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.