Further Contributions to the Tradition
The Greek East
Returning to the set of connected texts which makes up the hysteria tradition, the Byzantine empire preserved many medical ideas of antiquity through the work of encyclopedists such as Oribasius, Aetius, and Paul of Aegina.[208] Such writers, often dismissed as "the medical refrigerators of antiquity" working in "une époque de stagnation," were nevertheless more than compilers whose labors have preserved for us the work of earlier writers; "not dumb copyists," they selected and paraphrased, added and cut material, according to the specific needs of their audience.[209] Although they may add little new to our picture, they are of interest because they combine the elements of Soranus's and Galen's accounts in different ways. Thus, for example, it will be seen that both Aetius and Paul use Soranus, but—like Galen—bring back the scent therapy that he had rejected. Both use Galen's ideas of retained matter that must be expelled, while Aetius repeats the story of the widow. It is also in the work of these encyclopedists that certain remedies for the condition become standardized, while it is through them that many of the ideas of earlier writers reached Islamic medicine.
In the upper echelons of the Byzantine world, knowledge of classical literature was regarded as the mark of an educated man. Medical education too was largely textual, traditional, and classical. We know of very few teaching centers in the fifth to seventh centuries A.D .; those students who neither came from a medical family nor were apprenticed to a physician were obliged to rely largely on texts for their instruction in both theory and practice.[210]
Alexandria again became an important medical center from the late fourth century A.D .; the medical student there would read about eleven Hippocratic treatises—including the Hippocratic Aphorisms and Diseases of Women —and fifteen or sixteen texts from the Galenic corpus. The Hippocratic texts were, however, read through a "Galenic filter."[211] Alexandria is associated with the seventh-century encyclopedist Paul of Aegina, whose work was itself based to a large extent on the fourth-century, seventy-volume work of Oribasius. It is easy to underestimate the work of Oribasius, Paul, and their successors. N. G. Wilson summarizes: "Very little can be said of any positive achievement of Alexandrian medicine. Paul admits openly in his introduction that he contributes practically no original material of his own." However, he goes on to point out that Paul's work circulated widely,[212] and it is important to see which parts of the hysteria tradition were strengthened by the choices made by such writers.
Oribasius's compilation, derived from the work of Galen, Soranus, and a number of lost works, was itself summarized in two editions of nine and four books respectively. His description of the anatomy of the womb and other female sexual organs, explicitly taken from Soranus, survives in the seventy-volume version of his work.[213] For his discussion of hysterike pnix , which survives in the nine-volume Synopsis , Oribasius uses the lost work of Philumenos of Alexandria,[214] which recommends bandaging the extremities, rubbing the lower limbs, and scent therapy; foul odors at the nostrils, and sweet oils injected into the womb. Shouting at the patient and provoking sneezing are also acceptable, with bleeding once she is conscious. Castoreum is also highly recommended; even on its own, it may produce a cure. In an earlier chapter Oribasius gives further remedies for pnix , including the by now familiar list of foul-smelling substances, namely bitumen, castoreum, gum resin, pitch, cedar resin, extinguished lamp wicks, burned hair, rue, asafetida, onion, and garlic.[215] This closely resembles the list of substances Soranus criticized earlier writers for using; and, of course, Soranus also disagreed with the use of loud noises to rouse the patient. Thus, despite following Soranus's anatomy of the womb, Oribasius takes his remedies from the traditions Soranus despised.
The capital of the Byzantine empire, Constantinople, was another medical center. Oribasius worked there in the fourth century, and it was later to be associated with Aetius of Amida—whose sixteen-volume compilation, made in the sixth century, was based on Oribasius and others—and with Alexander of Tralles, whose twelve-volume Therapeutica was probably written a few decades after Aetius.[216] The work of Oribasius, Aetius, and Paul was later transmitted through the collection of medical knowledge compiled by Theophanes Nonnos in the tenth century. Nonnos worked as part of a deliberate program to stimulate learning, initiated by the emperor Constantine Porphyrogenitus, who was concerned with encouraging education and himself wrote several books and poems.[217]
Aetius based his description of hysterike pnix on Galen's On the Affected Parts , merging this with the Philumenos material preserved by Oribasius.[218] He accepts that the womb, which only seems to move, causes the condition, the higher organs being affected through "sympathy." Using the Galenic model of the body, he describes how spasms reach the heart via the arteries, the brain through the spinal marrow, and the liver through the veins.[219] As a means of discovering whether or not the patient lives, he repeats a test given in Galen, by which either a woolen thread was placed at the nostrils, or a bowl of water on the navel.[220] However, even if no movement occurred in the wool or the water, he warned—again, following Galen—that it was possible that life remained. He sees the disorder as seasonal; it happens mostly in winter and autumn, especially in young women who use drugs to prevent conception.[221] This appears to be a special concern of Aetius, although it recalls Plato's image of the womb deprived of the offspring it desires, running wild through the body. For Aetius, as for Galen, the cause of the symptoms is the decay in the womb of seed or other material, which cools: the coldness is then passed on to the brain and heart.[222] He cuts out the story from Heracleides, but repeats—indeed, claims as his own eyewitness account[223] —Galen's story of the widow who felt "pain and pleasure at the same time" before expelling the corrupt seed; here, however, a little more detail is given by Aetius, so that we are explicitly told that the remedies used consisted in sweet ointments rubbed into the genitalia, something that is recommended again later in this passage.[224] Like Philumenos and Oribasius, Aetius recommends shouting at the patient and repeats word for word the advice of Philumenos-Oribasius that "castoreum alone often cures."[225] The status of scent therapy is reinforced, even increased.
The description of hysterike pnix given by Paul of Aegina[226] in the
seventh century follows Aetius closely, but states that the womb itself "rises up"[227] to affect by sympathy the carotid arteries, heart, and membranes. The patient loses her senses and her power of speech, the limbs being "drawn together." The cause—as in Galen—is the womb being full of seed or of some other substance that becomes rotten.[228] Most sufferers die suddenly during the spasms; the pulse becomes frequent and irregular, and asphyxia then follows. Breathing, at first faint, is cut off. The condition is most prevalent in winter and autumn, and most affects the lascivious, and—in almost the exact words of Aetius—those who use drugs to prevent conception.[229] During the attack the extremities should be bandaged and the patient rubbed all over. Foul-smelling substances—including stale urine—should be placed at the nostrils, and cupping and anal suppositories used. Sweet-smelling substances should be employed in order to draw the womb back to its proper place. To rouse the patient, one should shout at her roughly and induce sneezing with castoreum, soapwort, and pepper.[230] Like Soranus and Oribasius, Paul separates treatment for the fits, or paroxysmoi , from treatment for the whole body; the latter begins with venesection[231] and goes on to purging, exercise, and baths.
Although the tendency in the East was toward the compilation of encyclopedias, one independent Greek text, probably from the sixth century, survives in a ninth-century manuscript. This is the Book of Metrodora , a practical treatise in many ways reminiscent of Hippocratic medicine. It includes some remedies for hysterike pnix , which make use of the traditional foul- and sweet-smelling substances, namely castoreum, rue with honey, and pig's dung with rose water.[232]
Thus in Byzantine medicine a composite picture of hysterike pnix was built up, incorporating the Galenic belief in retained substances poisoning the body, Soranus's anchoring membranes, Hippocratic scent therapy, venesection as in Celsus, and a belief in the value of sneezing, derived from the Hippocratic Aphorisms and Galen's commentary on them, which will be discussed in detail below. Although the main authorities, Soranus and Galen, had vigorously denied that the womb could move, this idea came close to being reinstated by Paul of Aegina. Aetius preserved the Galenic tests to determine whether the patient still lived, while writers with otherwise divergent views agreed on the therapeutic value of castoreum.
The Latin West
In the West, meanwhile, the picture was in some ways very different. Although the Aphorisms circulated widely, few of the works of classical
medicine survived, especially after knowledge of Greek declined during the fifth and sixth centuries. Although in northern Italy some Byzantine commentaries and encyclopedias were adapted into Latin during the sixth century—among them, the work of Oribasius—most "new" medical texts were short works based on Soranus.[233] The late fourth- or early fifth-century[234] Latin version of Soranus by Caelius Aurelianus survived into the Middle Ages, while the fifth- or sixth-century version by Muscio circulated more widely. Muscio plays down Soranus's attack on the idea that the womb moves around the body, going so far as to add to Soranus's introduction to the condition a new phrase claiming that the womb rises up toward the chest.[235] Thus the versions of Soranus that circulated in the West included womb movement from an early date.
Several of the texts produced in the West originated in Africa, among them the works of Caelius Aurelianus and Muscio. Predating these is the late fourth century Euporiston of Theodorus Priscianus, a pupil of Vindicianus, whose own Gynaecia was a text on parts of the body and their development in the womb. Originally written in Greek, the Euporiston was translated by Theodorus Priscianus himself into Latin.[236] This version contains a section entitled De praefocatione matricis , which follows the constriction/relaxation approach of Soranus, omits womb movement, but includes scent therapy. In A.D . 447 another African writer, Cassius Felix, took a different approach, publishing an encyclopedia allegedly based on Greek medical writers of the logical, or dogmatic, sect, but in fact owing much to Soranus as translated by Caelius Aurelianus; this contains a very Hippocratic description of hysterical suffocation, incorporating womb movement as well as scent therapy.[237]
Other Latin texts of this period survive and are probably more representative than the African works of medicine in the West after the fall of Rome. A dialogue allegedly between Soranus and a midwife, apparently designed as a midwives' catechism, is preserved in a ninth-century manuscript but may date to the sixth century; this is the Liber ad Soteris .[238] Another short text from this period is the Gynaecia by pseudo-Cleopatra.[239] It mentions a condition called suppressiones vulvae , the main symptom of which is difficulty in speaking and which thus may be identified with hysterike pnix ; however, womb movement is not mentioned, nor is scent therapy advised.
The ancient Hippocratic theories were not, however, entirely lost to the West. Between the fifth and seventh centuries A.D . many Hippocratic texts were translated into Latin at Ravenna, among them Aphorisms and Diseases of Women (1.1, 1.7-38, and extracts from 2).[240] Several texts on womb movement and suffocation are included in such translations.[241]
Also translated was Galen's On the Method of Healing, to Glaucon , with its reference to scent therapy for a moving womb; the Ravenna commentator considers that, by using scent therapy, Galen is apparently endorsing the wandering womb theory.[242]
It is, however, as misleading to regard the work of the scholars of Ravenna only as translation as to dismiss the Byzantine writers as mere compilers. It is important to understand the purposes for which they used these texts, since these in turn influenced the translation. These purposes fall under two headings: practice and instruction. Hippocratic medicine was seen above all as being of immediate relevance for medical practice; the Ravenna texts are thus not academic editions, but manuals. As a result the more theoretical or speculative Hippocratic texts were neglected, while those selected for translation were adapted according to the different moral and historical context within which they were now to be used.[243] The second, closely related aspect instruction led to the recasting of some texts in new formats in which extracts were set out in question-and-answer form, as dialogues like the Liber ad Soteris , as calendars, as visual representations, or as letters. The letter format, direct and personal, was very popular, an example being the Epistula ad Maecenatem , the Letter to Maecenas . Also known as the De natura generis humani , this comprises extracts from the Hippocratic Diseases of Women (1) and from Vindicianus. The Epistula ad Maecenatem is found in the ninth-century manuscripts Paris BN Lat. 7027 and Paris BN Lat. 11219, and in these manuscripts it includes two passages of Diseases of Women used in the hysteria tradition: 1.7, on movement of the womb to the liver, and 1.32, on movement of the womb in a pregnant woman.[244] The late eighth century/early ninth century manuscript Leningrad Lat. F.v.VI.3 is a handbook including Latin translations of sections from Diseases of Women , one of which is our 2. 127, a further description of the movement of the womb to the liver. In the recipes given for cures, substitutions are made in the pharmacopoeia according to what was available in the period.[245]
The Arab World
Another route of transmission of Hippocratic ideas to the West was through the Arab world. The most obvious contact between medical systems took place after the Arabs took Alexandria in A.D . 642, possibly while Paul of Aegina was there; the medical school at Alexandria continued to exist until around A.D . 719, probably still using Greek as its language of instruction.[246] The great age of translation began in the ninth century; Greek manuscripts were taken as booty in conquest, and
those translating them into Arabic—sometimes through the medium of Syriac—enjoyed royal patronage. From this time onward, versions of Hippocratic texts, based on several manuscripts, were produced; the most famous early translator was Hunain ibn Ishaq al-'Ibadi—known to the West as Johannitius—the Christian son of a druggist, who was also responsible for translating works by Galen, Oribasius, and Paul of Aegina. Hunain also listed all the works of Galen that had been translated into Arabic or Syriac by about A.D . 800; these included such key works in the hysteria tradition as On the Affected Parts, On Difficulty in Breathing , and the commentary on the Aphorisms , from which the Hippocratic Aphorisms themselves were excerpted and then transmitted separately.[247] There thus exists a striking contrast between East and West in the ninth century; as R. J. Durling puts it, "Whereas European knowledge of Galen was limited to a few Galenic works, and those either unimportant or clearly spurious, Arabic translations of almost all his writings were made." Something similar occurs with regard to much of the Hippocratic corpus; in contrast to the Latin West, where emphasis was placed on translating those texts of immediate practical value, the Arabic translators did not neglect the more theoretical and speculative treatises, so that the "Arabic Hippocrates" is more complete than the "Latin Hippocrates."[248] This does not, however, apply to Hippocratic gynecology; neither Diseases of Women nor Nature of Woman was translated into Arabic, although two Byzantine commentaries on Diseases of Women 1.1-11 were in circulation in the Arab world before the eleventh century, together with Byzantine medical encyclopedias.[249]
The main means by which Greco-Roman ideas were transmitted was through the compilation of new encyclopedic works. The Firdaws al hikma (Paradise of Wisdom) of 'Ali ibn Rabban at-Tabari (810-861) was completed in 850 and includes approximately 120 quotations from the Hippocratic corpus, and a large amount of Galenic material, together with extracts from other Greek and Islamic writers such as Aristotle and Hunain.[250] At-Tabari believes that the essential wetness of woman leads to menstrual loss; retained moisture sinks to the lowest part of the body and then comes out, "just as in a tree the excess moisture comes out as gum."[251] In his section on uterine disorders, he includes suffocation of the womb. He writes, "Sometimes, through damming-up of menstrual blood and lack of sexual intercourse, vapours develop." He explains that the retained blood becomes thick, and produces vapors that then affect the whole body, causing such symptoms as painful breathing, palpitations, head pain, and suffocation of the womb.
A further discussion of suffocation occurs in the context of womb
movement. The womb can lean to one side, but sometimes it actually rises up until it reaches the diaphragm, causing suffocation. "Then the woman loses consciousness, with the result that her breath is stopped. Then one puts a bit of wool under her nostrils in order to see whether she is alive or dead." The cause here is not menstrual blood, but accumulated seed; if there is an "excess, lack or absence" of intercourse, seed will accumulate in the womb, rot, and become poisonous and thick. The womb then moves to the diaphragm and the woman suffocates.[252]
Thus womb movement was readily combined with a Galenic etiology of retained seed or menses, but to this mixture at-Tabari added the explanatory device of vapors. Where Greco-Roman writers employed the concept of sympathy to account for the effects of the womb on other parts of the body, writers in the Arab world also used vapors; as we shall see, this development entered the western hysteria tradition when texts were translated from Arabic to Latin from the eleventh century onward.
The next writer from the Arab world who should be considered here is Muhammad ibn-Zakariyya' ar-Razi (Rhazes), whose Kitab al-Hawi , a twenty-four-volume collection of excerpts from Greek, Arabic, and Indian writers known in Latin as the Continens , was written around A.D . 900.[253] Also translated into Latin was his Kitab al-Mansori , which includes a chapter on uterine suffocation. Here Rhazes gives a basically Galenic account of the condition, including retained menses and seed, the patient falling down as though dead, and scent therapy; he includes the recommendation that a midwife should rub the mouth of the womb with a well-oiled finger. He does not say that the womb moves, although he describes a sensation "as if something is pulled up."[254]
The work of 'Ali ibn al-'Abbas al-Majusi, known in Europe as Haly Abbas, was produced in the tenth century A.D . It too combines Hippocratic etiologies with a predominantly Galenic approach, often read through the eyes of Paul/Aetius; but al-Majusi plays down the membranes anchoring the womb, claiming instead that the womb can move around the body. He includes both sympathy and vapors. He explains that suffocation of the womb is a very dangerous condition because sympathy leads to the vital organs, the brain and heart, being affected. If a woman does not have intercourse, a large quantity of seed will collect and will "stifle and extinguish the innate heat." Retained menstrual blood has similar effects.[255]
In a separate section on treatment, he retains the Hippocratic scent therapy, but explains its success partly in terms of vapors. Bad smells administered to the nose rise to the brain, "warming, dissolving and diluting the cold vapors," but also driving the womb back down.[256] For
al-Majusi, the womb is "more or less an independent living being," yearning for conception, annoyed by bad smells and leaning toward pleasant smells. Plato's description of the womb as an animal desiring conception was known to the Arab world through Galen.[257] Al-Majusi also recommends sexual intercourse as a cure, especially for virgins, whose strong desire for sex and thick menstrual blood predisposes them to the condition.[258] In the absence of this, he repeats the Galenic therapy of instructing a midwife to rub sweet-smelling oils on the mouth of the womb, and states explicitly that this has the same effect as intercourse, in warming and thinning the seed, so that it can drain away and the woman can "find peace."[259]
Also working in the tenth century was Ibn al-Jazzar, whose main work was the Kitab Zad al-Musafir in seven books. This was a particularly important source for medieval European medicine; it was translated into Latin, Greek, and Hebrew, and is known in Latin as the Viaticum .[260] Book 6, chapter 11, describes suffocation of the womb; the condition begins with loss of appetite and the chilling of the body, which is attributed to corruption of retained seed, particularly in widows and young girls of marriageable age. From the seed a fumus —a smoke, or vapor—rises to the diaphragm, because the diaphragm and womb are connected; then, since further connections exist between the diaphragm and the throat and vocal chords, suffocation ensues. similar problems may result from retained menses, and scent therapy and the application of fragrant oils to the mouth of the womb are recommended. Repeated here is a version of the story given in Galen of the woman who lay as dead but was known to be alive by the presence of innate heat; here, however, Galen rather than Empedocles becomes its hero![261]
Finally, Ibn Sing (Avicenna), born in A.D . 980, included discussions of hysterical suffocation in his Qanun (the Canon ); translated into Latin by Gerard of Cremona in twelfth-century Toledo, this influential text was printed thirty-six times in the fifteenth and sixteenth centuries.[262] He devotes four successive chapters to the condition, its signs and cures, and the preferred regimen for sufferers. He bases his description on Galen as interpreted by Aetius, favoring sympathy (communitas ) over vapors, and including the test for life with a piece of wool and the story of the widow; cures include phlebotomy and the rubbing of scented oil into the vulva, while the regimen includes the use of foul-smelling substances at the nose and sweet scents at the vagina.[263]
Thus it can be seen that the distinctively Hippocratic features of womb movement, scent therapy, and the therapeutic value of sexual intercourse survived even in the directly contradictory environments of
Galenic theory and Islamic culture. Despite the rejection of the moving womb by both Soranus and Galen, it soon returned to the fore in the explanations of hysterical suffocation given by writers and compilers in both East and West. In the Arabic world, Soranus's Gynecology may not have been translated, so his attack on the theory of the mobile womb may have remained unknown;[264] as for Galen, although he explicitly rejects Plato's womb-as-animal theory in On the Affected Parts , he implicitly accepts it in To Glaucon , thus leaving the matter open for future commentators. Such elements of the hysteria tradition as the wool test for life and the story of the widow and the midwife, retained by the Byzantine encyclopedists, continue to survive in Arabic medicine; the story of the woman raised from apparent death by Empedocles is found in Ibn al-Jazzar but plays a minor role, perhaps because the short reference to it in Galen is insufficient for its reconstruction.
In terms of the most likely victims for the condition, it is of interest that Galen's preference for widows is ignored; virgins become a prime target. This is not a return to Hippocratic etiology since, as I have argued above, the Hippocratic hysteria texts rarely give a particular target population for womb movement; furthermore, when a particular group is specified, this tends to be the childless in general (since their flesh is not "broken down"), older women not having intercourse, or young widows. The Hippocratic text that may be at the root of this interest in virgins is one that was available in the Arab world, since it is cited twice by Rhazes: the Diseases of Young Girls .[265] This is a short and vivid description of a condition that arises not from womb movement, but instead from retention of menstrual, or possibly menarcheal, blood. The target population consists of parthenoi —meaning young girls, unmarried women, and/or virgins—who are "ripe for marriage" but remain unmarried. Their blood is described as being plentiful due to "food and the growth of the body." If "the orifice of exit" is closed, the blood that has moved to the womb ready to leave the body will travel instead to the heart and diaphragm, causing visions, loss of reason, and a desire to commit suicide by hanging. The author states that he orders girls with this condition to marry as quickly as possible; if they become pregnant, they will be cured. I would suggest that this text, retrospectively diagnosed as hysteria by several writers during this century, lies behind al-Majusi's interest in the thick blood of a virgin and in intercourse as a cure, as well as explaining Ibn al-Jazzar's target population of girls of marriageable age.[266]
Finally, in these writers, a new explanatory device is used to account for the effects of the womb on other parts of the body: vapors. Yet the
concept of sympathy continues to exist, sometimes—as in Ibn al-Jazzar—involving very precise connections between particular organs of the body.