previous part
One— Once upon a Text: Hysteria from Hippocrates
next chapter

Once upon a Text:
Hysteria from Hippocrates

Helen King

Labels and Origins: a Name Without a Disease?

In the beginning was Hippocrates, the Father of Medicine, who freed the emerging science from the chains of superstition, introduced empirical observation and the bedside manner, and both identified and named "hysteria." So runs the established wisdom on the Hippocratic origins of both medical science in general and of the diagnosis of hysteria in particular. Yet recent work on Hippocratic medicine has called into question much of this tradition. Once it was an acceptable scholarly pursuit to debate the inclusion of particular treatises in the canon of "The Genuine Works of Hippocrates": now it is widely accepted that not a single text of the Hippocratic corpus can be attributed with any certainty to the Father of Medicine.[1] In place of a canon of "Genuine Works," we have a diverse set of multi-author texts. Once the Hippocratic doctor was seen as a model of medical etiquette and morality: now he can be restored to his own historical and cultural context, where he becomes only one of the numerous brands of healer competing for clients in the ancient world, unafraid to improve his chances of employment by the use of tactics questionable by later standards.[2] With the improved visibility made possible by the new Hippocratic studies, the time has surely come to reexamine the texts so confidently labeled by the nineteenth-century Dr. Robb as "Hippocrates on Hysteria"[3] and to review the relationship between the text of the Hippocratic corpus, its interpreters over time, and the discussions of hysteria.

Since the Hippocratic texts are so often quoted—and misquoted—in


contemporary debates on the status of the diagnosis hysteria, such a study will not only contribute to the growing body of work on Hippocratic medicine and its place in ancient society but also inevitably feed into these debates. Eliot Slater, questioning the value of the diagnosis in our own times, has argued that "the justification for accepting 'hysteria' as a syndrome is based entirely on tradition and lacks evidential support."[4] This tradition goes back to the alleged origin of the diagnosis of hysteria in the Hippocratic corpus, and it is only by reclaiming the relevant texts from their use in the tradition that we can understand and question the diagnosis in later centuries. If a fresh reading of the ancient texts shows that their use by the tradition is unwarranted, this will have important implications for the history of hysteria in general.

Recent work on hysteria in the Hippocratic corpus by medical historians, psychologists, and physicians is, almost without exception, based on the history of hysteria published in 1965 by Ilza Veith. On the name itself she wrote,

In the Egyptian papyri the disturbances resulting from the movement of the womb were described, but had not yet been given a specific appellation. This step was taken in the Hippocratic writings where the connection of the uterus (hystera ) with the disease resulting from its disturbance is first expressed by the term "hysteria." It appears in the thirty-fifth aphorism, which reads: "When a woman suffers from hysteria . . ."[5]

Since the publication of Veith's book, these points have achieved canonical status. For example, R. A. Woodruff states that "the name, hysteria, has been in use since the time of Hippocrates"; P. B. Bart and D. H. Scully refer back to "the time of Hippocrates, who coined the name"; and S. B. Guze cites Veith as his only source for the "information" that "disorders diagnosed as hysteria have been encountered for about 2,500 years" and furthermore that, "as everyone knows, the term hysteria originated in Greek antiquity."[6] These apparently confident assertions cover not only the origin of the word "hysteria," but also the very essence of ancient Greek gynecology. R. Satow, a psychotherapist and sociologist, asserts that "'hysteria' has been a label used for a potpourri of female ailments and non-ailments alike since antiquity. . . . The Greeks and Romans called almost all female complaints hysteria and believed the cause of all these female maladies to be a wandering uterus. . . . In various Hippocratic texts the term hysteria is applied to a large variety of female complaints."[7]

What "everyone knows" is, however, not necessarily true. The earth is not flat, although once "everyone knew" that it was. Even leaving aside


the attempt to use Egyptian evidence, which has already been widely questioned,[8] Veith's claims for Greek medicine are seriously flawed. As only one recent writer on hysteria, E. Trillat,[9] has recognized, the "various Hippocratic texts" applying the term "hysteria" to many different complaints simply do not exist; moreover, to suggest that Hippocratic gynecology is about calling almost everything "hysteria" is a gross over-simplification. A total revision of our understanding of the tradition is thus long overdue.

Let us return to the text claimed by Veith as the inaugural moment of hysteria, "the thirty-fifth aphorism." It is a significant choice, since the Aphorisms is one of the most widely translated and best-known works of the Hippocratic corpus, believed for many centuries to have been written by Hippocrates himself as a distillation of the wisdom of a lifetime's clinical experience, and thus taken to be one of the most genuine works.[10] Immediately, however, we encounter a difficulty; there is no "thirty-fifth aphorism." A. Rousselle[11] has criticized Veith for reading back contemporary ideas into antiquity, but the problem is greater than this would suggest; Veith puts too great a trust in poor secondary sources. What she is referring to here is, in fact, Aphorisms 5.35 (L4.544), which does not use the term "hysteria" at all; instead, using the plural form hysterika , it begins Gynaiki hypo hysterikon enochloumenei , and it may be translated as: "In a woman suffering from hysterika , or having a difficult labor, a sneeze is a good thing."

What are these hysterika , and what is so good about a sneeze? Such questions plunge us directly into the heart of the hysteria debate. It is tempting to translate hysterika as "hysterics," but an apparently familiar word does not necessarily convey the meaning we would most naturally expect. Galen of Pergamum noted the difficulties of translating this aphorism (K 17b.824-825). Hysterika , he wrote in his commentary on the Aphorisms , could refer to all diseases of the womb[12] or to only a particular condition called hysterike pnix (best translated "suffocation of the womb"), described by a number of post-Hippocratic writers and which will be discussed at length below, or to problems with the afterbirth, also known as ta hystera . He favors setting the aphorism in the context of hysterike pnix , for the following reasons. First, hysterika cannot refer to the afterbirth, because hystera and hysterika are not the same word. Second, it cannot refer to all diseases of the womb, because Hippocrates says that it is helped by sneezing. Clearly, not all diseases of the womb are helped by sneezing and, since Hippocrates cannot be wrong, Galen concludes that the passage must refer to hysterike pnix .

There is, however, no reason why we must follow Galen's line of ar-


gument since, despite his objections, there is nothing to prevent translating the phrase as "When a woman suffers from diseases of the womb." The argument that not all such diseases are helped by sneezing does not necessarily apply to pre-Galenic medicine. A sneeze expels various kinds of matter that may cause disorders, and thus has value in many situations; in a specifically gynecological context, substances such as mustard, black or white hellebore, and castoreum were widely recommended in the ancient world to promote menstruation or the expulsion of the afterbirth.[13] Since retained menses were thought to be the cause of many female disorders, the expulsive value of a sneeze could often be beneficial.

It is in a passage of Pliny the Elder, written a century before Galen, that the sternutatory powers of mustard appear in the narrower context of "suffocation of the womb." Mixed with vinegar, mustard was thought to rouse women suffering from an epileptic fit or "vulvarum conversione suffocatas,"[14] translated in the Loeb edition as "fainting with prolapsus" but more literally meaning "suffocated by the turning of their wombs." This may suggest another value of the sneeze, which was seen as being of particular importance in "suffocation." Many ancient writers discuss the difficulty of knowing whether a sufferer from the condition they call "suffocation of the womb" is, in fact, alive or dead. Pliny himself gives the case of a woman who lay as if dead for seven days with "conversio vulvae," turning of the womb.[15] In such cases, it was necessary to test for life by holding a feather or a piece of wool at the nostrils. A sneeze was welcomed as evidence of the presence of life.

Sneezing, due to its expulsive powers, can thus be "a good thing" for many disorders affecting women, but by the first century A.D ., when Pliny was writing, it had come to be seen as particularly valuable in "suffocation of the womb" because it could recall to life a patient lying as if dead. It is thus possible that it had the first meaning in Aphorisms , but that this had been overlaid with the second by the time of Pliny. Galen, writing a hundred years or so after Pliny, put together the broad context of the Aphorisms passage and the more specific context of Pliny; the example thus makes us aware of the possible changing interpretations of a text over time.

Regardless of how we choose to translate the passage, it should above all be noted that this is not what Veith called "a specific appellation": a disease label. Veith admits that the form hysterikos , "from the womb," "connected with the womb," or, when applied to a woman, "liable to disorders of the womb," is "more frequently used,"[16] but she does not acknowledge that it is in fact used exclusively, and moreover that the Aphorisms example is only a further case of this general type.


It is not difficult to find the source for this particular misconception on the part of Veith. The idea that it is in the Hippocratic corpus that hysteria is not only described but also given its name can be traced back beyond her to the Emile Littré edition of 1839-61, the gynecological volumes of which—numbered 7 and 8—appeared in 1851-53. For the present purpose, a study of these must concentrate on the additional French material supplied by Littré. This appears in two forms. First, for many of the Hippocratic texts he provides section headings for each chapter; these have no analogue in the Greek manuscripts. This applies to the three volumes of the Gynaikeia , known in English as Diseases of Women ,[17] where several passages are headed "Hystérie." Second, additional material appears in the translation itself, where Littré uses the medical categories of his own time. The misplaced confidence of the title used by Robb in his article "Hippocrates on Hysteria"[18] is based on translating Littré into English while simultaneously incorporating distinctions made only in the headings.[19] As Rousselle has recently suggested, these owe far more to nineteenth-century debates and theory than to the Hippocratic texts they are supposed to summarize.[20] Just as Adams aimed to make the Hippocratic texts that he selected as "The Genuine Works of Hippocrates" intelligible to "any well-educated member of the [medical] profession at the present day,"[21] so Littré "read Hippocrates in his own image and in the image of the medicine of his time,"[22] with the explicit intention of using Hippocratic wisdom to improve the medical practice of his own day. "Until the nineteenth century, medicine nourished itself on Hippocrates—or at least on that which it believed it could find in Hippocrates."[23]

The section headings written by Littré go further than merely labeling certain sections "Hystérie." In addition to this, Littré distinguishes between imagined movement of the womb, which he classifies as hysteria, and real movement, which he describes as displacement. He thus makes such comments as, "This section appears to be a confusion of imaginary with real movements of the womb"; "This appears to be some displacement of the womb rather than hysteria"; and "The fact remains that there is confusion between imaginary and real displacements."[24] He believes that the Hippocratic texts do not make sufficiently clear the distinction he seeks, in contrast to Veith, who—again, wrongly—claims that "the Hippocratic physician was aware of the importance of a careful differentiation between hysterical symptoms and those of organic disease."[25] The writers of these ancient texts make no such distinction. They describe what is, for them, a real and organic condition: the movement of the womb (hystera ) to other parts of the body. Since it is Littré, rather than any Hippocratic physician, who is interested in the distinc-


tion, it may be suspected that Veith is basing her remarks on the Littrean section headings rather than on the Greek text.

The origin and process of transmission of the error in translation should now be plain. Littré read the Hippocratic corpus in the context of the mid-nineteenth century, in which hysteria was a recognized condition of debated etiology; he expected to find hysteria in the text, duly found it, and drew it out in the headings he wrote for the various sections. Robb translated into English the passages headed by Littré as "Hysteria," and subsequent readers of the Hippocratic corpus have accepted the categories imposed by Littré on his material. Taking only the Aphorisms passage, Littré translates "Chez une femme attaquée d'hystérie. . ." while Francis Adams gives "Sneezing occurring in a woman with hysterics," and J. Chadwick and W. N. Mann have "When a woman is afflicted with hysteria." In giving "When a woman suffers from hysteria. . ." Veith is following the widely available Loeb translation.[26]

Thus the diagnosis of hysteria is one made not by the ancient authors of the texts, but rather by the nineteenth-century translator of the Hippocratic corpus. At this point it would be possible to argue that this is of only minor importance; granted, the tradition is wrong to claim that the Greeks invented the name and thus the diagnostic category of hysteria, but if the Hippocratic texts nonetheless contain the first clinical descriptions of hysteria, should we much concern ourselves with the origin of the name? As a result it becomes necessary at this point to begin to consider what we are to understand by "hysteria." When a translator reads the diagnosis into a text, this would seem to suggest the belief that there is a fixed entity called hysteria, constant over time and place, so that we can say with Chariot that "L'hystérie a toujours existé, en tous lieux et en tous temps,"[27] and with D. W. Abse that "in fact, east and west, hysteria continues unabated in various guises."[28] If we believe this, it will be of relatively little significance that the name "hysteria" is not Hippocratic. A concept may exist even if it is not named; as G. Lewis points out, the ancient Hebrews had no word for what the Romans were to call lex talio , the law of retribution in kind, but they did say "An eye for an eye and a tooth for a tooth."[29] Further general questions about hysteria will also need to be addressed. Is it a disease like any other, and thus a fit subject for medical study and treatment? Is it a disease at all?[30]

If hysteria is constant, found throughout history, worldwide, we can begin to talk about whether or not Hippocratic medicine recognized it, regardless of whether the Hippocratics named it, just as we can talk about whether tuberculosis, epilepsy, and gonorrhea were recognized. Furthermore, if it is historically constant, a body of text of the length of


the Hippocratic medical corpus should, statistically, contain some cases of it. Any decision that it is constant therefore prejudges the question of whether or not it existed in Hippocratic times: by definition, it must have done, and our task is only to find the sections in the texts which provide a more or less accurate match with our chosen clinical picture. This task, however, is complicated by the belief that hysteria, like chlorosis, is a disorder that apparently disappeared in our own century; as Trillat says, "L'hystérie est morte, c'est entendu."[31] This could lead us to apply more stringent criteria to the Hippocratic texts, to conclude that hysteria was not present in classical Greece, and thus to revise our views on the significance of its apparent disappearance from the medical scene.

There are however two main obstacles standing in the way of a decision to treat hysteria as a historical constant. The first is that, unlike tuberculosis, epilepsy, and gonorrhea, hysteria is in no way a clearly defined disease entity for which most medical practitioners in our society would draw up the same list of symptoms; the second, that an integral part of the definition of hysteria often consists in its supposed ability to mimic symptoms of other diseases.

Contemporary medical writers on hysteria fall into two main groups. One group accepts that hysteria is "a valid, independent syndrome"[32] and, in applying this label, makes use of the Perley-Guze criteria, which list over fifty symptoms in ten areas; exhibiting twenty-five symptoms in nine out of ten areas qualifies as hysteria, in the absence of any other diagnosis.[33] One area is entirely concerned with menstrual difficulties;[34] since menstrual suppression is by far the most common symptom in Hippocratic gynecology—for reasons that relate to the belief that amenorrhea indicates the presence of a dangerous reservoir of unshed blood[35] —it should not be surprising that retrospective diagnosis of hysteria in the Hippocratic texts is common. The second group's position is conveniently summarized by Slater's (1965) lecture "Diagnosis of 'hysteria.'"[36] The single quotation marks around "hysteria" say it all. Slater picks up the Perley-Guze point that the label hysteria is applied "in the absence of any other diagnosis" and concludes that the diagnosis merely indicates the "absence of relevant physical findings"; it is "a disguise for ignorance and a fertile source of clinical error . . . not only a delusion but also a snare" and "a way of avoiding a confrontation with our own ignorance."[37] Edward Shorter suggests that diagnoses such as hysteria have often covered an undetected uterine infection.[38] C. D. Marsden, too, points out that a high percentage of patients diagnosed as having hysteria turn out to have an underlying organic disease and concludes


that "there can be little doubt that the term 'hysterical' is often applied as a diagnosis to something that the physician does not understand."[39]

Slater therefore argues that "the justification for accepting 'hysteria' as a syndrome is based entirely on tradition and lacks evidential support."[40] F. Walshe's response to Slater, significantly using the same title but omitting the quotation marks around the word "hysteria," defends "the concept of hysteria as a nosological entity in its own right."[41] The debate in medical circles continues, and Slater's contribution is discussed at length in Alec Roy's (1982) collection of essays, Hysteria .[42] R. Mayou gives a fair summary of the medical situation when he writes that there is at present "no agreement about diagnostic criteria" for hysteria.[43]

The second difficulty encountered in regarding hysteria as something constant is that, if anything is a widely accepted part of the definition, it is the suggestion that it can mimic the symptoms of any other disease.[44] In this case, how can hysteria itself be a disease, and what is to prevent it from taking such radically different forms in different epochs as to be almost unrecognizable as the same condition? The corollary is also true; as Shorter puts it, "every organic disease imaginable . . . has at one time or another been classified as hysteria."[45] Does a condition with such indistinct and shifting borders exist in any meaningful sense? As Trillat puts it, hysteria is "une maladie qui n'en est pas une, tout en l'étant . . ."[46]

Nineteenth-century medical literature suggests that hysteria can manifest itself in a highly dramatic form; in the ideal type of Charcot's "grande hystérie," violent muscular contractions culminating in the arched posture (arc-en-cercle ), paralysis, loss of voice, retention of urine, anesthesia, and blindness. In a recent study of admissions for hysteria to the Edinburgh Royal Infirmary in the late eighteenth century, however, G. B. Risse found that only a minority of alleged victims had fits of this kind; most women sufferers had loss of appetite or other digestive problems, menstrual difficulties, and fainting spells, symptoms suggestive of many organic diagnoses.[47] Yet one relatively constant feature of the diagnosis of hysteria in modern times is that it implies that the physical symptoms so labeled, whether dramatic or not, have no recognized organic cause. It should now be clear why hysteria has been described as "that most unsatisfactory of psychiatric syndromes."[48]

Marsden's recent discussion shows the widest possible extent of the definition of "hysteria." "Physicians use the term to describe the symptom (conversion disorder or disassociation state), the illness (somatization disorder or Briquet's syndrome), the personality (histrionic), a form of anxiety (phobic anxiety after Freud), an epidemic outbreak (mass hysteria) and irritating patients (if female they are hysterical; if male they


are psychopaths)."[49] The irritation felt by doctors toward hysteria patients is eloquently expressed in the words of a doctor writing in 1908, a time when the contracture or "drawing up" of a limb was a common symptom: "As Vance cut off the plaster cast from a 14-year-old girl whose leg had 'drawn up' a year previously, she cried, 'It is going to draw up; it is going to draw up,' at which Vance said severely, 'If it does draw up, I will break your d____d little neck.'"[50]

Other contemporary writers argue for a restriction of the definition of hysteria, excluding the syndrome and the personality type and using hysteria only for a universal human reaction, comparable to anxiety or depression.[51] Shorter's suggestions may be helpful here, insofar as they permit a degree of universality, while incorporating variation among cultures. He accepts that "'hysteria,' it appears, is a real psychiatric disease, in addition to being an epithet with which men have stigmatized women across the ages." However, he goes on, "the presentation of 'hysterical' symptoms tends to be molded by the surrounding culture" to a greater degree than that of, for example, the symptoms of schizophrenia. A major question to ask therefore concerns the social construction of the disease: Why is it that, from a wide repertoire of the possible, "certain symptoms are selected in certain epochs"?[52] I will return to this important question, in relation to the Hippocratic texts.

Definitions: the Textual Tradition

Thus the questions raised by hysteria are not only legion but often directly contradictory. Is hysteria another word for ignorance, or the perfectly adaptable mimic? Is it a dramatic performance or a minor gynecological disturbance? Is it caused by the womb or has it no organic cause? Is it a wide-ranging category, a "non-verbal language,"[53] or something universal but very specific? Beneath these questions lies the major one for anyone trying to write about the history of hysteria: that is, what definition should be used for the purposes of the present work? J. M. N. Boss takes what may appear to be an attractive option when tackling this problem; he writes, "In this paper the word 'hysteric' is used in the manner of the period of the writings referred to."[54] As I have already shown, however, in the ancient period the word "hysteria" is not used at all; hysterikos , "hysteric," is used, but with the very specific meanings "coming from the womb"/"suffering due to the womb." One way around this problem would be to restrict the present study to those sections of the corpus traditionally seen as descriptions of hysteria; for example, those so labeled by Littré. As I have already shown, the diffi-


culty here is that Littré imposes his own distinction between "real" and "imaginary" movements of the womb, a distinction alien to the ancient Greek writers. An alternative would be to study all sections of the corpus in which the womb is described as moving to another part of the body, but this only reiterates the point that later writers use hysteria for symptoms with no organic cause, whereas the Hippocratics regard womb movement as something entirely organic.

The difficulties of deciding what constitutes hysteria for the purposes of a historical study are by no means unique; indeed, they are directly comparable to those encountered by J. Gabbay in his discussion of the disease concept "asthma." Gabbay asks how far we "can rely on present-day knowledge of asthma to analyse historically the social nature of medical knowledge"[55] and concludes that we cannot assume that all writers in the past who used the term were referring to the same thing. With hysteria, of course, the problems are greater, because our sources are not even using a common name. Gabbay raises the question whether a diachronic study of a disease concept investigates a constant natural entity, or a vast range of different concepts,[56] and shows how this question all too easily leads the historian to the stage of "historical paralysis."[57] Like Medusa's head, the question, What exactly are we studying? turns the onlooker to stone.

Although it has this malign power, the question must at least be addressed, even in a negative way. To clarify: in the present work I am discussing neither all texts in which the writers name the condition they describe hysteria, nor all texts mentioning a particular combination of symptoms that I choose to label hysteria. Instead, I have chosen here to concentrate on a set of early texts conventionally linked by subsequent writers: a finite series of texts, each drawing on an increasingly fixed group of those written by earlier writers, yet each simultaneously—to some extent incorporating the ideas of its own age. I am thus studying hysteria from the perspective of a developing tradition of reading the Hippocratic corpus, a textual tradition that culminates in Littré. In order to illuminate the growth of this tradition, I will also draw on texts produced outside it in order to provide the necessary context for its origin and development.

Before turning to a more detailed study of the Hippocratic texts conventionally used as evidence for hysteria in ancient Greece, it is worth considering what implications the use of the label "hysteria" may have, for Littré and other writers.

The Greek adjective hysterikos means "from the womb"; as such, it is a purely physical description of cause, showing the part of the body from which other symptoms emanate. In a woman, as another Hippocratic


text puts it, "the womb is the origin of all diseases,"[58] so it would be fair to say that, in Hippocratic gynecology, all diseases are hysterical. But this word cannot have the same nuances for us as for an ancient author.

Littré uses hysteria in a rather different way. In his Dictionnaire de la langue française (1863-77) he defines hysteria as follows: "Hystérie: maladie nerveuse qui se manifeste par accés et qui est characterisée par des convulsions, la sensation d'une boule qui remont de la matrice dans la gorge et la suffocation" (Hysteria: nervous disorder that manifests itself in the form of a fit and is characterized by convulsions, by the sensation of a ball rising from the womb into the throat, and by suffocation). To understand Littré's position, we must first understand the debate within which he is situating himself. Boss has traced the etiology of hysteria up to the seventeenth century.[59] He argues that, before about 1600, the "hysteric affection" was, as the name implies, attributed to the womb. In the early seventeenth century hysteria was linked not only to the male condition known as hypochondria, in which the spleen was thought to give off vapors, but also to melancholy, found in both sexes. Robert Burton saw hypochondria and hysteria as forms of melancholy; Sydenham believed that both sexes could suffer from hysteria, but that in women it was the most common condition next to fever.[60] Thus there was a shift in "the limits of hysteria, as it united with hypochondria and annexed parts of melancholy's crumbling empire."[61] At the same time the cause of hysteria came to be seen as being the brain, or the whole person. In the eighteenth century, hysteria was increasingly classified as a neurosis; the excess blood naturally present in the female body led to increased nervous irritability, especially under the influence of too much meat, coffee, or tea and insufficient exercise.[62] At this time, "According to the conventional medical wisdom, hysteria was a chronic, quintessentially feminine, disease resulting from the peculiar constitution and physiology of women."[63] The only certain way to make sure one's fragile nerves were not further weakened was to conform to the "prevailing social and biological notions of womanhood."[64]

By the mid-nineteenth century, when Littré was writing, some doctors believed that the cause of hysteria was a physical disorder of the womb; others did not.[65] For most writers of this period, however they may have envisaged the mechanism of its production, hysteria nevertheless "was rooted in the very nature of being female."[66] Pierre Briquet rejected the idea that the womb was responsible, preferring the explanation of a "neurosis of the brain" in someone of the "hysterical type"; in other words, the hysterical personality was a necessary part of the development of the disorder.[67]

In some historical periods the implications of the label hysteria are


thus that the disease originates in the womb, while in others the implications are very different, hinting that there is no organic origin for the symptoms. Littré's dictionary makes his own position clear; he follows writers such as B. C. Brodie, who in a lecture published in 1837 wrote that "hysteria. . . belongs not to the uterus, but to the nervous system."[68]

Hippocratic Hysteria: the Womb and Its Destinations

For the Hippocratic writers, however, the texts that have been used in the construction of hysteria described something resulting from a firmly organic cause, the movement of the womb. It is to the role of the womb that we must now turn. The Hippocratic texts suggest that movement of the womb is caused by menstrual suppression, exhaustion, insufficient food, sexual abstinence, and dryness or lightness of the womb, and that it can be cured by marriage and/or pregnancy, scent therapy, irritant pessaries, and various herbal concoctions administered by mouth, by nose, or direct to the vulva.

Since the womb is believed capable of movement around much of the body, these texts attribute a wide range of symptoms to womb movement. In searching for Hippocratic hysteria, we could therefore narrow down the field by identifying some combination of symptoms which so closely resembles the picture of hysteria in later historical periods that the problem of the absence of a disease label might be dismissed. The question raised by this approach is, of course, which historical period's image of hysteria we should take as our ideal type against which the Hippocratic texts are to be measured—hysterike pnix in the early Roman Empire? or the hysteria of the mid-nineteenth century? Another, more productive, way of approaching the problem is to start from the opposite end, asking which sections of the Hippocratic corpus have traditionally been used as evidence that hysteria was found in classical Greece. Robb's "Hippocrates on Hysteria"[69] translates the Aphorisms passage and five chapters of the gynecological treatises: Nature of Woman , chapter 87; Diseases of Women book 1, chapter 7, and book 2, chapters 123-125. He also gives brief summaries of Diseases of Women book 2, chapters 126-127.

It is significant that these chapters are among the very small group of Hippocratic texts used in recent discussions of hysteria, the other major chapter most commonly brought into the debate being Diseases of Women 1.32.[70] Robb also cites the appendix to Regimen in Acute Diseases , which distinguishes between pnix —a breathing difficulty usually translated as "suffocation"—caused by the womb and that caused by spasm


or convulsions: if the patient feels pressure from the fingers, it is from the womb; if not, it is a convulsion.[71] However, close study of the above passages from Diseases of Women and Nature of Woman , so often the only examples of Hippocratic hysteria given in contemporary discussions, reveals that they have in common only a reference to the womb moving to another part of the body, and the symptom of pnix . The affinity between these is not, however, constant. For example, the womb may move in the absence of pnix , as in Diseases of Women 2.127 (L 8.272-274); this section is headed "Hystérie" by Littré. It is also worth noting that such features of nineteenth—and twentieth-century hysteria as grinding the teeth, loss of voice, cold extremities, and limb pains or paralysis do feature in the Hippocratic texts, often in the company of movement of the womb and suffocation, but may be found in the absence of either or both and may be attributed to a named organic cause; for example, in Diseases of Women 2.110 (L 8.234-238) they arise from a red flux.

The difficulties of finding a passage in the Hippocratic texts to serve as a paradigm for Hippocratic hysteria are increased when we look at Littré's classifications and at the texts themselves. Thus, of the six texts used by Robb,[72] only four are in fact headed "Hystérie" by Littré: one chapter from Nature of Woman , 87 (L 7.408), and three from Diseases of Women , 2.123-125 (L 8.266-270). Not only do they give largely different combinations of symptoms and prescribe different remedies, but in none of them does even the adjective hysterikos , "from the womb," appear.

This last point is of particular interest. Since the noun is not used in this period, it is entirely irrelevant for M. R. Lefkowitz, in a discussion of fourth-century medicine, to claim that "the term hysteria means 'wombiness'."[73] Maybe it does; but since it is not used, this is of little importance. One also searches for it in vain in the later gynecological writers of antiquity, such as Soranus and Aretaeus of Cappadocia, in whose work there does exist a condition thought to originate in the womb and to cause symptoms of suffocation, tooth grinding, loss of voice, and so on, but which is called not hysteria but hysterike pnix , "suffocation caused by the womb." The classic description of the symptoms that came to be collected under this label is Soranus's Gynecology 3.26-29; section 2.11 of Aretaeus is also headed "On hysterike pnix " (CMG vol. 2, PP. 32-34) but, unlike Soranus, he lists the remedies in a separate section, 6.10, "Treatment of hysterike pnix " (CMG vol. 2, pp. 139-141).[74]

The theories of Aretaeus and Soranus will be discussed in detail below. However, it is worth discussing why neither the category of hysteria nor that of hysterike pnix has a place in Hippocratic medicine. Not


only does pnix exist as a symptom in the Hippocratic gynecological texts, and hysterikos as an adjective, but one of the sections used by Robb and many others—Diseases of Women 1.7 (L 8.32)—even introduces the description with "If pnix suddenly occurs." Nevertheless, in these texts the two are not explicitly brought together. Why should this be so?

One of the reasons why neither hysteria nor hysterike pnix is a Hippocratic category is simply that Hippocratic gynecology does not work by fitting collections of symptoms into preexisting categories. We can learn a great deal from studying the ways in which the Hippocratic writers choose to describe and to name disease. In many cases, ancient gynecology distinguishes and separates different combinations of symptoms according to cause and treatment, rather than subsuming many symptoms under a single disease label that "covers over all the clinical detail";[75] it emphasizes description of symptoms rather than diagnosis.[76] Any attempt to impose the diagnosis of hysteria on the Hippocratic texts may therefore risk distorting their approach to illness.

Indeed, looking at the Hippocratic corpus in general, not all Hippocratic texts name the diseases they describe. V. Di Benedetto distinguishes four ways of presenting a disease in these texts: as "another disorder," as "if" or "when" followed by one or more symptoms, as "if" or "when" followed by the name of a disease, or by giving the name of the disorder at the very beginning of the section. He suggests that these different ways of presenting disease reflect a culture in which the relationship between doctor and disease is defined in more than one way. The "if symptom x, therapy y" form is the most ancient, found also in Assyrian and Babylonian medicine, but in Hippocratic medicine it is slightly modified because the patient and the disease are separated and the possibility admitted that different patients may suffer in slightly different ways from what is nevertheless the same disease. Turning this last point on its head, the Hippocratic writers thus have the notion of a disease as something unitary which, due not only to the differences between patients in age, sex, temperament, and coloring, but also to variations in climate and season, may nevertheless manifest itself in a variety of ways. One disease: different symptoms, according to other factors affecting its presentation.[77]

When the Hippocratic texts give a specific name to a disorder, it may be taken from the affected part; from the way in which the disorder presents itself; from the specific sensation caused; or from something that happens in the course of the disease.[78] Although there is no name given to the disorder, or disorders, in the texts usually seen as "Hippocratic hysteria," their opening words are relevant here. These fall into two


categories. Some start by describing the movement of the womb: "When the womb turns to the head" in Diseases of Women 2.123 (L 8.266). Others start with the symptoms of pnix , suffocation: the opening of Diseases of Women 1.32 (L 8.76) translates as "If pnix suddenly seizes a pregnant woman." The later name hysteria comes from the part believed to be affected: the womb. However, in the Hippocratic texts being considered here, the focus is either on the part that causes the symptoms or on the symptom that seems to have a central position: pnix . I will shortly return to the specific significance of this sensation in classical medicine.

The texts traditionally used as examples of hysteria in the Hippocratic corpus exhibit several features that make it difficult to merge them into one picture. I now propose to discuss those most commonly used by later commentators in order of their appearance in the gynecological treatises, and to set them within the context of the imagery associated with "woman" in ancient Greece.

The first description of interest is the second chapter of Diseases of Women book 1 (L 8.14-22), a discussion of menstrual suppression in a childless woman. Menstrual suppression is of central importance in Hippocratic gynecology,[79] due to a physiology of the female outlined in the previous chapter, Diseases of Women 1.1 (L 8. 10-14). Regular menstrual bleeding is seen as essential to female health—after maturity, outside pregnancy, and before the "drying out" of the menopause—because of the quality of female flesh. In women who have given birth, the body is "broken down" and its internal channels opened by childbirth and the lochia. A woman who has not given birth will suffer more pain if the flow of her menstrual blood is obstructed; because her body is more resistant, firmer, and more "thickly-packed," there is less open space into which the blood can travel. The writer of this chapter goes on to say that a woman's flesh is softer and of a looser texture than that of a man, and draws an analogy between female flesh and sheepskin, and between male flesh and a rug. If a fleece and a rug of equal weight are placed over water or in a damp place for two days and nights, the fleece will be found to have become much heavier than the rug. This is because sheepskin has a greater capacity to absorb water: a capacity shared with female flesh.[80]

Aristotle's characterization of woman as "a deformed male" and "a mutilated male" is well known, as is its persistence in Western culture.[81] However, Aristotle's biology may be seen as only one manifestation of the classical Greek belief that women are both fundamentally different from, and inferior to, men. In the seventh century B.C ., the poet Hesiod expressed this belief in chronological terms; women, the genos gynaikon


or "race of women," were created later than men. Before Zeus sent the first woman and mother of the "race," Pandora, as one stage in the sequence of gift and counter-gift between gods and men, men lived like the gods. The arrival of Pandora and her daughters creates the need for sexual reproduction and agricultural labor, since women are voracious consumers of all that a man can produce.[82] In the Timaeus , Plato too presents women as a late addition to the human race; in the second generation of humanity, men who acted in a cowardly or unjust way in the first are reborn as women.[83]

Defining the female in terms of the male is one way of expressing difference; chronology is another. Other images of male/female relations express it in other ways but show similar persistence: the agricultural metaphor, in which man ploughs the field that is woman and sows the seed in her passive body, or the war/childbirth opposition, in which man sheds the blood of others to defend the city in war, while woman bleeds from her own body and replenishes the city's stock of men.[84] By locating female difference at the level of the flesh, Hippocratic medicine incorporates the ideas of fundamental difference, sexuality, and bloodshed into its image of woman.

The direct consequence of the difference between the flesh of the two sexes is that women absorb more fluid from the digestive process, needing menstruation to remove the excess from their bodies. As a result, in the Hippocratic texts women are often described as "wetter" than men. Women are loose-textured and soft to the touch, thus by their very nature retaining moisture, and this retention is even presented as the explanation for women having breasts.[85] A further factor mentioned in Diseases of Women 1.1 is their way of life. A man does more strenuous and tiring work, which dries out any excess moisture he may have accumulated; women live sedentary lives, leaving menstruation as the only way of purging them of the excess fluid building up in their bodies.

It is in the context of these beliefs about the female body that Diseases of Women 1.2 should be read. In certain circumstances, even in the wet body of a woman, the womb may be deprived of sufficient moisture. The childless woman, due to the lack of spaces in her body in which moisture can be stored, is at particular risk, above all if she abstains from the "moistening" activity of sexual intercourse. In such a woman, the "dry and light" womb may suddenly "turn around"[86] and move up in search of moisture. Menstruation stops, and if it does not occur for three months there will be pnix from time to time, intermittent fever, shivering, and pain in the limbs. If there is no bleeding by the fourth month, these symptoms will worsen and will be joined by those of thick urine,


a swollen abdomen, grinding the teeth, loss of appetite, and difficulty in sleeping. In the fifth month all symptoms will be worse; if the condition persists into the sixth month with no menstrual loss, it will have become incurable, and the woman will suffer the additional symptoms of vomiting phlegm, extreme thirst, discomfort if touched, gurgling sounds from the blood in the womb which is unable to come out, loss of voice or difficulty in making herself understood, and irregular breathing. Finally the abdomen, legs, and feet will swell: death is imminent.

The disorder described in Diseases of Women 1.7 is similar, although it does not follow this month-by-month pattern, but the explanation for the symptoms is different, since the central point seems to be that they depend on the location to which the dry womb moves. The affected group is described as women not having intercourse, but older rather than younger women because their wombs are lighter in weight. Elsewhere in these texts it is explained that the younger the woman, the more blood there is present in her body.[87] If a woman's vessels are emptier than usual and she is more tired, the womb, dried out by fatigue, turns around and "throws itself" on the liver because this organ is full of moisture. This causes sudden pnix , by interrupting the route of the breath through the belly. During this pnix , the whites of the eyes are turned up, the woman is cold, and her complexion is livid; she grinds her teeth and has excess saliva, like a sufferer from Heracles' disease, another name for the condition that the Hippocratics usually called the sacred disease and which we would probably call epilepsy. Sometimes phlegm will run down from the head, causing the womb to leave the liver and return to its proper place, and the pnix will stop because the womb is now full of fluid and heavy. If the womb stays on the liver or in the area of the hypochondria for a long time, however, the sufferer will be choked; if it moves to the mouth of the bladder, it will cause strangury; or it may go to the limbs or side.

Diseases of Women 1.32 (L 8.76) gives an almost identical etiology for pnix and a very similar picture of symptoms, but it concerns the condition in a pregnant woman. Not only fatigue but also insufficient food can cause the womb to move; the womb itself is described as being overheated as well as dry. As in 1.7, phlegm—described as cold—may run down from the head and cause the womb to return to its proper position; if the womb does not return quickly, there is danger to the fetus.

The alleged hysteria texts in Diseases of Women 2.123ff. are much shorter than those so far discussed and give little information on the women most likely to be affected or on the mechanisms by which the


symptoms are produced. Instead, they start by naming the location to which the womb has moved (without saying why it has traveled there), then give a short list of "signs," and finally outline the treatment. Diseases of Women 2.123 (L 8.266) opens: "When the womb moves to the head and the pnix stops there, the head is heavy." The signs are that the patient says she has pain in the channels in the nose and under the eyes: there is lethargy and foaming at the mouth. The first treatment is to wash her with warm water; if this does not work, cold water or cooled boiled laurel or myrtle water should be put on the head, and the head anointed with rose oil. Sweet smelling fumigations should be applied below, foul smelling substances to the nostrils; she should eat cabbage and drink cabbage water.

Diseases of Women 2.124 (L 8.266-268) has an identical format and concerns movement to the heart; Diseases of Women 2.125 (L 8. 268-270) and 2.126 (L 8.270-272) concern movement to the hypochondria, for which drinks of castoreum and fleabane[88] are among the recommended remedies. As is usual in these texts, a range of different substances is given, perhaps in order to aid the doctor in catering for a range of abilities to pay, or to allow for seasonal difficulties in obtaining the substances. In general, in addition to pessaries, washing, bandages around the body to keep the womb in place,[89] oiling, and drinks, these texts make much use of fumigation, a frequent remedy for gynecological conditions.

The most detailed description of fumigation occurs in a text that is not traditionally used by later writers on hysteria: Diseases of Women 2.133 (L 8.284-286). This covers a forty-day program of pessaries and fumigations for a condition in which the womb moves to the hip joint, the mouth of the womb is closed and tilted, and the menstrual blood, unable to leave by its usual route, moves instead to the breasts. It is worth translating in full not only because of the details of the fumigation process, recommended to return the womb to its place and open it so that the menstrual blood can come out—part of the treatment for hysterical suffocation for many centuries—but also because it is only one of many chapters that could be used to show the existence of womb movement texts, the details of which the hysteria tradition chooses to ignore. Contributing to its neglect by the hysteria tradition is the fact that Littré diagnoses it not as hysteria but as "Obliquité latérale devenant chronique" leading to menstrual suppression, swollen breasts, and, eventually, breast cancer.

The description of fumigation reads as follows.


First give a fumigation to the womb. Take an earthenware pot with two-sixths capacity, put on it a dish, and fit them together so that no air can get in. Then pierce the bottom of the dish and make a hole. Put in the hole a reed, about a cubit long. The reed must be properly inserted in the dish so that no vapor escapes. When you have prepared this, place the dish on the pot and plaster it round with clay. When you have done these things, dig a hole in the ground, two feet deep, large enough to make room for the pot. Then burn firewood, until you have made the hole red-hot. When it is red-hot, take out the wood and the biggest and hottest pieces of charcoal, but leave the ashes and embers in the hole. When the pot is heated up and vapor rises, if the vapor is very hot, hold back; if not, she is to sit on the end of the reed, and pass it into the mouth [of the womb], then fumigate. If it cools, throw on red-hot charcoal, taking care that the fumigation is not too fiery. If, by adding the charcoal, the fumigation becomes more fiery than it should be, take away the charcoal. One should construct the fumigation in fine, still weather, so she is not cold: she should be covered with garments. In the pot you should put dry garlic, and pour in water so that it rises two digits above, and soak it well, and pour in seal oil too. Heat this. The fumigation must go on for a long time. After the fumigation, if she is able, she should wash her whole body as she pleases, the lower back and below the navel in particular. Give for dinner barley cake or wheat bread, and boiled garlic. On the next day, if she is weak from the fumigation, intermit that day: if not, go back to the fumigation. While she is being fumigated, if she is able to examine it, order her to touch the mouth [of the womb]. The fumigation itself inflates the womb, makes it more upright and opens it. It is because it is like this, and can do such things, that you should use a fumigation.[90]

On the constituents of this fumigation, it is noteworthy that elsewhere in this treatise seal oil is described as the best substance to use in a fumigation for movement of the womb to the hypochondria.[91] Garlic, like castoreum and fleabane, features because of its strong smell. In descriptions of therapy for womb movement, the olfactory qualities of substances often account for their use. The pattern is usually that fragrant substances are applied to the vulva, in order to attract the womb back, while foul-smelling substances are placed under the nostrils to drive the womb away from the upper parts of the body.[92] In addition-and in apparent contradiction—fragrant oils may be rubbed on the head and strong-smelling substances drunk, often in wine.

Littré's diagnosis apart, there seems little reason why the womb movement described in 2.133 should have been omitted from the construction of the hysteria tradition. That section demonstrates the prevalence


of the combination of womb movement and menstrual suppression throughout Diseases of Women . Returning to the alleged hysteria texts, Diseases of Women 2.127 (L 8.272) is another description of movement of the womb to the liver, which defines the affected group in a way different from that of the writer of 1.7. Where 1.7 saw the most likely sufferer as an older woman not having intercourse, 2.127 suggests movement to the liver is more common in older unmarried women and young widows, especially the childless and the sterile, because these women lack the beneficial purging of childbirth and the lochia. Here the argument is more reminiscent of 1.2. Section 2.128 (L 8.276) discusses movement to the hypochondria, for which a fumigation followed by intercourse is recommended, and 2.129 (L 8.276) covers movement to the ribs, which can cause a cough, pain in the side, and what feels like a ball in the side. Section 2.130 (L 8.278) concerns movement to the hips or flanks, and 2.131 (L 8.278) movement to the middle of the waist, in which the drawing up of the limbs is mentioned as a symptom.

A further set of texts concerning womb movement may be found at 2.200ff.; two significant points for the later history of hysteria occur in 2.201 (L 8.384), where it is recommended that the patient's groin and inner thighs should be rubbed with aromatics to cure movement of the womb to the diaphragm, and 2.203 (L 8.388), where we read, "When the womb causes pnix , light a lamp and snuff it out under the nostrils" and, later in the same chapter, "Take a lamp, throw on it a little oil, light it, and when it is extinguished hold it near the nostrils." The first therapy is used in a famous passage of Galen, which will be discussed below: the second, also found in one of the texts used in the hysteria tradition, Nature of Woman 87 (L 7.408),[93] occurs in many later discussions of hysteria.

It can be seen that the Hippocratic texts do indeed work by describing symptoms rather than giving a single disease name to these chapters, and that where they group symptoms and therapies together they do so according to the part of the body to which the womb is believed to have moved. Of these therapies, the recommendation of marriage/pregnancy occurs only in the discussion of womb movement to the hypochondria in Diseases of Women 2.128 (L. 8.276), which ends by saying that, after fumigation, the patient should sleep with her husband: "release from this disease, when she is pregnant." Nevertheless, it is this treatment for womb movement that has received most attention in the secondary literature, above all in the work of the psychoanalyst and classicist Bennett Simon, in his Mind and Madness in Ancient Greece . This includes a chapter titled "Hysteria and Social Issues," which opens with the familiar error:


"Hysteria, the disease of the 'wandering uterus,' was given its name by the Greeks."[94] Simon's overall approach to hysteria combines that of I. M. Lewis's study of spirit possession, trance, and shamanism, which presents the possessed state as an indirect mode of protest used by powerless and peripheral sectors of society,[95] with a Freudian model. According to what Simon calls a "psychodynamic understanding of hysteria," "a hysterical symptom, for a Greek woman, permitted a safe expression of certain unmet needs," as a result of which expression the doctor would intervene on the woman's behalf as the "wished-for good father."[96] To summarize the "culturally sanctioned dumb show"[97] that Simon envisages, an unmarried or widowed woman is supposed to feel sexually frustrated and to express this frustration by hysteria: the doctor then legitimates her wish by announcing that the cure consists in letting her have what she wants, since it is precisely marriage and childbirth that will make her healthy again.

This approach is inadequate because it shows little understanding of the institutional position of women, the ideal of marriage as universal, the ideal age at first marriage of fourteen for girls, and so on.[98] It also fails to come to terms with the fact that, in most of the texts labeled "Hystérie" by Littré, the marital status of the sufferer is not given[99] or she is explicitly described as married.[100] In his discussion Simon cites only one Hippocratic passage, Diseases of Women 2.151 (L 8.326), in which the woman patient is said to suffer in the same way as those who are struck with the sacred disease. In another passage on this last disease, Simon reveals that, like Veith, he has not studied the Greek text of the Hippocratic corpus in sufficient detail. After a brief discussion of the "madness of Heracles," which "was considered by some to be a case of epilepsy,"[101] Simon states, "To my knowledge, the Hippocratic corpus contains no mention of the mythical characters who went mad and were portrayed so vividly on the Athenian stage and in vase painting." However, as I have mentioned above, in Diseases of Women 1.7 (L 8.32) the writer states that women with the condition he describes resemble sufferers from "Heracles' disease"; hypo tes herakleies nousou , which Littré translates "aux épileptiques." The characters of myth, who had influenced the folk names of diseases, are thus present even in the Hippocratic corpus.

It is, furthermore, inappropriate to describe hysteria as a "safe expression" of a woman's needs when loss of voice, grinding the teeth, and "movement of the womb to the liver," far from being a safe way of attracting attention, may be the signal for the Hippocratic doctor to tie bandages around the patient's waist, place foul-smelling substances under her nose, insert beetle pessaries, inject hot oil into the womb, or


shower her with cold water. As examination of the texts has already shown, and contrary to what Simon implies, marriage and childbirth are rarely the prescribed remedies for this combination of symptoms,[102] and it is also unusual for the remedy to consist of something that could be seen as a form of indirect sexual gratification; for example, fragrant ointments to be rubbed on the vulva[103] or the vaginal insertion of objects specifically described as resembling the male sexual organ.[104] Finally, it is inappropriate to use Simon's "psychodynamic model" when in Hippocratic medicine there is no line drawn between psychological and organic illness.[105]

A similar approach to that of Simon is taken by Rousselle, who states that "Greek women had no legal right to make any decision regarding their own marriage: they could not ask a man to marry them, or even decide that they wanted to be married or to accept an offer of marriage, so it is perhaps not surprising that their impotent anger should take the form of a disease in which their womb was literally suffocating them."[106] D. Gourevitch traces the disappearance of "the hysterical virgin from medical literature" between the Hippocratics and the medicine of the Roman Empire; she attributes this disappearance to institutional change since, if the age at first marriage falls even further, fewer girls will remain to become hysterical.[107]

However, such approaches are rooted in our own society's views on what is normal for a woman, on the nature of hysteria, and on the relationship between medicine and sexuality. Yet for the writers of the Hippocratic texts—and probably for the patients they treat—intercourse and pregnancy rightly belong to the domain of the pharmacopoeia, due to their dramatic and beneficial physical effects. Not only does intercourse moisten the womb, thus discouraging it from moving elsewhere in the body to seek moisture, but it also agitates the body and thus facilitates the passage of blood within it. Furthermore, childbirth breaks down the flesh throughout the body and, by making extra spaces within which excess blood can rest, reduces the pain caused by the movement of blood between parts of the body. It causes complete purgation (katharsis ) of excess blood and may thus cure many women whose problems originate in menstruation. Since all disorders of women ultimately result from their soft and spongy flesh and excess blood, all disorders of women may be cured by intercourse and/or childbirth, to which marriage and pregnancy are the necessary precursors. There is thus nothing special about the prescription of these in cases of movement of the womb.

Hippocratic medicine thus gives a pharmacological interpretation to


what we may be tempted to see as the social processes of marriage and motherhood. We should, of course, never forget that the Greek word for mature woman, gyne , also means "wife." Womb movement, however, calls up a battery of other therapies, many of which-like the fumigation described above—make use of foul—and sweet-smelling substances. These therapies lie behind the assertion frequently made in later writers—but not in such authors as Soranus and Galen—that the Hippocratic womb was thought to be an independent living being, fleeing from foul smells but moving to seek out more pleasant odors. We must now decide whether any such belief is necessarily implied by the use of scent therapy.

Such therapy relies on the idea of connections existing between parts of the body, and in particular in the gynecological texts on the presence of a hodos or "way" from the nostrils and mouth to the vagina.[108] This is never anatomically described but is implicit in many therapies used. For example, a test to determine whether a woman can conceive involves putting a clove of garlic or another strongly scented substance at one end of the hodos and discovering whether the scent reaches the opposite end. If so, there is no obstruction present, and the woman can conceive.[109] Disorders of the womb can also be treated by using the hodos . A summary of treatments of the womb in Diseases of Women 2.137 mentions the top and the bottom of this tube as appropriate sites for the administration of medication.[110] If the womb has moved upward, foul-smelling substances are held at the nose, pleasant-smelling substances to the vulva, so that the womb is simultaneously repelled from above and attracted down to its correct place.[111] If the womb moves down, or starts to come out of the body through the vulva, foul smells are placed there and sweet smells at the nostrils to draw it up again.[112] There is no explicit discussion of the mechanism by which such therapy is supposed to work.

Plato and Aretaeus: the Wild Womb?

It is significant for later medicine that these descriptions of scent therapy also contain no suggestion that the womb is animate; that is, that it is a living being with a desire for sweet smells and a revulsion for foul smells. This brings us to a further important passage, Plato's Timaeus 91a-d, a description of the womb as animal, which has been highly influential in the history of hysteria. The womb is seen by Timaeus of Locri as a living creature desiring union, which, if it remains unfruitful (akarpos ) beyond its proper season, travels around the body blocking passages, obstructing breathing, and causing diseases. C. M. Turbayne says "Plato's account


follows that of Hippocrates who, in his Sicknesses of Women , coined the word 'hysteria' and ascribed hysteria to the wandering womb."[113] As one would expect, Veith is cited in a footnote.[114] Furthermore, this link between womb and animal is taken by F. Kudlien to be the assumption behind the "well known ancient concept" of uterine suffocation.[115]

Plato lived from about 498 to 347 B.C . and was thus writing at the same time as the authors of Diseases of Women , or a few years after. Is it therefore valid to merge his theories with theirs and conclude that the Hippocratic scent therapy necessarily implies the belief that the womb is animate, "a living thing inside another living thing," as the second-century A.D . medical writer Aretaeus later wrote?[116] The difficulty with this approach is that there are clear differences between the gynecology of Timaeus and that of the Hippocratic corpus, and there is ample evidence that the idea of the womb being—or being like—an animal was disputed even in antiquity. Its best-known expression, apart from the passage in Timaeus , is in Aretaeus, who states that movement of the womb mostly affects younger women, whose way of life and judgment are "somewhat wandering" so that their womb is "roving" (rhembodes ). Older women have a "more stable" way of life, judgment, and womb. This in itself varies from the Hippocratic theories, which tend to link movement of the womb with older women, whose wombs are lighter.[117] It is in this section too that Aretaeus describes the womb as hokoion ti zoon en zooi , usually translated as "like some animal inside an animal" but which could be less emotively rendered "like a living thing inside another living thing."

It has been suggested that the words of Aretaeus are based on a recollection of having read Timaeus at school:[118] as may be seen from the work of Soranus, also writing in the second-century A.D ., this was certainly a very outdated idea in second-century medicine. Soranus explicitly rejects the claim of "some people" that the womb is an animal, although he admits that in some ways it behaves as if it were, for example, in responding to cooling and loosening drugs. He reinterprets the success of therapy involving sweet—or foul-smelling substances to attract or repel the womb, saying that these work not because the womb is like a wild animal emerging to seek pleasant scents and fleeing from foul ones, but because the scents cause relaxation or constriction.[119] Galen, writing shortly after Soranus, discusses and rejects what he regards not as Hippocrates' but as Plato's theory of the womb as a living creature in On the Affected Parts 6.5. After quoting from Timaeus he writes, "These were Plato's words. But some [physicians] added that, when the uterus during its irregular movement through the body touches the diaphragm, it in-


terferes with the respiratory [movements]. Others deny that the uterus wanders around like an animal. When it is dried up by the suppression of menstrual flow, it extends quickly to the viscera, being anxious to attract moisture. But when it makes contact with the diaphragm during its ascent, it suppresses the respiration of the organism."[120]

It is thus clear from Soranus and Galen that, at least by the second century A.D ., medical opinion was split on whether womb movement necessarily entailed assigning the status of "living thing" or "wild animal" to the womb. It may further be questioned whether Plato's account—or, perhaps, the Locrian's account, since it is by no means certain that the passage represents Plato's own views[121] —is in any way following the Hippocratic Diseases of Women , as Turbayne argues. In general, Timaeus shows a strong humoral theory of disease in which the four humors are linked to the four elements: earth, air, fire, and water. The use of humoral theory in the Diseases of Women is minimal, perhaps because the female body is so heavily dominated by blood.

The description of the womb and of conception in Timaeus should be read in the context provided by the preceding sections on the human body, which show that analogies in which certain parts of the body are compared to living creatures are common in Timaeus . That part of the soul which is concerned with bodily desires is tied up in the body "like a wild creature";[122] a disease is described as being like a zoon , in that it has a natural span of life.[123] At the start of the second generation of mankind, all those who have proved cowardly or unjust in the first become women; it is at this point that the gods put into all human beings a zoon that desires sexual union. In males, the penis has a disobedient and selfwilled nature, "like a zoon " and, like the savage part of the soul, it does not obey reason, the logos .[124] When the womb is described, all that is different is that it is no longer put beside the zoon in a simile, but appears in a metaphoric relationship; not "like a living thing," but "a living thing desiring to bear children."[125] In both cases what is significant is that the organ moves independently of the will, in an uncontrolled way. Since Plato/Timaeus has already mixed apparently nonfigurative uses of zoon (the gods put a living creature in all humans) with obvious similes (the penis is like a zoon ), it would be unwise to make too much of the way in which the womb is described. It should also be noted that animal analogies are used elsewhere for the organs. Not only woman is thought to have a zoon inside her, since Plato himself likens the penis to an animal, and in Aristotle it is the heart that is like an animal, this in turn being likened to the genitals in a further analogy.[126]

In men, the zoon empsychon that makes the penis behave "like an ani-


mal" is in the seed, which comes from the spinal marrow.[127] The theory of the origin of the semen is consistent with Hippocratic anatomy, which traces its path up the spinal cord, behind the ears and to the head.[128] In the description of the corresponding part in woman, the womb, there are however some obvious differences from Hippocratic theories. Timaeus says that in coitus minute invisible and shapeless zoa are sown in the womb, where they will grow to maturity. Apart from the very general sowing analogy, this does not correspond to anything in the corpus; indeed, in the Hippocratic Generation 6 and 8, both male and female contribute seed, the sex of the child being determined by the strongest seed.[129]

Aretaeus's analogy is thus not characteristic of the medicine of his time but, on the contrary, stands out as an anachronism: Plato's (or Timaeus's) medicine, while sharing some anatomical features with Hippocratic theories, demonstrates many individual points. Galen and Soranus mention the belief that the womb is not just like an animal, but is an animal, yet Galen ascribes this only to Plato. From the list of treatments of which he disapproves, Soranus apparently thinks that the use of scents in therapy tends to imply the belief that the womb is an animal. However, the central role of scent therapy in disorders of the womb in the Hippocratic texts does not mean that the Hippocratic writers would inevitably have regarded the womb as an independent animate part of the body; as Soranus's own explanation of why scent therapy works shows, it would be possible to use this technique within an entirely different conceptual framework, openly rejecting the animate womb theory.

I would also question whether we would be so ready to read into Hippocratic medicine ideas of the womb as an animal, were it not for the influence of the imagery of Timaeus on Aretaeus and on other writers to the extent that Galen finds it necessary to refute the theory. Our own medical theories play a part in this: because it is self-evident to us that the womb not only is not a living creature, but also cannot move around the body, any suggestion that it does so move is startling, demands explanation, and may be given more weight than it deserves.

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.

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]

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.

The Meeting of Three Worlds

Returning to western Europe, most of Galenic medicine had been lost with the decline, from the late fourth century onward, in knowledge of the Greek language.[267] Soranus dominated gynecology in general; his writings, perceived as shorter and more practical than those of Galen, were preserved in abridged Latin versions that reinstated the womb movement he had so vehemently rejected. Hippocratic medicine fared worse, although Aphorisms continued to circulate after its translation into Latin in the sixth century; the Ravenna translations also included some of the sections of Diseases of Women describing womb movement. Some Galenic treatises, too, were translated at Ravenna; however, whereas 129 works of Galen were translated into Arabic, only 4 existed in Latin before the eleventh century. One of these was the practical work On the Method of Healing, to Glaucon but, as has been discussed above, this can be read as a further reinstatement of the wandering womb. The third volume of Paul of Aegina's encyclopedia, which includes his largely Ga-lenic description of hysterike pnix plus details of scent therapy, was translated into Latin, but probably only in the tenth century.[268]

The emphasis in the West lay firmly on the instructional and practical aspects of ancient medicine; thus the traditional therapies for hysterical suffocation were transmitted when discussions of its causation were not. The category of suffocation of the womb appears in several anonymous collections of texts from the eighth to the twelfth centuries. I have already mentioned Leningrad Lat. F.v.VI.3, a Latin manuscript dating from the eighth or ninth century which contains several short texts on gynecology, all of which show some resemblances to the second book of the Hippocratic Diseases of Women .[269] Of these, De causis feminarum gives practical advice on what to do "si vulva suffocantur" (if the womb is suffocated), giving the Greek name for the condition as "styrecersis": is this a garbled form of hysterike pnix or hysterika ? The patient should be given burned and pulverized stag's horn in wine or, if she has a fever, in hot water.[270] Another text in this collection, the De muliebria causa , claims that "uribasius"—Oribasius, the only authority named in these texts—recommends one drachma of agaric for suffocation of the womb.[271] This is repeated in a section of the following text, the Liber de muliebria , which later gives a more complex recipe for suffocation of the womb, in which the patient is choked at the neck, so that it is turned back to the chest.[272]


It was in the eleventh and twelfth centuries that Galenic treatises were returned to the West, through the translations from Arabic into Latin made by Constantine the African in the late eleventh century at Salerno and Monte Cassino; a few Galenic treatises were translated directly from Greek into Latin in the twelfth and thirteenth centuries, and these translations are usually of higher quality.[273] The effect of Constantine on the history of medicine cannot, however, be overemphasized; his arrival in Italy with a cargo of books of Arabic medicine, which he translated into Latin at Monte Cassino, transformed the "theoretical impoverishment" into which medical knowledge in the West had fallen. For our purposes here, what is most significant is that his translations included Galen's commentary on the Hippocratic Aphorisms , and works of al-Majusi and Ibn al-Jazzar.[274] Constantine translated much of the Kamil of al-Majusi as the Liber Pantegni ; this work was translated again in the early twelfth century by Stephen of Pisa as the Liber Regius and was printed in 1492 and 1523. The Kitab Zad al-Musafir of Ibn al-Jazzar was translated in an abbreviated form as the Viaticum , while Constantine's Expositio Aforismi is a translation from the Arabic of Galen's commentary on the Hippo-cratic Aphorisms .[275]

What effect do these texts have on the hysteria tradition in the West? We have already seen the wide range of variations that can occur on the theme of womb movement. In the Hippocratic texts a dry, hot, and light womb rises in search of moisture; Soranus believes that the anchoring membranes prevent any movement, while for Aretaeus, although the womb moves it is pulled back by its membranes, thus affecting the higher parts of the body only through sympathy. In Galen the problem is a womb filled with retained seed or menses, rotting to produce coldness. In Arabic medicine a Hippocratic mobile womb becomes a mobile womb with Galenic contents, and vapors as well as sympathy explain its effects on the higher parts. In the Latin West the focus on Soranus had been combined with acceptance of womb movement; while some extracts from Hippocratic gynecology circulated, Galenic theory was lost until the eleventh century.

The return of Galenic medicine from the Arabic world led to yet another variation on this theme of womb movement and its mechanisms. It was in the twelfth century at Salerno in southern Italy that the texts of the Hippocratic corpus, Soranus, and Galen finally came together after their varied travels through the Latin West, the Greek East, and the Islamic world.[276] The result was not a critical comparison of these traditions, but instead the decline of Soranus and the rise of the Galenic medical system of humoral balance and imbalance. One of the "masters"


of the school of Salerno in the twelfth century was Johannes Platearius. In his description of suffocation of the womb, in the late twelfth-century encyclopedia and textbook De aegritudinum curatione , he combined Galen and Paul of Aegina with Ibn al-Jazzar's claim that the symptoms were caused by vapors rising from the corrupt seed, menses, or other retained humor. However, Platearius went a step farther than this, suggesting that it was not the vapors, but the womb filled with vapors, that rose in the body to put pressure on the organs of breathing.

Green has argued that, since the Latin translations of al-Majusi's Kamil omitted the later section in which he describes scent therapy in terms of the womb as an animal annoyed by foul smells and seeking pleasant scents, this particular merger of the mobile womb with Galenic theory may come, not from Islamic medicine, but from the survival of the idea in popular thought in the West.[277] Other features of Platearius's description are more familiar, showing the overall dominance of the Galenic material found in the newly available Arabic sources; he recommends the Galenic tests of the woolen thread at the nose of the patient, or a glass flask full of water placed on her chest, and among his suggested cures one finds sneezing provoked with castoreum or pepper, and the use of foul scents at the nose and sweet scents at the vulva. However, here too Green points out that non-Galenic ideas surface; although Galen never specifically advised marriage as a cure, Platearius recommends it if the cause is retained seed. Again, al-Majusi did explicitly prescribe sexual intercourse as a cure; but, again, this was omitted from the Latin translation of his work.[278] It seems that the survival of Hippocratic theories—the wandering womb from Diseases of Women and the therapeutic value of intercourse from sections of that treatise and from Diseases of Young Girls —should not be underestimated.

Another writer associated with Salerno in the twelfth century is the female physician Trota, whose name is associated with a number of treatises of this period which are found in nearly a hundred manuscripts from the thirteenth to fifteenth centuries.[279] Suffocation of the womb is mentioned in both the more empirical Ut de curis , which refers to it occurring in young girls with epilepsy, and the more theoretical and Ga-lenic Cum auctor .[280] The Cum auctor version owes much to Ibn al-Jazzar, although it does not specify conclusively whether suffocation results from vapors, or the womb itself, rising up inside the body. Scent therapy is recommended, and the story of the woman who lay as if dead but was known to be alive through the presence of the innate heat, is transmitted through the Cum auctor ; as in Ibn al-Jazzar, Galen becomes its hero.[281]

The influence of Galenic theory grew with the translation of other


important Arabic texts into Latin; in particular, Ibn Sina's Qanun . The work of Soranus became "virtually obsolete by the thirteenth century";[282] the gynecological works of the Hippocratic corpus languished in the wings until the sixteenth century. However, one Hippocratic text remained in the center stage: the Aphorisms , including the section on gy-necology with the text with which this chapter began, the alleged origin for the label/diagnosis hysteria , 5.35: "In a woman suffering from hysterika , or having a difficult labor, a sneeze is a good thing."

Aphorisms circulated in both the Latin West and the Arabic world; in the latter, from before A.D . 800, it was coupled with the commentary of Galen, In Hippocratis Aphorismi . This commentary, probably written in A.D . 175, was restored to the West when Constantinus Africanus translated it from Arabic into Latin in the eleventh century. In terms of its printed editions in the Renaissance, it was the third most popular Ga-lenic treatise after Ars medica and De differentiis febrium .[283] The central position of the Aphorisms from the eleventh century onward results not only from its perennial popularity as a series of practical tips,[284] but also from its inclusion in the Articella , a group of medical writings "used for centuries at Salerno and elsewhere as a textbook for introductory courses in medicine."[285] The central text of the group is Hunain ibn Ishaq's Isagoge , in Constantine's translation from the Arabic; in addition to the Aphorisms , the nucleus also contains Galen's Tegni (the Ars parva ), the Hippocratic Prognostics , Theophilus on urines, and Philaretus on pulses.

I have argued that the opening words of Aphorisms 5.35 can best be translated "In a woman suffering from hysterika ," where hysterika means disorders of the womb. But this translation depends on reading the text without the Galenic commentary that instead pushes for a very specific translation, hysterike pnix . By looking at changes in the Latin translation of this aphorism, it is possible not only to trace its gradual incorporation into the hysteria tradition, but also to provide a test case for the period in which the humanists began to carry out philological work on the Galenic and Hippocratic texts. When were these texts read as the object of serious study? It is the brief Aphorisms , not the lengthy Galenic commentary, which occupied a central place in the medical curricula of the Renaissance. Despite its impressive printing history, I would argue that Galen's commentary was little read before the sixteenth century.

The earliest Latin translations of Aphorisms , found in manuscripts dating from the eighth to the twelfth centuries A.D ., can be traced back to fifth/sixth-century Ravenna.[286] Such Latin translations are very literal, the writers apparently having an equally weak grasp of both Greek and


medicine. The translation reads "Mulieri de matrice laboranti aut diffi-culter generanti, sternutatio superveniens, optimum" (In a woman troubled by the womb or giving birth with difficulty, a sneeze coming on unexpectedly is best).[287] At this period, then, the aphorism was not associated with hysteria or suffocation of the womb.

The Articella uses a different Latin translation of the Aphorisms , possibly produced in the eleventh century, and linked to the name of Con-stantinus Africanus. It is not known whether this was made from a Greek manuscript of Aphorisms , or by merely extracting the aphorisms from a copy of Galen's commentary. Whatever its source, it gives for 5.35, "Mulieri que a matrice molestat aut difficulter generanti: ster-nutatio superveniens bonum." It thus differs little from the Ravenna translation; a sneeze becomes "good" instead of "the best thing," and the womb continues to "distress" or "trouble" the woman. Fifteenth-century printed editions of the Articella retain slight variations on this translation, which remains the most commonly used well into the sixteenth century.[288] Some editions give two translations, setting this so-called versio antiqua beside the traductio nova of Theodorus Gaza. The new translation runs, "Mulieri quam vitia uteri infestant, aut que diffi-culter parit, si sternutamentum supervenit, bono est." The opening words, "In a woman in whom disorders attack the womb," again keep this aphorism within a very general gynecological context. Another variation in printed editions of the Articella is to print both translations together with a rearrangement of the Aphorisms by the part of the body discussed, on a capite ad calcem lines; thus the edition of 1519 gives this aphorism under "Concerning sneezing" and "Concerning the female generative organs."[289]

A further development in the printed versions of the Articella is that, where the manuscript versions gave only the Hippocratic text of the Aphorisms , the printed editions from 1476 give Galen's commentary beside it. Galen is thus "given a privileged status compared with other commentators."[290] However, an important question remains: Did anyone read the lengthy commentary, which sets it firmly in the context of hysterike pnix , as opposed to uterine disorders in general? Galen considers that apnoia , or absence of breath, is more accurate than "suffocation," seeing a spontaneous sneeze both as a "sign" (semeion ) that the patient has revived, and as a "cause" (aition ) of recovery, since in itself it revives the patient.[291] However, despite Galen's conclusion that hysterika is equivalent to hysterike pnix , the connection with the translation of the Hippo-cratic aphorism is not made. Neither the terminology of suffocation nor that of hysteria appears in the Latin of the Aphorisms ; instead, the woman


is said to be "troubled by the womb" or to have "disorders attack the womb." Reading the long discussion of the meaning of hysterika in Galen's commentary should lead to a change in the translation of the aphorism, away from this general terminology and toward that of hysterical suffocation, but no such change is made at this time.

It is in the fifteenth century that the first signs of close study of Galen's commentary and its implications for the translation of the aphorism appear, in the work of Ugo Benzi (1376-1439). Benzi wrote commentaries on the Canon of Avicenna, the Tegni of Galen, and the Hippocratic Aphorisms , omitting books 3 and 7; this last was probably first published in 1413 or 1414 while he was lecturing on medicine in Parma, but it was later revised. Like his contemporaries, of course, he still based his translations not on the Greek, but on "the medieval Latin versions from the Arabic." Although he follows the versio antiqua translation, he improves the Latin, discusses the views of Galen and Avicenna on uterine suffocation—in particular, on whether it is the womb or merely vapors that rise up the body—and also glosses the aphorism as follows: "Sternutatio superveniens mulieri suffocationem matricis patienti aut difficulter pari-enti est bonum" (A sneeze spontaneously occurring in a woman suffering from suffocation of the womb or a difficult labor is a good thing).[292]

The translation of Theodorus Gaza is used by Lorenzo Laurenziani (ca. 1450-1502),[293] while Niccolò Leoniceno (1428-1524) gives both this and the verso antiqua beside his own translation, which begins with another variation on the theme of general uterine disorders, "Mulieri qua uterinis molestant."[294]

The connection between text and commentary is made conclusively only in the 1540s, when the Aphorisms are first the object of detailed philological interest. The availability of printed Greek and Latin editions of the Galenic and Hippocratic works from the 1520s onward had no immediate impact but, after twenty years, comparison of the text both with the Greek manuscripts of Aphorisms and with Galen's commentaries is made, and the aphorism becomes explicitly "hysterical."

Antonio Brasavola's annotated edition of the Aphorisms and its Ga-lenic commentary was printed in 1541 at Basel. It discusses not only Galen's commentary but also the use of hysterika in Marcellus's commentary on Dioscorides, Philotheus, and Paul of Aegina. Brasavola (1500-1555) reasserts the identity of hysterika as hysterikg pnix , but still he does not take the step of adjusting the translation of Aphorisms 5.35, instead giving a variation on Leoniceno's translation, which reads: "Mulieri, quae uterinis molestatur, aut difficulter parit, superveniens sternutatio, bonum."[295]


The earliest translation I have found in which the terminology of the suffocation of the womb is directly applied to Aphorisms 5.35 is that of Leonhart Fuchs (1501-1566). Printed in 1545, this gives "Mulieri quae ab uteri strangulationibus infestatur, aut quae difficulter partum edit, sternutamentum superveniens, bonum." Here, for the first time, the translation itself becomes "hysterical"; "in a woman who is attacked by uterine suffocation," a translation justified by Fuchs on the grounds that Galen and Philotheus explain that hysterika equals suffocation here. He goes on to demonstrate that the basis of his translation is the comparison of Greek manuscripts, discussing whether a word in Galen's text should read lunga or pniga .[296]

The edition of Guillaume Plancy (1514-ca. 1568) takes the process a stage further. In this publication of 1552 the Latin reads "Mulieri hys-tericae, aut difficulter parienti, sternutamentum superveniens, bonum." A note justifies the translation by a reference to Galen's On the Affected Parts 6.5.[297] The connection has been made, not only between aphorism and commentary, but between the Galen of the commentary and the Galen of On the Affected Parts .

Once the aphorism has reentered the hysteria tradition, it is—with a few exceptions—there to stay. Claude Champier (fl. 1556) also mentions "vulvae strangulatus," while Jacques Houllier (ca. 1510-1562) follows Plancy's translation.[298] In keeping with his general interest in a return to the Greek classics in order to end error in medicine, Houllier also recalls Hippocratic ideas, giving a further type of suffocation due to a dry womb seeking moisture, for which a sneeze is less beneficial than baths.[299]

Thus, once the aphorism is read—rather than merely printed—in the context of Galen's commentary, it ceases to be understood as a reference to disorders of the womb in general, and comes to be absorbed into the hysteria tradition, that set of connected texts repeated by successive commentators on suffocation of the womb.

Glancing at its fortunes in vernacular editions, the English translation of the Aphorisms of 1610 by "S. H." gives "Sneezing hapning to a woman grieved with suffocation of the wombe, or having a painfull and difficult deliverance is good."[300] This is also found in a seventeenth-century manuscript in the British Library, Sloane 2811.[301] A commonplace book of the seventeenth century includes a Latin translation of the Aphorisms , giving "Mulieri hysterica, aut difficulter parienti sternutamentium su-perveniens bonum"—a variant of Plancy—and an English translation, reading "Sneezing happening to a woman seized with suffocation of the womb: or that hath a difficult deliverance: is good."[302] The comment on


this aphorism is that sneezing shakes off noxious humors and restores the natural heat that was almost extinguished. In the same book appears a work entitled "Select Aphorisms concerning the operation of medica-ments according to the place." This contains a section (pp. 121v -122r ) on "Hystericalls" which describes how the womb is drawn to aromatics and repelled by their contraries. It discusses how this mechanism works, and roundly rejects the belief of "some sotts" that the womb possesses "the sense of smelling." Even in the seventeenth century scent therapy is defended, but this does not mean that the womb is regarded as an animal.

If the old discussion of the implications of scent therapy for the status of the womb as, in the words of Aretaeus, "a living thing inside another living thing" is still itself alive and well in the seventeenth century, has the hysteria tradition made any progress over the two thousand or so years of its existence? I would argue that some change has, by this time, occurred. The tendency before the sixteenth century was toward an accumulation of descriptions, explanations, and remedies. Some features—such as scent therapy at both ends of the body, the use of an extinguished lamp wick to rouse a patient, and the application of aromatic oils to the sexual organs—went back to Hippocratic medicine, as transmitted by Galen. Others, although derived from the Hippocratics, were transformed by Galen's reinterpretation; for example, Hippocratic pnix concerns a hot womb seeking moisture to douse its fire, yet after Galen it becomes "obstruction of respiration," and the womb is seen as being filled with cold and corrupt substances rather than being hot and light. Other features remained in the tradition despite all that could be said to condemn them, most notably, the wandering womb, in coexistence with apparently contradictory features such as anchoring membranes.

Tradition or Truth?

By the mid-sixteenth century, the hysteria tradition was complete: the translation into Latin of texts from the Arabic and Greek made available virtually the full range of authors discussed above. Every commentator on suffocation of the womb knew which ancient authorities to consult for a description. Since these ancient authorities had themselves known and used the work of many of their predecessors, it is not surprising that the result was often merely further repetition. Latin and Middle English treatises from the thirteenth to fifteenth centuries tend to be heavily dependent on the Arabic writers' versions of Galen, and retain the features of scent therapy, provoking a sneeze as a cure (as opposed to


welcoming a spontaneous sneeze), venesection, and therapeutic intercourse.[303] However, in the mid-sixteenth century something new does occur: the stated desire to compare authorities, not only with each other, but with reality.

As an example of this we may take the work of Pieter van Foreest (1522-1597), Observationum et curationum medicinalium , Book 28 of which concerns women's diseases.[304] As the title suggests, rather than simply repeating the authorities, he also presents cases that he himself has seen. Observations 25-34 concern suffocation of the womb, covering cases due to retained seed or menses in widows, in pregnant and other women, and of varying severity. Rhazes, Ibn Sina, and Galen are cited; Galen is particularly favored and, although he is a supporter of the Hip-pocratic revival, van Foreest accepts Galen's attack on the Hippocratic theory that the womb dries out and seeks moisture.[305] He notes that the ancients believed the womb itself traveled the body, whereas "more recent writers" believe it is vapors that rise. The motif of the woman who uses hysteria to manipulate men is reintroduced, echoing Martial's epigram on women who announce they are hysterica in order to have intercourse with a young doctor; van Foreest states that some women simulate hysterical suffocation by imagining sexual intercourse, and he cites the "notorious poem" mocking this.[306]

His use of his own observations is first suggested when, after repeating Galen's statement that the symptoms from retained seed are worse than those from retained menses, he adds, "And this is true."[307] Even Galen must be tested against experience. Observation 27 repeats the story of the woman who lay as if dead, based on Pliny, and gives the standard tests for life, adding that a sneeze is more reliable than the wool or water tests. Observation 28 includes Galen's story of the widow who was cured after passing some thick seed. In Observation 30, on hysterical suffocation in pregnancy, he gives two cases he himself has seen, one dated to October 1589, while in Observation 31 he describes the case of a woman called Eva Teylingia, who was married in 1561 and was known to his wife. She was unsuccessfully treated by several named doctors for suffocation, and "on the third day I myself was called." Van Foreest's therapy—based on foul-smelling substances placed in the navel—was successful. In Observation 33 he gives the case of a girl of twenty, treated in September 1579, and in Observation 34 he gives a case dated March 1566.

Such works as this were used by Edward Jorden in his treatise of 1603, A Briefe Discourse of a Disease Called the Suffocation of the Mother .[308] What is most striking about this work, in which he sets out to show "in a vulgar tongue" that symptoms "which in the common opinion are imputed to


the Divell" are in fact due to the suffocation of the womb, is not the use of authorities such as Hippocrates, Galen, Pliny, and Ibn Sina, but his citation of recent cases seen and reported by men such as van Foreest, Amatus Lusitanus, and Andreas Vesalius.

Is this, then, the triumph of experience over tradition? It is not. As T. Laqueur puts it, "Experience, in short, is reported and remembered so as to be congruent with dominant paradigms."[309] Many elements of the hysteria tradition have an extraordinary vitality as paradigms, continuing to be repeated well into the nineteenth century. To take one example, Jorden himself repeats the story of the woman who lay as if dead but was known to be alive by the presence of the innate heat; he uses the version given by Pliny.[310] This story has inordinate staying power, turning up many times in seventeenth-century literature; for example, Guillaume de Baillou (1538-1616) claims that many women are being buried alive because it is wrongly assumed that the absence of a pulse indicates death.[311] In the nineteenth century, Thomas Lay-cock's Treatise on the Nervous Diseases of Women has a section on "Apparent Death" citing Diogenes Laertius's version of the same story, here diagnosed by Laycock as hysteria. As a general rule, Laycock recommends delaying burial in such cases until there are signs of decomposition.[312] He refers readers to Leigh Hunt's play A Legend of Florence , first performed in 1840, the year of publication of Laycock's own work. In this play, the moral and married Ginevra, receiving letters from a nobleman who declares his love for her, has a fainting spell and is mistakenly buried—fortunately, in an open vault. She wakes up but has difficulty persuading the people of Florence that she is not a ghost:

I am Ginevra—buried, but not dead,
And have got forth and none will let me in.
                      (act 4, scene 4)

This highly popular piece of drama, seen by Queen Victoria a number of times and regarded as Leigh Hunt's greatest dramatic success, was in turn based on Shelley's "Ginevra," published in 1821.[313] In Shelley's version, Ginevra marries a man she does not love and, on her wedding night, falls into a trance that drifts into death itself, in order to keep faith with her disappointed lover.

They found Ginevra dead: if it be death
To lie without motion or pulse or breath,
With waxen cheeks, and limbs cold, stiff, and white,
And open eyes . . .
                      (lines 145-148)


Shelley's words echo Diogenes Laertius's third-century A.D . account of the woman "without breath or pulse" but preserved, according to Galen, by her innate heat. Such powerful motifs as apparent death weave in and out of the medical accounts of suffocation of the womb and of later hysteria. Do such elements survive simply because they make such good stories? Or is the persistence of certain parts of the tradition evidence for the accuracy of that tradition, and thus for the accuracy of the diagnosis of hysteria?

Throughout this chapter I have emphasized how medicine worked as a series of texts. Medical education, particularly where it concerned women's bodies, was based on the text in the Byzantine, Islamic, and medieval worlds; even after publication of Vesalius's De humani corporis fabrica in 1543, "anatomy and surgery continued to be taught from books rather than from experiment and observation."[314] Specifically, in the texts of the Hippocratic corpus, neither the diagnosis of hysterike pnix nor of hysteria is made. The womb moves, causing a range of symptoms according to its eventual destination. At an unknown date, possibly—from the medical papyri—in the second century B.C ., a disease category of suffocation of the womb is created by the merger of a number of discrete Hippocratic texts giving symptoms, causes, and therapies. Galen challenges the label, but keeps the concept and develops a different explanation based not on womb movement so much as retained blood and seed. In the early Roman Empire, further stories are added to the disease picture, surviving in the different cultural climates of the Latin West, Greek East, and Arabic world. Particularly resistant to change are two of the original Hippocratic components, womb movement and scent therapy: so too is the need to give the concept antiquity by tracing it back in its entirety to the father of medicine.

I would suggest that what we hear in such texts as those discussed here is not the insistent voice of a fixed disease entity calling across the centuries, but rather what Mary Wack has called "the rustle of parchments in dialogue."[315] Indeed, it is rarely even a true dialogue. Deaf to pleas from anatomy and experience, the texts continue to tell one another the traditional stories. The language may shift—the womb travels, vapors rise, sympathy transmits symptoms through the body—but the message remains the same: women are sick, and men write their bodies. Nineteenth-century hysteria, a parasite in search of a history, grafts itself by name and lineage onto the centuries-old tradition of suffocation of the womb, thus making Hippocrates its adopted father. It is time that father disowned his hybrid child.



Sections of this chapter have been presented to the Pybus Club (Newcastle, 1985), the Classical Association Triennial Meeting (Oxford, 1988), a conference organized by the Wellcome Institute for the History of Medicine (London, 1990), and the Liverpool Medical History Society/Society for the History of Science (Liverpool, 1991). I am grateful to all who made suggestions as to its improvement on these occasions, but above all to the careful and generous scholarship of Monica H. Green and Mark Micale.

previous part
One— Once upon a Text: Hysteria from Hippocrates
next chapter