikai women, as they call themselves and as the iatrinai call them."^[193]Iatrinai , literally "female healers," may also be translated as midwives. Hysterikai is usually translated as "hysterical" but, in view of what has already been said about ancient medical terminology, it would be more accurately translated as "suffering from the womb." In a recent article, Trillat attaches great significance to this passage. As has already been mentioned, Trillat recognizes that the word hysteria never appears in the Hippocratic corpus; however, on the basis of this passage of Galen, he asserts that it is in Galen's work "qu'apparait le mot d'hystérie," albeit in adjectival form.^[194] Of course, this is not particularly

significant since, as I have already shown, the adjective hysterikos also appears in the Hippocratic corpus. However, Trillat goes on to use the Galenic passage as the basis for his statement, "Hippocrate adopte la théorie populaire et rejette le nom. Galien rejette la théorie mais adopte le nom" (Hippocrates adopts the popular theory and rejects the name. Galen rejects the theory but adopts the name).

This raises many questions. There is little evidence for the theory of the wandering womb in classical Greek "popular thought" apart from Plato's Timaeus , and Plato is hardly the Greek equivalent of the man on the Clapham omnibus. In the Roman Empire of Galen, there may be better grounds for believing that women described themselves as hysterica . A relevant passage from outside the medical corpus is Martial, Epigrams 11.71, where Leda tells her aged husband she is hysterica as a device to make him summon young doctors to carry out what was then thought to be the standard treatment, sexual intercourse. Moreover, can we accept that it is Galen who "adopte le nom"? We have already seen that the evidence of papyri from the third and second centuries B.C ., taken with the fragment of Mantias preserved in Soranus, suggests on the contrary that the category hysterike pnix existed at least four hundred years before Galen. Indeed, elsewhere Galen distances himself not only from the word hysterikos —referring to "the so-called hysterical symptoms"—but also from pnix , saying that apnoia , absence of breath, is a more appropriate term.^[195]

The passage from Martial is also of interest in that Galen too—unlike Soranus—regards sexual intercourse as beneficial for sufferers, and in his new etiology of the condition this therapy, mentioned in the Hippocratic corpus but only as one of many recommendations for suffocation caused by the womb, is given a central role. He considers that those most vulnerable to the disorder are "widows, and particularly those who previously menstruated regularly, had been pregnant and were eager to have intercourse, but were now deprived of all this."^[196] This passage is interesting, not only because it omits the childless, seen as particularly susceptible in several Hippocratic texts, but also because it points Galen toward the cause of the problem. He does not accept the Hippocratic etiology of womb movement in search of moisture, since dissection proves that it cannot occur; the womb may seem to move, but "it does not move from one place to another like a wandering animal, but is pulled up by the tension" of the membranes holding it in place.^[197]

Why do these membranes become tense? He suggests that it is because they are filled with menstrual blood, unable to move into the womb either because of its thickness or because the orifices through which the

blood passes into the womb are closed. Thus one cause of the condition is menstrual retention. This is not however the origin of the most severe form of hysterike pnix . Galen believes that women too contribute "seed"; this is not an entirely new idea, since some Hippocratic writers believed in its existence. For Galen, female seed does not elevate the female to an equal position with the male, since it is naturally inferior to male seed.^[198] Seed too can be retained in the womb, where it presents far more of a threat to health than retained menses.^[199] Galen goes on to compare the effect of such retained substances to that of the bite or sting of a poisonous creature; small amounts cause dramatic and possibly fatal symptoms.^[200] Retained seed can rot, causing noxious humors to affect the rest of the body through "sympathy"; for Galen, as for Aretaeus, this is how the breathing can be affected without the womb moving to put physical pressure on the diaphragm. It is an infinitely malleable concept that can claim Hippocratic credentials: On Joints (57) describes the "brotherly connections" that exist between parts of the body, permitting, among other things, the wanderings of the womb.^[201] Thus, where the Hippocratics attributed different groups of symptoms to the different organs to which the womb could move, Galen suggests that the basic cause is retained matter, different symptoms owing most to the nature of this matter; for example, black bile leads to despondency.^[202]

Monica Green has pointed out that it is of particular interest that, despite his rejection of the belief that the womb is a wandering animal, Galen nevertheless manages to retain the use of the full scent therapy. On the Method of Healing, to Glaucon includes a brief reference to its use in treating a "rising" womb, while in another treatise Galen lists substances—including castoreum and burned hair—to be placed at the nose of a woman with this condition.^[203] In a passage from On the Affected Parts taken up by the hysteria tradition, Galen describes the case of a woman who had been a widow for a long time and who was told by a midwife that her symptoms were due to her womb being "drawn up." The woman applied to her external genitalia "the customary remedies" (details of which are not given here) for this condition and passed a quantity of thick seed; the suggestion appears to be that rubbing in the traditional scented ointments causes orgasm, and thus releases the retained matter.^[204] For Galen, both menstrual blood and seed must be evacuated, otherwise they will become toxic and poison the body; scent therapy continues, but its rationale changes.

The third century A.D . is, in many ways, a hiatus in the development of the hysteria tradition. One source that should be considered here is a papyrus from Greco-Roman Egypt, which has been dated to the third

or possibly the fourth century A.D . In a collection of magical spells, one is included to be used in cases of "the rising up of the womb." It calls upon the womb to "return again to your seat, and that you do not turn into the right part of the ribs, or into the left part of the ribs, and that you do not gnaw into the heart like a dog, but remain indeed in your own intended and proper place."^[205] This fascinating source shows that the idea of a mobile and animate womb continued to flourish in the context of popular belief; the reference to it gnawing "like a dog" should perhaps be read in the context of Greco-Roman ideas concerning the insatiable sexual appetites of dogs—and women—together with the connection between kuon , meaning dog, and kuein , meaning to be pregnant. In this spell we are not very far from the womb of Plato's Timaeus , running through the body when its desire to conceive is thwarted.^[206]

In the late fourth century A.D ., a further literary source is of interest because it makes explicit the identification of the Greek hysterike pnix and the Latin suffocatio . This is the Book of Medicines of Marcellus Empiricus, which gives remedies for the disorder in a section on acute and chronic conditions of the head. It identifies only two symptoms—severe head pains and suffocation—which, if originating in the womb, "the Greeks call hysterikg pnix ." The condition is considered comparable to epilepsy, frenzy, and dizziness, except in its organ of origin.^[207]