Homo Patiens - Approaches to the Patient in the Ancient World [1° ed.] 9789004305557, 9004305556

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Homo Patiens Approaches to the Patient in the Ancient World

Studies in Ancient Medicine Edited by John Scarborough Philip J. van der Eijk Ann Ellis Hanson Joseph Ziegler

VOLUME 45

The titles published in this series are listed at brill.com/sam

Homo Patiens - Approaches to the Patient in the Ancient World Edited by

Georgia Petridou and Chiara Thumiger

LEIDEN | BOSTON

Cover image: Patients arrived to consult a physician from a medieval manuscript now in Paris, Bibliotheque Nationale cod. gr. 2243, fol. 10 verso. After fig. 1 from Medical Illustrations in Medieval Manuscripts by Loren Carey MacKinney, Wellcome Historical Medical Museum,  London  1965. Library of Congress Cataloging-in-Publication Data   Names: Petridou, Georgia, editor. | Thumiger, Chiara, editor. Title: Homo patiens : approaches to the patient in the ancient world / edited  by Georgia Petridou and Chiara Thumiger. Description: Leiden ; Boston : Brill, [2016] | Series: Studies in ancient  medicine, ISSN 0925-1421 ; volume 45 | Includes bibliographical references and index. Identifiers: LCCN 2015032061| ISBN 9789004305557 (hardback : alk. paper) |  ISBN 9789004305564 (e-book) Subjects: LCSH: Physician and patient—History. | Medicine, Ancient. |  Medical ethics—History. Classification: LCC R135 .H66 2016 | DDC 610.9—dc23 LC record available at http://lccn.loc.gov/2015032061

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Contents Acknowledgements ix List of Figures x Notes on the Contributors xi Bibliographical Note xv Introduction: Towards a History of the Ancient Patient’s View 1 Georgia Petridou and Chiara Thumiger

part 1 Medical Authority and Patient Perspectives 1 “This I Suffered in the Short Space of my Life”. The Epitaph for Lucius Minicius Anthimianus (CIG 3272; Peek GV 1166) 23 Lutz A. Graumann and Manfred Horstmanshoff 2 Questioning the Patient, Questioning Hippocrates: Rufus of Ephesus and the Pursuit of Knowledge 81 Melinda Letts

part 2 Case Histories in the Hippocratic Corpus 3 Patient Function and Physician Function in the Hippocratic Cases 107 Chiara Thumiger 4 Case History as Minority Report in the Hippocratic Epidemics 1 138 John Z. Wee 5 Voice Pathologies and the ‘Hippocratic Triangle’ 166 Colin Webster

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part 3 Patients and Psychological Illness 6

Galen’s Anxious Patients: Lypē as Anxiety Disorder 203 Susan P. Mattern

7

Experiencing Madness: Mental Patients in Medieval Arabo-Islamic Medicine 224 Pauline Koetschet

part 4 Emotional Aspects of the Patient-Physician Relationship 8

Interpretations of the Healer’s Touch in the Hippocratic Corpus 247 Jennifer Kosak

9

Patience for the Little Patient: The Infant in Soranus’ Gynaecia 265 Lesley Bolton

10

Compassion in Soranus’ Gynecology and Caelius Aurelianus’ On Chronic Diseases 285 Amber J. Porter

11

Galen on the Patient’s Role in Pain Diagnosis: Sensation, Consensus, and Metaphor 304 Courtney Roby

part 5 Material Aspects, Diagnostic Techniques and their Impact on the Patient-Physician Relationship 12 The Μισθάριον in the Praecepta: The Medical Fee and its Impact on the Patient 325 Giulia Ecca 13

The Practical Application of Ancient Pulse-Lore and its Influence on the Patient-Doctor Interaction 345 Orly Lewis

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14

Images of Doctors and their Implements: A Visual Dialogue between the Patient and the Doctor 365 Patricia A. Baker

15

Case Histories in Late Byzantium: Reading the Patient in John Zacharias Aktouarios’ On Urines 390 Petros Bouras-Vallianatos

part 6 The Informed Patient: Self-Healing and the Patient as Physician 16

Treatment of the Man: Galen’s Preventive Medicine in the De Sanitate Tuenda 413 John M. Wilkins

17

Literary and Documentary Evidence for Lay Medical Practice in the Roman Republic and Empire 432 Jane Draycott

18

Aelius Aristides as Informed Patient and Physician 451 Georgia Petridou

19

“It may not cure you, it may not save your life, but it will help you” 471 Katherine D. van Schaik

20 Epilogue: Approaches to the History of Patients: From the Ancient World to Early Modern Europe 497 Michael Stolberg Index locorum 519 Index rerum 543

Acknowledgements All but one of the contributions included here were first presented in a threeday international conference, which took place at Humboldt University in July of 2012. The conference was organised by the editors under the auspices of the ‘Medicine of the Mind—Philosophy of the Body, Discourses of Health and Disease in the Ancient World’ research programme and was generously funded by the Alexander von Humboldt Foundation. We are extremely grateful to Philip van der Eijk, the director of the programme, for supporting us throughout the process of organising the conference and publishing the proceedings. We would also like to thank the Alexander von Humboldt Foundation for its generous financial support, which made both the original conference and the ensuing publication possible. We are indebted to the speakers and the participants of the original conference for making it an informative and memorable occasion. Special thanks are owed to Brooke Holmes, Michael Fontaine, Carin Green, Ido Israelowich, Lesley DeanJones, George Kazantzidis, Helen King, Karl-Heinz Leven for livening up the discussion during the original event, but whose papers do not appear in this volume. Finally, we are extremely grateful to Manfred Horstmanshoff for providing inspiration and expert advice on all matters related to ancient medicine and patient history. We are particularly grateful to all contributors to this volume for trusting us with their work and bearing with us throughout the process of publication. Michael Stolberg, the author of the only chapter which was especially commissioned for this book, is especially to be thanked for accepting our invitation to provide an expert discussion of approaches to the history of the patient in early modern Europe. Furthermore, we would like to thank the anonymous reviewers of the individual chapters for their detailed comments and for helping us to improve the quality of this volume. We are also grateful to Katharina Hess, Annette Schmidt and Konstantin Schulz for their valuable assistance in formatting the book. We are indebted to the Wellcome Trust, the University of Cologne database (Arachne) and the Deutsches Archaeologisches Institut for their help with sourcing the images. Special thanks are owed to Paul Scade for improving the English in a number of places, to the ERC funded ‘Lived Ancient Religion’ project Max-Weber Kolleg, University of Erfurt, and its director Jörg Rüpke, for supporting Georgia Petridou during the final year of the preparation of this volume. Finally, we should thank Richard Gordon for reading a draft of our introduction and the editorial board of Studies in Ancient Medicine at Brill, as well as Caroline van Erp, Tessel Jonquière, and Tessa Schild for their help and assistance.

List of Figures 1.1

The Epitaph for Lucius Minicius Anthimianus (CIG 3272, Peek GV 1166) 29 10.1 Midwife birthing scene from the tomb of Scribonia Attice, Isola Sacra, Ostia. Mid-second century AD 291 14.1 Roman Cupping Vessel. 1st–3rd century. Copper Alloy 384 14.2 A Greek medical relief located in the Archaeology Museum in Basel. After Berger 1970, fig. 1. Drawing by L. Bosworth 384 14.3 Drawing of a fifth century BC aryballos depicting a doctor or surgeon treating a patient 384 14. 4 Votive Relief from Piraeus, Greece. After Berger 1970, fig. 96. Drawing by L. Bosworth 385 14. 5 Funerary monument of Jason the Doctor. Athenian, Second century AD 385 14. 6 Relief from Ravenna. After Berger 1970, Fig. 79. Drawing by L. Bosworth 385 14. 7 Fragment of a relief from the Asclepion at Piraeus, fourth century BC 386 14. 8 Roman fresco painting of the doctor Iapyx treating Aeneas, Casa di Sirico, Pompeii, first century AD 386 15.1 Bononiensis 3632 (mid-15th c.), fol. 20v, with permission of the Bibliotheca Universitaria di Bologna. The miniature shows John holding a urine vial with an inscribed motto derived from the opening phrase of his work ‘On Urines’, reflecting the popularity of his uroscopy treatise 401

Notes on the Contributors Patricia A. Baker (PhD, University of Newcastle upon Tyne, 2001), is a Senior Lecturer in Classical and Archaeological studies at the University of Kent, Canterbury, UK. She has published monographs, edited books and journal articles on ancient medicine. Her most recent monograph is The Archaeology of Medicine in the GrecoRoman World with Cambridge University Press (2013). Lesley Bolton (PhD, University of Calgary, 2015), is a Sessional Instructor in the Classics and Religion Department at that university. She is currently preparing her dissertation, a new edition and translation of Mustio’s Gynaecia, for publication, and completing a textbook on medical terminology. Petros Bouras-Vallianatos has been recently awarded his PhD focusing on the late Byzantine medical author John Zacharias Aktouarios, and teaches medical history at King’s College London. He has published several articles on Byzantine and Early Renaissance medicine and pharmacology, including a new descriptive catalogue of the Greek manuscripts at the Wellcome Library in London. He is also co-editing the Brill’s Companion to the Reception of Galen. Jane Draycott is Lecturer in Classics at the University of Wales Trinity Saint David. After receiving her PhD from the University of Nottingham, she was 2011–12 Rome Fellow at the British School at Rome, and Associate University Teacher in the Department of Archaeology at the University of Sheffield. She has published a monograph and a number of articles on the history and archaeology of ancient medicine. Giulia Ecca (PhD, Humboldt-Universität zu Berlin, 2014) is currently working at the BerlinBrandeburgische Akademie der Wissenschaften. Her Ph.D dissertation (in press) is a new critical edition with translation and commentary of the Precepts, a treatise included in the Corpus Hippocraticum. The main focus of her current research is Galen’s Commentary on the Hippocratic Aphorisms.

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Lutz Alexander Graumann (PhD, MD, Philipps University Marburg, 2000), is a Paediatric Surgeon at the University Hospital of Marburg. He has published several articles and his thesis on the case-stories of the Hippocratic Corpus, and contributed a paper on ancient hermaphrodites in a volume co-edited by Laes, Goodey and Rose (Brill, 2013). He is now focusing on ancient children’s activities with medical implications for his forthcoming book, Children’s Accidents in the Roman Empire. Manfred Horstmanshoff (PhD, Leiden University, 1989), is Emeritus Professor of the History of Ancient Medicine at that University and Research Fellow at the University of the Free State, Bloemfontein. He was Fellow-in-residence at the Netherlands Institute for Advanced Study and the Internationales Kolleg Morphomata, University of Cologne, visiting scholar at the Humboldt University, Berlin, and the MaxWeber Kolleg, Erfurt. He has published widely on ancient medicine and is now studying the patient’s history in a comparative perspective. Pauline Koetschet CNRS-Aix Marseille Université, TDMAM UMR 7297, is a Researcher working on Arabo-Islamic philosophy and medicine. She is currently involved in a project that focuses on the critical reception of Galen in the formative period of Arabic philosophy. Jennifer Kosak is an Associate Professor of Classics at Bowdoin College and Chair of the Classics Department. She specialises in Greek language and literature. Her particular interests include Greek tragedy, Greek and Roman medicine, Greek intellectual history and gender studies. She is the author of Heroic measures: Hippocratic medicine in the making of Euripidean tragedy (Brill, 2004) and numerous other studies. Melinda Letts read Classics at St Anne’s College, Oxford and subsequently worked for 25 years in the UK non-profit sector, latterly at the helm of various health-care policy and campaigning bodies. She returned to academic life in 2009, and is now Lecturer in Greek and Latin at Jesus College, Oxford, while pursuing doctoral work on Rufus of Ephesus. Publications include ‘Rufus of Ephesus and the Patient’s Perspective in Medicine’, in British Journal for the History of Philosophy 22.5 (2014): 996–1020, and ‘Psychological Factors in the Work of Rufus of Ephesus’ (forthcoming).

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Orly Lewis (PhD, Humboldt-Universität zu Berlin, 2014), is a Research Fellow at the Excellence Cluster TOPOI, Humboldt-Universität zu Berlin. Her research focuses on Greco-Roman anatomy, physiology and psychophysiology. Her dissertation examined the theories of Praxagoras of Cos on pneuma and arteries. She has also published on the ancient pulse theory and practice and on the Ps.-Aristotelian treatise De spiritu. Susan P. Mattern (PhD, Yale University, 1995), is Distinguished Research Professor of History at the University of Georgia. Her most recent book is The Prince of Medicine: Galen in the Roman Empire (Oxford University Press, 2013). Georgia Petridou (PhD, University of Exeter, 2007), is a Research Associate at the Max-Weber Kolleg, University of Erfurt. She works on classical literature, history of religions and Graeco-Roman medicine in its socio-cultural context. She is the author of Divine Epiphany in Greek Literature and Culture (Oxford University Press, 2015). Amber J. Porter (PhD, University of Calgary, 2014), is a Sessional Instructor in the Department of Classics and Religion at that university. She is currently in the process of preparing her PhD dissertation for publication with Ashgate. Courtney Roby is Assistant Professor of Classics at Cornell University. Her research includes articles and a forthcoming book (Technical Ekphrasis in Ancient Science: The Written Machine between Alexandria and Rome, Cambridge University Press) on literary and cognitive aspects of ancient technical texts. Katherine D. van Schaik (MA, MD PhD candidate), is pursuing her MD at Harvard Medical School and her PhD in Ancient History at the Harvard Department of the Classics. She has published articles on health and disease in Greco-Roman antiquity, physical and social anthropology, paleopathology, medical decision making, and medical education.

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Michael Stolberg Univ.-Prof. Dr. is, since 2004, the Chair of history of medicine at the University of Würzburg, Germany. He has published widely on learned medicine, the experience of illness and concepts of the body in early modern Europe. Chiara Thumiger is a Research Associate at Humboldt Universität (Berlin) within the Alexander von Humboldt Professorship Project ‘Medicine of the Mind—Philosophy of the body’. She has previously worked on the representation of self and mental facts in literary sources (especially tragedy) and published a monograph on Euripides’ Bacchae (Hidden paths, London 2007) as well as a various articles and chapters about tragedy. At the moment she is finalising her monograph on mental disorder in early Greek medicine, and working on several projects related to the study of ancient ideas about mental life. Colin Webster (PhD, Columbia University, 2014), is an Assistant Professor of Classics at UC Davis. He has written on multiple topics in ancient science, including both optics and medicine, and is currently working on a monograph about how theorists in antiquity utilise material technologies as cognitive tools. John Z. Wee (PhD, Yale University, 2012), is Assistant Professor of Assyriology at the University of Chicago. His book Knowledge and Rhetoric in Medical Commentary and edited volume The Comparable Body are both forthcoming in Brill. He has also authored several articles on the history of medicine, astronomy, and mathematics in Mesopotamian and Classical antiquity. John Wilkins John Wilkins is Emeritus Professor of Greek Culture at the University of Exeter. He has edited Galen and the World of Knowledge (with C. Gill and T. Whitmarsh, CUP 2009) and Galien: sur les facultés des aliments (Budé 2013), among numerous studies on ancient diet and nutrition.

Bibliographical Note The abbreviations used for the ancient literature follow those given in the H. G. Liddell, R. Scott and H. S. Jones, Eds. (19409) A Greek-English Lexicon, Oxford. Supplement (1996), and S. Hornblower, A. Spawforth, A. and E. Eidinow, Eds. (20124) The Oxford Classical Dictionary, Oxford. There are a few easily recognizable exceptions, most notably for the Hippocratic and Galenic texts, where the abbreviations of Fichtner are used: G. Fichtner, (1992) Corpus Hippocraticum: Verzeichnis der hippokratischen und pseudohippokratischen Schriften, Tübingen, and (1990) Corpus Galenicum: Verzeichnis dergalenischen und pseudogalenischen Schriften, Tübingen. Of course, Fichtner’s catalogues have been updated several times since 1992, the most recent versions are on the CMG website at http://cmg.bbaw.de/ online-publications/hippokrates-und-galenbibliographie-fichtner. References to Hippocratic texts generally contain the volume and page number of the Littré edition: E. Littré, Ed., Oeuvres complètes d’Hippocrate, vol. 1–10, Paris 1839–1861, repr. Amsterdam 1961–1963. Some authors have added references to the editions used in the Loeb Classical Library. An analytical list of the editions the individual authors have employed in their work follows each of the chapters. References to Galenic texts contain the volume and page number of the edition by Kühn: G. C. Kühn, Ed., Claudii Galeni Opera Omnia 1–20 (22 Volumes), Leipzig 1821–1833, repr. Hildesheim 1964–1965.

Introduction: Towards a History of the Ancient Patient’s View Georgia Petridou and Chiara Thumiger This is a volume about the homo patiens in the Graeco-Roman world: the ancient suffering man, woman, and child, their role in ancient medical encounters and in broader cultural contexts,1 as well as their relationship to the health providers and medical practitioners of their time. The participle patiens is used here in its etymological sense denoting the ‘afflicted’, ‘the suffering’ person (who would be variously described in Greek as ho arrhōstos, ho nosōn, ho kamnōn, ho trōtheis, ho katakeimenos, or simply ho paschōn) and, as far as possible, freed from any Foucauldian connotations.2 The title of this collected volume, Homo Patiens: Approaches to the Patient in the Ancient world, stresses our particular interest in the ancient patient’s view, while simultaneously alluding

1  The concept of medical cultures—that is the notion of cultural systems of health and illness— appeared for the first time in the late seventies in the work of Arthur Kleinman. Kleinman with his 1978 Concepts and a Model for the Comparison of Medical Systems as Cultural Systems (Social Science and Medicine 12, 85–93) and his 1980 Patients and Healers in the Context of Culture: an Exploration of the Borderline between Anthropology, Medicine and Psychiatry looked for the first time at something as ‘objective’ as medicine and the body, and attacked the positive-reductionist views of clinicians and historians alike by re-­contextualising them both and declaring them both to be as ‘subjective’ as any product of a cultural system. 2  Roy Porter (1985a). ‘The patient’s view. Doing medical history from below’, Theory and Society 14.2, 175–98 discusses Foucault’s position that modern patients are constructs of the ‘medical gaze’ or ‘the medical glance’ (original French term “le regard”), criticizing it as misleading. See also Foucault, M. ‘La politique de la santé au 18e siècle’, in Foucault, M. et al. (1976a). Les machines à guérir. Aux origines de l’hôpital moderne, 11–21. Porter envisions a more active role for the patient in the medical encounter and prefers less marked terms such as ‘the sick’ or ‘the sufferer’ (on which see below). For more information on the perennial question of whether a ‘patient’ should exist in isolation, independently from the prying eyes of the examining or attending physicians, see Armstrong, D. (1984). ‘The patient’s view’, Social Science & Medicine 18,737–44, and Cooter, R. (2007). ‘After-death/after-life: The social history of medicine in post-postmodernity’, Social History of Medicine 20, 439–62; in addition, the excellent discussion in Condrau, F. (2007). ‘The patient’s view meets the clinical gaze’, Social History of Medicine 20.3, 525–40.

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to ­influential recent works in history of medicine, such as Michael Stolberg’s Homo Patiens. Krankheits- und Körpererfahrung in der Frühen Neuzeit.3 Our collection appears at an interesting time for the history of medicine and the history of medical ethics: it coincides with the thirtieth anniversary of Roy Porter’s programmatic plea for a patient-centered history of medicine, in a seminal article with the explicit title The Patient’s View: Doing Medical History from Below.4 Furthermore, it comes almost a decade after Roger Cooter’s 2004 groundbreaking manifesto about what he described as “the end of the social history of medicine”.5 Most history of medicine, argued Porter, has been written in the form of grand stories of scientific progress and expanding knowledge, largely organised around a sequence of biomedical breakthroughs. Porter’s article was the first call for a fundamental rewriting of the history of medicine, shifting the perspective towards the patient’s point of view. Cooter, on the other hand, went as far as to declare the end of the social history of medicine and urged a radical re-consideration of the good old trusty categories of knowledge, science, scientific breakthrough, disease, and even the biomedical causes of death. Cooter’s extreme position can be explained and justified if we consider the fact that the development of the history of the patient’s view has in fact fallen far short of what was promised by Porter and others in the 1980’s. It is the case, of course, that some steps in the right direction have been taken: for example, in the field of medical ethics emphasis has increasingly been laid on the ‘power relations’ between the sufferers and their healthcare providers—not least in certain areas of modern psychological theory. The move is not only theoretical but has an influence on operational strategies too, as is perhaps most evident in the area of psychotherapeutic and psychoanalytical practices, whereby patient narratives are increasingly valued as a fundamental diagnostic tool.6 3  Originally published in 2003, and translated into English in 2011 as Experiencing Illness and the Sick Body in Early Modern Europe. Houndmills: Basingstoke, UK; New York, NY: Palgrave Macmillan. 4   Porter, ‘The patient’s View’, 175–98. Cf. also Porter, R. ‘Introduction’, in Patients and Practitioners. Lay Perceptions of Medicine in Pre-industrial Society, 1–22. 5  Cooter, R. ‘ “Framing” the end of the social history of medicine’, in Huisman, F. and Warner, J. H. (2004). Locating Medical History. The Stories and their Meanings, 309–37. 6  See Holmes, J. ‘Narrative in psychotherapy’, in Greenhalgh, T. and Hurwitz, B. (1998). Narrative based medicine: Dialogue and discourse in clinical practice, 176–84; and Thumiger’s contribution (Chapter Three, 109–110 with n. 3. in this volume.). Power as problem, that is, how various institutions exert power on individuals and groups of individuals, and how those latter resist and affirm their own identity, is a central theme in Foucault’s historical and philosophical work. See for instance, Foucault, M. (1962). Maladie mentale et psychologie; id. (1969). L’archéologie du

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Despite these promising starting points, “it is also undoubtedly true that mainstream historiography has not incorporated the radical change of perspective for which Porter argued”.7 The dominant medical and historiographical discourses are still shaped by the physician’s view and, as such, they give us inadequate access (if at all) as to how individuals experienced their bodies, negotiated sickness, and signified their suffering to others. Indeed, at the level of clinical practice the attention paid to the perspective of the patient still leaves much to be desired. The diagnostic and therapeutic power of medical action and theory may have advanced enormously in modern times, but this advancement does not correspond with greater rapport, intimacy, nor empathy between the suffering person and his or her healthcare provider. Advances in clinical examination, pathological anatomy, and microbiology have had the result of limiting close observation and reducing the time and attention devoted to ‘taking history’. The effect of this has been to reduce the opportunities for physical and emotional intimacy between the patient and the physician, sometimes to the point of true estrangement between the two. To put it in Edward Shorter’s words: Advances in clinical investigation since the Second World War entailed the downgrading of careful history-taking and physical examination. . . . With the advent of such post-modern techniques of investigation as computerized blood tests, computerized tomography scans, magnetic resonance imaging, and ultrasonography, old-fashioned percussing, palpating, and auscultating seemed increasingly irrelevant, for the new techniques yielded far more information. The ‘history’ too became downplayed, and letting the patient talk was perceived as a waste of the busy physician’s time.8 Awareness of this change can be seen not only in theoretical reflections about the history of medical practices, but also increasingly in clinical environments. Arthur Kleinman’s work on the illness narratives, as he called them, and his savoir; and id. (1976b). Histoire de la sexualité, 3 vols. (La volonté de savoir, L’usage des plaisirs, and Le souici de soi, which was translated in English by Robert Hurley as = History of Sexuality, 3 vols: Introduction, The Uses of Pleasure, and Care of the Self. The ‘power relation’ issue is given more prominence in Foucault’s 1963 book entitled Naissance de la clinique, which was translated in English by Allan Sheridan as The Birth of the Clinic. 7  Condrau, ‘The Patient’s View’, 526. 8  Shorter, E. ‘The history of the doctor-patient relationship’, in Bynum, W. F. and Porter, R. (1993). Companion Encyclopaedia of the History of Medicine, 794.

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raising awareness about the difference between medically defined illness and “illness as lived experience” was undoubtedly a major step towards the radical redefining of the social history of medicine.9 Perhaps the most promising recent development in patient-centered medical practice, inspired by the critical suggestions coming from social history of medicine and medical anthropology, is the emergence of the so-called ‘Narrative-based Medicine’ (NBM), which puts the patient at the center of the medical encounter.10 Narrativebased Medicine lays emphasis on both the narrative structure of medical knowledge and on narrative as a tool to gain access to the perspectives of patient as well as caregiver. Furthermore, the epistemic value of the patient’s view, and of the narrative he or she constructs, has risen to prominence in discussions concerning palliative care, the area of healthcare focusing on preventing and relieving the patients’ suffering.11 Providing relief for the sufferer by tailoring the means of treatment and by ameliorating overall conditions of life is especially relevant to those afflicted by chronic and incurable illness, as is argued in Chapter Nineteen of this volume. These developments in clinical practice have been spurred on and mirrored at the theoretical level by studies examining the comparative history of the patient in the modern period, such as Stolberg’s Experiencing Illness and the Sick Body in Early Modern Europe. In this spirit, our volume hopes to further advance the theoretical and clinical foregrounding of the patient as the protagonist of the medical encounter, by offering a historical perspective on the contributions made by ancient patients to the healing encounter. The socio-cultural contexts of these meetings are of vital importance to the project of uncovering the perspective of the ancient sufferers, and as such they are given a prominent place in several of our chapters. Chapters Fourteen and Fifteen, in particular, focus on how the patient’s social status affects not only the patient-physician relationship but also the effectiveness of the medical treatment. Chapters Twelve and Fourteen, on the 9   Kleinman, A. (1988). The Illness Narratives: Suffering, Healing, and the Human Condition, 4. 10  The origins of this movement can be found in the late 1990s, when physicians like Rachael Niomi Remen and Rita Charon emphasised the importance of narrative in general, and patients’ narratives in particular for both the diagnostic encounter and the healing process. See Greenhalgh, T. and Hurwitz, B. (1999). ‘Narrative based medicine: Why study narrative?’ BMJ 318, 48–50 for further discussions. 11  The ultimate goal in palliative medicine, as opposed to curative medicine, is to provide both the patient and his or her family with relief from both the physical and psychological distress of disease and improve quality of life, regardless of the prognosis. The Preface in Fins, J. J. (2006). A Palliative Ethic of Care. Clinical Wisdom at Life’s End provides an informative exposition of the subject. See also van Schaik’s contribution pp. 471–496 in the present volume.

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other hand, emphasise the ambiguous social status of the attending physicians and care-givers in Graeco-Roman antiquity.12 The cases of renowned and popular physicians like Rufus and Galen seem to be the exception rather than the rule. The majority of our contributors examine the way ancient patients experienced their bodies and illnesses; how they qualified and quantified pain; and how they signified their suffering. All these feed into that enterprise which can be described as ‘doing ancient medicine from below’, to echo Porter’s concerns and apply them to the field of ancient medicine. Although our focal point is the relationship between the ancient sufferer and his or her healer, this volume hopes to move beyond past and current preoccupations with the question of the significance or insignificance of the patient’s personal narrative in the physician’s diagnostic quest.13 The theoretical and methodological agenda of the volume foregrounds the contrast between the views of medical experts and the perspectives of the ancient patients during the diagnostic and prognostic process, and in the course of therapy; but it also moves beyond that. By reminding ourselves how central the patient’s role is to the dynamic of the so-called ‘power relation’ established with the physician or healthcare provider, we want to invite a move beyond the medical practitioner’s rhetoric of control and competence and delve deeply into the emotional range of these relationships. Furthermore, we set out to explore the impact that seemingly more superficial material aspects had on the psyche of the suffering person, such as the self-presentation of medical activity as profession and privilege, the condition of the doctor’s medical apparel, the concrete issues of fees and bed-side manners, as well as the diagnostic techniques. These issues did not simply affect the patient’s psychology; they also influenced decisively the progression of the illness and the healing process as a whole. Our concerns do not lie exclusively with physical illness but address also the complexities of mental disorder. Individuals suffering from mental illness are an especially poignant example of the irreducibility of the patient. This is well shown well by the discussions of Graeco-Roman and Arabic examples of the mentally ill in the contributions included in the third part of the book, which explore the sufferers’ attempts to qualify and quantify pain and seek help. 12  This is a topic that has been explored from various angles. See Ecca’s contribution (Chapter Twelve), 323–344 in this volume. 13  There are many popular medical handbooks on how best ‘to take history’ from a patient. See, for instance, Fishman, J. and Fishman, L. (2005). History Taking in Medicine and Surgery. On the historical development of the concept of ‘taking a history’ and its application in clinical praxis, see the chapters included in the first part of this volume.

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Ultimately, what we hope to have offered here is an example of how much a patient-centered approach to the history of ancient medicine can deepen our understanding of ancient societies and their medical markets, as well as enrich our knowledge of the history of medical ethics. In other words, this volume is a first attempt towards shaping a history of the ancient patient’s view, which will be of use not only to the ancient historian, the student of medical humanities, and the historian of medicine, but also to the historian of medical deontology and ethics. Moreover, the contributions in our volume can also be employed as stimulating comparative perspectives for medical students and practitioners interested in the experience of the patient. This volume brings together scholars from diverse methodological backgrounds and with a wide range of expertise in medicine, ancient history, history of medicine, archaeology, history of religions, material culture, classical literature and medical humanities. We aim to present a balanced combination of established scholars and new voices, bringing together broad theoretical reflections on medical ethics and cultural history, on the one hand, and practical concerns of such topics as laypeople’s medicine, on the other. As such, our collection of contributions offers a new synthesis in the field of the history of medicine, which has so far been dominated by an emphasis on the authority and perspective of medical practitioners as the source of knowledge, and sets out to unravel the ancient patient’s view. Having outlined our general theoretical and methodological framework, it is time to pose the all-important question: to what extent can we access the ancient patient’s view? 1

Our Sources and Some Methodological Considerations

It has become more acceptable these days among the scholarly community to expose the elusiveness of scientific biomedical certainties and the dominance of the medical professional’s view in historical analysis and subsequently urge a new perspective in the ancient history of medicine. That fact, however, has not made our task any easier. Indeed, the efforts of the ancient medical historian to gain an insight into the patients of the past, their views, voices and experiences of illness, are often thwarted by well-known methodological challenges. First and foremost, we are faced with the perennial problem posed by the nature of the available sources. The social historian of ancient medicine has access to an extremely limited quantity of personal testimonies such as patient letters, personal correspondence, autopathologies and autobiographies, materials and resources to which the modern historian of medicine has much greater

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access.14 The bulk of the ancient material is, in fact, constituted by thirdperson narratives, self-styled as objective reports or scientific treatises. These narratives may address, with varying degrees of depth, the perspective of the patient as it filters through the organising structure imposed by the medical author; but they hardly attempt to shed light on the patient’s view in its own right. How can one unravel the figure of the patient from the tightly knitted ‘rhetoric of power’ that operates in a large number of ancient medical texts, most obviously from the second century AD, but also shaping to a large extent the much more varied and less codified medical texts of the fifth and fourth centuries BC? All history belongs to those who have written it and this remains as true for the history of medicine as for any other field. A number of our contributors deal with precisely these methodological issues and examine our main textual corpora and the imposing authorial and narrative personas of their authors with an eye to the ancient patients, their views and feelings, as well as their dealings with their medical providers. This problem is further exacerbated by the innumerable distinctions (chronological, generic, textual transmission, etc.) one should bear in mind when dealing with the individual works of the Corpus Hippocraticum, or with Galen or any other prominent physician such as Rufus, Soranus and John Zacharias Aktouarios. Chapters Two, Nine, Ten, Eleven, Twelve and Fifteen address these challenges. Other contributions, such as Chapters Eighteen and Nineteen, address analogous (and equally tantalizing) methodological problems in accessing the ancient patient’s view in the case of highly elaborate and exceptionally self-conscious representations of patienthood. These narratives may strike the modern reader as intimate, even autobiographical, but the extent to which we can consider these literary creations by highly educated patients as genuine autopathographies (comparable to modern patient diaries or letters) remains a matter of debate. Chapters One and Fourteen, on the other hand, expose well how data stemming from sources of material culture are riddled with difficulties of their own. Artefacts, inscriptional and sculptural alike, such as honorific and funerary reliefs, contain highly stylised and formulaic patients’ narratives and, thus, present us with a whole new set of conventions and constraints which need to be discounted in a search for the ancient patient’s subjectivity. Secondly, there is the equally important methodological caveat about applying modern conceptual categories and distinctions to ancient sources. Is this a case of purely anachronistic and largely ahistorical application, or can modern conceptual tools be used, with caution, to throw light on the ancient patient’s 14  More on these issues in Stolberg, Experiencing Illness, 1–4.

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view? Chapters One, Three, Four, Five and Six deal with, among other issues, the recurrent methodological problems that result from turning to modern categories and conceptual tools such as ‘anxiety’, ‘depression’, ‘placebo’, and discuss the fallacy of retrospective diagnosis when it comes to the patient of the past. Even the very category of the ‘patient’ is problematic and has long been called into question, in the wake of Foucault’s socio-historical critique.15 One can only imagine how much more complicated things become when we relocate this modern category, with its deeply structured socio-political implications (e.g. in relation to public health care systems, work exemptions, and so on), to the much less categorised figures of the sick and the sufferer of the ancient world. Porter rightly maintains that “it is probably preferable to speak historically of ‘sufferers’ or ‘the sick’, some of whom opted (original emphasis) to put themselves into relations with medical practitioners”. As it becomes obvious from the sixth part of our book (Chapters Sixteen to Nineteen), this is especially true in the case of the ancient sufferers, who quite often put themselves not in the hands of an esteemed member of the medical profession (whose social status, however, was far more complicated than it is nowadays), but in those of a family member or close friend. Alternatively, some of the ancient patients effectively took the role of the healer upon themselves and opted for self-healing. Therefore, in both the introduction to this volume and the individual contributions the term ‘patient’ is used rather loosely to refer to the sufferer of the ancient world and is used in full-awareness of the methodological problems the strict application of the term entails. Likewise, the labels ‘physician’, ‘medical professional’, ‘care giver’ or ‘healthcare provider’ are used equally loosely and encompass not only recognised medical experts (the iatros or the medicus), but also the midwife and even the members of the familial circle in their nursing roles. In exploring this set of issues, our contributors also re-evaluate (and in some cases reject) widespread—but not necessarily functional or helpful— methodological frameworks that have much influenced previous scholarship in the field, such as a narrow focus on the epistemic value of patients’ narratives in diagnosis and treatment, a fixed distinction between physical and psychological health, or a reliance upon rigid binaries such as those of scientific and sacred medicine. At the same time, the volume as a whole exhibits a variety of approaches in an attempt to celebrate the diversity of our rich source material. 15  More on this topic in n. 2.

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The common denominator in all the chapters of the present volume is the shift of focus away from the authoritative voices and views of the ancient health practitioners and historians and on to the medicine of the layperson and the subjective experience of the sufferers, for the first time with specific reference to the ancient world. As such, it refocuses this fairly recent theoretical and methodological development of foregrounding the patient and considering him or her as the center of the medical encounter in order to examine its bearing on ancient medical texts and artefacts. 2

Earlier Work on the History of the Ancient Patient

To be sure, we are not claiming that a patient-focused ancient medical history is our own theoretical and conceptual novelty. As this introduction, as well as the rich bibliographical references in the individual contributions, reveals, the present volume follows in the steps of earlier historiographical and methodological enterprises. A classic on the topic of individual patients, their relationship to illness and interaction with their attending physicians is the study by Danielle Gourevitch, Le Triangle Hippocratique dans le Monde Gréco-Romain (1985). The book covers a variety of related topics, from studies of famous sufferers like Cicero, Aelius Aristides,16 and Galen’s Simulatores (those who faked illness), through disabled and disfigured patients, and from those afflicted by gout, to the victims of Pliny’s frightfully greedy and ruthless physician, who thinks nothing of poisoning his own patients.17 Also in 1985, Vivian Nutton offered ancient history’s response to Porter’s call for a patient’s history across cultures and chronologies, when he wrote an extensive article entitled Lay attitudes to medicine in classical antiquity.18 The study expertly surveyed a plethora of what he calls “non-medical evidence”, as opposed to the writings of the Hippocratic authors and the works of Rufus, Soranus and Aretaeus. The second part of the paper, in particular, looked at laypeople’s views and outlooks towards competent and incompetent medical practitioners. This is perhaps the closest we have yet come to a history of 16  On Aelius Aristides’ Hieroi Logoi as a patient-centred narrative, see the bibliographical references in Petridou and van Schaik in the present volume. 17  More on this topic in Ecca in this volume. 18  Nutton, V. ‘Murders and miracles: lay attitudes towards medicine in classical antiquity’, in Porter, R. (1985). Patients and Practitioners. Lay Perceptions of Medicine in Pre-industrial Society, 23–54.

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the ancient patients’ view as envisaged by the editors of this volume. Nutton is absolutely right in underlining the scale of the task and the impossibility of seeking to cover in a single monograph the ancient patient’s perspective while working on such extensive and disparate material, each piece of which presents the student of ancient medicine with a different set of difficulties. A collected volume, where various approaches to the patient’s history are presented, offers a more adequate forum for this sort of enterprise. Other studies have paid particular attention to the history of the patient in specific authors, works or media. Galen’s patients, for instance, have received much scrutiny—as shown by articles such as those of Manfred Horstmanshoff or thematic studies such as that published by Susan P. Mattern in 2008.19 Specific aspects of ancient medical writings, such as the ‘case histories’ in the Hippocratic Epidemics, the Galenic works, and the reception of the Galenic case histories in the medical treatments of medieval Islamic writers have also attracted great scholarly interest.20 Other students of patient history have focused on age- or gender-specific groups of ancient sufferers, such as children, virgins, child-bearing mothers and old people. The ­parthenoi in the Hippocratic On the Diseases of the Virgins, or the women of child-bearing age in Soranus’ gynecological treatises have also been studied most notably by Helen King and Lesley Dean-Jones, among others.21 Moreover, the patient and his or her involvement in the local healthcare has

19  Horstmanshoff, H. F. J. ‘Galen and his Patients’, in Eijk, Ph. J. van der et al. (1995). Ancient Medicine in Its Socio-Cultural Context, vol. 1, 83–100; Mattern, S. P. Galen and the Rhetoric of Healing. Other important studies of Galen’s patients include Ilberg, J. (1905). ‘Aus Galens Praxis: Ein Kulturbild aus der römischen Kaiserzeit’, Neue Jahrbücher 15, 276–312; Garcia Ballester (1995). ‘Elementos para la construcción de las historias clínicas en Galeno’, Dynamis 15, 47–65. 20  On this aspect specifically, see Thumiger, Wee, and Webster in this volume, where more bibliographical references can be found. See Lloyd, G. E. R. ‘Galen’s un-Hippocratic case-histories’, in Gill, C. et al. (2009). Galen and the World of Knowledge, 115–31, for an informative analysis of the case histories in the Hippocratic texts and Galen. On the reception of Galenic case histories in Byzantine medical authors, see Bouras-Vallianatos in this volume; on the receptions of Galenic case-histories in Islamic medical writers, see Koetschet’s contribution in this volume. 21  E.g.: King, H. (1988). Hippocrates’ Women: Reading the Female Body in Ancient Greece; ead. (2004). Disease of Virgins: Green Sickness, Chlorosis and the Problems of Puberty; DeanJones, L. (1994). Women’s Bodies in Classical Greek Science; and ead. (1992). ‘The politics of pleasure: female sexual appetite in the Hippocratic Corpus’, Helios 19, 72–91. On Soranus’s Gynaecology, see the contributions of Bolton and Porter in this volume.

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been the center of scholarly research devoted to specific media of textual transmission, such as the medical papyri of the Fayum region.22 Finally, mental health is something of a separate chapter in the scholarship, in which attention to subjectivity is, so to speak, embedded in the topic from the very start. In fact, one may argue that the questions and concerns of patient-centered medicine are necessarily part of the methodological challenges of a history of psychiatry, regardless of the approach one wishes to take, thus making it a useful hermeneutical model. Key contributions to the study of ancient medical ideas on mental health have been offered by Jackie Pigeaud: La maladie de l’âme. Étude sur la relation de l’âme et du corps dans la tradition medico-philosophique antique (1981); Folie et cures de la folie chez les medicines de l’antiquité gréco-romaine. La manie (1987). Melancholiē and maniē, on the other hand, have received much scholarly attention along with other aspects of mental health in individual texts or authors. More recently, a volume edited by William Harris (Mental Disorders in the Classical World, 2013) has brought together numerous contributions with a broad range of topics and a theoretically-minded frame, in interrogating the subjectivity of the mentally ill both as a problem and as a theoretical challenge. The first original feature of the papers collected in this volume lies in the explicitly programmatic character of its conception of ‘doing ancient medical history from below’, that is, its rejection of top-down approaches, which offer bird’s eye view of the ancient sufferer and medical practitioner but miss the specifics. The second innovative element of this volume is the extensive chronological and generic distribution of the material covered in the individual chapters of the volume. The layperson’s experience of illness and healing is examined in literary texts from the fifth and fourth century Epidemics (Thumiger, Wee) and the writings of first century authors like Rufus (Letts) and Soranus (Bolton and Porter), to the medical works of Galen (Mattern, Roby, Wilkins); and from the post-classical Hippocratic writings (Ecca) and patientcentered narratives like the Sacred Discourses of Aelius Aristides (van Schaik, Petridou) to the writings of Byzantine medical writers (Bouras-Vallianatos) and those of the medieval Islamic medical authors (Koetschet). Some of the contributions take a more comparative look at laypeople’s medicine and the experience of suffering in the ancient world (Horstmanshoff and Graumann, van Schaik, Stolberg); while others focus on the material aspects of the patient-physician relationship (Ecca, Lewis, Baker), equally illuminating 22  E.g.: Hanson, A. E. ‘Greek medical papyri from the Fayum village of Tebtunis: patient involvement in a local healthcare system?’, in Eijk, Ph. J. van der (2005). Hippocrates in Context, 387–402. More on this topic in Draycott’s contribution (Chapter Seventeen), 432–450 in this volume.

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of the medical encounters of the past. Many of our contributors, finally, examine how the ancient patient’s experience of health and illness was shaped by gender-related issues (Bolton, Kosak and Porter, for example). Furthermore, this volume explores the patient’s perspective and experience in a range of sources and media which have remained relatively unexplored to this day: from sculptural artefacts (Baker) to papyri, ostraca, and tablets from the Roman Republic and Empire (Draycott), and highly stylised and formulaic patients’ narratives, such as honorific and funerary reliefs (Horstmanshoff and Graumann); and from the writings of Byzantine physicians like John Zacharias Aktouarios (Bouras-Vallianatos) to those of the medieval Islamic medical authors, such as Abû Bakr al-Râzî and Ishâq ibn Imrân (Koetschet). 3

Our Volume at a Glance

The first part of our volume, MEDICAL AUTHORITY AND PATIENT PERSPECTIVES, revisits both inscriptional and literary sources for the patient history in the ancient world and looks at them afresh with an eye to how understanding the patient’s agency and identity in illness and health can help modern patients, medical practitioners, public health officials, and indeed healthcare policy makers in making their own choices. In Chapter One (‘ “This I Suffered in the Short Space of my Life”. The Epitaph for Lucius Minicius Anthimianus’), Manfred Horstmanshoff and Lutz Graumann focus on the child patient and explore the harsh reality of childrens’ deaths in Graeco-Roman Antiquity. By examining the funerary monument dedicated to the four-year-old Lucius, Graumann and Horstmanshoff offer an original and inspiring argument for the value of narrative medicine in conveying the marginalised voice of the patient, complementing the approach with a reasoned and cautious discussion of the possibilities of retrospective diagnosis. In a genuinely interdisciplinary fashion, this chapter brings together the views of an eminent historian of medicine and a distinguished physician, who establish a dialogue to discuss the funerary inscription that relates the death of young Lucius and the grief that his death brought upon his family, along with the possibility of a very much culture-specific retrospective diagnosis of Lucius’s cause of suffering and subsequent death. Melinda Letts (‘Questioning the Patient, Questioning Hippocrates: Rufus of Ephesus and the Pursuit of Knowledge’) argues that Rufus of Ephesus not only did think that engaging patients in the epistemic process is a fundamental prerequisite of good medical practice, but that he was alone in devoting a scientific treatise to the topic. By comparing Rufus’s conceptualisation of the

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relevance and use of questioning the patient, on the one hand, and that which can be seen in the theoretical and descriptive works of Galen and the Hippocratic authors, on the other, Letts puts forward the ground-breaking thesis that Rufus exhibits an avant-garde grasp of the epistemic value of the patient’s personal narrative. More significantly, Rufus’s treatise On Questioning the Patient shows resonances with some of the modern preoccupations of Western healthcare systems. Thus, this treatise is, as Letts maintains, of cardinal importance not only for the historical debate between expert medical knowledge and the layperson’s knowledge, but also because it can provide paradigms of fruitful embedment of subjective information into the medical agenda of clinicians, public health officials, public and private health policy makers. The second section of the volume, CASE HISTORIES IN THE HIPPOCRATIC CORPUS, concentrates on a key genre among ancient medical sources, and one that has attracted much theoretical interest in contemporary medical discussions: the patient-report, or ‘case history’. All three papers in this section discuss the rich, and often puzzling, information preserved by the Hippocratic Epidemics, a collection of texts from the fifth- and early fourth century which contains reports on a number of individual cases, whereby patients are even named and vivid details are supplied. Chiara Thumiger (‘Patient Function and Physician Function in the Hippocratic Patient Cases’) follows the strategies of narratological and stylistic analysis to establish variations in the construction of patient cases, between the reporting of a patient’s experience and the doctrinal and operative influence of the visiting and writing physician. John Wee (‘Case History as Minority Report in the Hippocratic Epidemics 1’) discusses one specific case, that of the patients of the first book of the Epidemics, addressing the epistemological function of the individual case (usually taken as exemplum) in the economy of the medical doctrine put forth by the doctor. The anecdotal section, he argues, functions in this case not as illustration of a norm, but as an exploration of the exception to it, a shift in perspective that further illuminates what we know about the relationship between theory and observation-based data at this early stage in the development of Greek medicine. Finally, Colin Webster (‘Voice Pathologies and the Hippocratic Triangle’) tackles directly the question of subjectivity by looking at what is perhaps its most direct expression in medical exchanges: the actual voice of the patient, an element closely scrutinised by the doctor in these texts. The voice is an instrument of verbal, articulate communication, central to the understanding of the patient’s state; but it is also a signifier of health on a more basic level—its sound, its strength, its quality deliver information about what is going on inside the body, in a manner similar to the bodily excreta the Hippocratic doctor examines and interprets.

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PATIENTS AND PSYCHOLOGICAL ILLNESS is a theme that occupies a special place in the patient-centered perspective. That the specific case of the history of psychiatry and mental disorder, as we have suggested, may be seen as providing the model, the archetype for any discussion about the subjectivity of the medical experience and its deep rooting in any medical communication. This section includes both a study of a specific topic in one specific author (the distress caused by anxiety in Galen) and a broader historical survey reaching into the Arabic reception of Greek authors who discussed mental disorder. In the first chapter (‘Galen’s Anxious Patients: Lypē as Anxiety Disorder’) Susan P. Mattern explores Galen’s use of the term lypē as a marker of a specific form of distress, in many ways comparable to what we may call ‘anxiety disorder’. Mattern explores a wealth of Galenic examples for such forms of mental suffering, and offers a sensitive discussion of the validity of current taxonomical labels of mental disorder when approaching the ancient world. The second chapter, Pauline Koetschet’s ‘Experiencing Madness: Mental Patients in Arabo-Islamic Medicine’, takes us on a journey through the work of two esteemed physicians of the early centuries of the Common Era, Galen again and Rufus of Ephesus, reconstructing the reception of their ideas about melancholy and mental distress in Arabo-Islamic medicine. The key questions addressed here are how these physicians would recognise and categorise cases of mental illness, what the discussion of several individual patients can tell us about the experience of mental illness in these contexts, and how mental illness was represented in its social contexts. The focus of the fourth part of our volume is entitled EMOTIONAL ASPECTS OF THE PATIENT-PHYSICIAN RELATIONSHIP. Studies of ancient medicine have fallen somehow behind in this recent wave of scholarly contributions, so that the four essays in this section mark an important step in bringing medicine into dialogue with the emotions as they are now studied in the ancient setting. In this section we have grouped together papers that look especially at the emotional level of the subjective experience of suffering, involving the person-patient in a fuller sense, influenced by aspects of gender, social class, age and authority. Jennifer Kosak (‘Interpretations of the Healer’s Touch in the Hippocratic Corpus’) begins by addressing the act of ‘touching’ as healing gesture, with the emotional and personal aspects it involves, and interrogates the gender specifics one might expect to influence this part of the medical encounter. Lesley Bolton (‘Patience for the Little Patient: the Infant in Soranus’ Gynaecia’) takes us to the realm of children patients, by looking at the work of the great physician Soranus, whose work on gynecology and pediatrics have come down to us. Bolton explores the attitudes of Soranus towards his child patients, the display of tenderness and compassion towards the child as child, and the attempt to address the little patient’s emotional needs and distresses.

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The emotions of both patient and physician are also the focus of Amber Porter’s ‘Compassion in Soranus’ Gynecology and Caelius Aurelianus’ On Chronic Diseases’. Porter looks at the work of Soranus, as well as the writings of lateantique Caelius Aurelianus, a writer-physician who draws on a variety of earlier sources to highlight a shift, in medical authors in the early centuries of the first Millennium, towards the display of greater compassion and empathy towards patients and their subjective suffering. The section is completed by a contribution that adds an important theoretical discussion to the picture, Courtney Roby’s exploration of the conceptualisation of and reliance on pain as a diagnostic tool in Galen (‘Galen on the Patient’s Role in Pain Diagnosis: Sensation, Consensus and Metaphor’). This chapter not only surveys Galen’s views on the variations and qualities of pain as well as its use as an indicator of health, but also poses the difficult questions of the reliability and measurability of pain experiences in medical procedures, a challenge with which the ancient doctors were familiar. Bernhard Liehrsch, a well-known and well-documented nineteenth century physician from Dresden, admonished his colleagues on the preliminaries of medical examination with the following words: “You should never omit feeling the pulse, and looking at the urine and the tongue. These are the three matters to which every patient attaches value”.23 Part five of our volume (MATERIAL ASPECTS, DIAGNOSTIC TECHNIQUES AND THEIR IMPACT ON THE PATIENTPHYSICIAN RELATIONSHIP) argues that the ancient medical provider had analogous concerns about the impact diagnostic techniques had on his or her rapport with the patient. The four chapters included here look closely at the impact of these techniques on the sufferer’s psyche; they focus on the trust and/or distrust, the relief or anxiety these diagnostic techniques caused to the ancient patient. In short, this part of our volume argues that the quality of the relationship between sufferer and medical expert was determined in a significant way by certain material aspects, most notably by the medical practitioners’ fees, as well by their medical utensils and equipment, professional behavior and appearance. Giulia Ecca (‘The Μισθάριον in the Praecepta: the Medical Fee and its Impact on the Patient’) examines the issue of financial transactions and reciprocal exchange of favours between patient and physician, and its impact on their relationship as it emerges through a close reading of the Precepts—an underappreciated Hippocratic treatise which deals with issues of medical ethics. Orly Lewis (‘The Practical Application of Ancient Pulse-Lore and its Influence on the Patient-Doctor Interaction’) investigates the role of ‘the technē of the pulses’ in the process of (un)mediated transfer 23  Liehrsch, B. (1842). Bilder des ärztlichen Lebens, oder: die wahre Lebenspolitik des Arztes für alle Verhältnisse, 148.

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of knowledge from the patient to the physician and the diagnostic process as a whole. The main focus of the paper is Galen; Lewis, however, casts her net more widely too, and looks at ‘pulse-lore’ (ancient theories of the pulse) in medical texts attributed to physicians of the fifth century BC. In the same vein, Patricia A. Baker (‘Images of Doctors and their Implements: A Visual Dialogue between the Patient and the Doctor’) focuses on visual representations of the ancient medical encounter, and how they might enhance our knowledge of the ancient patient and his relationship with the medical professional. In this chapter, surviving images of Graeco-Roman doctors are critically assessed to establish the patients’ perceptions of medicine and doctors. These images, Baker claims, offer us a clearer insight into laypeople’s expectations of what medical providers should look like and what sort of medical equipment they should carry with them. In the final chapter included in this section of the book, Petros Bouras-Vallianatos (‘Case Histories in Late Byzantium: Reading the Patient in John Zacharias Aktouarios’ On Urines’) examines the way in which the intimate relationship of Aktouarios and his patients unfolds in his extensive urological treatise On Urines. This text, Bouras-Vallianatos argues, contains a detailed chronicling of John’s visits to his patients, and thus offers us a unique insight into the patient’s point of view, as well as glimpses of how physical intimacy and gender-related variables affected the diagnostic and therapeutic procedure. All chapters included in this part of the book deal with topics that are of cardinal importance for the history of medical ethics, such as appropriateness of bed-side manners, the physician’s self-representation and the effect of these factors on the patient’s psyche and the success of the treatment. The focus of the sixth part of the volume (THE INFORMED PATIENT: SELF-HEALING AND THE PATIENT AS PHYSICIAN) is twofold: it explores the active role of the patient in a variety of medical contexts, while looking at the key issues of wider availability and dissemination of medical knowledge in Graeco-Roman Antiquity. The contributions included here revisit key-themes of this volume, such as the multiple ways that effective communication between patient and healthcare provider, as well as a good grasp of the patient’s socio-cultural background can affect not only the patient’s experience of their own body and illness, but also the efficacy of the treatment. John Wilkins (‘Treatment of the Man: Galen’s Preventive Medicine in the De sanitate tuenda’) offers us a discussion of Galen’s preventive medicine and of the patients, who acquired for themselves a proactive, rather than a reactive role in medicine and hygiene. Wilkins argues that Galen’s ideal patient, as delineated in his treatise On Hygiene, does not become a patient at all, but remains a healthy person able to maintain his or her health without need of

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remedies or other therapies. This chapter explores the extent to which the male patient who is well-educated in medical matters can effectively function independently of healthcare providers like nurses, trainers and masseurs and keep his body and soul in balance. Georgia Petridou (‘Aelius Aristides as Informed Patient and Physician’) focuses on an individual sufferer and his illness narrative by close-reading sections of Aristides’ Hieroi Logoi. This knowledgeable member of the second century socio-political elite, Petridou maintains, takes the notion of self-healing one step further and presents himself not only as an active agent in his own medical encounters with both earthly and divine healers but also as intimately involved in the treatment of others, thus functioning as a physician of sorts. Jane Draycott’s focus is the lay medical practitioner of the Roman empire as (s)he emerges from literary and documentary papyri, ostraca, and other documents from ancient Britain, Syria and Egypt. Draycott’s chapter (‘Literary and Documentary Evidence for Lay Medical Practice in the Roman Republic and Empire’) offers the reader a unique insight into lay medical practices, which can be accessed far more satisfactorily if we move the scope of our investigation away from ancient medical literature to other genres, and incorporate treatises devoted to horticulture, agriculture, animal husbandry, and even religion and magic. Documentary evidence, Draycott maintains, “gives voice not only to lay medical practitioners diagnosing and treating their family members, friends and acquaintances, but also to the patients who were experiencing these cures alongside their health problems”. In the final chapter of this section, Katherine van Schaik (‘It may not cure you, it may not save your life, but it will help you’), both a physician-in-training and a historian of medicine, offers a comparative study of the layman’s medical experience in the context of acute and chronic disease between the patient of Graeco-Roman antiquity and the cancersufferers in Western Australia. In particular, van Schaik considers the challenges faced by Indigenous palliative care patients and palliative care providers in Western Australia, as well as considerations of the challenges faced by chronically or terminally ill patients as they determine their own treatment preferences. In this rich, truly interdisciplinary and inter-cultural study, van Schaik addresses the key-issues of the patient-physician relationship and that of the cultural specificity of disease and its treatment. She also demonstrates powerfully the significance of mutual trust and belief in the effectiveness of the suggested medical treatment. The EPILOGUE to this volume returns to some of the broader questions with which the volume opened: ‘Approaches to the History of Patients: from the Ancient World to Early Modern Europe’. Michael Stolberg is not only a practicing physician, but also a distinguished advocate of the need to bring the patient

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more front-and-center in histories of medicine. This chapter takes a comparative look at the late medieval and early modern period and proceeds to sketch a more general outline of the volume’s research agenda, connecting the patient of the past with the patient of the present and tracing the main lines of research that should shape future enquiries. Stolberg warns against the risks of using physicians’ case histories to retrieve the patient’s experience of illness, a procedure he sees as involving deeply rooted methodological problems, rather than a specific difficulty with ancient sources such as the Hippocratic patient cases. He also returns to the problem of retrospective diagnosis which has surfaced several times in a number of our contributions. Our aim, of course, has not been to produce an exhaustive history of the ancient patient’s view, nor to provide the final word on the theoretical discussions we have just surveyed. We will however be satisfied if we have succeeded in making a first step towards a history of the ancient patient, presenting here a sample of the possibilities this field of research can offer, and contributing to a dialogue not only within history of ancient medicine or classical studies, but within the larger community of the history of medical ethics and the medical humanities as a whole. References Armstrong, D. ‘The Patient’s View.’ Social Science & Medicine 18, (1984): 737–44. Charon, R. ‘Narrative medicine: A model for empathy, reflection, profession, and trust.’ The Journal of the American Medical Association 286.15, (2001): 1897–1902. Condrau, F. ‘The Patient’s View Meets the Clinical Gaze.’ Social History of Medicine 20.3, (2007): 525–40. Cooter, R. ‘ “Framing” the End of the Social History of Medicine’, in Locating Medical History. The Stories and their Meanings, ed. F. Huisman and J. H. Warner, 309–37. Baltimore: Johns Hopkins University Press, 2004. ———. ‘After-Death/after-Life: The Social History of Medicine in Post-Postmodernity.’ Social History of Medicine 20, (2007): 439–62. Dean-Jones, L. A. Women’s Bodies in Classical Greek Science. Oxford: Oxford University Press, 1994. ———. ‘The Politics of Pleasure: Female Sexual Appetite in the Hippocratic Corpus.’ Helios 19, (1992): 72–91. Fins, J. J. A Palliative Ethic of Care. Clinical Wisdom at Life’s End. Ontario and London: Jones and Bartlett Publishers, 2006. Fishman, J. and Fishman, L. History Taking in Medicine and Surgery. Cheshire: Pastest LTD, 2005.

Introduction

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Foucault, M. Maladie mentale et psychologie, Paris: Presses Universitaires de France, 1962 = Mental Illness and Psychology, trans. A. Sheridan, New York: Harper and Row, 1976. ———. Naissance de la clinique, Paris: Presses Universitaires de France, 1963 = The Birth of the Clinic, trans. A. Sheridan, New York: Pantheon, 1973. ———. L’archéologie du savoir, Paris: Gallimard, 1969 = The Archaeology of Knowledge, trans. A. Sheridan, New York: Harper and Row, 1976. ———. ‘La politique de la santé au 18e siècle’, in Les machines à guérir. Aux origines de l’hôpital moderne, ed. M. Foucault, B. Barret-Kriegel, A. Thalamy, F. Béguin and B. Fortier, 11–21. Paris: Institut de L’Environnement, 1976a. ———. Histoire de la sexualité, 3 vols. (La volonté de savoir, L’usage des plaisirs, and Le souici de soi), Paris: Gallimard, 1976b. = History of Sexuality, 3 vols: Introduction, The Uses of Pleasure, and Care of the Self, trans. R. Hurley, New York: Vintage Books, 1988–90. Garcia Ballester, L. ‘Elementos para la construcción de las historias clínicas en Galeno.’ Dynamis 15, (1995): 47–65. Gourevitch, D. Le triangle hippocratique dans le monde gréco-romain: le malade, sa maladie et son médecin. Rome: École française de Rome, 1984. Greenhalgh, T. and Hurwitz, B. (eds.). Narrative Based Medicine, London: BMJ Books, 1998. Hanson, A. E. ‘Greek Medical Papyri from the Fayum Village of Tebtunis: Patient Involvement in a Local Healthcare System?’ in Hippocrates in Context: Papers Read at the XIth Hippocrates Colloquium, University of Newcastle upon Tyne 27–31 August 2002, ed. Ph. J. van der Eijk, 387–402, Studies in Ancient Medicine 31. Leiden: Brill, 2005. Harris, W. V. Mental Disorders in the Classical World. Leiden and Boston: Brill, 2013. Holmes J. ‘Narrative in Psychotherapy.’ in Narrative Based Medicine: Dialogue and Discourse in Clinical Practice, ed. T. Greenhalgh, B. Hurwitz, 176–84. London: BMJ Books, 1998. Horstmanshoff, H. F. J. ‘Galen and his Patients.’ in Ancient Medicine in Its Socio-Cultural Context, ed. Ph. J. van der Eijk, H. F. J. Horstmanshoff and P. H. Schrijvers, 2 vols., 83–100. Amsterdam: Rodopi, 1995. Huisman, F. and Warner, J. H. (eds.) Locating Medical History: The Stories and their Meaning, Baltimore: Johns Hopkins University Press, 2004. Ilberg, J. ‘Aus Galens Praxis: Ein Kulturbild aus der römischen Kaiserzeit.’ Neue Jahrbücher 15, 1905: 276–312 = reprinted in Antike Medizin, ed. H. Flashar, 361–416. Darmstadt: Wissenschaftliche Buchsgesellschaft, 1971. Kleinman, A. ‘Concepts and a Model for the Comparison of Medical Systems as Cultural Systems.’ Social Science and Medicine 12, 1978: 85–93. ———. Patients and Healers in the Context of Culture: An Exploration of the Borderland between Anthropology, Medicine, and Psychiatry. Berkeley: University of California Press (Comparative Studies of Health Systems and Medical Care, No. 3), 1980.

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———. The Illness Narratives: Suffering, Healing, and the Human Condition, New York: Basic Books, 1988. King, H. Hippocrates’ Women: Reading the Female Body in Ancient Greece, London and New York: Routledge, 1988. ———. Disease of Virgins: Green Sickness, Chlorosis and the Problems of Puberty, London and New York: Routledge, 2004. Liehrsch, B. Bilder des ärtzliches Lebens, oder: die wahre Lebenspolitik des Arztes für alle Verhältnisse, Berlin: Liebmann, 1842. Lloyd, G. E. R. ‘Galen’s un-Hippocratic Case Histories.’ in Galen and the World of Knowledge, ed. C. Gill, T. Whitmarsh and J. Wilkins, 115–31. Cambridge: Cambridge University Press, 2009. Mattern, S. P. Galen and the Rhetoric of Healing. Baltimore: Johns Hopkins University Press, 2008. Nutton, V. ‘Murders and Miracles: Lay Attitudes towards Medicine in Classical Antiquity.’ in Patients and Practitioners. Lay Perceptions of Medicine in Pre-industrial Society, ed. R. Porter, 23–54. Cambridge, London, New York, New Rochelle, Melbourne and Sydney: Cambridge University Press, 1985. Pigeaud, J. La maladie de l’âme: Étude sur la relation de l’âme et du corps dans la tradition médico-philosophique antique. Paris: Les Belles Lettres, 1981. ———. Folie et cures de la folie chez les médecins de l’antiquité gréco-romaine. La manie. Paris: Les Belles Lettres, 1987. Porter, R. ‘The Patient’s View: Doing Medical History from below.’ Theory and Society 14.2, (1985a): 175–98. ———. (ed.), ‘Introduction’, in Patients and Practitioners. Lay Perceptions of Medicine in Pre-industrial Society, 1–22. Cambridge, London, New York, New Rochelle, Melbourne and Sydney: Cambridge University Press, 1985b. Shorter, E. ‘The History of the Doctor-Patient Relationship’, in Companion Encyclopaedia of the History of Medicine ed. W. F. Bynum and R. Porter, 783–800. London and New York: Routledge, 1993. Stolberg, M. Homo patiens. Krankheits- und Körpererfahrung in der Frühen Neuzeit, Köln, Weimar, Wien: Böhlau, 2003 = Stolberg, M. Experiencing Illness and the Sick Body in Early Modern Europe, New York: Palgrave Macmillan, 2011.

PART 1 Medical Authority and Patient Perspectives

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CHAPTER 1

“This I Suffered in the Short Space of my Life”. The Epitaph for Lucius Minicius Anthimianus (CIG 3272; Peek GV 1166) Lutz A. Graumann and Manfred Horstmanshoff Herewith we present an interdisciplinary study of the metrical funerary inscription from the third century CE (CIG 3272; Peek GV 1166). This emotional Greek epitaph reports the short life (from birth to death) of the 4 year old Lucius Minicius Anthimianus. This is the first detailed study since the dissertation by Klitsch (1976). The inscription presents an ideal case for a truly interdisciplinary study of the patient-history, in that its interpretation involves the study of Greek literature and linguistics, epigraphy, social and religious history, and ancient medicine. It also offers ample opportunity to show the contradictions inherent in proposing retrospective diagnosis, without neglecting the relevant information modern medicine has to offer for the interpretation of this case history. We argue that Lucius’ father was most probably a physician, that the text of the inscription stems from expert knowledge of ancient medicine and that the traditional retrospective diagnosis of this case, tuberculosis, is an untenable hypothesis. *  Although both authors accept responsibility for the text of this article it goes without saying that sections 9–10 rely on the expertise of Lutz Alexander Graumann as an experienced clinician. We would like to thank all, who have given us so many fruitful suggestions at the public presentations of the growing content of this paper: in Mainz 2009, Calgary 2010, Tartu 2010, Marburg 2011, Cologne 2012, Berlin 2012–2013 and Erlangen 2013. Especially, we would like to mention our editors Georgia Petridou and Chiara Thumiger, as well as Rita Amedick, Joan Booth, Dietrich Boschung, Philip van der Eijk, Antje Krug and Peter Toohey. Further thanks go to Carin Kruithof, Leiden, who has done great research work in the course of her MA-thesis on the epitaph. We would also like to thank Gudrun Wlach, Österreichisches Archäologisches Institut Vienna for her kind information about Josef Zingerle. Manfred Horstmanshoff wishes to thank the Internationales Kolleg Morphomata, Cologne, for the time he could spend on this project during his fellowship (2011/2012) and Philip van der Eijk for arranging his stay as a visiting scholar at the Humboldt Universität zu Berlin in 2013. We gratefully acknowledge the assistance of Cornelis van Tilburg in harmonising bibliography and footnotes.

© koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_003

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1 Introduction The cruel reality of children’s premature death in Graeco-Roman antiquity has been a major topic in many recent historical discussions.1 Rather surprisingly, there are hardly any new medical-historical contributions to this theme. This fact has prompted us to undertake an interdisciplinary research project on the funereal inscription for the four-year-old Lucius Minicius Anthimianus, dating from the third century AD. The epitaph is a unique document permitting insight into the social, cultural and religious life of children and families during the Roman Empire. Furthermore, it offers an understanding of contemporary medicine in general and medicine for children in particular. During the last century, this inscription has been interpreted without exception as a classical clinical picture of tuberculosis in childhood. This is a typical case of a retrospective diagnosis that has not previously been called into question.2 Today this single medical interpretation appears rather simplistic. We present here a new interdisciplinary approach to this epitaph which contextualises it properly and adopts two main perspectives: a philological-historical and a medical one. It is our view that only such an interdisciplinary approach can really advance our understanding both of this document, and of ancient patienthistory in general. 1  Golden, M. (1988). ‘Did the ancients care when their children died?’, Greece & Rome 35, 152– 63, esp. 153; Nielsen, H. S. (1996). ‘The physical context of Roman epitaphs and the structure of the Roman family’, Analecta Romana Instituti Danici 23, 35–60; King, M. ‘Commemorations of infants on Roman funerary inscriptions’, in Oliver, G. J. (2000). The Epigraphy of Death, 117–54; Rawson, B. ‘Death, burial, and commemoration of children in Roman Italy’, in Balch, D. L. and Osiek, C. (2003). Early Christian Families in Context, 277–97. 2  Meinecke, B. (1927). ‘Consumption (tuberculosis) in classical antiquity’, Annals of Medical History 9, 379–402 [our text: 385–86.]; Zingerle, J. (1928). ‘Ein Fall von Kindertuberkulose vor 1700 Jahren’, Zeitschrift für Kinderheilkunde 46, 440–44; Meinecke, B. (1940). ‘A quasi-autobiographical case history of an ancient Greek child’, Bull. Hist. Med. 8, 1022–31; Klitsch, H. D. (1976). Eine inschriftliche Krankengeschichte des 3. Jh. n. Chr.: Das Grabgedicht für den fünfjährigen Lucius Minicius Anthimianus, Med. Diss., Universität Erlangen; Grmek, M. D. (1983). Les maladies à l’aube de la civilisation occidentale, 289; Gourevitch, D. (1968). ‘Une observation pédiatrique pour épitaphe: Un texte inédit’, L’Écho medical au service du médecin, 145; Gourevitch, D. (1969). ‘Déontologie médicale: quelques problemès’, Mélanges d’archéologie et d’histoire 81, 519–36; 523–24 (“une tuberculeuse généralisée”); Gourevitch, D. (2001). I giovani pazienti di Galeno: Per una patocenosi dell’impero Romano, 86–87; Mattern, S. P. (2008). Galen and the Rhetoric of Healing, 36 also mentions the “famous inscription in Greek verse” of Lucius, citing the works of Klitsch (1976) and Petzl, G. (1981). ‘GVI 1166—eine Krankengeschichte aus Smyrna?’, Chiron 11, 303–08, but without offering any diagnosis.

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The twentieth century has seen a paradigmatic shift in medical history, following analogous developments in society, where the position of the patient in relation to the physician has become stronger.3 Whereas in the nineteenth and early twentieth century the aim of contemporary medical history was to describe the progress of medicine as a science, in the later part of that century the focus has shifted more towards the practice of medicine and towards the patient’s perspective, thus lessening the distortion caused by the traditional physician-centered account.4 The consequence of this shift in focus was the use of different sources: not only learned medical treatises, but also case histories, patients’ diaries and letters.5 The history of ancient medicine has followed this trend, albeit at a slower pace, and thus testimonies from papyri and inscriptions have become more important in establishing an overall picture of healing in Graeco-Roman Antiquity. Philip van der Eijk has summarised the situation aptly: “From appropriation to alienation”, from Hippocrates as the ‘Father of Medicine’ to understanding ancient medicine in its social and cultural context.6 “I have seen the patient”; these words, if spoken by a medical doctor, mean a lot: the doctor has used his or her senses, insight, knowledge and experience; he or she has ‘taken a history’. When a medical historian ‘takes a history’ of individual patients from the past he or she makes individuals visible in history. Medical concepts, ideas and terminology played an important role in case histories as they ‘dripped down’ into literature and society. In our research, we address case histories in ancient Graeco-Roman medical writing, their function, form and medium, including the relationship between case descriptions in medical and in non-medical writings and their visual representations. We argue that patient history can make an important contribution not only to the history of ancient medicine, but also to the study of ancient society and mentality. Furthermore, the study of ancient case histories may serve as an introduction for modern medical practitioners to ‘narrative-based medicine’.7 3  For an overview see Huisman, F. and Warner, J. H. (2004). Locating Medical History: The Stories and their Meanings. 4  Ackerknecht, E. H. (1967). ‘A plea for a “behaviorist” approach in writing the history of medicine’, Journal of the History of Medicine and Allied Sciences 22, 211–14; Porter, R. (1985). ‘The patient’s view: doing medical history from below’, Theory and Society 14, 175–98. 5  See e.g. Stolberg, M. (2003, Engl. Trans. 2011). Homo patiens: Krankheits- und Körpererfahrung in der Frühen Neuzeit. 6  Eijk, P. J. van der (2005). Medicine and Philosophy in Classical Antiquity, ‘Introduction’, 1–42. 7  Horstmanshoff, H. F. J. (2006). Patiënten zien: Patiënten in de antieke geneeskunde; Charon, R. (2004). ‘Narrative and medicine’, The New England Journal of Medicine, February 26, vol. 350 No. 9, 862–64. On narrative-based medicine see also the introduction to this volume.

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The document we examine offers a unique opportunity for such a new approach. While reading it closely and carefully, we rediscovered the value of Hans-Georg Gadamer’s Truth and Method as a tool for understanding.8 As a health-care professional (Graumann) and a classicist (Horstmanshoff), we are both historians of ancient medicine, but each with a different background and set of values, each with a different intended audience or in Gadamer’s terminology, a different ‘horizon’. “Historical consciousness is aware of its own otherness and therefore makes a distinction between the horizon embedded in the tradition and its own”.9 Attempting a historical reconstruction of the event in its own right would be as futile as to apply present-day medical knowledge to a past case history. We realise that to understand this text we have not only to ‘fuse’ our individual ‘horizon’ of understanding with the horizon of its author, but also with each other and with earlier interpretations. We enter into a dialogue with the text. 2

The Slab

The slab is made out of white marble and presents an arched top adorned by a wreath. It is a square, 56 centimeters long and 56 centimeters broad, and is almost completely covered with text: 32 lines of Greek verse in capital letters. The total number of Greek letters is 1149, with an average of 37 letters per line (with the exception of the first and the penultimate line, which counts 46 letters). The stone is in good condition. Its present location is the Palazzo Barberini in Rome, Via Quattro Fontane 13, where it is inserted in the inner wall of the Palazzo’s courtyard. The original physical context is unknown. It may have been part of a single grave or columbarium, at the side of some road near Rome, perhaps the Via Appia, or in one of the catacombs.10 Although its origin 8    Gadamer, H. G. (2006). Wahrheit und Methode: Grundzüge einer philosophischen Hermeneutik. 9   “Das historische Bewußtsein ist sich seiner eigener Andersheit bewußt und hebt daher den Horizont der Überlieferung von dem eigenen Horizont ab”, Gadamer, Wahrheit, 311 (slightly revised translation suggested by Joan Booth). 10  Dietrich Boschung (Cologne) kindly suggested that the slab was originally part of a columbarium. On the location, see McLean, B. H. (2002). An Introduction to Greek Epigraphy of the Hellenistic and Roman Periods from Alexander the Great down to the Reign of Constantine (323 BC–AD 337), 269: “Epitaphs that address passersby were especially common on tombs located by the sides of the roads leading out of the city”. On funeral practice and commemoration in imperial Rome, see Nielsen, H. S. ‘The value of epithets in pagan and Christian epitaphs from Rome’, in Dixon, S. (2001). Childhood, Class and Kin

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has been debated, there is now general agreement that it must have been written in Rome.11 Commemorations of dead children below the age of five years, independently of their gender, are most commonly found in the larger urban centres of Rome and Ostia.12 Interestingly, any kind of iconographic representation is missing, with the exception of a schematic representation of a wreath on the first line. The slab may originally have been part of an ensemble, containing a family picture with the traditional three-person grouping (father-son-mother) pictured above the inscription, or only one stylised head of a child.13 The inscription is dated to the end of the second or the beginning of the third century AD.14 Roman grave monuments were usually placed in prominent positions, so as to be visible for the passersby (line 6), alongside pathways leading in and out of the city or in catacombs. They were meant to be a memoria, a commemoration of the dead. This brings us to an important point: for whom was this inscription intended? Who were its supposed readers? Were inscribed epigrams really read by anyone? Nowhere in ancient literature is it attested that passersby actually stopped to read an inscription, let alone such an elaborate and difficult one.15 Our sepulchral monument is that of a single family member, a male child’s tomb; and hence, a monument of private character. Although addressed to a passersby, it contains many private features.16 in the Roman World, 166. Antje Krug kindly proposed the idea of a location in a catacomb. For more on this possiblity, see Liverani, P. et al. (2010). The Vatican Necropoles: Rome’s City of the Dead. 11  For a long time it was supposed that the stele came originally from Smyrna. Major arguments in favour of Rome can be found in Petzl, ‘Krankengeschichte’. 12  McWilliam, J. ‘Children among the dead: the influence of urban life on the commemoration of children on tombstone inscriptions’, in Dixon, S. (2001). Childhood, Class and Kin in the Roman world, 79. 13  See Backe-Dahmen, A. (2006). Innocentissima aetas: Römische Kindheit im Spiegel literarischer, rechtlicher und archäologischer Quellen des 1. Bis 4. Jahrhunderts n. Chr. for the usual forms of children’s grave stones from that period. 14  On the basis of the letter forms and the structure of personal names (tria nomina) mentioned in the text, while no decisive internal evidence can be found; see McLean, Introduction, 123. 15  Bing, P. ‘The un-read Muse? Inscribed epigram and its readers in antiquity’, in Harder, M. A. et al. (2002). Hellenistic Epigrams, 39–66. Attitudes toward inscribed epigrams began to change in the course of the Hellenistic period, due to the interest of poets and scholars. We thank Rolf Tybout for the reference. 16  For example, it was clearly not a ‘consolation decree’-epitaph sponsored by the city/ dēmos/boulē for the consolation of deceased children of local civic (usually aristocratic) politicians or benefactors; see Strubbe, J. H. M. (1998). ‘Epigrams and consolation decrees

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On the other hand, “within the Roman necropolis (. . .) there is some evidence of competition, for families using expensive sepulchral portraits in an attempt to win attention.”17 Would this apply also to texts? Since we have no information about the original location of the inscription, we will never know. An informed guess would be that family and friends returned yearly to the grave, where offerings were made and someone read the inscription aloud to commemorate the young heros. 3

Text and Translation

Text18

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Θεοῖς (corona) Ἥρωσιν Λούκιος Μινίκιος Ἄνθιμος καὶ Σκρειβωνία Φηλεικίσσιμα ἀτυχεῖς γονεῖς Λ. Μινικίῳ Ἀνθιμιανῷ τέκνῳ γλυκυτάτῳ καὶ θεῷ ἰδίῳ ἐπηκόῳ ζήσαν(τι) ἔτη δ’, μῆνας ε’, ἡ(μέρας) κ’. Νήπιός εἰμι τυχὼν τύμβου τοῦδ’, ὦ παροδεῖτα. Ὅσσ’ ἔπαθον δ’ ἐμ βαιῷ τέρματί μου βιοτῆς ἐνκύρσας λαϊνεᾳ στήλλῃ τάχα καὶ σὺ δακρύσεις μητρὸς ἀπ’ ὠδείνωμ ὡς εἰς φάος ἤγαγον Ὧραι, ἐκ γαίης με πατὴρ ἐμὸς εἵλατο χερσὶ γεγηθώς καὶ μ’ ἀπέλουσε λύθρου καὶ εἰς σπάργανά μ’ αὐτὸς ἔθηκεν, η{ε}ὔχετο δ’ ἀθανάτοις, ἅπερ οὐκ ἤμελλεν ἔσεσθαι Μοῖραι γὰρ πρῶται περί μου κεκρίκεισαν ἅπαντα καὶ μ’ ἔτρεφεν γενέτης μητέρα μου τροφὸν εἱλάμενος

for deceased youths’, L’Antiquité Classique 67, 45–75, especially 59–75. Of course, it should be noted that any discussion about public or private character of epitaphs from this historical period projects our own recent understanding of public and private into that past where surely not the same image has predominated. On the distinction between private and public monument in the Graeco-Roman world, see Ma, J. (2013). Statues and Cities. Honorific Portraits and Civic Identity in the Hellenistic World. esp. Part 3, ‘Statues and families’. 17  Mander, J. (2013). Portraits of Children on Roman Funerary Monuments, 152. 18  Earlier editions: Boeckh, A. (1828–77). CIG 3272; Hondius, J. J. E. et al. (1979). SEG 29, 1003; Dübner, F. et al. (1864). Epigrammatum Anthologia Palatina 3, ch. 2, 637 (pages 196–97) (with Latin translation and commentary); Kaibel, G. (1878). Epigrammata Graeca ex lapidibus conlecta 314; Peek, W. (1955). GV 1166; Moretti, L. (1968–90). IGUR 4, 1702; Vérilhac, A. M. (1978–82). ΠΑΙΔΕΣ ΑΩΡΟΙ 1, 165–68 no. 106; Pleket, H. W. (1969). Epigraphica II, Texts on the Social History of the Greek World, nr. 55. For full references see infra Texts Used.

the Epitaph of L. M. Anthimianus

FIGURE 1.1 The Epitaph for Lucius Minicius Anthimianus (CIG 3272, Peek GV 1166), National Gallery of Ancient Art of Barberini Palace, Rome. Photo DAI-ROM-58.1431 Courtesy Deutsches Archäologisches Institut, Rome.

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αὐτίκα δ’ η{ε}ὐξανόμην εὐερνὴς καὶ πᾶσι ποθητός. Ἐν δ’ ὥραις ὀλίγαις Μοιρῶν γὰρ σφραγεῖδες ἐπῆλθον, αἵ με νόσῳ πῆξαν χαλεπῇ διδύμους πέρι ἀλλ’ ὁ ταλαίφρων γεννήσας εἰάσατό μου νόσον αἰνήν τοῦτο δοκῶν ὅτι μοῖραν ἐμὴν εἰάμασι σώσει. Καὶ τότε δή μ’ ἑτέρα νόσος εἷλε κακίστη τῆς προτέρης νούσσου πουλύ τι χειροτέρη· σῆψιν γὰρ οῦ πεδίον ποδὸς εἶχεν ἐν ὀστοῖς. Εἶτ’ ἔταμόν με φίλοι γενέτου καί μου ὀστέ’ ἀνεῖλαν λύπας καὶ στοναχὰς τοῖς τεκέεσσι διδόντα, καὶ ταῦθ’ ὡσαύτως εἰάθην πάλιν, ὡς τὰ πάροιθεν. Οὐδ’ οὕτως μου Γένεσις δεινὴ πλησθεῖσ’ ἐκορέσθη, ἀλλ’ ἑτέραν πάλι μοι νόσον ἤγαγε γαστρὸς Μοῖρα σπλάγχνα μου ὀγκώσασα καὶ ἐκτήξασα τὰ λοιπά, ἄχρις ὅτου ψυχήν μου μητρὸς χέρες εἷλαν ἀπ’ ὄσσων. Ταῦτ’ ἔπαθον βαιῷ τέρματί μου βιοτῆς, ξένε, καὶ κατέλειπον τηκεδόνα στυγερὴν τοῖσί με γιναμένοις, αἰνόμορος, λείψας τρεῖς συνομαίμονας ἀστεφανώτους.

Translation We present here the established English translation by Bruno Meinecke from 1927/1940.19

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Dis Manibus! [To the sacred spirits] Lucius Minicius Anthimus and Scribonia Felicissima, miserable parents, for L[ucius] Minicius Anthimianus, their sweetest child and for their own merciful god. He lived 4 years, 5 months and 20 days. A helpless child am I who have reached this tomb, o traveller; even you who have chanced upon my stony slab will straightway weep at the suffering which I have endured in the brief compass of my life. When the Horae brought me into the light by the travail of my mother, my father joyfully took me up in his hands from the earth,

19  Meinecke, ‘Consumption’, 385 = Meinecke, ‘Quasi-autobiographical’, 1023–24. Translation in other languages: Latin (Boeckh, CIG; Cougny, AP); German (Zingerle, ‘Fall’); French (Gourevitch, ‘Observation’, 14 = Gourevitch, ‘Déontologie’, 523–24, note 7; Vérilhac, ΠΑΙΔΕΣ 1, 167); Italian (Gourevitch, Giovani, 86–87); Dutch (Hoefmans, M. (1967–68). Bijdrage tot de studie der Griekse metrische grafschriften; Horstmanshoff, Patiënten).

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and washed me clean of the impure blood, and he in person placed me in swaddling clothes. My father made prayers to the gods which were not to be; for the Fates were the first to make all decisions about me; and my father chose my mother as nurse and reared me. Forthwith I grew lustily like a young plant and was beloved by all; but in a few seasons the seal of the Fates came upon me, who made me fast with a dread disease about the testicles; but my distressed father healed my dire disease, thus thinking to save my fate by medical treatment. And then, moreover, another disease seized me, most grievous by far, and many times worse than the former; for the metatarsi of my (left) foot had sepsis in the bones, and so my father’s friends performed an operation on me and took out my bones which were the cause of grief and groans to my parents, and in this way I was healed again as before. Not even thus did my ill-boding birth have its fill of smiting, but fate again brought upon me another disease of the belly, enlarged my intestines and wasted away the other parts, until such time when my mother’s hands snatched life from my eyes. This I suffered in the short space of my life, o stranger, and I, doomed to a sad end, survived by three unwedded siblings, have left the hated consumption to those who begat me. Language, Style, Metrical Aspects and Structure of the Text

Grave epigrams were common at Rome, and they were written both in Latin and in Greek. Latin carmina funeralia have a more formal structure than Greek ones, mentioning full names, status, age and profession. Greek grave epigrams are more freely composed and less elaborate. It might seem surprising at first that a Greek inscription was made in Rome. Greek inscriptions were, however, no exception there.20 Epitaphs for children appeared both in Greek and Latin, and even bilingual ones.21 20  See IGUR; for this inscription: 4, 1702. 21  Rawson, ‘Death’, 350; cf. the epitaph for Quintus Sulpicius Maximus (who lived 11 years, 5 months and 12 days; after 94 AD), the verse-writing child prodigy, with texts in Latin and Greek: IGUR 3, 1336, Kaibel EG 618, GV 1924; Vérilhac, ΠΑΙΔΕΣ 1, no. 78.

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This epitaph combines two traditions: the old Greek epigrammatic tradition and the Latin gravestone tradition of Rome as a virtually bilingual city.22 The language is that of the Greek koine, but the detailed biographical information about the child is reminiscent of the Latin inscriptions. The style is archaising, interspersed with frequent allusions to the Homeric poems. We have adopted the translation by the American classicist Bruno Meinecke who tried to emulate this style using a sort of biblical English. The structure and part of the content of the poem are traditional. After an introduction (titulus ll. 1–5), including the apotheosis (τέκνῳ γλυκυτάτῳ / καὶ θεῷ ἰδίῳ ἐπηκόῳ ll. 4–5), follows the proper grave poem (carmen funerale ll. 6–29). In l. 6 the παροδεῖτα, the traveller (Latin viator) is addressed, while in l. 30 it is the stranger (ξένε).23 In l. 15 young Lucius is called πᾶσι ποθητός “beloved by all”: the ever present theme of childish charm.24 Another conventional element of the inscription is the so-called ‘boast’, (laudatio ll. 10–29) put into the mouth of the deceased himself.25 In the case of the four year old Lucius this is not a cursus honorum, nor an account of his bravery on the battlefield, but rather a description of his birth and early years, and, contrary to the usual practice in children’s epitaphs, of his three illnesses as the causes of his death.26 In adult Greek epitaphs, other causes of death are commonly mentioned, such as accidents, war wounds etc., but only rarely diseases. It is conventional in grave epigrams to mention the cruelty of death itself. Especially in cases of young people or children, the dead are called ἄωροι “untimely”,27 and death itself is thought of as mors immatura “unseasonable death”, and funus acerbum “a bitter demise”. Supernatural causes of death are frequently stated, e.g. Tyche, or like here (l. 16) the Moirai (the Fates). The text is not devoid of literary aspirations e.g. ll. 10 and 29 form a moving counterpoint:

22  Kajanto, I. (1963). ‘A study of the Greek epitaphs of Rome’, Acta Instituti Romani Finlandiae 2.3, 6. 23  Cf. e.g. Kaibel, EG 711; GV 1612. 24  Liddell, H. G. and Scott, R. (1978). A Greek-English Lexicon (LSJ) 1427, Suppl. 6, 253, s.v. ποθητός; AP 7,467,5; IG 7, 3434; SEG 33, 1475 (Cyrenaica 1./2.); IG 5, 2, 491 (Megalopolis second / third century AD); GV 958; GV 395. Cf. Laes, C. ‘High hopes, bitter grief: Children in Latin literary inscriptions’, in Partoens, G. et al. (2004). Virtutis Imago, 58. 25  Lattimore, R. (1942). Themes in Greek and Latin Epitaphs, 288. 26  Backe-Dahmen, Innocentissima, 96. 27  For a discussion of the term, see Vérilhac, ΠΑΙΔΕΣ 2, 152–54.

the Epitaph of L. M. Anthimianus

l. 10 με πατὴρ ἐμὸς εἵλατο χερσὶ l. 29 ψυχήν μου μητρὸς χέρες εἷλαν  ἀπ’ ὄσσων

33 “my father took me up in his hands” “my mother’s hands took the life  from my eyes”.28

There might even be an intentional juxtaposition between light and darkness in ll. 9 (μητρὸς ἀπ’ ὠδείνωμ ὡς εἰς φάος ἤγαγον Ὧραι) and 29 (ἄχρις ὅτου ψυχήν μου μητρὸς χέρες εἷλαν ἀπ’ ὄσσων): it is the mother who gives birth, brings the newborn baby “to the light” (εἰς φάος) and the mother’s hands who took the light out of Lucius’ eyes. Is there an allusion to the same notion of light in the name Luc-ius (Latin lux)?29 The last two lines (conclusio ll. 31–32) stand apart. Introduced by καί, concluded with ἀστεφανώτους “unwedded”, they make up a special conclusion. To conclude, the poem is carefully composed. Its length is exceptional and so is the fact that it is devoted to a very young child; while the striking medical details—a description of three diseases on which see below—make it unparalleled. 4.1 Latin Influence Θεοῖς Ἥρωσιν (l. 1), the translation of Dis Manibus (DM), which is the usual invocation of the gods of the underworld (spirits of the deceased), is the first example of Latin influence.30 The phrase Θεοῖς Ἥρωσιν itself is quite rare; in Rome there are only two other known examples.31 More commonly attested as translation of Dis Manibus is Θεοῖς Καταχθώνιοις.32 The boy’s name, Lucius Minicius Anthimianus, is quoted in full, and so is his age (ll. 4–5). The recording of age in terms of years, months and days is another striking feature of Latin influence.33

28  On the repeated use of εἵλατο, εἷλαν and related forms see above. 29  For frequent use of φώς cf. Vérilhac, ΠΑΙΔΕΣ 1, 134 no. 85, 145 no. 94. For the expression cf. Hom., Il. 16.333–34 τὸν δὲ κατ’ ὄσσε/ ἔλλαβε πορφύρεος θάνατος καὶ μοῖρα κραταιή. On the theme ‘light and darkness’: Griessmair, E. (1966). Das Motiv der mors immatura in den griechischen metrischen Grabinschriften, 19–23. 30  The dedication Dis Manibus became customary only during the second century AD. The spirits of the deceased are also often adressed as the Lemures (Kajanto, ‘Epitaphs’, 8–10). 31  IG 14, 1572 and 1795. 32  Vérilhac, ΠΑΙΔΕΣ 1, 167. 33  Cf. the epitaph for Secundus Glykytatos, 100–10 AD, who died at 5 years, 3 months, 19 days (Kleiner, D. E. E. (1987). Roman Imperial Funerary Altars with Portraits, 190–91); Kajanto, ‘Epitaphs’, 13. See also the remark on the horoscope in n. 63.

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4.2 Homeric Elements Ἥρως (l. 1) has a Homeric tinge. In l. 6 the epic νήπιος “infant”, like Latin infans, “not speaking”, is used instead of the more common ἄωρος (“untimely”). L. 24 λύπας καὶ στοναχὰς τοῖς τεκέεσσι διδόντα “which were the cause of grief and groans to my parents” is reminiscent of the Homeric formula ἄλγεα τέ στοναχάς τε.34 A keyword in this epigram is αἰνόμορος (“doomed to a sad end”) in l. 32. It describes how the child (his parents are speaking through his mouth) sees himself and is unmistakably Homeric.35 The same goes for l. 29: ψυχή here means ‘breath’, ‘the breath of life’. If someone dies, his ψυχή leaves him usually through his mouth.36 Here the mother closes her son’s eyes. 4.3 Metrical Aspects The poem is written in rather clumsy Greek dactylic hexameters alternating with pentameters.37 In some lines the meter is used to produce a special effect. Exactly where the poet tells us that the boy’s life span was short in l. 7 (ἐμ βαιῷ τέρματί μου βιοτῆς, “in the brief compass of my life”), there is a katalexis, that is: the last element of the colon is missing, perhaps echoing Lucius’ abrupt end of life.38 In l. 20 the dramatic tension becomes visible and audible. The metrum stops suddenly: μ’ ἑτέρα νόσος εἷλε κακίστη “another most terrible disease seized me”. A complete (metrical) foot is lacking, so that the expected hexameter is cut down to a pentameter. “After Fate brought another disease, having caused my innards to swell” (σπλάγχνα μου ὀγκώσασα, l. 28), a slow hexameter, comes a halting pentameter in l. 29, ψυχήν μου μητρὸς χέρες εἷλαν ἀπ’ ὄσσων “my mother took the life from my eyes”.39 The last two lines (conclusio ll. 31–32) have a different metrical structure.

34  E.g. in Hom., Il. 2.39 or Od. 14.39, cf. GV 855,4. 35  Hom., Il. 22.481; Hom., Od. 9.53. Cf δύσμορος AP 9,158; Vérilhac, ΠΑΙΔΕΣ 1, 126 no. 79, 2 years old, Rome; νήπιος ὠκύμορος in Vérilhac, ΠΑΙΔΕΣ 1, 190 no. 123, 4 years old, Rome. 36  Hom., Il. 5.696; 9.408. 37  Gallavotti, C. (1979). Metri e ritmi nelle inscrizioni greche, 48–50; Kruithof, C. (2010). ‘Dit heb ik geleden in de korte tijd van mijn leven, vreemdeling’: Een interpretatie van het grafgedicht voor de vierjarige Lucius Minicius Anthimianus (GVI 1166)’. Unpublished MA-thesis, 36–42, gives a complete metrical analysis of the poem. 38  For τέρμα as ‘the end of life’, see A., Fr. 362; S., OT 1530; Eur., Alc. 643. On inscriptions for παῖδες ἄωροι, see Vérilhac, ΠΑΙΔΕΣ 1, 190 no. 73; 114–15 no. 77; 129–30 no. 82. 39  On the repeated use of εἵλατο, εἷλαν and related forms see above p. 33 and n. 28.

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Socio-Cultural Context

It was especially common among immigrants from Asia Minor to erect Greek epitaphs in Rome. Most of them had a higher social status,40 and many of them mentioned a medical profession in their inscriptions. This should not surprise us, since the majority of the physicians in the Western part of the Empire and also in Rome itself were of Greek origin. Many of them had acquired a medical education in Ephesus and Smyrna in the second century AD.41 Epitaphs for children are generally rare, especially among the upper classes. It was rather unusual in that historical period that children should hold any socially relevant office as persons. Still, their role within the familial context was important:42 12 % of all known Latin pagan funerary inscriptions of a literary kind are dedicated to children; while 67 % of the Latin epitaphs for children belong to the class of the liberti (freedmen). An explanation of the fact that liberti apparently devoted grave epigrams to young children more often than the elite might be found in the steadfast belief of the upper classes that it was not appropriate to grief overtly for the death of a child. We know that liberti were more prone to extravagant expressions of funerary sarcophagi and inscriptional texts precisely because they could not hold public offices in real life. Through epigraphic dedications they could make public the fact that their children were freeborn.43 5.1 Onomastic Criteria The dedicators are Lucius’ parents, Lucius Minicius Anthimus and Scribonia Felicissima. The tria nomina (praenomen, nomen gentilicium and cognomen) indicate that the father was a Roman citizen.44 Women usually had no praenomen. The name of the father indicates that he had probably been ­manumitted. The individual praenomen Lucius is a very frequently attested 40  Kajanto, ‘Epitaphs’, 6. 41  Nutton, V. ‘Murders and miracles: Lay attitudes toward medicine in classical antiquity’, in Porter, R. (1985). Patients and Practitioners, 23–53, especially 27, 33. Nutton, V. (2013). Ancient Medicine, 263: “In the city of Rome itself in this period more than 90 per cent of the names of doctors are Greek”. 42  Schörner, G. ‘Saturn, Kinder und Gräber: Zur Beziehung von Götterverehrung und Kinderbestattungen im römischen Nordafrika’, in Rüpke, J. and Scheid, J. (2010). Bestattungsri­ tuale und Totenkult in der römischen Kaiserzeit, 215–35. 43  Laes, ‘Hopes’, 47–48; Wypustek, A. (2013). Images of Eternal Beauty in Funerary Verse Inscriptions of the Hellenistic and Greco-Roman Periods, 55–57. 44  But, there is of course a “real possibility of error” about the social status (free, freed, or still slave) of Lucius’ father; McLean, Introduction, 131.

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name.45 The freed father (libert[in]us) adopted the name of his former master (patronus), Lucius Minicius, as his praenomen and nomen adding his own (originally Greek) personal name Anthimos as his cognomen.46 Even as freedman, he may have stayed with his own ‘family’ in the household (domus) of his patron.47 Lucius, the little boy who died prematurely, was his freeborn son. To underline this, he was given his own tria nomina: Lucius Minicius Anthimianus. The praenomen Lucius was taken from his father, most probably because he was his eldest (and only) son, while the cognomen Anthimianus was derived from his father’s cognomen Anthimus, meaning “son of Anthimus”.48 The Prosopographia Imperii Romani, the ‘Who is who?’ of the Roman Empire, gives evidence of quite a few Minicii (gens Minicia), who could have been the master of our little boy’s father. There is no unequivocal evidence, however, pointing with certainty at one identifiable person. We can only speculate about their family connections. The father may have moved to another family after manumission.49 In the Hellenistic tradition even behind a Greek name there could be a non-Greek (e.g. an Egyptian) person.50 Apparently the father, Lucius Minicius Anthimus, and the mother, Scribonia Felicissima, originated from two different households. It is conspicuous that the mother is not called γυνή, the equivalent of Latin uxor. This could be interpreted as an indication that Lucius’s mother was still a slave at the time of the erection of the inscription. The background of the mother remains, thus, rather difficult to fathom: her name could be interpreted as Scribonia Felicissima, meaning “the daughter of Scribonius Felicissimus”, or as “daughter of Scribonius” with the added cognomen Felicissima, possibly for being mother 45  McLean, Introduction, 119 (Lucius meaning “born by day” from luce natus). 46  ἄνθιμος “flowering” from ἄνθος “flower”; LSJ, s.v. Many Greek slaves are known to have had ‘flower-names’; McLean, Introduction, 103. Are we allowed to speculate further about the not uncommon ornamental corona in line 1: does it symbolise something like an heraldic family-sign? Cf. GV 1244. For personal names of the former patronus used as cognomen see McLean, Introduction, 128. 47  Mattern, Galen, 22: “Many physicians were slaves in aristocratic households; as freedmen, they also formed part of their patron’s entourage”. 48  McLean, Introduction, 119; 121. 49  Rawson, B. ‘Degrees of freedom’, in Dasen, V. and Späth, T. (2010). Children, Memory, and Family Identity in Roman Culture, 213–14. A possible candidate for Anthimus’ patron is Thrasea Priscus (Roman senator and consul of 196, who died under Caracalla in 212; D. C. 78 (77) 5,5), full name Lucius Valerius Publicola Messal(l)a Helvidius Thrasea Priscus Minicius Natalis; PIR2 5, 95, AE 1998, 280. 50  Kudlien, F. (1986). Die Stellung des Arztes in der römischen Gesellschaft: Freigeborene Römer, Eingebürgerte, Peregrine, Sklaven, Freigelassene als Ärzte, 120.

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of at least three children: our Lucius and three other (perhaps female) children. Their social status (free, freed, or slave?) remains entirely unclear.51 Συνομαίμονας (line 32) could be said of sisters or brothers, hence “siblings” is the preferred translation, as in the German Geschwister. We surmise, however, that sisters are meant. By sheer accident a grave epigram has been preserved for a fifteen year old girl, daughter to a certain Lucius Anthimus, so probably the same parents lost a second child.52 We may conclude that the parents had four liveborn children, so they had the ius trium liberorum. When, probably, the only male heir, our Lucius, died, his three sisters were still alive. The fact the last line begins with αἰνόμορος and ends with ἀστεφανώτους “unwedded” is not a coincidence.53 5.2 Social Status We venture then to explore the hypothesis that our little boy was the son of a freedman of relative wealth, relatively high social status and erudition, a physician, originating from Asia Minor, who had high expectations from his son, perhaps—but this is speculation—as his successor.54 Véronique Dasen aptly pictures the expectations of parents, who cultivated the ambition to compensate a lack of prestigious ancestors by investing on their descendants, thus, placing their pride in their future, as opposed to their past lineage: “The child is a substitute for powerful patrician ancestors. Freeborn children, who may be still alive, become ancestors.”55 6

Religious Aspects

The inserted corona, the wreath or crown, is a conventional, almost ornamental epigraphical symbol. It could symbolise some funeral sacrificial offering, 51  McLean, Introduction, 127. 52  IG 14, 2037. 53  Cf. Kaibel, EG 314, 27; Vérilhac, ΠΑΙΔΕΣ 1, 27 (p. 49). 54  On physicians as slaves or freedmen in ancient Rome in general, see Korpela, J. (1987). Das Medizinpersonal im antiken Rom: Eine sozialgeschichtliche Untersuchung, 110–13; as men of culture, see e.g. Samama, É. (2003). Les médecins dans le monde grec, 155, where a wedding epigram with mythological content for a physician’s daughter drawing from the Oresteia. For a discussion of arguments in favour of this hypothesis, please see below. 55  Dasen, V. ‘Wax and plaster memories: Children in elite and non-elite strategies’, in Dasen, V. and Späth, T. (2010). Children, Memory, and Family Identity in Roman Culture, 136. Cf. also Backe-Dahmen, Innocentissima, 80 “[die Freigelassenen] projizieren die eigenen Hoffnungen auf einen gesellschaftlichen Aufstieg auf die Kinder.” In general: King, ‘Commemorations’.

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or more specifically refer to the cult of a deity,56 or it could be interpreted as a heraldic family sign. Perhaps one could draw a connection with l. 32 ἀστεφανώτους “unwedded”, said of Lucius’ sisters. Literally ἐπήκoος in l. 5 (καὶ θεῷ ἰδίῳ ἐπηκόῳ) means ‘listening to’. The word is very common in inscriptions from Asia Minor and is often associated with healing deities like Asclepius, Apollo, Zeus Hypsistos, Hercules.57 It is never used in a grave inscription, except here, and so is in itself proof of Lucius’ apotheosis. We read καί here as explicative, “that is their own god, giving ear to them”, in Meinecke’s translation “merciful”. He will act as a kind of guardian angel for the family. It is remarkable that this apotheosis is added to the more conventional γλυκυτάτος, Latin dulcissimus “sweetest”), one of the most frequently used epitheta in funeral inscriptions for very young children, especially in Asia Minor.58 The three Ὧραι (l. 9), goddesses of the hours, daughters of Zeus and Themis, called Eunomia, Dike, and Eirene, are in the Homeric Iliad the keepers of the heavenly gate. They watch over the seasons, and especially over the right time of birth. They symbolically induce life. Μοῖραι (l. 16) means implicitly the three Moirai (Latin Parcae), Clotho, Lachesis and Atropos.59 Γένεσις (l. 26) is quite rare in funerary inscriptions. Its literal meaning is, of course, “birth”, but here she is personified: Fate, like the Μοῖραι.60 7

Emotional Aspects61

Even though the wording is sometimes formulaic the text of the inscription is an emotional roller coaster: from pride and joy at the start, to alternating hope 56  Backe-Dahmen, Innocentissima, 103. 57  Weinreich, O. (1912). ‘ΘΕΟΙ ΕΠΗΚΟΟΙ’, Mitteilungen des Deutschen archäologischen Instituts; Athenische Abteilung 37, 21 no. 104, and 37–38; Chaniotis, A. (2011). Ritual Dynamics in the Ancient Mediterranean, 274, n. 39. 58  Kajanto, ‘Epitaphs’, 35–36; Backe-Dahmen, Innocentissima, 90; Vérilhac, ΠΑΙΔΕΣ 2, 37, no. 110. 59  Them., Or. 32 describes their activities elaborately. Only Klotho is twice mentioned explicitly in child epitaphs: Vérilhac, ΠΑΙΔΕΣ 1, 113 no. 76,1, Mysia second century AD, and 1, 217 no. 145,2, Rome, second-third century AD. 60  Cf. Vérilhac, ΠΑΙΔΕΣ 1, 233 no. 160, Tomis, v.9; Vérilhac, ΠΑΙΔΕΣ 2, 90; IG 12, 3,870, l. 14. A striking Latin parallel is offered by Laes, ‘Hopes’, 52: D(is) I(nfernis) M(anibus)/ Aurelie Aureliani| a(nnos) n(atae) XXXV et Bono fi(lio)| a(nnos) n(ato) X / Quem mihi | crudelis Genesis| abstulit de scola| immerentem, / Et| Iuste filie a(nnos) n(atae) V,| Que erat ingressa | atminestrare pa|rentibus dulcissi|mam aetate(m). 61  On emotions in Greek Antiquity: Konstan, D. (2006). The Emotions of the Ancient Greeks: Studies in Aristotle and Classical Literature; in inscriptions: Lattimore, Themes; in Latin

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and sadness at every new onset of disease, to fatalism at the end. From line 6 onwards, the child becomes his own spokesperson. The emotions of the child, however, remain in the dark. As readers we share the pride and hope of the parents, who (including their three daughters) were still alive when the stone was erected. In l. 4 the tria nomina of “their sweetest child” (τέκνῳ γλυκυτάτῳ) take pride of place. In l. 10 the father lifts up his son “joyfully” (γεγηθώς), a son who is “beloved by all” (πᾶσι ποθητός l. 15). When the illnesses hit the child, the father remains hopeful: “thinking to save my fate” (δοκῶν ὅτι μοῖραν ἐμὴν (. . .) σώσει l. 19). Even after the second illness there is still hope that Lucius will be healed “as before” (ὡς τὰ πάροιθεν, l. 25). We get involved in their despair and sadness. In l. 3 the coupling of the Latin nomen Φηλεικίσσιμα (Felicissima) and the clichéd Greek epithet ἀτυχεῖς (corresponding to Latin infelices), traditionally said of bereaved parents, is rhetorically impressive and probably not accidental.62 There is even more sadness in l. 8: καὶ σὺ δακρύσεις “even you (traveller) will straightway weep”. In l. 18 the father is ταλαίφρων “distressed” and l. 24 describes the λύπας καὶ στοναχάς the “grief and groans” of the parents after the operation. In l. 26 we find a trace of an emotion that is formulated more clearly in other funerary inscriptions: envy. Οὐδ’ οὕτως μου Γένεσις δεινὴ πλησθεῖσ’ ἐκορέσθη, “Not even my Genesis (the goddess of my Birth) was completely satiated”. The goddess, a kind of Fate, or Moira, almost a personified horoscope, is envious of human happiness and is only satiated after she has destroyed a young life.63 Hatred against the disease is expressed in the epithet στυγερήν “hated” (l. 31), referring to the corpse of the child that is wasted away, now lifeless, not anymore the embodiment of Lucius.64 inscriptions: Pikhaus, D. (1978). Levensbeschouwing en milieu in de Latijnse metrische inscripties: Een onderzoek naar de invloed van plaats, tijd, sociale herkomst en affectief klimaat. 62  Backe-Dahmen, Innocentissima, 90. 63  In some epigrams like GV 1732. In Merkelbach, R. and Stauber, J. (1998–2004). Steinepigramme aus dem griechischen Osten (SGO) (3), no. 14/13/05 the personified Greek Φθόvος (Envy) is clearly to be blamed for the premature dead of a child or youth, see Strubbe, J. H. M. ‘ “Niet Tijd maar Nijd. . . . . .”: Dood en hiernamaals in de Griekse en Romeinse grafinscripties’, in Horstmanshoff, H. F. J. (1994). Pijn en Balsem, Troost en Smart: Pijnbestrijding en Pijnbeleving in de Oudheid, 138–39. In SGO (1), no. 01/12/15, an inscription from the tomb of a three year old boy, Marcus Audius, in Halicarnassus in Caria, presents Hades as a divine being that is pleased by sacrifices being made of people and children, of death and tears. On horoscopes see Barton, T. S. (1994). Power and Knowledge: Astrology, Physiognomics, and Medicine under the Roman Empire; the precise age recording of years, months and days in l. 5 may point in this direction. 64  Cf. Samama, Médecins, fragments 023; 072; 155; 175. Tηκεδόνα στυγερήν does not refer here to the surviving parents’ hateful old age, but to the effect of the disease.

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The parents may have found consolation in the idea that the young boy henceforth will watch over them θεῷ ἰδίῳ ἐπηκόῳ, like “their own hearkening god”. Such elements are common in grave epigrams.65 There is an element of comfort too, in the idea that a traveller might check his paces to read the inscription and show compassion (ll. 6–8, 30). Furthermore, the making and erecting of the slab itself, and possibly the yearly commemoration, would have been an effective part of the mourning process.66 The prevailing emotion in the poem, however, is fatalism: so much is clear as early as the first appearance of the Horae (l. 9). The decision of the Fates (Μοῖραι, l. 13) makes all prayers (l. 12) and even medical treatment (l.19) futile. Their seal is inescapable (l. 16). This feeling of fatalism is accentuated by linguistically contrasting the terms γονεῖς “parents” (l. 3), γενέτης “father” (l. 14), γεννήσας “father” (l. 18), and γιναμένοις “those who begat me” (l. 31) with the all-conquering divine Γένεσις “Birth”, who prevents Lucius’ parents from claiming their own son for themselves. He belongs to the Moirai rather than to his genitors. His mother gave birth to him; his father assisted actively in the process and intervened bravely when his son was ill, but none of these mortal parents could claim real ownership of Lucius, who thus is imagined to have joined the divine world. He leaves his parents and his siblings behind, twice expressed in κατέλειπον (l. 31) and in λείψας (l. 32).67 In ll. 10 εἵλατο (the father) “took up”, 14 εἱλάμενος (the father) “chose”, 23 (the friends) ἀνεῖλαν “took out”, and 29 (the mother) εἷλαν “took” (life from my eyes) the same verb and verbal forms occur. The verb refers to a very ‘hands-on’ approach to Lucius’s birth, upbringing and course of life in general. Unfortunately, and despite the family’s interventionist approach, the Moirai or the Genesis get hold of little boy, a rather pessimist view of human fighting against fate. When Fate brought down a third disease on him (l. 27), there could only be one conclusion: this boy was αἰνόμορος, “doomed to a sad end” (l. 32), the leitmotif of the poem.

65  Rawson, ‘Death’, 362. 66  Yearly commemoration of the dead as a social act was common in mid second century AD, and was a product of Roman mourning rituals. Cf. McWilliam, ‘Children’; and King, ‘Commemorations’. 67  Cf. AP 7,467,8; 7,662: a daughter follows her brother.

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Medical Context

8.1 The Perspective of Ancient Medicine It is not easy to describe the course of the disease(s) in this inscription from the perspective of ancient medicine. We only have a few clues in favour of the idea that specialised medical knowledge was involved. Ancient physicians were generally reluctant to treat children.68 Lucius died at a very young age of only 4 years old. Numbering of an exact age length (“4 years, 5 months and 20 days”, ll. 4–5) does not necessarily mean that the exact age of Lucius was really known. Age rounding was not uncommon in Roman antiquity, and as, for example, Galen’s extant writings suggest, exact age calculations were of no particular medical significance.69 The chronological details in this particular case were important—perhaps because a horoscope was or had been cast for the baby more or less at birth. Attending a birth was in Antiquity, as in many cultures, women’s business.70 From ll. 10–11, however, it may be deduced that the father was not only present, but performed in person several tasks usually destined for a midwife. He took the baby from the earth, washed it and swaddled it.71 Αὐτός (“in person” in l. 11) emphasises the special character of this action72 L. 14 tells us explicitly that the father chose the mother as nurse (τροφὸν εἱλάμενος) and reared the infant himself. This was quite exceptional: even among the less well-to-do the common 68  Children should not be treated like adults, Celsus, Med. 3.7.1. On diseases of children in ancient medicine in general: Bertier, J. ‘La médicine des enfants à l’époque impériale’, in Temporini, H. and Haase, G. G. W. (1995). ANRW 2.37.3, 2147–2227; Hummel, C. (1999). Das Kind und seine Krankheiten in der griechischen Medizin: Von Aretaios bis Johannes Aktuarios (1. bis 14. Jahrhundert). 69  Mattern, Galen, 106; on a possible reference to a horoscope see above n. 63. 70  See the contributions of Porter (Chapter Ten) and Bolton (Chapter Nine), 285–303 and 265–284 in this volume. 71  “The environment [of birth], human and divine, is entirely female”, with Dasen, V. (2009). ‘Roman birth rites of passage revisited’, Journal of Roman Archaeology 22, 204; cf. also Dasen, V. ‘Le pouvoir des femmes: Des Parques aux Matres’, in Hennard Dutheil de la Rochère, M. and Dasen, V. (2011). Des Fata aux fées: Regards croisés de l’Antiquité à nos jours, 115–39. On duties of (medical) men attending especially difficult births in cooperation with midwives and their female helpers, see Hanson, A. E. (1994). ‘A division of labor: Roles for men in Greek and Roman births’, Thamyris 1, 157–202. 72  This may not have been so unusual: the poet Statius reports in two of his Silvae both his own and his friend Melior presence at the birth of a child (Stat., Silv. 2,1,78–81; 5,5,69–72); see also, Laes, C. ‘Delicia-children revisited: The evidence of Statius’ Silvae’, in Dasen, V. and Späth, T. (2010). Children, Memory, and Family Identity in Roman Culture, 265. Dasen, ‘Pouvoir’, 122, points out that Cato Maior attended in person the washing and swaddling of his son (Plut., Vit. Cat. Mai. 20,4–5).

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practice was to employ a wet nurse, often a slave woman. Only a few voices were raised in favour of being breastfed by the baby’s own mother.73 However, the father’s active involvement in Lucius’ life continues. The father healed (εἰάσατο l. 18) with medicaments (εἰάμασι l. 19) his son’s disease about the testicles. Eἰάμασι is a general medical term, which could encompass bandaging as well as medicaments. The Roman encyclopedist Celsus mentions the treatment of testicle problems, with medicaments, and even with surgery or bandaging.74 In the Hippocratic and Galenic tradition, children were classified as having “hotter” ’ and “wetter” qualities than adults, which required correspondent treatment in case of sickness.75 Galen advises ‘moistening and cooling’ with specific salves against inflammations of the genitals.76 The Byzantine physician Paulus Nicaeus in his manual several treatments of testicular inflammation describes using dressings soaked with honey, vinegar and different types of oil.77 As to the operation following the second disease (ll. 22–23), a comparable case is described in the Hippocratic Epidemics: fatal gangrene of middle foot in the female slave of Aristion.78 Generally, any surgical intervention was the ‘treatment of last resort’.79 Celsus recommends excision, or finally amputation,

73  One of them was the medical author Soranus (second century AD), Sor., Gyn. 2.16–18. On Soranus, see Bolton and Porter in this volume. More specific information about newborn’s feeding: Bradley, K. (1994). ‘The nurse and the child at Rome’, Thamyris 1, 137–56; Gourevitch, D. (1998). ‘L’ alimentation du petit enfant romain’, Revue internationale de pédiatrie 289, novembre–décembre, 43–46; Wiesehöfer, J. ‘Selbstsüchtige Mütter und gefühllose Väter? Bemerkungen zur Ernährung und zum Tod von Neugeborenen und Säuglingen in der Antike’, in Mauritsch, P. et al. (2008). Antike Lebenswelten: KonstanzWandel-Wirkungsmacht, 503–31. 74  Treatment with medicaments: Celsus, Med. 6.18.6, with surgery: 7.18–19, with bandaging: 7.20. 75  Gal., De plac. Hipp. et Plat. 8.6 (K. 5.692–93 = De Lacy CMG V, 4,1,2, 516). On children in Galen’s works, see Byl, S. ‘L’enfant chez Galien’, in López-Férez, J. A. (1991). Galeno: Obra, Pensamiento e Influencia, 107–17. 76  Gal., De meth. med., 10.9 (K. 10.702–03 = Johnston and Horsley 62–65); De tumor. praeter nat., 15 (K. 7.729): terminology of swellings relating to the scrotum and its content. 77  Paulus Nicaeus, De re medica 85 (Ieraci Bio 172–73). 78  Epid., 5.41 (L. 5.232.6 = Smith 172 = Jouanna 20): ὁ ποὺς ἐσφακέλισε κατὰ μέσον τοῦ ποδὸς ἔνδοθεν, “the foot spontaneously ulcerated in the middle of the foot”. The illness was diagnosed by M. D. Grmek as metatarsal osteomyelitis caused by staphylococci; cf. also Jouanna, 147. In this very short case-story, therapeutical measures are not mentioned. Eventually the patient dies. 79  Nutton, Ancient Medicine, 246.

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if a bone is really rotten.80 Elsewhere he calls gangrene therapy not difficult in the initial phases, utique in corpore iuvenile, “especially in young patients”.81 The father was supported by his friends or colleagues, who were surgeons themselves: ἔταμόν με φίλοι γενέτου ‘my father’s friends performed an operation on me’ (l. 23). Was he a partner within a medical group practice? There is evidence for medical group practices in the ancient world,82 as there is for collegial friendship, membership of a collegium and master-pupil relationships in a kind of guild. From the first century AD onwards, there were colleges, ‘clubs’ of physicians at Rome, but it was not until 368 AD that a kind of super-elite guild, the ‘College of Physicians in Rome’, was established by law.83 There is some technical language in the inscription. In l. 22 two termini technici are used: σῆψις, “putrefaction” and πεδίον ποδός, “part of the feet next the toes”,84 also known as the ‘midfoot’. Galen advises in a comparable situation: “but if some part of what is suppurating seem to have putrefied (σεσηπέναι), it is necessary to cut this out.”85 The combination πεδίον ποδός—which itself may have evolved from the metaphor of a ‘ploughed field’—is only found in medical authors of the second and third century AD, like Rufus, Galen and Oribasius.86 But we may interpret this term more broadly in a less ‘anatomically’ correct way: at the time there was not yet an international standard on human anatomic terminology. Πεδίον ποδός may simply mean some external part of the foot namely the back of the foot (dorsum pedis).

80  Celsus, Med. 7.33; 8.2.5. 81  gangrenam vero, si nodum plane tenet, sed adhuc incipit, curare non difficillimum est, “But gangrene, when not yet widespread, but only beginning, is not very difficult to cure, at any rate in a young subject”, Celsus, Med. 5.26.34. 82  Nutton, V. ‘The medical meeting place’, in Eijk, P. J. van der et al. (1995). Ancient Medicine in its Socio-Cultural Context, 3–25. 83  Samama, Médecins, 68; Nutton, Ancient Medicine, 256. 84  LSJ 1352, s.v. 85  Gal., De meth. med. 13.5 (K. 10.886 = Johnston and Horsley 336). 86  Ruf., De ossibus 39 (Daremberg-Ruelle, 193); Onom. 125 (Daremberg-Ruelle, 149); Gal., De ossibus (K. 2.777.7); De usu part. (K. 3.194.18); Orib., Med. Coll. 25.22.6.2 (CMG VI, 2,1 Raeder); Theophilus Protospatharius, De corp. hum. fabr. 1.20.6 a.o.; See the detailed discussion in Michler, M. (1961). ‘Zur metaphorischen und etymologischen Deutung des Wortes Pedíon in der anatomischen Nomenklatur’, Sudhoffs Archiv 45, 216–24; and Skoda, F. (1988). Médecine ancienne et métaphore: Le vocabulaire de l’anatomie et de la pathologie en grec ancien, 49–50.

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Further on, we find more technical words: ἐκτήξασα “wasted away” (l. 28), and τηκεδόνα “consumption” (l. 31), both from the verb τήκω, have medical connotations.87 Τὰ λοιπά probably refers here extremities and the thorax.88 Furthermore, the word νόσος, “disease” is mentioned four times (ll. 17, 18, 20, 27). Τhere is a chronological description of disease evolution, comparable to those archetypical ancient case histories of the Hippocratic Epidemics.89 The whole story, with its focus on the three ailments of the little boy, has a ‘morbid’ character, almost unbearable for a layperson, but not for a physician. Remarks on prognosis (e.g. based on qualitative signs like fever, pulse, urine), typical for case histories, are lacking,90 but no one would expect them in an epitaph. 8.2 Conclusion Does the content and the language of our epigram point towards a possible medical profession for the father-narrator? The presence of the father at birth, his active role immediately after the birth and his decision to choose the mother as nurse could be explained by assuming that the father had at least something more than superficial medical knowledge. The fact that he healed the first disease by himself (l. 18–19) and was supported by his friends in operating on his child’s foot (l. 23), as well as the use of some technical terminology, all point in the same direction. These arguments put together favour the hypothesis that the father was indeed a physician.91 None of them is completely convincing if taken on its own, but the cumulative evidence might tip the scale. After all, we know of several manumitted physicians with tria nomina originating from Asia Minor, 87  For reasons explained in sections 9–10, the anachronistic translation “tuberculosis” should be avoided. 88  Klitsch, Krankengeschichte, 207–08; Zingerle, ‘Fall’, 442. 89  Graumann, L. A. (2000). Die Krankengeschichten der Epidemienbücher des Corpus Hippocraticum: Medizinhistorische Bedeutung und Möglichkeiten der retrospektiven Diagnose; νόσος as a divine punishment is mentioned repeatedly in the so called confession inscriptions from Asia Minor, but they contain no technical medical language, see Chaniotis, A. ‘Illness and cures in the Greek propitiatory inscriptions and dedications of Lydia and Phrygia’, in Eijk, P. J. van der et al. (1995). Ancient Medicine in its Socio-Cultural Context, 323–44; Petzl, G. (1994). Die Beichtinschriften Westkleinasiens. 90  On the meaning and importance of ancient prognosis, see Graumann, Krankengeschichten 64–66. 91  Zingerle, ‘Fall’, 443–44; Meinecke, ‘Quasi-autobiographical’, 1026–27. Meinecke’s argument is partly based on his belief in the Smyrnean origin of the slab and its presupposed connection to a Greek medical school.

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who practised their profession in the higher classes of Rome during the second and third centuries AD.92 The father, Lucius Minicius Anthimos, may have been one of those freedmen.93 On the other hand, there is no explicit mention of any physician in this text (ἰατρός or χειρουργ(ικ)ός); neither the father nor his friends are called physicians.94 The father himself might have been non-medical, but with medical friends in his narrower relationship.95 Even the father’s friends could have been some sort of “amateurs of medicine” (φιλίατροι) who were practicing medical procedures only based on general knowledge.96 Nevertheless, it may be argued that this text is a dedication to the child, not to the father, much less to his friends. The child is in the centre of the story, and this leaves remarks about professions understandably to the background.97 At any rate, in case of manumitted physicians the omission either of the professional title or of the manumitted state (libertus) on grave stones is far from being a rare finding.98 In the special case of Greek physicians in Rome, even a tria nomina could be interpreted as a strong sign of assimilation (Romanisation), of a freeborn, not enslaved Greek physician after receiving the full civis Romanus.99

92  Korpela, Medizinpersonal, 110–13. 93  Unfortunately, there is no other contemporary epigraphic evidence for a physician with the name ‘Anthimos’ in Rome or in other Roman cities. To our knowledge, there is only one inscription by a military physician named ‘Lucius Fabius Anthi[mus]’ dated to ca. the end of second century AD from Großkrotzenburg, Germania Superior: CIL 13, 7415; Rémy, B. (2010). Les médecins dans l’Occident romain (Péninsule Ibérique, Bretagne, Gaules, Germanies), 162–63. 94  We may expect some wording like “friends who are doctors” (φίλοι ἰατροί), as those found in Galen: see Mattern, Galen, 20, 209, n.43 and 211, n.62. Long before, Georg Kaibel (1849– 1901) had expressed some doubts EG 314, 120. 95  Mattern, Galen, 22. 96  Salazar, C. F. (2000). The Treatment of War Wounds in Graeco-Roman Antiquity, 91. Nutton, Ancient Medicine, 259, speaks of “learned lay men and women”. Mattern, Galen, 25 on the example of Galen and his ‘friends and companions’. One of Galen’s own patients could serve as an exemplary case (De meth. med. 5.12 (K. 10.362): “The patient himself was not inexperienced in medicine, but rather was one of those who is experienced at therapy from practice and exercise [of the art]”; trans. Mattern, Galen, 125. 97  In Greek child epigrams the father’s profession is rarely mentioned; Vérilhac, ΠΑΙΔΕΣ 2, 96 presents only five cases, none of them features a physician. 98  Kudlien, Stellung, 133 and 149. 99  Kudlien, Stellung, 62–64.

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The particular use of ἰάομαι, especially in both lines 18 and 19, does not automatically mean that the described act of healing is exclusively performed by a physician.100 Discussing medical content was not confined to medical specialists. There was indeed an ongoing and informal cultural interchange between medical professionals and laymen, and it is generally believed that both categories shared the same language and explanatory models.101 There was no secret medical wisdom, and a specific medical vocabulary was not yet fully established.102 The practice of medicine, in fact, was much more of a public (agonistic) art.103 We will end in a somewhat circular argument without any objective conclusion: the father is a physician, so he uses medical description; the father uses medical description, so he must be physician. If we argue a contrario, the father himself probably was a well-trained, sophisticated Greek teacher, a sort of a medical autodidact, and simply interested in medicine as a caring father.104

100  Samama, Médecins, 579, citing: Brock, N. van (1961). Recherches sur le vocabulaire medical du Grec ancien: Soins et guérison, 42 (ἰάομαι only means doing some healing, but does not automatically imply a physician). 101  For ‘explanatory model’ as concept in medical anthropology, see Kleinman, A. (1980). Patients and Healers in the Context of Culture: An Exploration of the Borderland between Anthropology, Medicine, and Psychiatry; Nijhuis, K. ‘Greek doctors and Roman patients’, in Eijk, P. J. van der et al. (1995). Ancient Medicine in its Socio-Cultural Context, 49–67. 102  Nutton, ‘Murders’, 32; Jori, A. (2009). ‘Medizinische Bildung für Laien’, Sudhoffs Archiv 93, 67–82. Mattern, Galen, 24: “The works of several aristocratic laymen of the first and second centuries AD [. . .] display medical erudition or a keen interest in (some might say obsession with) health and medical matters.” On Galen, Mattern states: “Galen believed that educated aristocrats should know something about medicine, and he values [. . .] patient’s medical expertise”; Mattern, Galen, 125. Eventually, one may refer to the anecdote in the second century author Aulus Gellius (Gell., NA 18.10.8) about the common medical knowledge in his lifetime and his remark: turpe esse ne ea quidem cognovisse ad notitiam corporis nostri pertinentia, “not to know even such facts pertaining to the knowledge of our bodies”, trans. Rolfe 1952. 103  Cf. Nutton, ‘Murders’, 37: “medicine in classical antiquity was an open science”. See also, Nutton, Ancient Medicine, 270; Mattern, Galen, 26. We may only refer to the famous example of Celsus’ unclear medical profession. 104  Barton, Power, 167. Gourevitch, D. ‘The sick child in his family: A risk for the family tradition’, in Dasen, V. and Späth, T. (2010). Children, Memory, and Family Identity in Roman Culture, 273–92, here 290: “Good and bad fathers (those at least we know) [in the Roman Empire] were genuinely interested in medicine”. One may think of the exemplary case in Galen: Piso observes and intervenes in the medical treatment of his own, severely injured child; Gal., De ther. ad Pis. 1 (K. 14.212–14).

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The Perspective of Modern Medicine

9.1 Medical Historical Discussion Why is it important to interpret this sad story from the perspective of modern medical science? What does it add to its general interpretation apart from what we know about its historical, philological and archaeological context? We have a linear, chronological description of an illness with a beginning and an end, but we miss a final, explicit medical diagnosis. The sophisticated reader is tempted, almost urged, to make a retrospective medical diagnosis.105 9.2 Retrospective Diagnosis: Overview There have been several modern attempts for retrospective diagnostic. Verdicts are surprisingly in unison from 1927 to 2001: Lucius suffered from tuberculosis.106 The three diseases of Lucius have been interpreted as: urogenital tuberculosis (testicle disease), tuberculous osteomyelitis (foot disease), and fatal tuberculous peritonitis (belly disease). It is remarkable that only two of all the ‘diagnostic experts’ listed here namely Klitsch and Grmek, were themselves professional physicians.107 Tuberculosis (TB) and its Standard Clinical Symptoms among Children Tuberculosis (TB) is first of all a lung disease (pulmonary TB) with prevailing respiratory symptoms, but it is also a multi-organ infection potentially spreading in all tissues and organs other than the lungs (extrapulmonary TB). One of the classical symptoms of pulmonary TB is the chronic, more than two or three weeks persisting, non-remitting, partly agonising cough. This 9.3

105  Graumann, Krankengeschichten, 125–26. Of course, we are not the only recent investigators performing retrospective diagnosis on ancient epigraphical material; see for example: Prêtre, C. and Charlier, P. (2009). Maladies humaines, thérapies divines: Analyse épigraphique et paléopathologique de textes de guérison grecs, and Charlier, P. (2009). Male mort: Morts violentes dans l’Antiquité. 106  We have considered before a few ancient diagnoses. See the discussion above. Modern diagnoses: Meinecke, ‘Consumption’/‘Quasi-Autobiographical’; Zingerle, ‘Fall’; Klitsch, Krankengeschichte; Grmek, Maladies, 289; Gourevitch, ‘Déontologie’; ead., Giovani. 107  At the time of publication of his work, Klitsch (born 1948) had still limited experience as a clinical practitioner. This discussion was his medical doctoral thesis. Only then he started working as a practising physician. Grmek, although educated as a physician, turned his research interests to philology and history of sciences already in the course of his medical training. See Fantini, B. (2001). ‘Obituary Mirko Dražen Grmek’, Medical History 45, 273 and 275.

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cough may be sometimes associated with coughing up blood (haemoptysis).108 Checking the narrative on our stone, there is no hint of coughing or coughing up blood in the chronicle of Lucius’ diseases.109 In childhood, especially in early childhood (0–5 years), symptoms of (pulmonary) TB may be rather subtle, non-specific, or even absent. The same holds true for cough. Only the combined presence of persistent, non-remitting cough of more than two weeks’ duration, an objective weight loss over three months with failure to thrive, and fatigue in children over 3 years of age provides a ‘good’ diagnostic tool for pulmonary TB.110 Today, TB is a rather endemic disease, especially in children. From the perspective of Europe and the USA, however, TB is a ‘historical’ disease, vanished from the limelight, or perhaps re-emerging with changing patterns due to increasing drug-resistance.111 Malnutrition, poverty, poor hygiene, badlyventilated narrow and overcrowded living spaces are all factors that predispose children in particular toward the infection.112 Just before the advent of chemotherapy in the 1940s, a decline in tuberculosis has been noted in Western countries.113 Taking the example of modern Germany in 2008, only 124 chil108  “Coughing up blood” as the classic symptom of (pulmonary) tuberculosis is interestingly also mentioned by non-medical authors like Mattern, Galen, 6. Note, however, that medical authors already at the beginning of twentieth century have mentioned that haemoptysis is not significant at all. E.g., Much, H. (1923). Die Kinder-Tuberkulose: Ihre Erkennung und Behandlung. Ein Taschenbuch für praktische Ärzte, 49: “Blutspucken spielt so gut wie keine Rolle.” Moreover, the sign of haemoptysis especially in children is noted very rarely by ancient medical authors: Hummel, Kind, 209 refers only to Cael. Aur., TP 2.12.138; cf. also 139. 109  Cough may have been so common in childhood in this period that it was not worth mentioning. Can this be interpreted as an argument from silence? 110  Marais, B. J. et al. (2006). ‘A refined symptom-based approach to diagnose pulmonary tuberculosis in children’, Pediatrics 118, 1350–59. 111  TB is endemic in Eastern Europe, Southeast Asia, India, Thailand and the Philippines. TB in Europe with special reference to children: Walls, T. and Shingadia, D. (2007). ‘The epidemiology of tuberculosis in Europe’, Archives of Disease in Childhood 92, 726–29. On drug-resistance (Iranian perspective), see: Velayati, A. A. et al. (2009) ‘Emergence of new forms of totally drug-resistant tuberculosis bacilli: Super extensively drug-resistant tuberculosis or totally drug-resistant strains in Iran’, Chest 136, 420–25. 112  Roberts, C. A. and Buikstra, J. E. (2003). The Bioarchaeology of Tuberculosis: A Global View on a Reemerging Disease, 54–61; Connolly, C. A. (2008). Saving Sickly Children: The Tuberculosis Preventorium in American Life, 1909–1970, 56. 113  This was probably due to improved nutrition and healthier living conditions, especially due to the introduction of standard pasteurisation of milk by which the risk of cowborne TB (infection with Mycobacterium bovis through cow milk intake) was minimised.

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dren under the age of fifteen were diagnosed, while the incidence for children below five years of age was only 1.8 (per 100.000), with about eighty per cent of those children suffering from pulmonary TB.114 Today, there is a close correlation of TB with malnutrition and immunologic compromise, especially in case of AIDS/HIV. Children could be infected at a very young age through inhalation (pulmonary disease) after being in contact with an infected adult, or through ingestion of infected animal milk, or even breast milk. Congenital TB (infection before birth) is also possible.115 In the natural course of TB (without antibiotic treatment), infected children would develop pulmonary symptoms impairing their lungs or tracheo-bronchial tree within one year at a rate of about sixty or eighty per cent;116 up to a quarter of the cases would develop extrapulmonary symptoms, most commonly in the lymph nodes (mainly cervical), the bones, the joints, the pleura, and the meninges,117 but also in the abdominal and genitourinary tract.118 Extrapulmonary tuberculosis is reported to be more widespread among children younger than three years of age, because of their immature immune system, which translates effectively to a higher frequency of lymphohaematogenous spread.119 Prolonged household exposure to the disease (such as close contact with a person with open pulmonary tuberculosis, e.g. an infected mother) makes up the eighty per cent of the risk factor for children.120 Especially young, infected infants are at high risk of severe disease progression and death. Without any antibiotic treatment one third of all Alternatively, this decline may also be due to a kind of natural (long lasting) epidemic cycle. More on this topic in Roberts and Buikstra, Bioarchaeology, 12; Connolly, Saving, 7. 114  Robert-Koch-Institut, Germany. http://www.rki.de/cln_151/nn_274324/DE/Content/InfAZ/ T/Tuberkulose/Download/TB2008.html (received on 31.05.2011). 115  Roberts and Buikstra, Bioarchaeology, 49. 116  Marais, B. J. and Donald, P. R. ‘The natural history of tuberculosis infection and disease in children’, in Schaaf, H. S. and Zumla, A. I. (2009). Tuberculosis: A Comprehensive Clinical Reference, 136. 117  Wang, P. D. (2008). ‘Epidemiological trends of childhood tuberculosis in Taiwan 1998– 2005’, International Journal of Tuberculosis and Lung Disease 12, 250–54. Interestingly, a high local incidence of bone and joint tuberculosis in up to 56% of extrapulmonary symptoms is reported in Taiwan: Nong, B.-R. et al. (2009). ‘Ten-year experience of children with tuberculosis in Southern Taiwan’, Journal of Microbiology, Immunology, and Infection 42, 516–20. 118  Graham, S. M. et al. ‘Clinical features and index of suspicion of tuberculosis in children’, in Schaaf, H. S. and Zumla, A. I. (2009). Tuberculosis: A Comprehensive Clinical Reference, 154. 119  Reuter, H. et al. ‘Overview of extrapulmonary tuberculosis in adults and children’, in Schaaf, H. S. and Zumla, A. I. (2009). Tuberculosis: A Comprehensive Clinical Reference, 377. 120  Marais and Donald, ‘History’, 133.

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patients (adults and children alike) will die out of TB (pulmonary or systemic failure). In our case, Lucius has suffered and survived his disease complex for nearly five years. If we compare the three supposed types of TB in Lucius (in the testicles, the midfoot and the abdomen) to recent descriptions of the illness we can assert that: 1) Genitourinary TB, such is for example the TB of the epididymis, is usually caused by haematogenous spread from any other primary infected organ (secondary TB). The illness usually presents itself as scrotal swelling, which later develops into a hard, craggy epididymis and sometimes results in a draining sinus on the scrotum. The disease in this case is usually not confined to the epididymis, it often includes the testicle (‘epididymo-orchitis’); while on occasion it can lead to specific tissue necrosis (‘caseation necrosis’) of both, epididymis and testicle. Antibiotic administration set aside, the treatment nowadays consists primarily in epididymectomy (i.e. the excision of the epididymis).121 But, the same disease can manifest itself very obscurely, for example as isolated TB only of the testicular sheath.122 2) Skeletal or bony TB, especially in metacarpal (midhand) or metatarsal (midfoot) bones (spina ventosa or tuberculous dactylitis), is nowadays rarely seen. It occurs usually as a secondary disease of primary pulmonary tuberculosis, which has gone undiagnosed.123 3) Abdominal TB in children mostly manifests itself with abdominal distension, pain or else painlessness (with or without peritonitis). Other symptoms include: fever, weight loss, night sweats, diarrhoea, bloody stools, and jaundice, but may vary considerably, thus, mimicking clinically many other diseases and 121  For an Indian perspective with an overview of 9 cases of genitourinary tuberculosis in children, see Chattopadhyay, A. et al. (1997). ‘Genitourinary tuberculosis in pediatric surgical practice’, Journal of Pediatric Surgery 32, 1283–86. Cf. also Fishberg, M. (1932). Pulmonary Tuberculosis, 188–89. 122  In this case, the physician can be led to the wrong diagnosis of acute scrotum, which results in unnecessary surgery of the testicle. See, for instance, the report of a 2-year-old child, who was misdiagnosed as suffering from testicular torsion, and for that reason “mistakenly” operated upon in Sookpatorom, P. et al. (2010). ‘Isolated tuberculosis of tunica vaginalis in a child’, Pediatric Surgery International 26, 763–65. 123  Roberts and Buikstra, Bioarchaeology, 108. Exemplary case: Patel, N. C. et al. (2000). ‘Tuberculous dactylitis (spina ventosa) secondary to pulmonary tuberculosis’, Applied Radiology 29, 34–35 (the case of a 6-month-old Asian girl with a draining sinus from the right foot). In their discussion, the authors name as differential diagnosis syphilis and pyogenic infection. The most common affected bone in children’s TB is neither hand nor foot, but the tibia (shinbone): Roberts and Buikstra, Bioarchaeology, 98.

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making diagnosis extremely difficult even nowadays. In up to twenty per cent of the cases it manifests itself as solid organ disease (liver, spleen or pancreas). Untreated cavitary (=open) pulmonary TB is strongly associated with gastrointestinal TB via prolonged exposure to swallowed infected secretions.124 9.4 Tuberculosis: Exact Diagnosis? Another pitfall when diagnosing TB lies in its clinical reality. Sometimes diagnosis itself could be a very difficult task. Signs and symptoms, especially in the sick child, are seldom clear from the beginning due to the great variety of the ways they manifest themselves. The symptoms of TB may be similar to those of other diseases. Precisely because TB is able to mimic other diseases, it can also have rare and unusual clinical presentations. In Lucius’ case, the complex of the three diseases described could easily be interpreted as set of symptoms of three different diseases. On the other hand, it is equally possible that the individual symptoms of TB can be related to different, non-tuberculous diseases, and this holds true even in the case of chronic cough, e.g. cough as sign of bronchial asthma. Even the so-called ‘classical signs’ of TB could be mimicked by other, non-tuberculous diseases, such as syphilis.125 Retrospectively, one has to admit that prior to microbiological diagnosis, the discovery of x-rays, the established use of the diagnostic skin test in children (epidermal tuberculin test), and the introduction of antibiotics a number of patients, especially children, were victims to other diseases not clearly distinguishable from TB. Their symptoms, due to lack of the appropriate diagnostic tools were confused and interpreted as symptoms of TB. Such was, for instance, the case with the Hodgkin’s disease, when it was combined with cervical adenitis, fever, and weight loss. Even nowadays, the diagnosis of TB and its subsequent treatment with antibiotics presupposes careful microbiological testing (using some kind of tissue specimen, most commonly sputum) in addition to positive tuberculin skin test (the intradermal Mendel-Mantoux), and positive chest x-ray findings in conjunction with newly developed immunological tests, and occasionally it must even be supported by animal testing (artificial infection of animals).126 Unfortunately, diagnosis of TB in children 124  Fishberg, Tuberculosis, 239; Reuter, ‘Overview’, 382–83. 125  Reuter, ‘Overview’, 387: “Extrapulmonary TB [= tuberculosis] may involve almost any body organ system and like syphilis is a great mimic of many other diseases”. 126  In Germany, the medical reference paper is: Schaberg, T. et al. (2001). ‘Richtlinien zur medikamentösen Behandlung der Tuberkulose im Erwachsenen- und Kindesalter’, Pneumologie 55, 494–511. New tests in children: Detjen, A. et al. (2006). ‘Immunologische Diagnostik der Tuberkulose-Interferon-γ-Tests’, Monatsschrift für Kinderheilkunde 154,

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is extremely complicated for many practical reasons, not least because in children a sufficient amount of sputum and other respiratory specimens are more difficult to collect and microbiological tests yield poorer positive results than in those made on adults. The tuberculin skin test is not specific enough and may be positive in non-tuberculous mycobacteria, too.127 Blood tests still are not able to diagnose childhood TB accurately. Even more difficult is diagnosis in immunocompromised children, such as HIV-infected children. Clinicians call that a ‘diagnostic dilemma’.128 Some physicians actually have stated that even today most cases of TB in younger children are only diagnosed either clinically (by physical examination), or by successful trial of antibiotic treatment (“who heals is right at all”).129 9.5 The TB Complex and the Concept of its Evolution A sometimes underestimated topic, but fairly important in human diseases caused by bacteria, is the very fact of biological evolution. Bacteria like other life forms are not static. Though mycobacteria are very resilient bacilli, recent scientific research has demonstrated that the prevalent strain of Mycobacterium tuberculosis emerged only one millennium ago in human pathological history. This does not automatically mean that this strain could cause other symptoms than Mycobacterium tuberculosis two millennia ago, but the possibility for a

152–59. Historically, it was not long before 1916 that standardised diagnostic criteria for tuberculosis were available in the USA, and before that “physicians relied on their own experience and judgment to make the diagnosis”: Connolly, Saving, 38. 127  Non-tuberculous mycobacteria, like Mycobacterium avium, can cause lymphadenitis, but not TB; Magdorf, K. (2006). ‘Tuberkulose im Kindesalter: Pathogenese, Prävention, Klinik und Therapie’, Monatsschrift für Kinderheilkunde 154, 126. 128  Marais, B. J. et al. (2006). ‘Childhood pulmonary tuberculosis: Old wisdom and new challenges’, American Journal of Respiratory and Critical Care Medicine 173, 1078–90. Similar difficulties in diagnosis were noted already at the beginning of twentieth century. Connolly, Saving, 37. E.g., Maurice Fishberg (1872–1934) begins his chapter on diagnosis of tuberculosis in infants as follows: “The diagnosis of tuberculous disease in infants is not an easy matter”; Fishberg, Tuberculosis, 25. 129  Driver, C. R. et al. (1995). ‘Tuberculosis in children younger than five years old’, The Pediatric Infectious Disease Journal 14, 112–17. It may be added, that also the interpretation of chest radiographs in children with suspected tuberculosis is far from being easy, and its clinical utility is even questioned today in some settings (e.g., in asymptomatic children): George, S. A. et al. (2011). ‘The role of chest radiographs and tuberculin skin tests in tuberculosis screening of internationally adopted children’, The Pediatric Infectious Disease Journal 30, 387–91.

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changing pathological picture over time (also known as pathomorphosis) even in the case of Lucius remains.130 Moreover, TB in humans is not only caused by a single bacillus, but by a group of bacilli, the so-called Mycobacterium (M.) tuberculosis complex: besides the most common M. tuberculosis, there is M. bovis, a cattle-borne pathogen which can be transmitted via infected raw dairy products (first of all milk), meat or inhalation of infectious droplets from the cattle or goat.131 The clinical pattern of M. bovis TB in humans is indistinguishable from M. tuberculosis TB.132 Bone or joint TB (such as the midfoot disease in Lucius) is more likely to have been caused by infection of M. bovis than by M. tuberculosis.133 However, the epidemiological impact of M. bovis in the past remains unclear.134 Especially in Roman times, cow milk was not consumed regularly, beef was eaten very rarely, and cattle contact in the ancient urban setting was less often. All this renders Lucius’ infection by this route quite improbable.135 9.6 Lucius’ Retrospective Diagnosis Revisited Moving back to the sad story of young Lucius, we should first reconsider ‘hard medical facts’, i.e. the medical status of ‘our patient’. We are dealing with a male child, breastfed by his own mother, born in a probably unspectacular way at home in the presence of his father. The child may have been born after (and later survived by) three more living children (his unwedded sisters).136 The boy seem to have developed well in the beginning, but many further medical questions about Lucius’ development and his environment remain unanswered. For instance, there is no information about the health status of other 130  Hirsh, A. E. et al. (2004). ‘Stable association between strains of Mycobacterium tuberculosis and their human host populations’, Proceedings of the National Academy of Sciences of the USA 101, 4871–76. 131  M. tuberculosis complex: M. bovis (with its subspecies bovis and caprae), M. africanum, M. microti, M. pinnipedii and M. canettii. M.bovis has recently shown to be also (re-)transmittable from human to cattle: Fritsche, A. et al. (2004). ‘Mycobacterium bovis tuberculosis: From animal to man and back’, International Journal of Tuberculosis and Lung Disease 8, 903–04. Cattle-borne TB (pearl disease, German ‘Perlsucht’) was not known before 1895; Connolly, Saving, 46. 132  Roberts and Buikstra, Bioarchaeology, 5. 133  Roberts and Buikstra, Bioarchaeology, 88. 134  During early twentieth century researchers claimed that more children with TB suffered from M. bovis than from M. Tuberculosis. Today, this opinion is questioned. Cf. Connolly, Saving, 46. Roberts and Buikstra, Bioarchaeology, 77; 84. 135  Gourevitch, Giovani, 121, n.30. 136  See above p. 37 n. 53.

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family members, Lucius’ father, his sisters and his mother. Lucius may have been in prolonged direct household contact with his mother, who was perhaps herself suffering from open TB. Concrete information is lacking about the nutritional status of the baby Lucius (possible malnourishment, vitamin deficit, or insufficient calcium intake), his birth weight, the exact duration of his mother’s pregnancy (full-term or preterm baby). There is no hint for the season of the sickness’ first occurrence (perhaps in winter time?), as well as for the exact duration of each of Lucius’ illnesses. Furthermore, we have no information about any possible contact with animals, his living conditions (perhaps in overcrowded Rome?), and, more importantly, the epidemic or endemic state of TB in Rome at the time. We also do not know of the sickness’ first occurence, a fact that makes it impossible to draw any connections with the disease’s evolution, as we know it today. Again, we only know of three disease patterns recognised as different disease entities, and that Lucius finally died in the fifth year of his life in the course of the third disease, and after an unknown period of suffering.137 All in all, we haven’t got any other additional material evidence, no portrait of the boy, nor do we possess his human remains (bones or ashes) to conduct further palaeopathological examinations so as to collect evidence for specific diseases.138 At the moment, we can consider four possibilities: the described three diseases patterns could have been caused by: 137  More precisely, from contemporary view only signs of illness recognised by the fathernarrator are described. Nevertheless, we will further speak of ‘disease pattern’ keeping this in mind. 138  In human remains it is possible today to show TB infection by detecting mycobacterial DNA, though this says rather little about the ways disease evolves in an individual or in a specific population. TB in Egyptian mummies: Nerlich, A. G. et al. (2002). ‘Paläopathologie altägyptischer Mumien und Skelette: Untersuchungen zu Auftreten und Häufigkeit spezifischer Krankheiten in verschiedenen Zeitperioden der altägyptischen Nekropole Theben-West’, Der Pathologe 23, 379–85. On the quality of palaeopathologic detection of Mycobacterium tuberculosis DNA, see Zink, A. R. et al. (2005). ‘Molecular identification of human tuberculosis in recent and historic bone tissue samples: The role of molecular techniques for the study of historic tuberculosis’, American Journal of Physical Anthropology 126, 32–47. Compare Roberts and Buikstra, Bioarchaeology, 49 “However, even if tuberculosis has been identified and the person’s skeleton is aged accurately, it is almost impossible to ascertain when the disease started in the individual’s life and when the bone damage started occurring”; and Roberts and Buikstra, Bioarchaeology, 107: “Even if a positive tuberculous ancient-DNA result has been established for a skeleton with rib lesions, this does not indicate that TB [=tuberculosis] caused them”. There is only the spectacular ‘Grottarossa mummy’, excavated 1964 in Rome, the remains of a 8-year-old girl from second century, who died of pneumonia (unsure detection of TB): Ascenzi, A. et al.

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a single contemporary disease (like TB) two different contemporary diseases three different contemporary diseases or, finally, they could have been caused by one or more unknown causative factors.139

First, we have to ask ourselves, what degree of medical accuracy can be expected. The described nosological facts remain implicit, whereas the explanatory medical model remains in the dark.140 Typical children’s diseases from the same historical period are not mirrored in the poem’s description.141 Classical symptoms like fever, secretion or excretion of body fluids (cough, feces, urine, blood, phlegm) are not reported here, and we just can’t conjecture missing symptoms. 9.7 First Disease (l. 17): αἵ με νόσῳ πῆξαν χαλεπῇ διδύμους πέρι Beside testicular TB, there is a plethora of other diagnostic scenarios that could match the description: inguinal hernia (possibly incarcerated, but reducible), hydrocele, torsion of testis, torsion of Morgagni’s hydatide, epididymitis (nontuberculous; viral, bacterial, or chemical via reflux), orchitis (viral, such as mumps, or bacterial), scrotal abscess (staphylococceal) and idiopathic scrotal edema (a benign, full reversible skin affection). Further possiblities include: malignant tumor of testis (teratoma or seminoma), leukemia, lymphoma, sarcoidosis (bilateral granulomatous orchitis), primary (idiopathic) or secondary (due to some, perhaps malignant intra-abdominal process) varicocele, secondary scrotal swelling (edema) caused by abdominal, retroperitoneal tumor (benign or malignant), scrotal or testicular metastasis of any other malignant tumor. A brief look at this list of ten possible diagnoses other than TB quickly reminds us that TB is not an unquestionable candidate. From the inscription we hear of some affection around the testicles or around the scrotal area, for which Lucius was treated. There is, nonetheless, no explicit description of ‘The Roman mummy of Grottarossa’, in Spindler, K. et al. (1996). Human Mummies: A Global Survey of their Status and the Techniques of Conservation, 205–17. 139  Graumann, Krankengeschichten, 79. 140  Compare Graumann, Krankengeschichten, 57–61. Classic example: the ‘standard’ interpretation of cyclic fever in antiquity as sign of malaria may be misleading; Graumann, Krankengeschichten, 104; Mattern, Galen, 155–58. 141  See the meticulous analysis of diseases in children described by second century physician Galen in Gourevitch, Giovani.

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this ‘treatment’: as mentioned above ἰάομαι is a general medical term that can denote treatment by medicaments (e.g. ointment or purgatives) or bandaging without cutting or cauterising. This does not preclude the possibility that some invasive procedure was involved: such as incision of a scrotal abscess that could even include (semi-)castration of the child, or venesection (following ancient medical methodology) to drain any surplus of pus.142 The text gives the impression that in the eyes of the father-narrator the illness was successfully treated. However, if there is any connection between the first illness and those that followed, how could one speak of a ‘successful’ treatment? The notion of cure remains vague and implicit, and the possibility of it serving as a literary device to raise the dramatic tension should not be excluded. As medical historians we should be aware of our own historical horizon and not simply superimpose our own horizons on either those of the father-speaker in the inscription or those of subsequent generations of interpreters. Neither should we try to dissemble our modern knowledge and experience in attempting to reconstruct a medical event in the past. Such a (pseudo-)reconstruction would be nothing more than a value-avoiding, lifeless description. We should try, however, to build a bridge of understanding between the past and the present, inviting the reader to walk with us over that bridge, to and fro, gaining new knowledge and insights into the past, the present and the future.143 9.8 Second Disease (l. 22): σῆψιν γὰρ λαιοῦ πεδίον ποδὸς εἶχεν ἐν ὀστοῖς Even in this second disease pattern, a kind of purulent necrosis in the left midfoot,144 many diseases other than TB fit the description: osteomyelitis (non-tuberculous; staphylococceal), primary osseous tumor (benign or malignant), posttraumatic wound infection, secondary (malignant) metastatic tumor, syphilis, haemoglobinopathia (such as thalassaemia), dactylitis (in 142  Mattern, Galen, 142. 143  Gadamer’s hermeneutics can be successfully applied to present day medical ethics, see Widdershoven, G. A. M. and Metselaar, S. (2012). ‘Gadamer’s truth and method and moral case deliberation in clinical ethics’ in Kasten, M. et al. (2012). Hermeneutics and the Humanities. Dialogues with Hans-Georg Gadamer, Leiden, 287–305. 144  The explicit mention of σῆψις in the ‘left’ (λαιοῦ) side of the foot may have no further function in the whole description of disease than providing precision. Prima facie, it appears as an unnecessary piece of information. But, if we reconsider the Greek background of the narrator, we could interpret the disease on the left side as disease on the weaker, on the ‘bad’ or ‘unlucky’ side of the child, which may confirm the fatality of disease in the eyes of the narrator. See Wirth, H. (2010). Die linke Hand: Wahrnehmung und Bewertung in der griechischen und römischen Antike. On λαιός and σκαιός and their Latin counterparts laevus and scaevus, see especially his broad discussion in 14–48.

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sickle cell disease),145 or aseptic necrosis of metatarsal bone (Köhler’s disease) with subsequent bacterial superinfection. The features of illness as described in our inscription are by no means pathognomonic for tuberculous osteomyelitis: no swelling is mentioned while no specific information is given about the surrounding tissue, the part of bone involved (the diaphysis, that is the shaft of the bone, the epiphysis, that is the tip of the bone, or the whole bone), and whether σῆψις was accompanied by pain or not. At least, who could argue against a symptom of (perhaps congenital) syphilis here without any microbiological counter-evidence?146 Third Disease (l. 27–28): ἀλλ’ ἑτέραν πάλι μοι νόσον ἤγαγε γαστρὸς Μοῖρα σπλάγχνα μου ὀγκώσασα καὶ ἐκτήξασα τὰ λοιπά Here, personal experience in contemporary paediatric medicine teaches us that a sure and single diagnosis is not possible. Apart from the diagnosis of a fatal tuberculous peritonitis, the incomplete list of possible fatal diseases (all combined with sudden or slow onset of the clinical picture of an ileus)147 in this age group starts with congenital abdominal anomalies, acute and chronic inflammatory diseases, and ends up with malignant diseases of different kind, such as: volvulus (that is gut strangulation based on congenital malrotation of intestines), duplications of intestinal tract, mesenteric or omental cyst, symptomatic Meckel’s diverticulum (that is perforation, or also gut ­strangulation), appendicitis (quite possibly perforated), abdominal typhus, 9.9

145  A form of vaso-occlusive crisis most common in young infants (mostly under age 2 years) with sickle cell disease associated with vaso-occlusion of the nutrient arteries, which supply the metacarpal and metatarsal bones See, Friday, J. H. ‘Hematologic and oncologic emergencies’, in Selbst, S. M. and Cronan, K. (2001). Pediatric Emergency Medicine Secrets, 178. 146  Compare the differential diagnoses of tuberculous dactylitis in Storm, M. and Vlok, G. ‘Musculoskeletal and spinal tuberculosis in adults and children’, in Schaaf, H. S. and Zumla, A. I. (2009). Tuberculosis: A Comprehensive Clinical Reference, 502 and in Roberts and Buikstra, Bioarchaeology, 108 (congenital syphilis, osteomyelitis, sarcoidosis, sickle cell anemia). Going further back in time, syphilis has always been riddled with diagnostic difficulties: Karewski, F. (1894). Die chirurgischen Krankenheiten des Kindesalters, 148: “[Mit der Tuberkulose] konkurriert fast nur die Syphilis und in der That ist die Differentialdiagnose von dieser Krankheit häufig recht schwer”. In this first German manual of paediatric surgical diseases, 214 pages out of 780 pages are dealing exclusively with the topic of tuberculosis in childhood! It is even possible that both diseases, syphilis and tuberculosis, could co-exist in the same person. More on this topic, in Fishberg, Tuberculosis, 202. 147  We indicate that the usual Greek word εἰλεός or ἰλεός, “intestinal obstruction” is missing from the inscription. On ἰλεός in childhood in ancient medical authors, see Hummel, Kind, 231–32.

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intussusception, Hirschsprung’s disease (intestinal aganglionosis), infantile Crohn’s disease, mesenterial infarction (thrombosis, metastatic vessel occlusion), Non-Hodgkin-lymphoma (also known as Burkitt’s lymphoma), neuroblastoma, Wilms’ tumor (or nephroblastoma), abdominal lymphangioma or haemangioma, hepatoblastoma, hepatocellular carcinoma, and rhabdomyosarcoma.148 Accurate (‘lege artis’) diagnosis today is only possible by diagnostic tools like radiological imaging (conventionally, sonography, CT, MRI), specific blood tests (e.g. microbiological examination, tumor markers), histopathological examination (of excised tumor material), and, of course, many years of clinical experience. The Context of the Initial Diagnosis of Tuberculosis: Medical and Historical Considerations After so many different, plausible possibilities for a medical diagnosis one may wonder: why in the light of so much uncertainty have people in the past considered tuberculosis as the only diagnostic possibility?149 One reason could be that a historian of medicine who is not a practising physician bases his dogmatic theoretical medical diagnosis only on manuals and misses insight into the uncertainties of daily medical practice. This must lead to misconceptions. The other important reason could be found when this sort of diagnosis is placed in its own historical context. Following many different scientific contributions about the infectious character of TB as disease entity in the early 9.10

148  Compare the differential diagnoses of abdominal tuberculosis in children in Rey Nel, E. de la ‘Abdominal tuberculosis in children’ in Schaaf, H. S. and Zumla, A. I. (2009). Tuberculosis: A Comprehensive Clinical Reference, 435. The thought experiment of the diagnosing a malignant disease in Lucius’ case may run as follows: the diagnosis of Wilms’ tumor (nephroblastoma) is based on the first disease being interpreted as primary symptomatic inguinal hernia or varicocele, the second disease as osteogenic metastasis with osseous necrosis, and the third disease as growing abdominal (in fact, retroperitoneal) tumor (which would have been the original tumor of nephroblastoma) combined with ileus and followed by death by starvation. The diagnosis of rhabdomyosarcoma: primary paratesticular tumor, osseous metastasis with necrosis, ileus and death by abdominal metastasis (in the liver?). The clinical image on which the diagnosis of neuroblastoma is based includes primary adrenal tumor with scrotal metastasis, osseous metastasis, and finally death caused by ileus. Cf. the recent case report by Reed, R. C. and Casale, A. (2011). ‘Metastatic neuroblastoma presenting as a scrotal mass in an infant’, Journal of Pediatric Urology 7, 495–97. 149  The inscription is mentioned as part of a broader discussion about ancient case-­histories in Mattern, Galen, 36, too, and it is classified as famous medical history, but without any further statements about a probable diagnosis. She only cites Klitsch and Petzl; see Mattern, Galen, 216, n.115.

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nineteenth century, TB was redefined as specific microbial, germ-borne infectious disease since the discovery of M. tuberculosis in 1882 by Robert Koch, thus, rendering possible this new, germ-disease-based possibility of retrospective diagnosis. The first scholar known to have written of retrospective diagnosis of TB in modern context was Bruno Meinecke in 1927, in his broad and twenty four pages long article, which was entitled ‘Consumption (tuberculosis) in classical antiquity’ and published in the Annals of Medical History.150 Meinecke himself was a Michigan-based classical philologist of German origins with a general interest in ‘consumption’ in ancient literature. His brother was a physician.151 In Meinecke’s view, TB was one of the most common diseases of classical antiquity.152 Thirteen years later, in 1940, when he was an established member of the faculty at the University of Michigan and a member of the American Association for the History of Medicine, Meinecke re-diagnosed TB in a single ten pages long article entitled ‘A quasi-autobiographical case history of an ancient Greek child’, which was published in the Bulletin of the History of Medicine.153 In 1928 and independently (as far as we know) Josef Zingerle also diagnosed TB as the cause of Lucius’ death.154 Despite being a classical

150  Meinecke, ‘Consumption’, 385–86. His presentation and discussion of the grave stele and the inscription takes up one whole page of his article. He is citing Georg Kaibel (no. 314) and August Boeckh (CIG 3272), but does not reveal wherefrom he acquired his knowledge of the inscription. The article was based on his own doctoral dissertation at the University of Michigan. He was also the first who translated the Lucius’ inscription in English. 151  Dunlap, J. E. (1966). ‘Commemoration (Bruno Meinecke)’, Classical Journal 62, 142–44. In his 1927 article, Meinecke acknowledges in an introductory note (p. 379) especially his brother, who was a physician: “I desire, too, to record my thanks to my brother, H. A. Meinecke, M. D., of Detroit, who gave me many valuable suggestions and whom I often consulted to verify my own conclusions”. 152  Meinecke, ‘Consumption’, 399. 153  Meinecke, ‘Quasi-autobiographical’. On page 1028, Meinecke is citing his own article of 1927 extensively. The result of his own “fascinating game of diagnostic speculation” (1027) reads as follows: “we may be reasonably sure that this Greek child had tuberculosis of the |testicles, of the bone, and of the intestine, whether as a primary or secondary factor”; cf. also pages 1029–30. 154  He was the son of the famous Austrian classical philologist Anton Zingerle. Josef Zingerle was an experienced epigraphist with a special interest in Greek epigraphy. He was also a member of the Austrian Archaeological Institute: Wlach, G. ‘Die Direktoren und wissenschaftlichen Bediensteten des Österreichischen Archäologischen Institutes: Josef Zingerle (1868–1947)’, in Kandler, M. (1998). 100 Jahre Österreichisches Archäologisches Institut 1898–1998, 122–24; Schauer, C. ‘Die ‘Sekretäre’ des Sekretariats Athen und ihre

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philologist and not a physician—initially he had wished to study medicine and had attended some medical lectures—he published this spectacular article entitled ‘A case of a child suffering from tuberculosis 1700 years ago’ in the international renowned German paediatric journal Zeitschrift für Kinderheilkunde.155 Both, Meinecke and Zingerle, lived and published their papers in the Interbellum, in the 1920s. At that time, childhood tuberculosis was the major topic in the medical circles and in general in the Western developed societies of Europe and the USA. Around the fin de siècle, international scientific research revealed that most infections with tuberculosis took place in early childhood.156 Since 1907, and after the introduction and the institutionalisation of the tuberculin skin test, it was possible to elucidate TB-related infections, especially in children before any symptoms of disease appeared. Active measures to prevent TB in children were taken and infected children were separated from their ‘tuberculous families’ in sanatoria and preventoria. Moreover, food and water supply and common hygiene were improved including the wider application of technologies like pasteurisation.157 At the end of World War I, however, and especially in Germany the incidence of TB had risen again dramatically, before it was reduced once again by half at the beginning of the 1930s.158 Between 1921 and 1924, the first active immunisation with the live attenuated (weakened) strain of M. bovis, the Bacille Calmette Guérin, was introduced by which the risk of active TB could be reduced. But, the real, causal treatment was not possible until after the introduction of antibiotics like streptomycin, and certainly Tätigkeit: Josef Zingerle (1901–1902)’, in Mitsopoulos-Leon, V. (1998). Hundert Jahre Österreichisches Archäologisches Institut Athen 1898–1998, 38–39. In 1928, Zingerle held the office a ‘Hofrat’ (court counsellor) and was vice-president of the Austrian Archaeological Institute in Vienna, two very prestigious positions, which may have opened the doors for him to publish in a rather specialised medical journal, despite not being himself a paediatrician. 155  His publication takes only five pages of this journal, under the rubric “Kleine Mitteilungen und Kasuistik” (‘short communications and case-stories’). Maybe the publisher’s motive was to broaden the scientific spectrum of his highly specialised journal. 156  Connolly, Saving, 25. The most famous promoter of that idea was the first ever Nobel Prize winner in medicine, Emil von Behring (1854–1917): Connolly, Saving, 97. Compare the slogan of the famous German paediatrician Arthur Schloßmann (1867–1932) in 1910: “Der Kampf gegen die Tuberkulose setzt in der Kindheit ein” (‘the fight starts in childhood’): Schlossmann, A. ‘Die chronischen Infektionskrankheiten: Tuberkulose’, in Pfaundler, M. and Schlossmann, A. (1910). Handbuch der Kinderheilkunde. Ein Buch für den praktischen Arzt, 533. We thank Ulrike Enke, Marburg, for her kind remarks on Behring. 157  Connolly, Saving, 49–60. 158  Gloser, C. (2007). Die Tuberkulosebekämpfung in Thüringen in der Zeit von der Entdeckung des Erregers bis 1933, 66; 85.

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not before 1944.159 It is our view, that in this specific historical, pre-antibiotic setting the view that TB had been an analogously great threat for the children in antiquity was quite widespread among scholars.160 Meinecke, in 1927, reflects contemporary medical knowledge regarding childhood TB in his statements. He is not citing any specific medical literature, but at the end of his long article there is a ‘general bibliography’ with mainly medical monographies about TB and medical history; while his bibliographical references consisted in primarily German titles.161 In his investigation of the Lucius’ case, Meinecke used und gave special emphasis to an 1896 German monograph about TB in children.162 For instance, he declared that Lucius’ death was a typical case of sepsis in systemic tuberculosis,163 that tuberculosis in children was mostly a disease of early age,164 that tuberculosis was the result of an intestinal infection in up to a thirty per cent of the cases,165 and, finally, that fatal tuberculosis infection may be caused by another co-infection typical of children’s diseases like whooping cough, or measles.166 Meinecke 159  Connolly, Saving, 114. The next antibiotic agent, the isoniazid, was introduced in 1954: Connolly, Saving, 118. Today’s standard combination chemotherapy against tuberculosis was developed as early as in the 1960s; Harries, A. D. (2008). ‘Robert Koch and the discovery of the tubercle bacillus: The challenge of HIV and tuberculosis 125 years later’, International Journal of Tuberculosis and Lung Disease 12, 241–49. 160  Good examples of that “historical trend” in that specific era follow: Baumann, E. D. (1930). ‘De phthisi antiqua’, Janus 34, 209–25; Major, R. H. (1939). Classic Descriptions of Disease: With Biographical Sketches of the Authors [on tuberculosis: 58–81]; Ebstein, E. (1932). Tuberkulose als Schicksal: Eine Sammlung pathographischer Skizzen von Calvin bis Klabund 1509–1928. Even the famous classicist Arthur Stanley Pease had spent some time on this trend topic: Pease, A. S. (1940). ‘Some remarks on the diagnosis and treatment of tuberculosis in antiquity’, Isis 31, 380–93. Based on a presentation at the Harvard Medical School in 1939, besides a philological discussion this article contains a list of famous Roman victims of suspected tuberculosis. 161  29 titles from 1828 (Medicinisches Wörterbuch, Berlin) to 1917 (L. Cobbett, The Causes of Tuberculosis, Together with Some Account of the Prevalence and Distribution of the Disease, Cambridge); Meinecke, ‘Consumption’, 402. 162  Dennig, A. (1896). Über die Tuberkulose im Kindesalter. Dennig was at the time resident in internal medicine at the University Hospital of Tübingen. 163  Meineke, ‘Consumption’, 386. 164  Meineke, ‘Consumption’, 386. Cf. Dennig, Tuberkulose, 8–9. 165   Meineke, ‘Consumption’, 386. Cf. Dennig, Tuberkulose, 236–35., who differentiates between “tuberculous peritonitis”, “intestinal ulceration”, and “mesenterial lymph node tuberculosis.” 166  Meinecke, ‘Consumption’, 386. Cf. Dennig, Tuberkulose, 17, who mentions measles, whooping cough, pneumonia, scarlet fever, and typhus.

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­ resupposed that unhygienic behaviour and in particular the ingestion of p infected (tuberculous) milk made children prone to TB.167 Again, in 1940, in his second article on the inscription, he reinterprets the case-story “in the light of modern observation and experience” as “manifestations of a general tuberculosis”, and repeats verbatim his line of argumentation from 1927.168 In that article, Meinecke did not cite any medical literature.169 Back in 1928, Zingerle also cited very little medical literature170 although he did use very broad medical terminology and contemporary knowledge throughout his work despite not being a doctor. In particular, he cited the medical pathologist and historian of medicine Walter Pagel, who at that time was a TB expert.171 But, following Zingerle’s argumentation and terminology is very much like reading a TB manual of that time, and often reminds the reader heav167  Meinecke, ‘Consumption’, 386 = Meinecke, ‘Quasi-autobiographical’, 1029 “This [=incidence of tuberculosis in young children] undoubtedly can be explained by the fact that in early childhood children convey the infectious material to their mouths by their fingers, inasmuch as they play on their hands and knees during that period, and also by the fact that at this time infected milk would be taken most freely.” Cf. the preventive measures which suggest following a strict infant’s hygiene and only using boiled cow milk in Dennig, Tuberkulose, 251. 168  Meinecke, ‘Quasi-autobiographical’, 1029 = Meinecke, ‘Consumption’, 386. Interestingly enough, Meinecke did not used or cited recent literature on the topic. One would have expected to find, for instance, the US standard work of reference Tuberculosis among children (1938) written by the famous Lymanhurst ‘tuberculosis crusader’ Jay Arthur Myers; cf. Connolly, Saving, 106. 169  Meinecke reflects in his introduction on some early twentieth century-thoughts about scientific progress, as put forward by the German physician Hans Much (Das Wesen der Heilkunst, “The essence of medicine”). Meinecke probably knew that Much himself was a specialist in TB in children and had published the often reprinted manual on that topic, which was translated in English in 1921: Much, H. (1920). Kinder-Tuberkulose, 3rd–5th ed. 1923; Much, H. (1921). Tuberculosis in Children. In this manual Much also emphasised the role of immunity during the infection and the progress of tuberculosis, which was negatively influenced especially by systemic co-infection by measles, whooping cough, influenza and scarlet fever: “Von den Krankheiten, die das allgemeine Gleichgewicht plötzlich verschieben, sind für uns die gefährlichsten Masern, Grippe und Keuchhusten. Auch andere, wie Scharlach kommen in Frage.”; Much, Kinder-Tuberkulose, 23. 170  In an article that contains no footnotes, Zingerle cites both prime sources and secondary bibliography only very sparingly. 171  Pagel, W. (1927). Die allgemeinen pathomorphologischen Grundlagen der Tuberkulose, 29–31; id. (1927). ‘Die Krankheitslehre der Phthise in den Phasen ihrer geschichtlichen Entwicklung’, Beiträge zur Klinik der Tuberkulose und spezifischen Tuberkuloseforschung, 66–68.

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ily of Pagel’s own literary style.172 Especially his usage of the two terms ‘metastatic’ (for haematogenic or lymphatic dissemination of bacteria) and ‘virus’ (for the tubercle bacillus) were extremely common at that time. Nowadays both terms are deemed obsolete.173 Zingerle speculates, that the progress in Lucius’ disease as shown by him contracting TB in the bones may have been induced by some typical undercurrent infectious disease like measles, or scarlet fever,174 and mentions en passant high mortality rates in children, who were infected in the first year of their life.175 He equates the father of Lucius to an (ancient) internist, who has knowledge of pulmonary signs of TB and would not, while practicing meticulous anamnesis, have overlooked symptoms,176 and who consults his surgical colleagues in a skilled manner.177 By that, Zingerle is retrojecting uncritically and anachronistically modern ideas on to the past. In order to support his retrodiagnosis of tuberculosis, Zingerle presupposed a constant pathomorphology of tuberculosis since antiquity,178 and pronounced the huge scientific medical progress in diagnosing and treating TB in his time.179 He also lamented the ancient inability to understand the microbiological origin of TB180 and criticised the wrong treatment of the bone affection.181 Again, Zingerle here neglects the historical fact, that it was only in his lifetime that extrapulmonary manifestations of TB were proved by detection of tubercle bacilli in extrapulmonary tissues, and were integrated into the whole new defined paradigm of TB disease complex as a general or systemic disease, whose onset is attributed to an infection in early childhood.182 Moreover, surgical 172  Zingerle, ‘Fall’, 441–43. Cf. Pagel, Grundlagen 77. 173  The term ‘metastasis’ today is reserved for dissemination of cancer, ‘virus’ is confined today to the DNA-, or RNA-based infectious pathogens. Compare ‘virus’ as term of the tuberculous germ in Pagel, Grundlagen, 77, 86, 91, and 95. On ‘metastasis’, see also Pagel, Grundlagen, 77: “lympho- und hämatogene Metastasen.” 174  Zingerle, ‘Fall’, 442. 175  Ibid., 443. 176  Ibid., 443. 177  Ibid., 444. 178  Ibid., 443, using his own retrospective diagnosis of tuberculosis as proof of the persistent existence of tuberculosis in his days: a circular argumentation! 179  Zingerle, ‘Fall’, 443. 180  Ibid., 443. 181  Ibid., 442. 182  Spitzy, H. ‘Die chirurgische Tuberkulose’, in Pfaundler, M. and Schlossmann, A. (1910). Handbuch der Kinderheilkunde: Ein Buch für den praktischen Arzt, 195: “Die tuberkulöse Infektion wird hervorgerufen durch den Tuberkelbacillus (Robert Koch). Durch diese Entdeckung wurde die Zusammenfassung einer ganzen Reihe von Erkrankungen verschiedener Disziplinen ermöglicht und auch durch die Verfeinerung der Untersuchungsmethode

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i­nterventions with fatal outcomes were still practiced in the early twentieth century.183 By excluding any accidental coincidence of three different diseases184 and narrowing his thought experiment to one single cause,185 Zingerle unconsciously projected his own contemporary knowledge of the extrapulmonary character of TB into the ancient past, when such knowledge was both unavailable and unattainable within the ancient mental framework.186 Zingerle’s beliefs in the possibility of reaching an accurate and certain medical diagnosis on the basis of the fragmentary information of our inscription are mirrored in multiple statements like “explicit diagnosis”, or “prosaic-meticulous objectivity”.187 In their statements about the unequivocal diagnosis of tuberculosis both Meinecke and Zingerle reflect contemporary, naïve beliefs in progress, superiority and objectivity in the biomedicine of their own time. This renders both men typical representative of the “epidemic trend” of embarking on unreflective, microbiologically grounded retrospective diagnoses in the early twentieth century.188 Eventually, their interest in the sick child and his possible tuberculous disease can also be seen as a typical result of the new child-saving ethos of the early twentieth century.189 Successive interpreters of Lucius’ case such as Klitsch, Grmek, and Gourevitch have all followed and cited Meinecke und Zingerle with their retrospective diagnosis of TB, partly combined with a more or less growing inclusion eine Anzahl von chirurgischen Erkrankungen der Gelenke und Knochen, die früher als getrennte Krankheitsbilder beschrieben wurden, ihrem Wesen nach erkannt und in die Gruppe der tuberkulösen Erkrankungen eingereiht.” 183  Connolly, Saving, 38. See the overview of trends in surgical treatment of tuberculosis until 1910 in Spitzy, ‘Tuberkulose’, 197–99. 184  Zingerle, ‘Fall’, 441 “ist die zufällige Koinzidenz dreier pathogenetisch selbständiger Affektionen auszuschließen.” 185  Zingerle, ‘Fall’, 441 “Das Syndrom von Hoden-, Knochen- und Bauchaffektion ist so charakteristisch, daß unter Ausschluß differentialdiagnostischer Erwägungen kurzweg auf Tuberkulose als dem gesamtkomplexe übergeordnete ätiologische Einheit geschlossen werden darf.” 186  Interestingly, although cited by Zingerle, Walter Pagel came quite close to realising that the term ‘phthisis’ did not imply the same concept of disease in early nineteenth century was comparable to that of his own time. Similarly, Pagel claimed to have found a timeless, constant leitmotif in tuberculosis: Pagel, ‘Krankheitslehre’, 67, 91. 187  Zingerle, ‘Fall’, 440: “alle Elemente für die Erstellung einer eindeutigen Diagnose”; “nüchtern-pedantische Sachlichkeit”. 188  Graumann, Krankengeschichten, 132. 189  Connolly, Saving, 14.

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of other diagnostic possibilities (e.g. leukaemia, malignant tumors).190 While the retrospective diagnosis of TB persisted in the scholarly pages, TB itself was vanishing from the public eye and people’s awareness thanks to long and successful post-war anti-TB campaigns.191 Simultaneously, the medical experts observed in their life-time a pathomorphosis, a changing clinical picture of TB in children.192 Therefore, both the careful medical discussion undertaken by Klitsch in 1976 and the shorter medical discussion by Grmek in 1983 have now only historical value. One must remember, however, that by that time there was no longer such a great public interest in TB as in the times of Meinecke and Zingerle. In sum, from our own current perspective based on the illness’ low incidence, TB may be still a possible diagnosis, but it is not the only diagnosis. Lucius’ symptoms as described in our inscription could be interpreted as the symptoms of a wide range of different diseases known to us today. There may be descriptions of disease which overlap with our modern concept of TB, thus allowing us to diagnose it as TB, but nothing is for sure. From the historical perspective of early twentieth century, TB has been regarded as the most probable diagnosis mainly due to the broad and public interest of that specific period in the illness. Many out of our contemporary well-known and defined disease entities that could mimic symptoms of TB were unknown, or not yet ‘well’ defined at that time. The issue of whether TB was indeed a common disease in childhood in Rome of Imperial times remains open to discussion, because we do not have at our disposal (and quite possibly we will never obtain) robust epidemiological data of that specific era.193 Thus, the retrospective diagnosis 190  Klitsch, Krankengeschichte 129–30, who uses the now outdated medical terminology of a paediatric textbook of 1972 as main reference; cf. Grmek, Maladies, 289, who remains very vague in his medical terminology, but includes the possibility of dealing with three different diseases in Lucius’s case. 191  In Western Germany, in 1976 there was a reported drop of in-hospital treated children with open TB from 26.794 in 1953 (incidence 245.3: 100.000 children) to 2.994 in 1973 (incidence 24.6), also a major decrease in mortality from TB in children from 449 in 1953 to only 6 cases (4,1: 100.000 resp. 0,04). Cf. Spiess, H. (1976). ‘Kindertuberkulose einst und jetzt’, Praxis der Pneumologie 30, 406. 192  Spiess, ‘Kindertuberkulose’, 406. In fact, this was almost true at the beginning of the 1960s with the disappearance of former classical symptoms like spina ventosa (bony TB in metacarpals or metatarsals in children): see Brügger, H. (1964). ‘Das veränderte Erscheinungsbild der Tuberkulose des Kindes und des Jugendlichen in den letzten 35 Jahren’, Der Landarzt 40, 310–18. 193  This, at least, admits Grmek, too: Grmek, Maladies, 290. We may add that even the nice diagnostic try to identify signs of tuberculosis in Roman children’s portrait sculpture

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of TB made by so many different authors in the past is in itself a historical diagnosis. 9.11 Conclusion We have clearly shown that a single retrospective diagnosis of tuberculosis is not unequivocal. In theory, there are innumerable other diagnostic possibilities with tuberculosis being only one option. Bearing in mind the low incidence of children’s tuberculosis in contemporary Western developed societies, TB seems like a rather a simplistic, less probable option, and, moreover, itself an historical diagnosis. To put it simply, today we cannot really say of what kind of disease Lucius ultimately died. We have to abandon the image of disease as trans-historical, cross-cultural entity. The diagnostic process, even the retrospective one, changes and differs over time. Retrospective diagnosis could only serve as point of orientation within its own framework. It is, ultimately, a contingent explanatory tool.194 Beside the medical aspects, what remains is a quite expensive marble artefact which survived almost two millennia, and preserved a very long, sophisticated, and carefully composed text to the purpose of granting eternal memory to young Lucius.195 This tombstone and, of course, our own discussion here counteracts the negative impression of fading names on withering stones as was famously lamented by the fourth-century author Ausonius in his epigram 37,9–10: monumenta fatiscunt,/mors etiam saxis nominibusque venit, “tombstones decay, death comes even to stones and the names on them”.196 Reporting to us a single life event in the historical context of Roman antiquity, this text conveys how much loved and valued this particular boy, Lucius, was by his own parents (especially his father). It offers some kind of consolation, an attempt (= iconodiagnostic) is based on unsound ground (e.g., Backe-Dahmen, Innocentissima, 106, where the author critically mentions this diagnostic interpretation of a boy’s sculpture from second century AD with narrow chest and slight upper arms). 194  Graumann, L. A. ‘Die Krankengeschichten in den “Epidemien” des “Corpus Hippocraticum”. Retrospektive Diagnosen als ein Beispiel für Kontingenz’, in Labisch, A. and Paul, N. (2004). Historizität. Erfahrung und Handeln—Geschichte und Medizin, 118–19. 195  McWilliam, ‘Children’, 86: “Yet taking the trouble to erect a permanent burial-marker for a child (and for many members of the Roman society this would have involved considerable expense) implies a strong motivation for doing so”. 196  Cf. the full of pathos poetic example in Statius (Silv. 2.1.54f.; ca. 90 AD): cuncta in cineres gravis intulit hora | hostilisque dies; nobis meminisse relictum, “A heavy hour, a hostile day has brought all to ashes: to us is left a memory”. Trans. Shackleton Bailey 2003. Vérilhac has collected many funeral inscriptions for children, which contain the same idea of eternal memory: ΠΑΙΔΕΣ 1, 126–27 no. 80, 196 no. 126, 218 no. 146, 232 no. 159.

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to cope with grief, a ‘Trauerarbeit’. Simultaneously, it must have served as traditional, socially expected and public means of self-representation (a status symbol) for Lucius’ parents as manumitted citizens.197 With this putative medical background in mind, we may further speculate that the father-narrator has perhaps also implicitly hoped, by writing down the medical history of his own child’s fate, that there would come a time when physicians will be able to heal similar illnesses. Did he have Thucydides in mind, who wrote his history as a κτῆμά τε ἐς αἰεί, “a possession for all time”, and his description of the plague in order that “from the study of it a person should be best able, having knowledge of it beforehand, to recognise it if it should ever break out again”?198 We are fully aware of the fact that considering our text as a sort of ‘physician’s testament’, that is a plea for medical research from the past, cannot rise above the level of speculation. This is not history on a grand scale, but miniature family history.199 Mourning for one’s own deceased children seems to be a constant in human history, no matter how much rituals might differ. We cannot say if people in antiquity mourned more or less emphatically or intensely, than today. But we know that they mourned in their own way and with their own possibilities of expression.200 10 Epilogue This unique Roman pagan epitaph has been erected to commemorate the individual existence of one deceased and beloved child with his individual sad story of sickness. Beside its own undeniably funereal context, it provides us with some medical information by describing the course of the diseases and their treatment. Retrospective diagnosis of this pattern of sickness is feasible, but has to be regarded only as a relative, self-reflecting and tentative thoughtexperiment limited by its own historical context. To focus only on a single diagnosis like tuberculosis is oversimplifying the complex, very contingent phenomenon of sickness itself. While reading this ancient poem we realised that not only our horizons and those of Lucius and his parents differ, but that there have already been 197  McWilliam, ‘Children’, 91: “a mark of social prestige.” 198  Respectively, Th. 1.22.4 and 2.48.3. 199  Dixon, S. ‘The “other” Romans and their family values’, in ead. (2001). Childhood, Class and Kin in the Roman World, 13. 200  Golden, ‘Ancients’, 159–60: “The way we shape our feelings is culturally determined, the feelings have some physiological and even biological basis”.

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encounters in the past between them and many generations before us, each with its own horizon. Through engaging in dialogue with the text and with earlier interpretations of it, we are changed, and so too, in a way, is the text.201 In confronting the past and in taking due note of the tradition from which we come, we had to test our own prejudgements.202 Texts and Translations Used Inscriptions

l’Année épigraphique. Revue des publications épigraphiques relatives à l’antiquité romaine (AE). Ed. R. Cagnat et al. Année 1888–. Paris: Presses Universitaires de France. 1889–. Corpus Inscriptionum Graecarum (CIG). Ed. A. Boeckh, vol. 1–4. Berlin: Reimer, 1828–77. Corpus Inscriptionum Latinarum (CIL). Consilio et auctoritate Academiae litterarum Regiae Borussicae. Ed. O. Hirschfeld and C. Zangemeister, vol. 132. Partis secundae fasciculus 1, ed. C. Zangemeister. Berlin: apud Reimer, 1905. Epigrammata Graeca ex lapidibus conlecta (Kaibel vel EG). Ed. G. Kaibel. Berlin: Reimer, 1878. Epigrammatum Anthologia Palatina (AP). Ed. F. Dübner, E. Cougny et al., vol. 1–3. Paris: Firmin-Didot, 1864–90. Griechische Vers-Inschriften (GV). Ed. W. Peek, Grab-Epigramme, vol. 1. Berlin: Akademie-Verlag, 1955. Inscriptiones Graecae (IG). Ed. Academia Scientiarum Berolinensis. Academia Scientiarum Brandenburgensis. Berlin: Reimer, 1873–, later: Berlin: De Gruyter. Inscriptiones Graecae Urbis Romae (IGUR). Ed. L. Moretti, vol. 1–4, Studi pubblicati dall’ Istituto italiano per la storia antica. Rome: Istituto italiano per la storia antica, 1968–90. Steinepigramme aus dem griechischen Osten (SGO). Ed. R. Merkelbach and J. Stauber, vol. 1–10. Stuttgart: Teubner/München: Saur, 1998–2004. Die Beichtinschriften Westkleinasiens. Epigraphica Anatolica 22. Ed. G. Petzl. Bonn: Habelt, 1994. Prosopographia Imperii Romani saeculi 1, 2, 3 (PIR2). Consilio et auctoritate Academiae Litterarum Borussicae. Iteratis curis Ed. E. Groag and A. Stein. Berlin and Leipzig: De Gruyter, 1933–. 201  Gadamer, Wahrheit, 311, English translation 305; Frank, R. ‘On the field’, in: Engen, J. van (1994). The Past and Future of Medieval Studies, 204–16, especially p. 210. 202  Gadamer, Wahrheit, 290, Engl. Translation, 305.

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Epigraphica 2, Texts on the Social History of the Greek World. Ed. H. W. Pleket. Leiden: Brill, 1969. Samama, É. Les médecins dans le monde grec: Sources épigraphique sur la naissance d’un corps médical. École Pratique des Hautes Études, Sciences historiques et philologiques 3, Hautes Études du monde Greco-Romain 31. Genève: Droz, 2003. Supplementum Epigraphicum Graecum (SEG). Ed. J. J. E. Hondius et al., vol. 1. Leiden: Sijthoff, later Amsterdam: J. C. Gieben; Leiden: Brill, 1923–. ΠΑΙΔΕΣ ΑΩΡΟΙ, 1–2, ΠΡΑΓΜΑΤΕΙΑΙ ΤΗΣ ΑΚΑΔΗΜΙΑΣ ΑΘΗΝΩΝ. Ed. A. M. Vérilhac, vol. 41. Athens: ΓΡΑΦΕΙΟΝ ΔΗΜΟΣΙΕΥΜΑΤΩΝ ΤΗΣ ΑΚΑΔΗΜΙΑΣ ΑΘΗΝΩΝ, 1978–82.

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CHAPTER 2

Questioning the Patient, Questioning Hippocrates: Rufus of Ephesus and the Pursuit of Knowledge Melinda Letts Rufus of Ephesus’ short treatise, Quaestiones Medicinales, the only ancient medical work that takes as its topic the dialogue between doctor and patient, has usually been seen as a procedural practical handbook serving an essentially operational purpose. In this paper I argue that the treatise, with its insistent message that doctors cannot properly understand and treat illnesses unless they supplement their own knowledge by questioning patients, and its remarkable appreciation of the singularity of each patient’s experience, shows itself to be no mere handbook but a work addressing the place of questioning in the clinical encounter. I illustrate some of the differences between Rufus’ conceptualisation of the relevance and use of questioning and that which can be seen in the theoretical and descriptive writings of Galen and in the Hippocratic corpus, and show how apparent resonances with some of the preoccupations of modern Western healthcare can be used judiciously to elucidate the significance of those differences. 1 Introduction Rufus of Ephesus, who worked around the time of Trajan,1 was for more than a millennium considered one of the great names in Greek medicine. The great majority of his work having disappeared, he has less of a reputation today. It is probably fair to say that his modern image is that of a competent, essentially practical physician who, though praised by Galen, was ultimately effaced by his overpowering successor.2 The epithets attached to his name do not tend to 1  The date is provided by the Suda, s.v. Ροῦφος. Biographical details about Rufus are scanty; for a summary, see Pormann, P. ‘Introduction’, in id. (2008). Rufus On Melancholy, 4; or, for a full discussion, Abou Aly, A. (1992). The Medical Writings of Rufus of Ephesus, 15–55. 2  See for example Eijk, P. J. van der ‘Rufus’ On Melancholy and its philosophical background’, in Pormann, Melancholy, 159–60, and, in the same volume, Nutton, V. ‘Rufus of Ephesus in the medical context of his time’, 140. © koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_004

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include words like ‘innovative’, ‘bold’ and ‘controversial’. Yet Rufus did something that no-one else did, so far as we know: he wrote a treatise urging the systematic questioning of patients. The subject matter of this work is unique in the extant corpus of ancient medical writing,3 and, of Rufus’ undoubtedly prolific output, it is one of only four authentic treatises to have survived in Greek.4 Unlike other works of Rufus, it receives no attention from Galen.5 The treatise originally attracted my attention because, after studying classics as an undergraduate, I had spent two decades leading UK advocacy organisations that worked on behalf of people with long-term conditions, persuading health care professionals and policy makers to recognise the unique and transformative effect of the patient’s narrative on the clinical encounter. Returning to classics I was naturally drawn to ancient medicine, and became aware of the comparative dearth of material (both primary and secondary) that showed much interest in the patient’s perspective. The understudied status of Rufus’ treatise is a case in point. Often characterised as a practical manual,6 the work is surely more than that, with its lucid and insistent message that the doctor does not know enough on his own and that information elicited from the patient is a sine qua non of successful diagnosis and therapy. It is a message that captures one of the central preoccupations of the politics of modern western healthcare remarkably well. What I want to offer here are some ideas prompted by wondering why Rufus, and apparently only Rufus, should have been moved to devote a treatise to the topic. What could he have been aiming to achieve? Though we may not be able to isolate the definitive factors behind an author’s decision to write something, there is obvious value in considering what those factors might have been, and forcing ourselves to distinguish elements of our hypothesis that anachronistically reflect our own pre-occupations from those that might illuminate the ancient text or help it to illuminate others. 3  Gärtner, H. (1962). CMG Suppl. IV, 19–20 and 106; Abou Aly, Rufus, 192–93. See also Jouanna, J. (1992). Hippocrates, 135. A hypothesis advanced by both Wellmann and Gossen that two Herophileans, Callimachus and Callianax, wrote works on the same topic that have not survived is dismissed by Gärtner (ibid. 19–20). 4  Nutton, ‘Medical context’, 139–40. 5  References to Rufus—some complimentary, some less so—are scattered across several of Galen’s books. No doubt attaches to the authenticity of this treatise. Galen may have simply not considered it a significant work. Initiatives to improve the delivery of care routinely attract less attention and fewer resources than pushing back the frontiers of medical knowledge (see for example Westfall, J. et al. (2007). ‘Practice-based research: “Blue highways” on the NIH roadmap’, Journal of the American Medical Association 297.4, 403–06). The study of ancient medicine is not immune from this tendency; see next paragraph. 6  See for example Nutton, V. in Brill’s New Pauly, s.v. Rufus [5]: “a handbook for doctors on the questions to ask their patients”; cf. Nutton, V. (2004). Ancient Medicine, 209.

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I shall refer to Rufus’ treatise as On Questioning the Patient, the title of my new translation. Quotations from the text are taken from Hans Gärtner’s Teubner edition of 1970.7 All translations in this paper are my own unless otherwise specified.8 2

More than a Manual

On Questioning the Patient (henceforth QP) is clearly more than a practical handbook. Rufus does not merely cover what doctors should ask about, but insists repeatedly (eleven times in the course of this short work) that unless they ask, and listen, their knowledge will be inadequate to the physician’s task. The idea is articulated in a variety of ways, but the running theme is clear: any doctor who fails to incorporate questioning into his clinical practice must necessarily operate in ignorance of a range of crucial factors, none of which can be discovered by any other means, and, even when there are indicative signs (σημεῖα) to point the way, he will greatly improve the quantity and quality of his knowledge by asking questions.9 Rufus disagrees with others who hold different views. He is exasperated by a school of thought that expects doctors to be able to tell whether a patient has eaten by touching him rather than asking (§ 37), and downright critical of “the physician Callimachus”10 for having pronounced it unnecessary to ask any questions at all: 7  These references are identified by the letter ‘G’. This text is an improved version of Gärtner’s 1962 edition, which was published (with commentary and German translation) as CMG Suppl. IV. 8  My translation, which forms part of my doctoral thesis, is the first complete English version. For a partial English translation, see Brock, A. (1929). ‘Rufus of Ephesus: On the interrogation of the patient’, in id. Greek Medicine, Being Extracts Illustrative of Medical Writers from Hippocrates to Galen, 112–24. For a French translation, see Daremberg, Ch. and Ruelle, Ch. É. (1879). ‘De l’Interrogatoire des Malades’, in id. Oeuvres de Rufus d’Éphèse. Texte collationné sur les manuscrits, traduit pour la première fois en Français, avec une introduction, 195–218. For Gärtner’s German translation, see note 7. A Dutch translation appeared as this article was being finalised: Haak, H. (2013). Rufus Ephesius: medicus gratiosus, 40–59. 9  For example, ἐγὼ δὲ ἡγοῦμαι μὲν καὶ παρ’ αυτοῦ δύνασθαί τινα πολλὰ τῶν ἐν ταῖς νόσοις ἐξευρίσκειν, κάλλιον δέ γε καὶ σαφέστερον ἐν τοῖς ἐρωτήμασιν (‘I think that although one can certainly find out a lot about illnesses by oneself, one can do so better and with greater clarity by asking questions): QP 22, G. 6.8–10. See also §§21, G. 5.22–24; 23, G. 6; 26, G. 7; 33, G. 8; 34, G. 8; 37, G. 9; 38, G. 9; 40, G. 9–10; 64, G. 14; 73, G. 16. 10  Probably the late 3rd/early 2nd century BC Alexandrian, Callimachus of Bithynia. See Gärtner ad loc., CMG Suppl. IV, 64–65.

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ὥστε ἔγωγε θαυμάζω Καλλιμάχου τοῦ ἰατροῦ, ὃς μόνος τῶν ἔμπροσθεν, ὧν γε δὴ καὶ λόγον ἄν τις ποιήσαιτο, οὐκ ἔφασκε δεῖν ἐρωτᾶν οὐδὲν οὔτε περὶ τὰς ἄλλας νόσους οὔτε περὶ τὰ τραύματα, καὶ μάλιστα τὰ τῆς κεφαλῆς· ἀρκεῖν γὰρ καὶ τὰ ἐφ’ ἑκάστῳ σημεῖα τό τε πάθος σημῆναι καὶ τὴν αἰτίαν αὐτοῦ, ἐξ ὧν καὶ προγινώσκεσθαι πάντα καὶ θεραπεύεσθαι ἄμεινον. ἐπεὶ μηδὲ τὰς ἡγουμένας προφάσεις τῶν νόσων [καὶ] ἀναγκαίως ἐρωτᾶσθαι, οἷον διαίτης τε ἀγωγὴν καὶ τὰ ἄλλα ἐπιτηδεύματα καὶ εἰ κοπιάσαντι συνέβη νοσῆσαι καὶ εἰ ψυγέντι· μηδὲν γὰρ ἂν τούτων μαθεῖν τὸν ἰατρόν, εἰ τὰ σημεῖα ἀκριβῶς ἐκμελετήσαι τὰ συμπίπτοντα ταῖς νόσοις.11 I am amazed, then, by the physician Callimachus, who alone of earlier doctors—at least of those whom one would take seriously—denied the need to ask questions about illnesses, including wounds, and especially head-wounds. He claimed that the signs in each case were sufficient to indicate both the condition and its cause and should preferably be used as the basis of all prognosis and treatment. He said there was no need to ask even about the immediate causes of illnesses—such as the regimen being followed, and the other habits of life, or whether the person was tired or cold when he fell ill—on the grounds that the physician had no need to learn anything from these factors if he considered carefully and accurately the signs occurring along with the illnesses. He also criticises Hippocrates. In the treatise’s closing section, Rufus defends himself against a putative charge of un-Hippocratic thinking with the countercharge that his illustrious predecessor did not go far enough: εἰ δέ τις φησειέ μέ ἐναντίον γιγνώσκειν Ἱπποκράτει, ὃς δὴ τέχνην ἔλεγεν ἐξευρηκέναι, δι’ ἧς δυνήσεται ὁ ἰατρὸς ἀφικόμενος εἰς πόλιν, ἧς ἄπειρός ἐστι,12 περὶ τῶν ὑδάτων εἰδέναι καὶ περὶ τῶν ὡρῶν, ὅπως τε τοῖς ἀνθρώποις αἱ κοιλίαι ἔχουσι, καὶ εἰ φιλοπόται εἰσὶ καὶ εἰ ἐδωδοί, καὶ περὶ τῶν νοσημάτων ὁποῖα ἐπιδημεῖν εἴθισται, καὶ αἱ γυναῖκες ὅπως πρὸς τοὺς τόκους διάκεινται, καὶ ὅσα ἄλλα ἐκεῖνος ὑπέσχετο τῇ τέχνῃ, μηδένα ἐρωτῶν τῶν ἐπιχωρίων, ἀλλὰ παρ’ ἑαυτοῦ, μανθάνειν· ταῦτα δὲ εἴ τις προ[σ]φέρων ἐπιμέμφοιτό μοι ὡς τῷ ἀρίστῳ τῶν ἰατρῶν περὶ τῶν μεγίστων συγγιγνώσκοντι, λέγω πρὸς ἐκεῖνον οὐδέν με[ν] τῶν ἐκείνου ἀτιμάζειν, ἀλλὰ τὰ μέν τινα καὶ οὕτως εὑρεθῆναι περί τε 11  QP 21, G. 5.24–6.8. 12  Rufus quotes recognisably, if loosely, from Aer. 1.12–13 (L. 2.12.9–10), ἐς πόλιν ἐπειδὰν ἀφίκεταί τις ἧς ἄπείρός ἐστι; thereafter his paraphrasing of the Hippocratic work is inexact and even misleading.

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ὡρῶν καταστάσεως καὶ φύσεως σώματος καὶ διαίτης τρόπων καὶ ὑδάτων τὴν κοινὴν ἀρετήν τε καὶ κακίαν καὶ νοσημάτων τὴν κοινὴν [καὶ] ἰδέαν, τὰ[ς] δὲ [δι’] ἱστορίας τῆς παρὰ τῶν ἐνοικούντων εἰς τὴν διάγνωσιν χρῄζειν, καὶ μάλιστα ὅσα ἄτοπα καὶ ξένα ἑκάστοις ὑπάρχει. τοῦ μὲν σοφίσματος καὶ πάνυ ἄγαμαι τὸν ἄνδρα καὶ πολλαχῇ καλῶς αὐτῷ ἐξεύρηται, παρακελεύομαι δὲ μηδὲ τῶν ἐρωτημάτων ἀφίστασθαι τὸν μέλλοντα ὀρθῶς ὑπὲρ ἁπάντων γνώσεσθαι.13 If someone were to say that my thinking was opposed to that of Hippocrates, who as you know said he had invented an art by means of which a doctor could, on arrival at a city with which he was unfamiliar, have knowledge of the waters, the seasons, the condition of the inhabitants’ bowels, whether they enjoy drinking and eating, what disorders are endemic there, how the women experience childbirth, and everything else that Hippocrates professed to find out by the art, not by questioning any of the inhabitants but off his own bat; if anyone, citing this, were to find fault with me for disagreeing with the greatest of doctors about the most important matters, I say this: I do not disparage any of Hippocrates’ theories, and some things are certainly discovered by his method—things to do with the character of the seasons and the constitution of the body and modes of life, as well as the general advantages and disadvantages of the waters and a general picture of diseases—but there are other things that require research among the inhabitants in order for diagnosis to be made, especially anything unusual or strange that is present in them individually. I admire the man unreservedly for the cleverness of his method, and he used it to make good discoveries in many places; but I urge anyone aiming for accurate and complete knowledge not to reject questioning. How strong a criticism this constitutes is something on which recent authorities have disagreed, with assessments ranging from Nutton’s that it is “an extension, not a criticism, of Hippocrates’ views”, through that of Gärtner, who called it “slight criticism”, to Jouanna’s description of Rufus’ desire to defend himself against the hypothetical accusation of un-Hippocratic thinking as “significant”.14 There is not enough space in this paper to discuss this aspect in detail, but criticism of other doctors, including Hippocrates, was perfectly 13  QP 72–73, G. 15.23–16.18. 14  Nutton, Ancient Medicine, 210, arguing that Rufus was a faithful Hippocratic; Gärtner ad loc., CMG Suppl. IV, 65, drawing a contrast with the “distinctly polemical” character of the attack on Callimachus; Jouanna, Hippocrates, 135.

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normal practice, and Rufus is not averse to engaging in it elsewhere.15 Though the critique is undoubtedly polite, it is firm: the method by which Hippocrates claimed to acquire his knowledge was clever but, in its disregard of questioning, inadequate to the task of identifying particular, rather than just universal, complaints. Combined with the other criticisms and the frequent repetitions of his point, this emphatic closing statement suggests that QP constitutes a counter-argument to ideas or practices with which Rufus disagreed. 3

“Things that Even Laymen are Capable of Knowing”: An Enduring Debate

What lay behind this difference of opinion? Was it something as simple and timeless as poor practice: sloppy, lazy doctors not bothering—or perhaps lacking the time—to do something that Rufus considered a priority?16 Or was there some weightier point of principle at stake, a methodological or epistemological difference perhaps, or disagreement over what sorts of knowledge were relevant to understanding the workings of the body and where that knowledge might be found? On this latter possibility Galen, as so often, proves instructive. Though he postdated Rufus by a generation or two, he is close enough in time to stand witness to broadly contemporary patterns of medicophilosophical thinking. Not only do his writings betray a somewhat different attitude to dialogue with patients from Rufus’ own, as we shall see, but he explicitly articulates the view that “things that even laymen are capable of knowing” are incompatible with the Art and out of place in a medical 15  See for example QP 40, G. 9–10, on the praiseworthiness of physicians who are prepared to admit their own ignorance. Professor C. Pelling believes this sounds “particularly . . . agonistic, taking on an opposite view that may explicitly have been formulated” (personal communication, 2012). H. von Staden (1989, Herophilus: the art of medicine in early Alexandria, 481 with note 3) notes Rufus’ “polemical posture” towards some of the Alexandrians, citing his attack on “Egyptians who speak Greek poorly”. Nutton on the other hand (‘Medical Context’, 140) describes him as “eirenic”. On traditions of criticising other doctors, see Lloyd, G. E. R. (1991). Methods and Problems in Greek Science, 398 with note 3 (Galen claiming to have improved on Hippocrates: De praecogn., K. 14.665.5–6 = CMG V, 8.1, 134.3–4; De meth. med. K. 10.420.10–13 and 425.1–11) and 401 with notes 11 and 12 (a wealth of references for criticism of Hippocrates by Celsus, Soranus, Ctesias and Diocles); see also Nutton, ‘Medical Context’, 148. 16  Nutton (Ancient Medicine, 201) points out that in a city as large and busy as Ephesus there could have been considerable merit—for both patient and doctor—in keeping consultations short by following Methodist principles.

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treatise. This sharp conceptual distinction between what we might today call “expert” and “common” knowledge is of a piece with the intellectually competitive atmosphere of the first and second centuries,17 and it seems plausible to hypothesise that Rufus’ views on the importance of learning from the patient may not have been widely shared. The liveliness of this same debate in our own era should not mislead us into considering it a uniquely modern one; indeed its diachronic nature can be nicely illustrated by a brief excursus into medieval scholasticism. In the late thirteenth century, Taddeo Alderotti, celebrated professor of medicine at the University of Bologna, proposed a series of quaestiones18 concerning the epistemological role of patients and lay people in the production of medical knowledge, including “Whether the doctor ought to question the patient about all his symptoms and write a book about them” (utrum medicus debeat interrogare infirmum de omnibus accidentibus et de eis facere librum) and “Whether any of the things that are known to laymen ought to be added to the art of medicine” (utrum aliqua nota vulgo, arti medicinali addenda sint);19 and he chose to illustrate his discussion with quotations from Hippocrates and Galen. It was, then, legitimate within the thirteenth century European academic medical tradition not only to debate whether or not “things known to laymen” carried epistemological validity in medicine but— importantly for our purpose—to assume that the question had also taxed the minds of ancient physicians.20

17  The intellectual competitiveness of the “Second Sophistic” is succinctly described by Mattern, S. P. (2008). Galen and the Rhetoric of Healing, 9–11. On competitiveness between doctors specifically, see also Hankinson, R.J. ‘Galen on the limitations of knowledge’ in Gill, C. et al. (2009). Galen and the World of Knowledge, 239–42. 18  The use of quaestiones to explore important matters of principle was a standard technique of medieval scholasticism. 19  Thaddei Florentini Expositio in arduum aphorismorum Ipocratis volumen, In divinum pronosticorum Ipocratis librum, In preclarum regiminis acutorum Ipocratis opus, In subtilissimum Joannitii Isagogarum libellum (Venice, 1527), fol. 247v, cited and discussed by Siraisi, N. (1981). Taddeo Alderotti and his Pupils: Two Generations of Italian Medical Learning, 124– 25. On medieval academic medicine more generally, see Siraisi, N. (2001). Medicine and the Italian Universities, 1250–1600. 20  On the whole, despite valuing the patient’s narrative, medieval physicians “felt obliged to mistrust” it because laymen lacked medical training, according to Siraisi, N. (1990). Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice, 124. Taddeo himself defended the inclusion in learned medical tracts of information acquired from patients, and considered both Hippocrates and Galen mistaken on this point (Siraisi, Taddeo, 125).

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Taddeo’s Hippocratic quotation, from the opening paragraph of Regimen in Acute Diseases, rebukes the authors of the (now lost) Cnidian Maxims for having written too much about patients’ experiences and too little in the way of expert commentary: οἱ συγγράψαντες τὰς Κνιδίας καλεομένας γνώμας ὁποῖα μὲν πάσχουσιν οἱ κάμνοντες ἐν ἑκάστοισι τῶν νοσημάτων ὀρθῶς ἔγραψαν καὶ ὁποίως ἔνια ἀπέβαινεν· καὶ ἄχρι μὲν τούτων, καὶ ὁ μὴ ἰητρὸς δύναιτ’ ἂν ὀρθῶς συγγράψαι, εἰ εὖ παρὰ τῶν καμνόντων ἑκάστου πύθοιτο, ὁποῖα πάσχουσιν· ὁπόσα δὲ προσκαταμαθεῖν δεῖ τὸν ἰητρὸν μὴ λέγοντος τοῦ κάμνοντος, τούτων πολλὰ παρεῖται, ἄλλ’ ἐν ἄλλοισιν καὶ ἐπίκαιρα ἔνια ἐόντα ἐς τέκμαρσιν.21 The authors of what we call the Cnidian Maxims correctly recorded the sorts of things patients experience in individual diseases, and the outcomes of some of them; even a non-doctor would be able to do that, if he was well informed by patients about each illness and their experiences. But much of what the doctor ought to know besides, without a word from the patient, is omitted—different things in different cases, including some that are important for the interpretation of symptoms. Galen’s commentary on this passage goes further, leaving no room for doubt that he regarded laymen’s and doctors’ knowledge as very different things and thought that a work too liberally supplied with the former could not be regarded as a proper medical tract: οὐ μόνον οὐδὲν ὧν οἱ κάμνοντες πάσχουσι παρέλιπον οἱ τὰς Κνιδίας γράψαντες γνώμας, ἀλλὰ καὶ περαιτέρω τοῦ προσήκοντος ἐνίων ἐμνημόνευσαν, ὡς ὀλίγον ὕστερον δείξω. καὶ οὔπω τοῦτο τέχνης ἔργον, εἰ μηδὲν παρέλιπον τῶν καὶ τοῖς ἰδιώταις γνωσθῆναι δυναμένων· οὐ γὰρ οὗτος ὁ σκοπὸς τοῖς τεχνίταις ἐστίν,22 ἀλλὰ τὸ τὰ χρήσιμα πρὸς τὴν θεραπείαν ἅπαντα γράφειν, ὥστε καὶ προσθεῖναί τινα δεήσει πολλάκις, ὧν μὴ γινώσκουσιν οἱ ἰδιῶται πάντως, ἀφελεῖν τε πολλὰ τῶν γινωσκομένων αὐτοῖς, ἐὰν μηδὲν φαίνοιτο συνεργοῦντα πρὸς τὸ τῆς τέχνης τέλος.23

21  Acut. 1 (Loeb II.62.1–10 = L. 2.224.2–9), the first of three paragraphs criticising the Cnidian authors. 22  This is Kühn’s punctuation; Helmreich punctuates . . . γνωσθῆναι δυναμένων, (οὐ γὰρ οὗτος ὁ σκοπὸς τοῖς τεχνίταις ἐστίν), ἀλλὰ τὸ τὰ χρήσιμα. . .(for reference see next footnote). 23  Gal., In Hipp. Acut. comment.1 (K. 15.419 = CMG V, 9.1, 117.11–19).

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Not only did the authors of the Cnidian Maxims include every detail of what patients suffer, but they actually mentioned more than what was appropriate, as I shall show a little later.24 This is not yet the point of the medical art,25 if they omitted none of the things that even laymen are capable of knowing; the goal for practitioners of the Art is not this, but recording everything that is useful for therapy. This means that one will often need to include things of which laymen have absolutely no knowledge, and to exclude much of what they do know, unless it seems to contribute something to the fulfilment of the Art. 4

“We Try to Tell Without Asking”: Galen and the Art of Questioning

Galen’s concern with what was conducive to the telos of the Art is entirely characteristic. His work is permeated by a marked interest in the integrity, status and nature of medicine and in the assertion of his self-image as its guardian and protector, as well as by an overriding enthusiasm for order and control manifested variously, but consistently, in the content and organisation of his writings, in the opinions he expresses about the technē of medicine, in his teleological concept of the body, and in his concern with maintaining the authority of the physician.26 In his commentary on Hippocrates’ Epidemics 6.2.24 he discusses at length the value of questioning patients.27 He begins by explaining that it is particularly useful in cases where one does not have previous

24  Galen kept his promise but we are not, unfortunately, able to benefit from it; after the tantalising words “I said earlier that the Cnidian authors wrote . . .” the text is irrecoverably corrupt (K. 15.427 = CMG V, 9.1, 121. 22). 25  My translation is influenced by van der Eijk’s observation that Galen often refers to “the principal job (ergon) or aim (skopos) of the medical art” (Eijk, P. J. van der ‘Therapeutics’, in Hankinson, R. (2008). The Cambridge Companion to Galen, 283). 26  Concern with status and nature of the technai: Mattern, Rhetoric, 23; need for order and control, and image as protector of the integrity of the Art: Flemming, R. ‘Galen’s imperial order of knowledge’, in König, J. and Whitmarsh, T. (2007). Ordering Knowledge in the Roman Empire, 241–77; teleological approach to the body: Holmes, B. ‘Medical knowledge and technology’, in Garrison, D. H. (2010). A Cultural History of the Human Body in Antiquity, 101. 27  Gal., In Hipp. Epid. 6 comment. 2.45 (K. 17.1.995–99 = CMG V, 10.2.2, 115–117). For a discussion of the cognitive ability of lay people to report physical and mental symptoms and pain in Galen’s work, see Courtney Roby, ‘Galen on the patient’s role in pain diagnosis’ (Chapter Eleven) 304–322.

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knowledge of the patient, for the things a sick person says can reveal his state of mind, enabling one to judge how to behave towards him, and in particular how truthful one can be without frightening the nervous or encouraging disobedience in the over-confident:28 φρόνιμον μὲν γὰρ εἰ γνωρίσαις εἶναι τόνδε τινὰ τὸν ἄνθρωπον ἔτι τε μὴ δειλόν, ἀληθεύειν πειραθήσῃ μηδὲν ὑποστελλόμενος τῶν κατὰ τὴν νόσον ἐσομένων· ἄφρονα δὲ καὶ δειλόν, ἐξ ὧν ἂν εὐθυμότερος γένοιτο, πάντα ταῦτα ἐρεῖν μετὰ τοῦ μηδὲν μέγα ψεύδεσθαι. . . . τὰ γὰρ πλεῖστα τῶν ἐπισφαλῶν νοσημάτων ἀνατρέπει τοὺς κάμνοντας ἀπειθοῦντας τοῖς ἰατροῖς . . . ἀλλὰ καὶ θαρρήσαντες, ὡς ἀκινδύνως νοσοῦντες, οἱ πλείους τῶν ἀνθρώπων οὐ πάνυ κατήκοοι γίνονται τῶν ἰατρῶν.29 If you find the patient has presence of mind and courage, by all means try telling the truth, holding back nothing of what is going to happen during the illness; but if he is witless and cowardly then say whatever will improve his spirits, without telling any major untruths. . . . Mostly, dangerous illnesses destroy patients when they disobey their doctors . . . And besides, most people become less than obedient to their doctors if they are confident that they are not dangerously ill.30 Secondly, where one has some prior knowledge, questioning affords the opportunity to draw conclusions about the patient’s mental stability from his manner, for example if he speaks differently from normal.31 Thirdly, the voice itself can contain important diagnostic clues such as hoarseness, shrillness, lisping and hesitancy.32 Finally, skilful choice of questions based on the patient’s physical appearance will allow one to show off one’s medical skill by asking 28  K. 17.1.995–97 = CMG V, 10.2.2, 115.23–116.20. 29  K. 17.1.995–97 = CMG V, 10.2.2, 115.28–116.17. 30  On disobedience as the most likely cause of a poor outcome, see also de Arte 7 (L. 6.10– 12). On the risk implied for the physician, see Decent. 14 (L. 9.240.15–16): when patients fail to follow instructions and then die, “their behaviour is never admitted, but the physician gets the blame” (αὐτῶν μὲν οὐχ ὡς ὁμολογίην τρέπεται τὸ ποιηθέν, τῷ δὲ ἰητρῷ τὴν αἰτίην προσῆψαν). On Galen’s insistence on obedience see Mattern, Rhetoric, 145–49. 31  K. 17.1.997 = CMG V, 10.2.2, 116.21–26. For the idea that boldness in a normally mild-mannered patient is a bad sign, cf. Rufus, QP 2, G. 1; also Prorrh. 1.44 (L. 5.522.6): ἐκ κοσμίου θρασεῖα ἀπόκρισις κακόν. 32  K. 17.1.997–98 = CMG V, 10.2.2, 116.26–117.1. The patient’s voice as a diagnostic and prognostic tool in Hippocrates’ Epidemics is discussed by Colin Webster, ‘Voice Pathologies in the Hippocratic Corpus’ (this volume, Chapter Five) 166–199.

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questions which indicate a preternatural level of prior knowledge about his complaint and its attendant circumstances, while avoiding those that might suggest the opposite:33 ἐὰν γὰρ τὰ προγεγονότα καὶ τὰ προγινωσκόμενα τῷ τε κάμνοντι καὶ τοῖς ἀμφ’ αὐτὸν ὁ ἰατρὸς πυνθάνηται, θαυμάζουσιν εὐθέως αὐτόν, ὥσπερ κἂν εἴ τινα τῶν ἐναντίων τοῖς γεγονόσιν ἐρωτῴη, καταγινώσκουσιν. ἀλλὰ καὶ τῶν συμβεβηκότων τοῖς κάμνουσιν ἔνια, πρὶν ἀκοῦσαι παρ’ αὐτῶν, ἐν μέσῳ σχήματι λέξεως ἐρωτήσεώς τε καὶ ἀποφάσεως ἐὰν εἰπὼν ἐπιτύχῃ, θαυμάζεται. λέλεκται δ’ ἅπαντα ταῦθ’ ἡμῖν ἑτέρωθι.34 For if the doctor enquires about things that have already happened, and things that the patient and his companions already know, they immediately admire him; similarly, they condemn him if he asks about anything that is the opposite of what has happened. And if in the middle of the question-and-answer process he happens to mention some of the things that have befallen patients before they tell him themselves, he is admired. All this I have said elsewhere. As a statement of Galen’s attitude to dialogue with patients, this whole commentary is rich and revealing. His interest in maintaining control and exciting admiration comes through very clearly. A modern taxonomy of question types characteristically includes a range such as open, closed, factual, probing, hypothetical, reflective and leading questions.35 Galen conceptualises questioning in a way that today appears limited and superficial: in his account, q­ uestions 33  K. 17.1.998–99 = CMG V, 10.2.2, 117.4–19. The Hippocratic author of Prorrhetic 2 advises that doctors “make their predictions, if they are sensible, only after the disease has become fixed”, adding that “when you are successful in making a prediction you will be admired by the patient you are attending, but when you go wrong you will not only be subject to hatred, but perhaps even be thought mad”, Prorrh. 2. 2 (L. 9.8–10); tr. Potter, Loeb vol. 8, 219–221. 34  K. 17.1.998–99 = CMG V, 10.2.2, 117.13–19. 35  For a contemporary list, see http://www.changingminds.org/techniques/questioning/ questioning.htm (accessed 23rd August 2015). For a scholarly discussion, see Dillon, J. T. (1990). The Practice of Questioning, especially chapters 5, ‘Clinic Questioning: Medicine’ and 10, ‘Notions of Questioning’. Dillon (p. 54) quotes research demonstrating that “physicians commonly believe that questioning skills are unnecessary” and comments “But . . . the way they ask questions can clearly affect both the informationgathering and therapeutic value of the interview”. For a discussion of how the content and timing of a question affects the answer, see Loftus, E. F. (1975). ‘Leading questions and the eyewitness report’, in Cognitive Psychology 7, 560–72.

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are tools through which the doctor can assert control, manipulate the patient’s behaviour, secure obedience, conjure up signs36 (the patient’s manner and voice) and, if he deploys them cleverly enough, demonstrate the accuracy of his initial suppositions. The respect and trust which, according to the Hippocratic authors of Prognostic 1 and Decorum 11, flow from successful prognosis have in Galen’s analysis been transmuted into a kind of bedside shock and awe. There is a marked bias towards what today we call closed, leading and factual questions, the latter to be asked in specific symptomatic circumstances, as opposed to using questions throughout the consultation as a way of probing from different angles in order to penetrate the heart of the patient’s complaint. The injunction against questions that might suggest poor prognostic ability is highly significant, for it disallows the use of process of elimination as a diagnostic tool.37 So far as the patient’s answers are concerned, Galen is much more interested in delivery—the opportunity that questioning provides to observe the respondent’s behaviour and voice—than in content. In sum, his grasp of the use of questioning as a clinical technique seems to a modern eye narrow and underdeveloped, not to say self-serving,38 and, like his remarks about the Cnidian Maxims, devoid of the interest a modern doctor would be expected to show in the patient’s narrative. Three well-known case histories in Galen’s On Prognosis will serve for practical illustration at this point:39 those of the insomniac woman,40 the anxious slave, and the feverish son of Boethus. Each presents an initially baffling case, the first two involving psychosomatic symptoms and the third secretive behaviour on the part of a boy. All three cases, to modern sensibilities, cry out for careful, sensitive questioning of the patient. Yet despite emphasising his own appreciation of the relationship between body and mind, Galen mentions questioning the patient only once, in the case of the insomniac woman, when he simply says he asked about “all the things that tell us insomnia is present”; 36  On the importance of signs (σημεῖα) in ancient medicine, see for example Holmes, ‘Medical knowledge’, 90 and Hankinson, R. J. (1998). Galen on Antecedent Causes, 39–43; cf. Jouanna, Hippocrates, 291. 37  Contrast Art. 47 (L. 4.212.4–5), on the instructive value of describing failure. 38  Cf. Lloyd on Galen’s aim of presenting himself “as the most successful prognosticator and therapist of all time” (Lloyd, G. E. R. ‘Galen’s un-Hippocratic case-histories’, in Gill, T. et al., Knowledge, 131). 39  Lloyd points out (‘Un-Hippocratic’, 118) that although there are case stories “scattered through the oeuvre of Galen”, it is in On Prognosis that he chose to set out his “most concentrated collection of case-histories”. It must therefore be reasonable to turn to it for insights into his handling of the medical encounter. 40  This episode is also discussed by Mattern in ‘Galen’s Anxious Patients: Lypē as Anxiety Disorder’ (chapter six, 203–223.).

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he ascribes his success to his own powers of observation, natural intelligence and well trained logical faculty.41 The theoretical rationale for his interactions with patients is given in On Therapeutics to Glauco, where he explains that the way to resolve the tension between universal medical theory and messy individual reality is to employ logic, in the form of diairesis, a rebarbatively­ complex process which, if done properly (and most doctors usually fail, of course), will lead to faultless endeixis.42 Questioning the patient should not need to feature: “we try, as you know, to tell patients the preceding cause without waiting to ask them, and the acquisition of such an ability is the best indication that one is not mistaken” (ἡμεῖς δὲ, ὡς οἶσθα, πειρώμεθα λέγειν αὐτοῖς τὸ προηγησάμενον αἴτιον, οὐ περιμείναντες ἐρέσθαι τὸν κάμνοντα, καὶ ἔστι μέγιστον σημεῖον εἰς τὸ μηδὲν σφάλλεσθαι τὸ τοιαύτην τινὰ πεπορίσθαι δύναμιν).43 5

On Questioning the Patient

Galen’s advice on questioning implies an essentially hierarchical conception of knowledge. I refer not to the difference between technical and nontechnical knowledge—Galen expected all educated men to possess medical knowledge44—but to his apparent disregard for the diagnostic and therapeutic value of the empirical perspective that is available from, and only from, the person who inhabits the ailing body. Today it is recognised that the best understanding of an illness and how to treat it is likely to proceed from combining the patient’s empirical knowledge with the theoretical and empirical knowledge of the doctor.45 This chimes remarkably well with Rufus’ opening statement: ἐρωτήματα χρὴ τὸν νοσοῦντα ἐρωτᾶν, ἐξ ὧν ἂν καὶ διαγνωσθείη τι τῶν περὶ τὴν νόσον ἀκριβέστερον καὶ θεραπευθείη κάλλιον (“You must ask the patient 41  Gal., De praecogn. 6–7 (K. 14.630–41 = CMG V, 8.1, 100–110). Emphasis on body-mind connection: 6.15 (K. 634 = CMG, 104.14–18). 42  Gal., Ad Glauc. de meth. med. K. 11.4.7–5.11. For a new edition and translation, see Dickson, K. (1998). Stephanus the Philosopher and Physician: Commentary on Galen’s Therapeutics to Glaucon. For helpful discussions, see van der Eijk, ‘Therapeutics’, and Hankinson, ‘Limitations’, 231–33; cf. also Hankinson, R. J. (1991). Galen on the Therapeutic Method, Books 1 and 2. On Galen’s preference for deductive rather than inductive routes to knowledge, see Lloyd, ‘Un-Hippocratic’, 130, referencing in particular Galen, In Hipp. Epid. 1 comment. 1 (K. 17.1.251–53 = CMG V, 10.1, 126.11–127.17). 43  Gal., Ad Glauc. de meth. med. (K. 11.10.13–16). On ‘antecedent’ and ‘preceding’ causes, see Hankinson, Antecedent Causes, 24 with note 104, and 43–45. 44  Mattern, Rhetoric, 24–25. 45  See for example Malterud, K. (1995). ‘The legitimacy of clinical knowledge: towards a medical epistemology embracing the art of medicine’, Theoretical Medicine 16, 183–98.

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questions that will lead to more precise recognition of any of the factors surrounding the illness, and to better treatment”). Having set out his stall right at the start, Rufus proceeds immediately to explain that priority must be given to questioning the patient himself, because of the possibility this affords for combining observation of voice and manner with the gathering of information. If this is not possible (if the patient is deaf, or physically or mentally prevented from speaking, or is too young, too old, or a foreigner) then one must direct one’s questions to his or her companions. A series of areas for questioning is advised, which we can group under fourteen headings: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Timing of onset (11–14) Whether or not the complaint is a new one (15) The patient’s nature (φύσις) and habits (ἐθισμούς) and any current divergences from his norm (16–23) Distinguishing between obvious and hidden causes (24–27) The quantity and quality of urine, faeces and saliva compared to dietary intake (27) Current patterns of sleep compared to the patient’s norm (28) Visions and dreams (29–33) Congenital diseases: patterns of recurrence, presentation, previous attacks (34–35) Current dietary and therapeutic regimes, and their effects (36) Current food consumption, preferences and reactions (37–40) Pain, especially the distinction of genuine pain from histrionics (41–43) Ease or otherwise of bodily waste processes (44) When treating animal bites, whether or not the beast was rabid (46–49) When treating wounds, the type of weapon and wound and the patient’s subsequent reactions (50–62).

All this might be considered unremarkable. Good Hippocratics question their patients in order to flesh out their own observations, improve their interpretation of signs, and enlist the patient’s co-operation.46 Is Rufus’ treatise, then, simply a particularly forceful articulation of Hippocratic adherence, designed to encourage the same in others? I think that there are some significant factors that set it apart, a couple of which I want to highlight briefly.

46  Jouanna, Hippocrates, 135–36; cf. Nutton, ‘Medical Context’, 147.

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First, although questioning is implied or recommended by a number of Hippocratic authors,47 they tend, like Galen in the commentary discussed earlier,48 to prescribe specific questions to be asked at specific moments or under specific circumstances. A good example is the sequence of questions recommended in Prognostic 2, shown opposite in diagrammatic form to illustrate the algorithmic nature of the process.49 This type of questioning is not part of a free-flowing conversation where the physician follows interest to build his knowledge incrementally, as modern doctors are trained to do when taking a patient’s history;50 rather, it forms part of a procedural protocol for the doctor to use at prescribed junctures when his own visual observations yield insufficient signs for diagnosis or prognosis. For Rufus, on the other hand, questioning the patient is a primary and indispensable activity, and the process he implies is comparatively fluid, and conducive to a greater variety of question types. Where the author of Prognostic supplies a script, Rufus takes us on a tour of the areas the doctor ought to ask about, supporting each of his recommendations with an explanation of how the information thus acquired will enhance the doctor’s knowledge. The questioning recommended in Prognostic starts from the disease and implies a kind of standardised mechanics of the body; Rufus’ starts from the person and emphasises individuality. As he puts it, “things the physician might fear, thinking them the hardest to prevent and the most resistant to treatment, may be unproblematic in the case of this individual, or not unfit for treatment in the present illness. . . . for we are not all constituted the same; on the contrary, we are completely different from one another, in every respect whatsoever”.51 47  See notes 55–57 below. 48  In Hipp. Epid. 6 comment. 2.45 (K. 17.1.998.7–13 = CMG V, 10.2.2, 117.5–11). 49  Progn. 2 (L. 2.112–18); cf. also 7 and 16 for similarly prescriptive questioning recommendations. 50  See Hatton, C. and Blackwood, R. (2003). Lecture Notes on Clinical Skills, 8: “Try, if feasible, to conduct a conversation rather than an interrogation, following the patient’s train of thoughts”. This handbook for medical students covers the history-taking process in considerable detail (see chapter 1, pages 6–25); for a summary of the structure of a patient history, see http://www.gpnotebook.co.uk/simplepage.cfm?ID=-2120613880 (online resource, accessed 23rd August 2015). 51  ἅπερ ἂν καὶ δείσαι ὁ ἰατρὸς χαλεπώτατα [καὶ] διακωλῦσαι καὶ οὐ[τε] προσφόρως θεραπευόμενα οὔτε χαλεπὰ τούτῳ τῷ ἀνθρώπῳ ὄντα οὔτε ἀνεπιτηδείως τῇ παρούσῃ νόσῳ θεραπευόμενα . . . οὐ γὰρ πάντες πεφύκαμεν τρόπῳ τῷ αὐτῷ, ἀλλὰ καὶ πάνυ ἀλλήλων διαφέρομεν εἰς ὁτιοῦν χρῆμα. (QP 15–16, G. 4.16–24). Rufus goes on to observe, “there is no single theory to explain the actions of all these substances [foodstuffs and medicines]”, a theme echoed a little later in § 40. For a fuller discussion of Rufus’s thinking on patient

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His purpose is not to provide a script or a check-list, but to outline a method that doctors can adapt for themselves: ἤδη οὖν μοι σαφὴς ἡ γνώμη ἐστίν, †ὅτι ἂν ἀφικέσθαι βούληται†. τὰ μέντοι σύμπαντα οὔτε λόγος αὐτάρκης οὔτε χρόνος ἱκανὸς σημῆναί τε καὶ ἐξευρεῖν. τὸ δὲ κεφάλαιον τῆς γνώμης εὑρεθὲν καὶ ὑποβληθὲν τῷ ἰατρῷ ἔχοι ἂν πάμπαν τὸ δέον.52 So now my thinking is clear. . . . A speech is not, of course, sufficient for explaining or learning everything, nor is there enough time.53 But if the doctor grasped the essence of my thinking and based his work on it, it would contain everything he needed. Secondly, the Hippocratic texts are not noticeably concerned about who exactly supplies the answers to the questions. This has considerable bearing on how we think about the information that is elicited. Bystanders (παρόντες) are a familiar feature of the ancient bedside scene.54 Sometimes they are explicitly drawn into Hippocratic texts by having questions addressed to them.55 Sometimes the patient himself is named as the interlocutor.56 But quite often neither is specified.57 To appreciate the implications of this, we individuality, see Letts, M. (2014). ‘Rufus of Ephesus and the patient’s perspective in medicine’, British Journal for the History of Philosophy 22.5, 1009–1012. 52  QP 71, G. 15.18–22. 53  Q P was, I argue in my thesis, probably composed for oral delivery. 54  For example Epid. 6.2.24 (L. 5.290); Gal. De praecogn. 3.3 (K. 14.614 = CMG V, 8.1, 82.19); Rufus, 3, G. 2; 9–10, G. 3; 21, G. 5.22–24; 63, G. 13.25. See also Mattern, Rhetoric, 88–92. 55  For example Prorrh. 2.2.10 (L. 9.30.7–8): “most of the people who look after the children will, if you ask them, agree” (οἱ μὲν πλεῖστοι τῶν τρεφόντων τὰ παιδία ἐρωτώμενοι ὁμολογήσουσι). 56  For example Fract. 5 (L. 3.432.9, cf. 434): after bandaging a fracture, “ask the patient if it is tight” (ἐρωτώης αὐτὸν εἰ πεπίεκται); Progn. 16 (L. 2.152.10–11): while the patient is lying on his good side, “ask him if it feels as if there is a weight hanging down from above” (ἐρωτᾷν εἴ τι αυτέῳ δοκέει βαρὺ ἀποκρέμασθαι ἐκ τοῦ ἄνωθεν); Acut. (spur.) 9 (L. 2.436.8– 438.1): ὀκόταν δὲ ἔρῃ αὐτὸν καὶ διασκέψῃ ταῦτα πάντα, “when you are questioning him and examining everything carefully”. 57  For example Aff. 37 (L. 6.246.16–18): “when you reach a patient, you must ask carefully about what he is experiencing, from what cause, for how many days, whether his bowels are moving, and what regimen he is following” (ὅταν δὲ ἐπὶ νοσέοντα ἀφίκῃ, ἐπανερωτᾶν χρὴ ἃ πάσχει, καὶ ἐξ ὅτου, καὶ ποσταῖος, καὶ τὴν κοιλίην εἰ διαχωρέει, καὶ δίαιταν ἥντινα διαιτᾶται); Progn. 7 (L. 2.126.12–128.2): “Such patients also experience nosebleed in the first period,

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Questioning the Patient, Questioning Hippocrates Presentation: appearance of facea bnormal, nose sharp, eyes hollow, temples sunken, ears cold with lobes turned outwards, facial skin hard, tense and parched, with yellow or black colour

If illness has lasted longer than three days

At beginning of illness

Examine the other signs

Make your conjecture

ASK if patient has had insomnia, loose bowels, or hunger

YES

Little danger;crisis likely after a day and a night

Examine signs in bodyand eyes

If conjecture not possible

Certain signs are listed that indicate imminence of death

NO

Recovery may occurafter a day and a night

If no recovery after a day and a night

Expect death

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must recognise that there are significant limits to an intermediary’s ability to represent a patient’s experience. The insertion of a rapporteur or interpreter into a dialogue—no matter how much integrity the intermediary brings to the task—alters its dynamic, circumscribing the scope of the doctor’s enquiry and compounding the risk of misinterpretation by a factor of two. By way of illustration, if the question “has there been a headache?” is answered by a third party—“yes, she complained of headache the night before the fever began”— the doctor can do little more than tick the question off on a check-list; but in an unmediated conversation with the patient, supplementary questions can be posed, such as “Had you done or felt anything unusual beforehand? Was it a dull pain or a throbbing one?” and so on. The mediated response forces a schematic approach to diagnosis, one that does not lend itself to probing and has been shown by modern research to tend towards mistaken diagnosis.58 The patient’s subjective response, on the other hand, may spark discussion of symptoms that might not otherwise have come to light, encouraging unforeseen lines of enquiry.59 The process is still abductive, but with a potentially much richer base of factors from which the physician can draw inferences.60 To a greater or lesser extent, then, relaying information via a third party compromises the subjectivity of that information. Even if the patient is present but simply unable to speak the language, there is an almost inevitable degree of contamination, given how hard it is for an interpreter’s choice of which is very helpful; but you must also ask if they have headache or visual impairment, for if one of those is the case, the illness will fall in that direction” (γίγνεται δὲ τουτέοισιν ἐν τῇ πρώτῃ περιόδῳ καὶ αἵματος ῥῆξις ἐκ τῶν ῥινῶν, καὶ κάρτα ὠφελέει· ἀλλ’ ἐπανέρωτᾷν χρὴ, εἰ τὴν κεφαλὴν ἀλγέουσιν ἢ ἀμβλυώπέουσιν· ἢν γάρ τι τοιοῦτον εἴη, ἐνταῦθα ἂν ῥέποι). 58  Patel, V. et al. ‘Thinking and reasoning in medicine’, in Holyoak, K. (2004). The Cambridge Handbook of Thinking and Reasoning, 739–40. Pain, Rufus advises, should not be taken at face value, since “many people, through softness and weakness, play the part of being in pain more elaborately than tragic actors groaning on the stage” (QP 41 G. 10.16–18). 59  For an eloquent discussion of the importance of effective dialogue in the clinical encounter, see Geisler, L. (1991). Doctor and patient—a partnership through dialogue, especially ‘Introduction’ and ‘Discussion techniques: general principles’; see also Malterud, ‘Legitimacy’, especially 184 and 187–88. For a fuller discussion of Rufus’s interest in subjectivity, see Letts, ‘Patient’s Perspective’, 1012–16. 60  This is one of the reasons why retrospective diagnoses—though diverting both for the doctors who make them and for the rest of us, to whom they offer vicarious thrills and a frisson of human interest—are of limited value. Retrospective diagnosis is a one-way conversation, an example par excellence of traditional, top-down, evidence-driven medical process. It cannot be considered a form of narrative-based medicine, because the narrative on which it relies is static and incapable of being developed.

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words, or even his or her facial expression and body language, to have no impact on the tenor and direction of the conversation.61 Indifference as to whether questions are answered by the παρόντες or directly by the patient implies that the author assumes them to be materially equivalent. For Rufus there is no such equivalence. His treatise begins by emphasising the primacy of questioning the patient himself. His opening declaration, ἐρωτήματα χρὴ τὸν νοσοῦντα ἐρωτᾶν62 (“You must ask the patient questions”, §1), is swiftly followed at the start of the next sentence by πρῶτον δὲ ἐκεῖνο ὑποτίθημι τὰς πεύσεις αὐτοῦ τοῦ νοσοῦντος ποιεῖσθαι63 (“That is my first principle: put your enquiries to the patient himself” §2). Only after restating the importance of questioning the patient at the very end of this section does he admit of the alternative, secondbest option: πρῶτον μὲν δή, ὡς εἴρηται, αὐτόν τινα χρὴ τὸν νοσοῦντα ἐρωτᾶν περὶ ὧν χρὴ εἰδέναι, ἔπειτα δὲ καὶ τοὺς παρόντας, εἰ κωλύματα εἴη παρὰ τοῦ νοσοῦντος μανθάνειν64 (“First, as I have said, you must question the patient himself about the things you need to know; then, if there are obstacles to learning from the patient, you must question his companions as well”, §9). I have not (so far) found this kind of hierarchical preference articulated in any Hippocratic texts. Taken together, the prescriptive questioning model and the apparent lack of concern about who provides the information suggest that, in the Hippocratic Corpus, questioning is conceived as essentially an extension of, rather than supplementary to, the collection of signs through observation. Seen in this light, Rufus’ clear preference for subjective information gained directly from the patient does not appear accidental. 6 Conclusion In conclusion, my point is not that Galen and the Hippocratic authors do not discuss questioning patients; obviously they do. Nor do I doubt the importance that, in their own ways, they attach to this aspect of the medical encounter. What this paper is concerned with is how different physicians conceptualise 61   See for example Angelelli, C. (2004). Medical Interpretation and Cross-cultural Communication, a study of the role of medical interpreters in situations where healthcare providers and patients do not speak the same language. Angelelli argues that the interpreter, far from being a passive conduit for language, has significant power over the medical encounter and the relationship between patient and provider. 62  QP 1, G. 1.3. 63  QP 2, G. 1.5–6. 64  Q P 9, G. 3.6–8.

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the questioning of patients: how they think about it and understand its place in their practice; and, by extension, how they think about the patient, both as a person and in relation to the doctor. To quote one respected modern authority, “The medical dialogue is the fundamental instrument through which the paradigmatic battle is waged: the patient’s problem will be anchored in either a biomedical and disease context or a broader and more integrated illness context that incorporates the patient perspective.”65 I have referred to contemporary discussions of doctor-patient relations at several points in this paper, not because they are necessarily transferable to analysis of how these things worked in the ancient world but because, in whatever age or culture, the clinical encounter reflects the enduring nexus of negotiated power represented by doctors’ specialist knowledge and the use that patients, and society, permit them to make of that knowledge. Studying how that plays out can illuminate the expression and resolution of tension between common knowledge and expert power in a community or society, while also providing insight to different ways of perceiving the human body.66 I find it hard to avoid seeing in Galen’s case studies a view of the patient as essentially a collection of symptoms, a malfunctioning physical entity that forms a convenient backdrop for the great physician’s own heroic role in the narrative.67 From the Hippocratic texts there emerges a greater uncertainty, indeed a frequent sense of perplexity as authors wrestle to draw valid inferences from a bewildering plethora of possible signs. Absent from both is any clear recognition of the value of probing the patient’s subjective experience through the kind of unstructured discussion advocated by Rufus. Today, the right of patients to be heard, and the importance of their experiential knowledge to the development of medical understanding, are increasingly recognised in western medicine, supported by both grass-roots campaigns and a growing academic literature. But when these issues first forced their way onto the policy agenda it was in reaction to institutionalised patterns of behaviour that were recognisably similar to the 65  Roter, D. (2000). ‘The enduring and evolving nature of the patient–physician relationship’, Patient Education and Counseling 39.1, 6. 66  Is it, for example, a machine that ‘goes wrong’? An intricate system of interdependent humours and qualities needing to be kept in equilibrium? A complex psycho-somatic organism some of whose responses to physical and mental challenge are uniform and predictable while others are highly individual? 67  I refer, of course, to how Galen chooses to present his conduct of the clinical encounter, rather than making any claim to know how those encounters were actually conducted. Cf. Lloyd’s opinion that the strategic purpose of Galen’s case studies was “to validate his claim as the most successful prognosticator and therapist of his time” (‘Un-Hippocratic’, 131); see above, p. 92.

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authoritarian, disease-focused clinical style projected by Galen.68 Perhaps part of the value of Rufus’ treatise lies in its ability to highlight the existence of an alternative paradigm subsequently overwhelmed by the Galenic tsunami, and thus to underline the challenge involved in achieving constructive, productive balance between expert knowledge and that of the person or people in relation to whom the expert wields his—or even her—power. Texts and Translations Used Galen. Opera omnia. Ed. C. G. Kühn. Leipzig: Cnobloch, 1821–33. ———. On Prognosis. (De praecogn). Ed. V. Nutton. CMG V,8,1. Berlin: Akademie-Verlag, 1979. ———. Commentary on Hippocrates On Diet in Acute Diseases (In Hipp. Acut. comment.) Ed. G. Helmreich. CMG V, 9.1, Leipzig and Berlin: Akademie-Verlag, 1914. ———. Commentary on Hippocrates Epidemics 1. (In Hipp. Epid. 1 comment). Ed. E. Wenkebach. CMG V, 10.1. Leipzig: Teubner, 1934. ———. Commentary on Hippocrates Epidemics 6 (In Hipp. Epid. 6 comment.) Ed. E. Wenkebach. CMG V 10,2,2. Berlin: Akademie-Verlag, 1956. Galen. On the Therapeutic Method, Books 1 and 2. Trans. R.J. Hankinson. Oxford: Oxford University Press, 1991. Hippocrates. Œuvres completes d’Hippocrate. Ed. and trans. E. Littré, vol. 1–10. Paris: J.-B. Ballière, 1839–61. ———. Regimen in Acute Diseases (Acut.). Ed. W. H. S. Jones. Hippocrates Vol. II. Loeb Classical Library. London: Heinemann and Cambridge, Massachusetts: Harvard University Press, 1923. Rufus. Oeuvres de Rufus d’Éphèse. Texte collationnée sur les manuscrits, traduit pour la première fois en Français, avec une introduction. Daremberg, Ch. and Ruelle, Ch. É. Paris: L’Imprimerie Nationale, 1879. Rufus von Ephesos. Die Fragen des Arztes an den Kranken. Ed. H. Gärtner (CMG Supplementum IV). Berlin: Akademie-Verlag, 1962. Rufus Ephesius. Quaestiones Medicinales (On Questioning the Patient, QP). Ed. H. Gärtner. Leipzig: Teubner, 1970.

68  For accounts of what was considered normal behaviour by physicians before pioneering voices began to demand change, see for example Millenson, M. (2011). ‘Spock, feminists, and the fight for participatory medicine: a history’, Journal of Participatory Medicine; Boston Women’s Health Book Collective et al. (1978). Our Bodies Ourselves, 535–37; Malterud, ‘Legitimacy’.

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References Abou Aly, A. The Medical Writings of Rufus of Ephesus. Unpublished PhD thesis submitted to University College, University of London, 1992. Angelelli, C. Medical interpretation and cross-cultural communication. Cambridge: Cambridge University Press, 2004. Boston Women’s Health Book Collective, Phillips, A. and Rakusen, J. Our Bodies Ourselves. London: Penguin, 1978. Brock, A. Greek Medicine, Being Extracts Illustrative of Medical Writers from Hippocrates to Galen. London: Dent, 1929. Dickson, K. Stephanus the Philosopher and Physician: Commentary on Galen’s Therapeutics to Glaucon. Leiden: Brill, 1998. Dillon, J. T. The Practice of Questioning. London: Routledge, 1990. Eijk, P. J. van der ‘Rufus’ On Melancholy and Its Philosophical Background.’ in Rufus of Ephesus On Melancholy, ed. P. Pormann, 159–78. Tübingen: Mohr Siebeck, 2008. ——— ‘Therapeutics.’ in The Cambridge Companion to Galen, ed. R. J. Hankinson, 283– 303. Cambridge: Cambridge University Press, 2008. Flemming, R. ‘Galen’s imperial order of knowledge.’ in Ordering Knowledge in the Roman Empire, ed. J. König and T. Whitmarsh. 241–77. Cambridge: Cambridge University Press, 2007. Garrison, D. H. (ed.) A Cultural History of the Human Body in Antiquity. Oxford: Berg, 2010. Geisler, L. Doctor and patient—a partnership through dialogue, tr. Janet M. Massey. http://www.linus-geisler.de/dp/dp00_contents.html. Frankfurt, 1991 (online publication). Gill, C., Whitmarsh, T. and Wilkins, J. (eds.) Galen and the World of Knowledge. Cambridge: Cambridge University Press, 2009. Haak, H. Rufus Ephesius: medicus gratiosus, Doctoral dissertation, University of Leiden, 2013. Hankinson, R. J. (ed.) Galen on Antecedent Causes. Cambridge: Cambridge University Press, 1998. ———. ‘The Cambridge Companion to Galen. Cambridge: Cambridge University Press, 2008. ———. ‘Galen on the Limitations of Knowledge.’ in Galen and the World of Knowledge, ed. C. Gill, T. Whitmarsh and J. Wilkins, 206–42, Cambridge: Cambridge University Press, 2009. Hatton, C. and Blackwood, R. Lecture Notes on Clinical Skills. Oxford: Blackwell Science, 2003. Holmes, B. ‘Medical Knowledge and Technology.’ in A Cultural History of the Human Body in Antiquity, ed. D. H. Garrison, 83–105. Oxford: Berg, 2010. Holyoak, K. and Morrison, R. (eds.) The Cambridge Handbook of Thinking and Reasoning. Cambridge: Cambridge University Press, 2005.

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Jouanna, J. Hippocrates. Trans. M. B. DeBevoise. Baltimore and London: Johns Hopkins University Press, 1999. König, J. and Whitmarsh, T. (eds.) Ordering Knowledge in the Roman Empire. Cambridge: Cambridge University Press 2007. Letts, M. ‘Rufus of Ephesus and the patient’s perspective in medicine.’ British Journal for the History of Philosophy (2014) 22:5, 996–1020. Lloyd, G. E. R. Methods and Problems in Greek Science. Cambridge: Cambridge University Press, 1991. ———. ‘Galen’s un-Hippocratic case-histories.’ in Galen and the World of Knowledge, ed. C. Gill, T. Whitmarsh and J. Wilkins, 115–31. Cambridge: Cambridge University Press, 2009. Loftus, E. ‘Leading Questions and the Eyewitness Report.’ Cognitive Psychology 7, (1975): 560–72. Malterud, K. ‘The legitimacy of clinical knowledge: towards a medical epistemology embracing the art of medicine.’ Theoretical Medicine 16, (1995): 183–98. Mattern, S. P. Galen and the Rhetoric of Healing. Baltimore: Johns Hopkins University Press, 2008. Millenson M. ‘Spock, feminists, and the fight for participatory medicine: a history.’ Journal of Participatory Medicine (2011) Jun 21; 3: e27. Nutton, V. Article s.v. Rufus [5]. In Brill’s New Pauly. ———. Ancient Medicine. London and New York: Routledge, 2004. ———. ‘Rufus of Ephesus in the Medical Context of his Time.’ in Rufus of Ephesus On Melancholy, ed. P. Pormann, 139–58. Tübingen: Mohr Siebeck, 2008. Patel, V., Arocha, J. and Zhang, J. ‘Thinking and Reasoning in Medicine.’ in The Cambridge Handbook of Thinking and Reasoning, ed. K. Holyoak and R. Morrison, 727–50. Cambridge: Cambridge University Press, 2004. Pormann, P. ‘Introduction.’ in Rufus of Ephesus On Melancholy, ed. P. Pormann, 3–23. Tübingen: Mohr Siebeck, 2008. ——— (ed.). Rufus of Ephesus On Melancholy. Tübingen: Mohr Siebeck, 2008. Roter, D. ‘The enduring and evolving nature of the patient-physician relationship.’ Patient Education and Counseling, Volume 39.1, (2000): 5–15. Siraisi, N. Taddeo Alderotti and His Pupils: Two Generations of Italian Medical Learning. Princeton: Princeton University Press, 1981. ———. Medieval and Early Renaissance Medicine: an Introduction to Knowledge and Practice. Chicago: University of Chicago Press, 1990. ———. Medicine and the Italian Universities, 1250–1600. Leiden: Brill, 2001. Staden, H. von. Herophilus: the art of medicine in early Alexandria. Cambridge: Cambridge University Press, 1989. Westfall, J., Mold, J. and Fagnan, L. ‘Practice-based Research—“Blue Highways” on the NIH Roadmap.’ Journal of the American Medical Association 297.4, (2007): 403–06.

Part 2 Case Histories in the Hippocratic Corpus

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CHAPTER 3

Patient Function and Physician Function in the Hippocratic Cases Chiara Thumiger This chapter looks at the patient cases of the Epidemics as testimonies to the interaction between the physician and the patient. My corpus of reference is the patient cases in fifth- and early fourth-century medical texts, mostly the more elaborated examples offered by Epidemics 1 and 3. A patient case collects information from various sources: the patient’s observable behavior and state; his or her account of her disease, its history and the patient’s lifestyle; the contribution given by relatives and friends; and, of course, the physician with his judgment, his agenda, his terminology and didactic aims. What remains elusive and hidden is the viewpoint of the patient and his personal experience within, or under the authoritative report compiled by the physician. In this chapter, I survey key stylistic features of these reports, which I see as significant to the reconstruction of the point of view of the ill in his or her encounter with the doctor. My main aim is to extract from these texts as much as possible information about the experience of suffering and patienthood in antiquity. In my analysis I look at the text not only, and not primarily as a definitive pronouncement stemming from the physician’s legislating mind, and from the material author’s ‘pen’, nor observations from by-standers and helpers in the sick room, nor even as the plaintive cries from suffering patient, but as a composition in which all the principal actors in the drama of a sickness must contribute.

*  I should like to thank the Alexander von Humboldt foundation which has supported my research and Philip van der Eijk for his ongoing help and advice; the audience at the Homo Patiens conference, and in particular Peter Singer, and Manfred Horstmanshoff; my colleagues in the AvH research group, for commenting on a final version; Petros BourasVallianatos for important bibliographical suggestions. I also benefited from discussions during the conference with Brooke Holmes and Helen King (unfortunately not included in this volume). Last and not least, I thank Annette Schmidt and Konstantin Schulz for their help with bibliographical researches.

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1 Introduction In this article I explore the interaction between patient and physician in the patient cases from the seven books of Epidemics, already a part of the Hippocratic Corpus—that collection of early medical writings among which Epidemics have figured prominently for the past two thousand years. I use the label ‘patient case’ in a comprehensive sense: a report focussing on one specific individual, mentioned by name or, in any case, identified as unique subject. A patient case in the strict sense generally narrates his or her illness in a prominent manner, from the beginning to the end or for a significant portion of time; but there is interest for our topic also in the brief mention of an individual in association with a pathology which is being discussed, or in analogy to a previous case. My aim is to assess the form that patient cases take in choice of words, stylistic features, syntax and narrative structure, for variation of these qualities within patient cases from the Epidemics offers clues as to the balance of power within exchanges of medical information. I propose to weigh patient functions in each exchange with doctor functions, and, by weighting patient experiences as of equal importance to the doctor’s medical knowledge, I hope to gain access to the suffering patient, the homo patiens. I leave aside distinctions among the seven books of Epidemics and fasten my gaze exclusively on patient and physicians, and how they interacted during the late-fifth and earlyfourth centuries. My interpretive approach will be primarily narratological, as I inspect the building blocks out of which patient cases were constructed. I shall consider these texts as speaking entities, individual voices rather than as the medium through which a controlling authorial voice purposefully organised and trumpeted his own medical knowledge.1 In this sense, I diverge substantially from Webster’s take in this volume, and his attention to the authors of Epidemics (and other texts) as organising minds and self-conscious speakers.2 This approach, as shown below, far from being an abstract digression into literary theory, is firmly rooted into a patient-centred project.

1  Narratology is a development of structuralist and, before that, formalist approaches to literature, therefore by nature interested in the text and its stylistic features, structures and mechanisms as text as opposed to external aspects such as a supposed authorial intention. 2  Webster in this volume, especially 166–168.

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Patient Cases: Historical and Theoretical Issues

Theoretical reflections on the patient in the so called ‘casuistry’ (the reporting on individual patient cases) and the importance and challenges of giving space to the voice of the sufferer therein, are at the heart of the project of this volume and central in current trends in the history of medicine and developing clinical approaches alike. There are thus three methodological aspects here: one (a) is theoretical and applies more generally to medicine and medical theory, concepts of patienthood and patient-narrative; the second (b) is historical, and has to do with ancient medical texts in connection with the doctor-patient relationship; finally (c), there are the issues implied when we try to bring (a) into dialogue with (b). The first point is a trans-historical and methodological one. The importance of considering the patient as active participant in the medical act has increasingly taken center stage in current medical practices (most notably psychotherapeutic and psychoanalytical,3 but not only so).4 History of medicine has responded to this shift. From Porter’s call onwards5 medical stories and histories have been increasingly scrutinised as testimonies to the voices of the ill, resiliently filtering through to the reader despite the normative control exerted by official medical figures, however all-mighty and pervasive they might seem to be.6 Personal narratives (not necessarily first-person) appeared from the start to be the privileged locus of expression of these voices, in opposition to the physician-centred doctrinal accounts, with their lists of signs, their 3  The leading psychiatrist Kächele (2011) for example, speaks of “the discovery of a narrative science” in his discussion of “single case study” as useful tool to “bring together clinicians and researchers” (‘The single case study approach as a bridge between clinicians and researchers’, Annual Meeting of the Rapaport-Klein Study Group. Austen Riggs Center); on the side of theoretical reflection, see Frank, A. W. (1995). The Wounded Storyteller for a reflection on the intertwining of illness and storytelling, describing the embodied narrative offered by suffering patients. 4  See Brody, H. (2003). Stories of Sickness, 11 and 16–17 on the “joint construction of healing narratives” as cooperation between patient and physician. See also, from earlier days, Kleinman, A. (1988). The Illness Narratives: Suffering, Healing and the Human Condition. Kleinman’s distinction between disease and illness (psychiatric, but not only so) points also at the gap between the biology of dysfunction and the subjective experience of a pathology, that is not a mere epiphenomenon to the biological datum, but indeed the ‘real thing’. 5  Porter, R. (1985). ‘The patient’s view: doing medical history from below’, Theory and Society 14, 175–98. For a practical illustration see his 1987 A Social History of Madness, a collection of case histories of mental patients aimed at foregrounding the point of view of the patient. 6  On the excesses of Foucault’s views on this matter, see Porter, ‘Patient’s view’, 197.

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technical language and theoretical generalisations. Narrative as seriously relevant to humanity in medical contexts, and not an accidental by-product or pre-scientific endeavor is thus taken as ineliminable part of medical knowledge in its fieri.7 Clinical medicine has long recognised this: Brody’s 1987 Stories of Sickness was among the pioneering contributions to the field; Montgomery Hunter”s 1991 Doctor”s Stories emphasises explicitly the application of the methodologies of the humanities for “understanding what it is that clinicians do”, proposing to look at the interactions between physicians (and patients too) as “literary” phenomena.8 She speaks firmly against hard-core “epidemiological” models of medicine, claiming that medicine is “not a science” but an interactive practice,9 to be studied “as narrative activity”.10 In addition, Epstein looks at case histories and case fictions, maintaining that “human understanding is finally achieved through narrativity”.11 All these reflections have in common the resort to literary approaches as trait d”union between an anthropologically minded medical history and the interpretation of textual material. DelVecchio Good, in particular, looks at “competence” in American medicine as a “social product”, which medical narrative well illustrates in terms of literary analysis: narratives are characterised by “plot” (the facts), ‘emplotment’ (the way the facts are turned into a story), and “narrative time”,12 three features to whose creation patient and physician must cooperate.13 Good develops these topics in a similar direction,14 using textual analysis, and comments insightfully on what he calls “subjunctivising” elements in illness narratives.15 Narrative, he 7  Brody, Stories of sickness, 8–11 for a summary of the rehabilitation of the scientific value of casuistry. 8  Hunter, K. M. (1991). Doctors” stories: The Narrative Structure of Medical Knowledge, 13–14. See Brody Stories of sickness, 3, 4, with n. 2, who, discussing modern patient narratives, speaks of the opportunity to eliminate the gap between fictional and real case: research must bring together “amateurish literary criticism” and “a philosophical inquiry into the nature of sickness”. On the operative side in the field of psychiatry, Kächele (see n. 5) includes in his clinical procedure an operative stage of “linguistic and computer-assisted text analysis” where levels of discourse, vocabulary, metaphors used by the patients, and as small print as “meaning structures” and “the use of pronouns” are investigated (9–10). 9  Hunter, Doctors” stories, 17. 10  Ibid., 21. 11  Epstein, J. (1995). Altered Conditions: Disease, Medicine, and Storytelling, 25; 31. 12  DelVecchio Good, M.-J. (1995). American Medicine: The Quest for Competence, 178–79. 13  Ibid., 180 speaks of a “therapeutic emplotment” in which the “ongoing experience of disease and treatment is created by clinicians and patients as they engage each other and interpret the impact of treatment on disease”. 14  Good, B. (1994). Medicine, Rationality, and Experience. 15  Ibid., 153.

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observes, aims to “subjunctivise” reality, i.e. to make the reader enter the world of the narrative: “to be in the subjunctive mode is . . . to be trafficking in human possibilities rather than in settled certainties”.16 It is in the nature of narrative to introduce elements of possibility, hypothesis and openness to the reader. These elements reflect a tension in the very creative genesis of a text, the interaction between the two (or more) parts at work. In short: medicine is interactive, and has an irreducible narrative, humanistic component, most evident in patient’s narratives as the basic feature of medical epistemology. These narratives are best approached not (or not only) by the standards of scientific factuality, but through literary lenses. This hermeneutic agenda naturally fits medical testimonies that are conceived to reflect the point of view of the patient from the start: diaries, epistolography, autobiography, and so on. Most of the modern thinkers we have just quoted look at these kinds of sources to build their argument on patient narratives. A quick glance at the material we have from antiquity easily reveals that no such evidence remains from the ancient period, with Aelius Aristides, a rhetorician of the Second Sophistic being the first exception.17 As far as the Epidemics are concerned, the inquiry into doctor-patient interaction in them is inseparable from the question of their aim and composition in the first place. As records of a patient-physician encounter, how and why did they become a written text? This is a huge topic that has received lengthy discussion,18 and we shall not dwell on it here, if not to remind ourselves that 16  Ibid., quoting Bruner, J. (1986). Actual Minds, Possible Worlds, 26, here and above. 17   Steger, F. (2007). ‘Patientengeschichte—eine Perspektive für Quellen der Antiken Medizin? Überlegungen zu den Krankengeschichten der Epidemienbücher des Corpus Hippocraticum’, Sudhoffs Archiv 91, 230–38 emphasises this point, 231, “doch ist für die Antike eine Autobiographie im engeren Sinn gar nicht auszumachen”; when we move to ancient medical texts, and to the Epidemics, the question is to what extent the material “einen Einblick in das Innere der Patienten läßt und damit Antworten auf die Fragen zuläßt, wie die Patienten empfanden, dachten und reagierten . . .” (234). On Aelius Aristides as patient and author see Petridou and van Schaik (Chapters Eighteen and Nineteen) in this volume 452–495. 18  On oral culture and medical texts see Lonie, I. M. ‘Literacy and the development of Hippocratic medicine’, in Lasserre, F. and Mudry, P. (1983). Formes de Pensée dans la Collection Hippocratique; Miller, G. (1991). ‘Literacy and the Hippocratic art: reading, writing and epistemology in ancient Greek medicine’, Journal of the History of Medicine and Allied Sciences 45, 11–40 for the status quaestionis; Eijk, P. van der ‘Towards a rhetoric’, 93–99 for an important correction; and Langholf, ‘Structure and genesis’, 222, who improves on the Havelockian comparison with Homer and exposes in these fifth- and fourth century ‘Hippocratic’ texts modes of communication that have still much in common with oral delivery.

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there are considerations of oral style, on the one hand, and history of composition and transmission, on the other that we must discount when giving a formalist interpretation of these ancient texts. This takes us to the last point. To what extent can we apply the methodological observations offered by the exciting developments in (a) to the non-autobiographical material of the Epidemics, given the specifics of composition we have briefly mentioned in (b)? Scholarship has often emphasised Hippocratic medicine as disproportionately siding with the authoritative physician, his doctrine and theories (in nosological or theoretical texts, for example), and offering a top-down account of the suffering patients (in the clinical texts). It is sometimes even taken for granted that Hippocratic medicine “laid the groundwork for a practice of medicine in which the physician does not talk to the patient” from the start.19 Very recently, Steger looked at the seven books of the Epidemics as a whole to conclude that, in their primary focus on ‘ “descriptions of signs of disease” ’ they do not reveal ‘ “how the patient lived his (or her) disease, how he viewed the way it had been dealt with”, and offer “no insight into the experience of the doctor in exchange with the patient, leaving the experience of the patient entirely precluded to us”.20 Other readers have been more nuanced in this respect. Allowing for a distinction within Hippocratic texts and ‘genres’ (if I may call them so), Jori explored how the importance of the information the patient can provide was recognised already by the physicians of the fifth and fourth centuries.21 It is undeniable that it would be the other model, the one based on theoretical knowledge totally dismissive of the patient’s view, which would shape the Western dominant medical culture. For 19  Cassel, E. J. (1976). The Healer’s Art, 56; in Brody, Stories of Sickness, 8; in a similar spirit Webster in this volume, 167 “in short, patients in this text (Epid. 1) are constructed essentially as sick bodies emitting verbiage, not as interlocutors contributing speech”. Entralgo concedes a little more (Entralgo, P. L. (1970). The Therapy of the Word in Classical Antiquity, 158–70) as he focuses on communication from the other side and explores the presence of a “suggestive word” (what he calls “psychotherapy”) in the Hippocratic texts as conducive to the “active cooperation of the patient”, albeit with “paucity and vagueness” (161, 165); Letts (Chapter Two), especially 85–86 in this volume recognises talk and even questions and answers as important in Hippocratic medicine, but opposes it to Rufus’ attentiveness to the patient’s viewpoint. 20  Steger, ‘Patientengeschichte’ 234, 237, my translation and emphasis. See instead already Pigeaud, J. (1981). La maladie de l’âme. Étude sur la relation de l’âme et du corps dans la tradition medico-philosophique antique, 11 who emphasises how Ancient Medicine in particular inaugurates a view of ancient medicine grounded onto dialogue . . . “la collaboration du médecine et du malade”. 21  Jori, A. (1997). ‘Il medico e il suo rapporto con il paziente nella Grecia dei secoli 5 e 4 A.C.’. Medicina nei secoli. Arte e Scienza 9/2, 189–222.

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the Hippocratic material, still, we could distinguish (with Jori) between two options: what he calls an “Hippocratic Model”, open to the view of the patient, and a “doctor-centred model”, exemplified for Jori by De Arte.22 The first is alive in the several instances in which the patient is called upon through questioning, or reports that appeal directly to his or her viewpoint. In the Prorrh. 2, for instance, the advice is repeatedly given to ask the patient, ἐπανερέσθαι; consider also Morb. 2, 51 (L. 7.78.16–17 = Jouanna 188, 10–12), καὶ ἢν ἐρωτᾷς αὐτόν, φήσει οἱ . . . (“if you ask him, he will tell you that he . . .”). References to patients being questioned by the physician are explicit, and frequent. Moreover, it is not only a matter of opposing a theoretical text like De Arte to clinically-minded ones. There is in fact a more radical objection to readings such as Steger’s: however much one might wish to portray the ‘doctor-centred model’ as authoritarian and insensitive to the patient’s viewpoint, the voice of the ‘oppressed’ patient still resists elision. Jori highlights contradictions and cracks even in the vertical authorial posture of De Arte, for example, when the author is shown to rely on the sensations of the patient for the formulation of his doctrine.23 In this way, even in a text in which the silencing of the patient appears to be programmatic,24 his or her presence is to a degree ineliminable. So, we are not only legitimised, but obliged to look at the interaction between patient and physician in ancient medicine, and especially in the case reports of the Epidemics, from two perspectives.25 From a historico-philological point of view (b), as these texts in the specific are the products of the long-lasting interaction between different voices: those of the authors which contributed to every stage from note-taking to draft, compilation and reworking; the speaking patient; the attending audience of professionals and/or relative and friends; the layers of tradition and commenting. Secondly, from a socio-methodological point of view (a), considering the constructedness of medical pathology, its being inseparable from the subjective experience of the sufferer which is not epiphenomenal. The sufferer’s experiences necessarily form the substructure on which a patient

22  Ibid., 191. This useful dichotomy (as Jori is well aware of) is useful precisely because we can see it eroded in different ways. 23  Ibid., 195 on De Arte 5, 35 (L. 6.8.3–12 = Jouanna 228, 12–229, 6) “intima incrinatura”. 24  Jori, “Il medico e il suo rapporto”, 204–06: “Il silenzio del terapeuta”. 25   See Leven, K.-H. ‘ “Mit Laien soll man nicht viel schwatzen, sondern nur das Notwendige”—Arzt und Patient in der hippokratischen Medizin’, in Reinhard, W. (2007). “Krumme Touren”—Anthropologie kommunikativer Umwege, 47–61, for a perceptive discussion of the specific conditions under which patienthood and authority were realised in ancient, and in particular Hippocratic doctor-patient encounters; on the patient cases of the Epidemics see also Graumann (2000).

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case is to be narrated.26 No patient history can really be written despite the patient, or entirely over his or her head; all medical discourses, on the other hand, contain a literary element that cannot be eliminated. 3 The Epidemics: The Material Circumstances of the Doctor-Patient Encounter27 We have some reliable information about the activities of the itinerant physicians in the fifth and early fourth centuries preserved in many of the texts of the so-called ‘Hippocratic Corpus’.28 Hippocrates and his entourage, as well as other doctors travelled around the Aegean visiting various locations in mainland Greece and Asia Minor, plausibly operating in the company of students and helpers. The activity of the doctor as itinerant is traditional to the medical profession in Greek culture;29 the very title Epidemics, perhaps given to the texts at a later stage, if surely before Galen, is taken to mean ‘visits to the city’, ‘visit to the people’ on the part of the physician, to underline the contextual (geographical and seasonal) nature of the texts, but also its nature as encounter. Visits to a place could last from weeks to months. The physicians would return time and again to visit the same patient, as it is sometimes stated explicitly. The chronology and topography of these visits are neat and clear in their details only in Epid. 1–3, while in the other books duration and location may be left uncertain.30 In terms of frequency, visits might occur every day, or even more times in the same day or for longer time for a week or more; or with lesser frequency altogether. 26  Kleinman, A. (1991). Rethinking Psychiatry, 25. 27  See Langholf, ‘Structure and genesis’, 249 on individual books and blocks of books; Jouanna, J. (1999). Hippocrates, 387–90 on 1–3; Smith, W. D. ‘Generic form in Epidemics 1 to 7’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien, 27 for a summary; Leven, ‘Mit Laien soll man nicht viel schwatzen’, 52–58. 28  On Hippocratic therapeutic practices, see Jouanna, Hippocrates, 112–40, 25–36 and Nutton, V. (2004). Ancient Medicine, 87–102. 29  See the famous passage in Odyssey 17, 383–86 on calling a doctor from a faraway land; Langholf, V. (1990). Medical Theories in Hippocrates, 36, 135–231; Nutton, Ancient Medicine, 40–41, 87; Horstmanshoff, H. F. J. (1990). ‘The ancient physician: craftsman or scientist?’, The Journal of the History of Medicine and Allied Sciences 45, 177–79; 188. 30  See Potter, P. ‘Epidemien 1/3: Form und Absicht der zweiundvierzig Fallbeschreibungen’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien, 9–19; Smith, ‘Generic Form in Epidemics 1 to 7’, in Baader, G. and Winau, R. (1989). Die Hippokatischen Epidemien, 144–58 for a survey of these aspects.

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The number of cases in each book varies greatly: as opposed to Epid. 1–3 and 5–7, Epid. 2, 4, 6 largely contain crowds of names listed to illustrate doctrinal points.31 As one might expect, this reflects in the very different degree of development of individual cases. We can then propose various typologies (without strict categorisation): a) cases proper, including previous circumstances (the so-called ‘anamnesis’), present illness, prognosis, outcome, and stretches of daily report; b) long narratives, which may be missing some of the elements just listed; c) short cases, focused on a particular element of relevance, covering only a segment of the illness; and finally, d) mentions of names to substantiate a general point, or to add statistically to an event described. In the case of longer reports, interaction between patient and physician may offer examples of intimacy and familiarity. First of all, let us consider the anagraphics: great precision in giving name and family connections, address and time of the year (especially in Epidemics 1 and 3), or a rather different kind of labelling, with anonymous but elaborate indications, to distinguish one individual from the next or offer a token for future recollection and re-elaboration, especially in Epid. 2 and 4. E.g.: “the wife of the leatherworker who made my shoes”, or “the woman with pain in the hips” in Epid. 2.2, 17 and 18 respectively (L. 5.90.7–12; 90.13–92.2). There are adjectives and qualitative comments about the patient, his or her condition and life, his or her appearance and so on, such as “the pretty virgin, the daughter of Nerios . . .”, ἡ παρθένος ἡ καλὴ ἡ τοῦ Νερίου (Epid. 5, 50, L. 5.236.11= Jouanna 23, 15). At the other end of the spectrum, we find quicker mentions that advertise no deep acquaintance, referring simply to the occasion of contact with the physician, or to the doctrinal reason for mentioning the patient. These variations reflect varying degrees of actual interaction, and interest in reporting on the interaction (or lack thereof). This is indeed an impossible and ultimately unnecessary distinction to make, insofar as we are looking at the text as text, and not trying to reconstruct a specific biographical fact. The recollection of the patient’s past circumstances is an important indicator: the narrative about the patient’s larger context and relevant past, his or her general lifestyle, past pathologies, and so on—in short, all the information that cannot be apprehended by the physician through the use of his senses upon the observation of the present state of things. The duration, frequency and intensity of the exchange, and possibly a role played by friends and family to convey information can be gathered from these anamnestic sections. On a parallel level, over the head, so to speak, of the patient-physician dialogue, there is the noise of professional talks that offer a background to the 31  Epid. 1–3 offers a limited number of articulated patient cases that are given exemplary prominence: 13 cases (plus 14 names listed in the constitutions) in Epid. 1 and 28 in Epid. 3, as against around 460 named individuals in the other books.

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condition of the patient: competitions, doctrinal reflections and debates, (self)-criticism, and comparisons between therapies and outcomes. 4

‘Doctor Function’ versus ‘Patient Function’: A Stylistic and Narratological Approach

On these premises, let us turn now to an analysis of the texts. There is an element of abstraction in our programme, of course, implicit in the very label ‘function’. This is inevitable, since it is not the actual autopathography we are considering, or a clinical report drafted by a doctor in a hospital of nowadays, a process whose routine, conventions, and interactive ratio we know well, at least in its broad lines. In the case of the Epidemics, these two actors, patient and physician, can only be approached as textual entities, and thus as literary functions. On the other hand, there is also a theoretical legitimisation to such a move: the literary approach advocated for by those scholars who have reflected on the clinical reality of modern and contemporary patients. As we have explored, several observers of the dynamics of case taking and patient reporting insist on the literary, narratological nature of patient stories. While in contemporary Western practice doctors produce narratives that are (at least, supposed to be) intelligible to the patients by incorporating the stories uttered by them, mostly in a way that makes that input clearly distinguishable (for instance, using explicit indirect speech markers), the pathographies of the Epidemics are authored by a third-person narrator who only exceptionally indicates his external source of information. More importantly, the cases of the Epidemics have been revised at several stages, and are aimed at professional audiences of largely unknown size and shape. So, our hermeneutic task is more complex and the object further removed. Still, if we succeed in avoiding a mechanicistic application of discourse analysis the tensions between the two forces, or ‘functions’, of patient and physician can be uncovered to some degree. 5

The Patient Function

5.1 Explicit Embedded Focalisation32 Perhaps the most evident way of voicing the perspective of the patient is the syntax of subjunctivisation and reported opinion, introduced by verbs 32  Embedded focalisation: “the representation by the narrator in the narrator-text of a character’s focalisation, i.e., perceptions, thoughts, emotions, or words (indirect speech).

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of thinking and especially of saying. In general, it is true that no sense of the importance of reproducing the patient’s words with precision is found in the ancient texts, as opposed to what current clinical practice recommends.33 Nonetheless, seemingly quoted speech is sometimes reported, although in ways that are not without problems and ambiguity: embeddment of this kind, in fact, can be equally a feature of channeling the point of view of another, or a way of conquering his or her space through an omniscient narratorial posture.34 Let us explore some of these possibilities.35 The incidental ἔφη, or ὡς ἔφη (a marker of explicit embedded focalisation) often indicate a received information on which doubt is cast, as at Epid. 4, 6 (L. 5.146.11–12), ἄρσεν δὲ καὶ ἄλλο πρὸς τὰς εἴκοσιν ἔφη, εἰ ἀληθέα, οὐκ οἶδα, “she said that she had lost another, a male, towards the twentieth day. Whether it was true, I don’t know”, or Epid. 4, 20 (L. 5.160.6–7), ἡ Τενεδίη τεταρταίη ἀπέφθειρεν, ὡς ἔφη. . ., “the woman in

Embedded focalisation can be explicit (when there is a shifter in the form of a verb of seeing or thinking, or a subordinator followed by a subjunctive or optative, etc) or implicit (when such a shifter is lacking)”. Here and below, I employ the useful glossary that introduces De Jong, I. J. F. (2001). A Narratological Commentary on the Odyssey, xi–xix. 33  See Epstein, Altered Conditions, 32 on this point; 35. To counterbalance the general impression, that the value of faithfulness to the wording of the patients is generally not recognised, we may quote here the checklist of items to observe at Epid. 6, 8, 7 (L. 5.346.6–7 = Manetti-Roselli 172, 11–12) which includes “speech, silence, saying what he wishes. The words with which he speaks: loudly or many, unerring or moulded (with Smith’s English)”, λόγοι, σιγή, εἰπεῖν ἃ βούλεται· λόγοι, οὓς λέγει, ἢ μέγα, ἢ πολλοί, ἀτρεκεῖς, ἢ πλαστοί. Not all items here have to do with the quality of the voice: in particular ἀτρεκεῖς, ἢ πλαστοί, which Manetti and Roselli translate as “se veri, se falsi”, may belong to a ‘literary’ appreciation rather than an evaluation in terms of veracity: “whether the words are precise/strict or instead built up/involute”: this would suggest an interpretative effort to understand the wording style of the patient. 34  Focalisation is notoriously a problematic theoretical point: does embedded focalisation express even more the view point of the narrator, who goes as far as fabricating his characters’ words, or withdraws it to really introduce that of someone else? See Rood, T. (2002). Thucydides: Narrative and Explanation, 294–96 for some important points, and Hühn, P. et al. (2009). Point of View, Perspective, and Focalization: Modeling Mediation in Narrative for a status quaestionis on the debate in narratology; to our purpose here, it is important to note that focalisation effectively does both, signaling the will of the narrator to report on someone’s words, and power of decision; and at the same time reporting these words. 35  Relevant here is the contract that joins patient and physician (on which Ecca, Chapter Twelve in this volume, 325–44). On the necessary trust and trustworthiness between patient and physician see Jouanna, Hippocrates, 136–42; and van Schaik (Chapter Nineteen) in this volume, 477–479; 486–489.

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Tenedos aborted on the fourth day, or so she said, . . .”.36 These idiomatic phrases oppose the statement of the patient to the unreliability the physician attributes to it, although he nonetheless mentions it. More interesting is the patient quoted at Epid. 5, 74 (L. 5.246.25–48.1 = Jouanna 34, 6–7) and 7.36 (L. 5.404.18–19 = Jouanna 74, 11–12): γλώσσης οὐ πάντ᾿ ἔφη δύνασθαι ἑρμηνεύειν (“problems with the tongue: he said he could not articulate everything”). Here the patient is reported uttering his own inability to utter properly, a passage that at first sight seems to expose its own fictionality but reveals, in fact, the complex interweaving of patient’s words on the one hand, and interpretation and final synthesis in the narrative, on the other. There is no way (unless we wish to suppose a malignant intention to fabricate facts) that a physician could write these words independently of an utterance from the patient. Genuinity is sometimes supported by the subjective and idiosyncratic content prevalent in most of these instances: Nicanor, at Epid. 5, 81 (L. 5.250.12 = Jouanna 37, 10) is quoted as he qualifies further his phobia as being more severe in the night, μόλις ὑπομένειν ἔφη ὅτε εἴη νύξ (see also Epid. 7, 86 with a very close wording), and Democles, his fellow patient, at Epid. 7, 87 (L. 5.444.18 = Jouanna 102, 4–5; see also Epid. 5, 82) is quoted on his own gephyrophobia (‘fear of bridges’): “he said he could not go along a cliff . . .” (καὶ οὐκ ἂν παρὰ κρημνὸν ἔφη παρελθεῖν). In these examples of indirect speech, we are led to take the words that follow as close in content, if not identical, to those of the patient. A special sub-group of shifters is constituted by verbs of seeming. The case of δοκεῖ and its forms is a central, and difficult one, as such verbal forms easily become ambivalent in respect to who their subject is. As Good explores with some sophistication, “narrative discourse” (made of reported opinions or judgments, and the modulation of intersecting perspectives) has the effect of “recruit[ing] the reader’s imagination” by enacting the different points of view in the text, and leaving it open notwithstanding its neat closure.37 The Greek form δοκεῖ does exactly this in cases when no dative is specified, and no overtly technical term signals the physician as source. Such openness is often left unresolved, as it is impossible to definitely assign a source to the judgment conveyed. Take Epid. 5.82 (L. 5.250.14–15 = Jouanna 37, 13–14), our Demοcles’ phobias of height: ὁ μετ’ ἐκείνου ἀμβλυώσσειν καὶ λυσισωματεῖν ἐδόκει (“Democles appeared to be/felt to be blurred in vision and slacken in the body”). What follows is the report on a subjective fear, so that we are invited to take ἐδόκει as subjective (“he felt”, “it seemed to him”—although Smith translates with the impersonal “seemed to”). Likewise at Epid. 5, 83 (L. 5.250 = Jouanna 38, 5–6): τὸ Φοίνικος· ἐκ 36  See also Epid. 4, 1, 22 (L. 5.162). 37  Good, Medicine, 153.

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τοῦ ὀφθαλμοῦ τοῦ δεξιοῦ τὰ πολλὰ ὥσπερ ἀστραπὴν ἐδόκει ἐκλάμπειν (“Phoinix’s problem. (To him) it seemed to see flashes like lighting in his right eye”). Once again, what seems to be a subjective report could be the interpretation of the physician as much as the patient’s impression. A description of a patient at Mul. 2, 174 bis (L. 8.356.2–5) could be also compared here as clear instance of subjectivity. The passage depicts a typology of patient with psychological suffering: δυσθυμέει τε καὶ αἰολᾶται τῇ γνώμῃ (“she is depressed and restless in her mind”), and later δοκεέι θανεῖσθαι (“it seems (to her) to be dying”): in the frame of her despondency, we can take the verb as describing the woman’s own feelings of fear and weakness. Many other cases, however, remain ambiguous as to whether they refer to patient and physician, in irreducible ways.38 Such is the case found at Epid. 7, 29 (L. 5.400.12–13 = Jouanna 70, 6–7) ὁπότε ἀπεμέσειεν, ἐδόκει ῥηΐων εἶναι, (“whenever he vomited, he seemed/he felt easier”); or at Epid. 7, 5 (L. 5.372.23–74.1 = Jouanna 53, 11–12) ἡ θέρμη λῆξαι ἐδόκει καὶ ἡ ὀδύνη, (“the heat and the pain appeared to abate”)—to the patient, or to the observer? And, a bit further, τῇ ἑβδόμῃ ὡς ὑγιής, (“on the seventh day seemingly/slightly improved”): does this ὡς subjectivise the doctor’s, or the patient’s view? Or is it perhaps supposed to oscillate in between, being an expression for the undefinable experience of suffering, in which the patient becomes spectator of himself and the doctor, to some degree, a sufferer himself?39 A last and striking example of the twoway traffic between the one who suffers and the one who cures behind these 38  In her paper delivered at the original Homo Patiens conference Brooke Holmes engaged with these topics, and noticed the exemplarity of δοκεῖν with its ambiguity. The transmission of our texts reflects that this must have been a point of tension also for earlier readers. At Morb. 2, 51 (L. 7.78.16–8 = Jouanna 188, 10–12) Jouanna has φήσει οἱ ἄνωθεν ἀπὸ τῆς κεφαλῆς κατὰ τὴν ῥάχιν ὀδοιπορεῖν οἷον μύρμηκας, “he says that like ants walk from his head down the neck”, while Littré prints κατὰ τὴν ῥάχιν κατέρχεσθαι δοκεῖν οἷον μύρμηκας, with δοκεῖν restitutum al. manu. At Epid. 7, 114 (L. 5.462.8–9 = Jouanna 113, 11–12) ἐπελιδνώθη πάντα κύκλῳ καὶ σαπρά· ἐδόκει ἀμείνον· ἀπέθανεν, “it all became livid in a wide circle and rotten; he seemed/felt to get better; he died”. In this passage ἀμείνον is omitted by the Ald. and I, where we have then σαπρὰ ἐδόκει, “they seemed rotten”. Several textual ambiguities appear around these ἐδόκει et sim.; which shows that an ambiguous nature is inherent to them, and not only our modern problem. 39  The sympathy and co-suffering of the physician with the patient is evidently present in the awareness of the Hippocratic physician, as stated famously in Flat. 1 (L. 6.90.3 = Jouanna 102, 3–4), whereby the medical art is described as one of those which are ἐπίπονοι (“painful”) to those who practice them, while bringing great advantage to their receivers. The physician “sees terrible sights, touches unpleasant things, and the misfortunes of others bring a harvest of sorrows that are peculiarly his” (ὁ μὲν γὰρ ἰητρὸς ὁρεῖ τε δεινά, θιγγάνει τε ἀηδέων, ἐπ’ ἀλλοτρίῃσί τε συμφορῇσιν ἰδίας καρποῦται λύπας (L. 6.90.4–6 = Jouanna 2,

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expressions, their being an interface between patient and physician, is offered at Epid. 6, 5.7 (L. 5.318.1–4 = Manetti-Roselli 110, 1–4), a case of placebo effect. The text: ἢν οὖς ἀλγέῃ, εἴριον περὶ τὸν δάκτυλον ἐλίξας ἐγχεῖν ἄλειφα θερμόν, ἔπειτα ἐπιθεὶς ἔσω ἐν τῷ θέναρι τὸ εἴριον, τὸ οὖς ἐπιθεῖναι, ὡς δοκέῃ τί οἱ ἐξιέναι, ἔπειτα ἐπὶ πῦρ ἐπιβάλλειν· †ἀπάτη†, (“if the ear aches, wrap wool around your fingers, pour on arm warm oil, then put the wool in the palm of the hand and put it over the ear so that something will seem to him to come out. Then throw it in the fire. †A deception†”). This passage has at the center the doctor, acting out what might seem to be a patronising ploy to provide the patient with psychological comfort; on the other hand, it is the deceived subjectivity of the patient that brings about the improvement, for he is the one upon whom the outcome depends (δοκέῃ . . . οἱ, “it will seem to him”). 5.2 Character Language40 Character language as indicator of the patient’s viewpoint is detectable in the use of unique imagery for the expression of subjective feeling. Take as exemple Epid. 7, 11 (L. 5.382.15 = Jouanna 58, 23). This case offers a rich and detailed report on a female patient’s mental disturbance. At the very opening we read καὶ τὴν καρδίην οἱ γυιοῦσθαι ἔφη (“and she said that her heart had been damaged”).41 Even if the term at stake here is a conjecture,42 it serves nonetheless as an instructive example. The verb γυιόω (“to be weak, lame”) is associated with γυῖα, limbs, and indicates a state of physical weakness, ‘to limp, to suffer a damage in the limbs or joints’.43 The expression would be therefore heavily metaphorical, ‘my heart is limping’, as opposed to technical, and as such unique: all these would strongly support the authenticity of the phrase as literal word choice of the patient. To confirm this point, a few lines below, the patient’s verbal communication emerges again, and more explicitly: μετὰ τὰς πρώτας ἡμέρας ἐρωτωμένη οὐκ ἔτι κεφαλὴν ἀλλ’ ὅλον τὸ σῶμα πονεῖν ἔφη (“after the first days, when asked, she said that no longer only the head, but now also her

102.7–103.2). On touching in ancient medical practice, see Kosak (Chapter Eight) 248–264 in this volume. 40  Character-language: “words which are typically used by characters, i.e., which occur mainly or exclusively in speeches and embedded focalisation”. 41  With Smith’s translation for γυιοῦσθαι. 42  Coray’s conjecture for M ὑγιᾶσθαι (which makes no sense). 43  Cf. Il. 8, 402 γυιώσω . . . ὑφ’ ἅρμασιν ὠκέας ἵππους, (“I shall break the horses’ legs underneath the chariot”), says Zeus planning to sabotage Hera and Athena’s journey.

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entire body ached”).44 A second (and analogous) example is another female patient, Polemarchus’ wife at Epid. 5, 63 (L. 5.242.10–11 = Jouanna 28, 14–29, 1): καὶ κατὰ τὴν καρδίην ἔφη τι ξυλλέγεσθαι αὐτῇ (“and she said that something was gathering to her in/on her heart”). Here the image is less extraordinary than in the previous case, but what is clearly at stake is again an irreducibly subjective experience: not only because the location in the καρδίη is invisible and impossible to guess from the outside, but also because of the psychological and emotional suggestions it carries traditionally in Greek culture.45 Interestingly, in the version of this case found at Epid. 7, 28 (L. 5.400.4–5 = Jouanna 69, 14–15), καὶ κατὰ τὴν καρδίην ἔφη δοκεῖν τι ξυνάγεσθαι ἑωυτῇ, the verb in the ‘quoted’ patient words is a different one, although the sense of the image used (‘to gather’, ‘to collect’) is the same. This semantic agreement works in support for the ‘gathering’ image as original, regardless of which verb was used. At Epid. 7, 45 (L. 5.414.2–5 = Jouanna 80. 1–5) we find a patient with an important subjective pathology, phobic anguish: οὐκ ἐξιέναι ἤθελεν ἀλλὰ δεδιέναι ἔφη· εἰ τέ τις περὶ νοσημάτων χαλεπῶν διαλέγοιτο, ὑπεξῃει φόβῳ· ἔστι δ’ ὅτε προσπίπτειν αὐτῷ πρὸς τὰ ὑποχόνδρια θερμασίην ἔφη καὶ τῶν ὀφθαλμῶν μαρμαρυγὰς παρακολουθεῖν (“he did not want to go out, but he said he was afraid; if someone spoke to him about severe diseases, he would withdraw in fear; he said sometimes that heat fell on his hypochondria and that sparks before his eyes continues”).46 The content of the patient’s utterance is his subjective experience of fear and anxiety, although the physician might be adding his own interpretation to it. The expression προσπίπτειν αὐτῷ πρὸς τὰ ὑποχόνδρια θερμασίην ἔφη, with heat falling onto the patient’s chest is more likely to reflect the patient’s representation of a sensory experience than the physician’s view of it.

44  Verbs of saying and those others denoting the experience of pain (therefore, the subjectivity of the patient in reporting) are associated in a very clear way in Prorrh. 2, 24 (L. 9.54.22), αὗται φήσουσι κεφαλὴν ἀλγέειν; 42 (L. 9.72.11), φήσει πολλάκις ἀλγέειν; 42 (L. 9.72.21–22), ἐπανερέσθαι καὶ κεφαλὴν εἰ ὀδυνῶνται· φήσουσι γάρ. Pain is an experience where the patient’s (and the physician’s) choice of words become especially pregnant. For further discussion on this topic see Roby (Chapter Eleven), 304–322 in this volume. 45  Representatively, see Sullivan, S. D. (1995). Psychological and Ethical Ideas: What Early Greeks Say; id. (1997). Aeschylus’ Use of Psychological Terminology: Traditional and New; id. (1999). Sophocles’ Use of Psychological Terminology: Old and New; id. (2000). Euripides’ Use of Psychological Terminology for a survey of tragic and early philosophical usage of καρδία respectively. 46  See Mattern (Chapter Six in this volume) on patient anxiety in ancient medicine, 203–223.

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5.3 Actorial Analepsis/Prolepsis47 Some passages are narratologically even more complex; the impression is that these are cases in which psychology, emotions and moods are foregrounded. Parmeniscus, a patient whose report offers an instructive illustration of depressive mood, appears in both Epid. 5 and 7. It is here interesting to compare the shortened and probably derivative passage in Epid. 5, 84 (L. 5.252.5–6 = Jouanna 39, 1–2) with the ‘longer version’ and speculate on the strategies of reporting at work in it. The short version: Παρμενίσκῳ καὶ πρότερον ἐνέπιπτον ἀθυμίαι καὶ ἀπαλλαγῆς βίου ἐπιθυμίη, ὁτὲ δὲ πάλιν εὐθυμίη (“to Parmeniscus it had happened also before to have low mood and desire to take his own life, and then again positive mood”). In the longer version at Epid. 7, 89 (L. 5.446.7–17 = Jouanna 103, 6–18) we find a recapitulative section in the second part, in which Parmeniscus is shown to discuss his previous state after the improvement: even though he lay still and facing away (he appears to be pointing out afterwards), he was vigilant and could recognise people all along (ἔφη δ᾿ ὕστερον ἐπιγινώσκειν τοὺς ἐσιόντας. In this small ἔφη δὲ ὕστερον, (“but he said afterward”) every word deserves italics: the particle δέ that establishes a correction, or a requalification of what the doctor had noted; the verb ἔφη that foregrounds communication of an otherwise inaccessible fact; and the adverb ὕστερον that gives us a glimpse of a therapeutic process that is ongoing, lasts across a long period of time, and contemplates post eventum discussion between patient and physician. 5.4 Anamnesis There are practical pieces of information that would arguably remain inaccessible without the direct cooperation of the patient. The best example is the anamnestic narrative—or aspects of anamnesis—the material that has to be provided by the patient or his or her entourage. In this sense, anamnesis is a form of extended analepsis. An example of extraordinary expansion is that at Epid. 5, 25 (L. 5.224.6–13 = Jouanna 15, 16–26), a female patient with a gynecological complaint: Ἐν Λαρίσῃ ἀμφίπολος Δυσήριδος, νέη ἐοῦσα, ὁκότε λαγνεύοιτο περιωδύνει ἰσχυρῶς, ἄλλως δὲ ἀνώδυνος ἦν. ἐκύησε δὲ οὐδέποτε. Ἐξηκονταέτης δὲ γενομένη, ὠδυνᾶτο ἀπὸ μέσου ἡμέρης ὡς ὠδίνουσα ἰσχυρῶς· πρὸ δὲ μέσου 47  Analepsis: “the narration of an event which took place before the point in the story in which we find ourselves”. Prolepsis: “the narration of an event which will take place later than the point in the story in which we find ourselves”. Both analepsis and prolepsis can be narratorial (made by the narrator) or actorial (made by characters).

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ἡμέρης αὕτη πράσα τρώγουσα πολλά· ἐπειδὴ ὀδύνη αὐτὴν ἔλαβεν ἰσχυροτάτη τῶν πρόσθεν, ἀναστᾶσα ἐπέψαυσέ τινος τρηχέος ἐν τῷ στόματι τῆς μήτρης. ἔπειτα, ἤδη λειποψυχούσης αὐτῆς, ἑτέρη γυνὴ καθεῖσα τὴν χεῖρα ἐξεπίεσε λίθον ὅσον σπόνδυλον ἀτράκτου, τρηχύν· καὶ ὑγιὴς τότε αὐτίκα καὶ ἔπειτα ἦν. In Larissa, the servant of Dyseris, when she was young, whenever she had sexual intercourse suffered much pain, but otherwise was without distress. And she never conceived. When she was sixty she had pain from midday onwards, like strong labour pain. Before midday she had eaten many leeks. When pain seized her, the strongest ever, she stood up and felt something rough at the mouth of her womb. Then, when she had already fainted, another woman, inserting her hand, pressed out a stone like a spindle top, rough. She was immediately and henceforth healthy. This case is a great concentrate of patient information. The pathological past in a realm that is especially sensitive (sex life, conception), with subjective notes (pain during intercourse, lack of distress); as well as the intrusion of the physician—she could not herself compare the pains to those of labour, having never conceived (or was it suggested by someone else?)—and the pain, “the greatest ever”, registered seemingly in its present insurgence. 5.5 Implicit Embedded Focalisation Finally, in the portrayal of the patient stand out those internal bodily experiences that must come directly from the experiencing patient, and cannot be the object of the physician’s direct appraisal—a separation, here, between the fabula and the main story:48 καὶ τὰ σπλάγχνα δοκεῖ οἱ κρέμασθαι, for example, at Vet. Med. 10 (L. 1.592.17 = Jouanna 131, 2–3), “it seems to him that his intestines are hanging”, in the description of a typology of patient, is one such example. Along similar lines, the common use of the verb δάκνω, (“to bite”), for stinging pain, or terms such as νυγμός (“sting”, a symptom repeatedly found in the gynecological texts) fall under this category. Other topics have by their own nature a subjective core that cannot be imposed externally: volition (i.e. wanting, desiring, or refusal) and awareness; refusal to communicate, silences; emotions, sensorial perceptions and their metaphors, as well as the sense of one’s bodily presence. These are there to remind us of that ingredient in the patient cases that resists organisation into 48  Fabula: “all the events which are recounted in the story, abstracted from their disposition in the text and reconstructed in their chronological order”. Main Story: “the events which are told by the narrator”.

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a pre-ordained schema. Even if intentionality and drives are not at the fore in these accounts, or perhaps precisely because of this, when they are found, they place an emphasis onto the patient as focaliser. Let us give some examples: at Epid. 7, 10 (L. 5.382.10–11 = Jouanna 58, 18–19) a patient is presented as φάμενος δὲ θέλειν τι ἑωυτῷ ὑπελθεῖν (“saying however/still that he wanted something to be put under him”). At Epid. 7, 5 (L. 5.374.22–23 = Jouanna 54, 13–15) we read τῇ δὲ φωνῇ κατὰ τὸν χρόνον τοῦτον εἰ μὲν σφόδρα ἀπεβιάσαιτο εἶπεν ἂν τελέως ἃ ἐβούλετο, εἰ δὲ προχείρως, ἡμιτελέα, “with his voice in this period, if he was very forceful, he succeeded in saying what he wished, but if it was casual, it was imperfect”; at Epid. 7, 11 (L. 5.384.17–19 = Jouanna 60, 11–13) παρηκολούθει δὲ τὸ ἀγριοῦσθαι καὶ τὸ θυμαίνειν καὶ κλαίειν εἰ μή οἱ ταχέως ὅ τι βούλοιτο ῥεχθείη, “ . . but she persisted in her wildness, her anger and tantrums if what she wanted was not done for her quickly”. Another case to consider is the ability (or lack thereof) to recognise one’s family and friends as indicator of health or illness, as in the case of Cydis’ son, a patient who, we read, could at times not recognise anyone (οὐκ ἐπεγίνωσκεν οὐδένα, Epid 7.5, L. 5.374.7 = Jouanna 53, 20–21). Anger, fear, sadness and despair are the dominant emotional spectrum of the Epidemics patient. If anger has a strong physiological, therefore visible, component, fear and especially grief and hopelessness are deeply introverted and inner emotions. At Epid. 3.17, case 11 (L. 3.134.2 = Kühlewein 241, 4–5) the patient is a γυνὴ δυσάνιος (“a refractory/uneasy woman”), whose illness is ἐκ λύπης μετὰ προφάσιος, “following a grief for a reason” (i.e. a loss, as opposed to general, unmotivated depression). Such remark suggests that the doctor knows perhaps about a loss the patient has suffered, and about her mental reactions to it.49 On a different level, sensorial abilities are meticulously reported in the Epidemics. If blindness and deafness proper could be a diagnosis that does not necessitate the voicing of a patient’s experience, the full range of visual impairment and disturbances these physicians took care to describe—ἀμβλύς, ἀμαυρόω, οὐ/οὐκ ὀξέα ὀρᾶν/βλέπειν, σκοτόδινος (which we can translate with vertigo), δῖνος (whirling, swooning),50 μαρμαρυγή (“flashes of light”/“sparks”), ἀστραπή, ἰλλαίνω and cognates and auditive phenomena (e.g. οὐκ ἀκούειν, κωφός, βαρυήκοος, βαρυηκοΐα, βαρυηκοέω; ἦχος, βόμβος, ψοφός)—must reflect an attempt to create order among the various self-reports the patients would give.

49  Likewise, at Epid. 3.17, case 15 (L. 3.142.7 = Kühlewein 244, 1–2) we find a woman whom a “fever with shivers and of the acute kind took hold of, following a grief”, πυρετὸς φρικώδης, ὀξύς, ἐκ λύπης ἔλαβεν. 50  Also Acut. (spur.) 17 (L. 2.426.8 = Joly 76, 5), δῖνοι.

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6.1 Explicit Embedded Focalisation The self-fashioning of the doctor, narrator and main focaliser51 is naturally more straightforwardly detected. Perhaps the most evident, and safest indicators of the physician function are those items which we might call ‘epistemological’ or ‘meta-cognitive’, which expose, that is, the process of thinking, evaluating, formulating an opinion, or knowing the medical truth about the patient. These emerge through the use of pronominal expressions or functionally equivalent features by which the narrator (and, here, focaliser too) is exposed and through the use of relevant verbs, especially forms of οἶδα (“I know”) and forms of δοκεῖ (“it seems to him/her”). The emphatic ἐγώ occurs only seven times across all seven books of the Epidemics, and in six occurrences it is used in conjunction with such forms: οἶδα (four times), οἶμαι (once), εἶδον (once). We can definitely see it as forceful insertion of the author adopting a scientific posture.52 The emergence of the first person more generally has an epistemological value—it is a marker of scientific inquiry and possess of knowledge but also, in negative, can indicate the physician’s presence through failure, impasse or pure and simple ignorance of facts. Some examples: at Epid. 2, 2.3 (L. 5.84.8–9), οὐκ οἶδα ποσταίῃ, “I do not know for how many days”; likewise at Epid. 4, 13 (L. 5.150.22), ποσταῖος οὐ γινώσκω; at Epid. 4, 6 (L. 5.146.11–12), “how many months pregnant, I don’t know”, ὁποσάμηνον οὐκ οἶδα. . .; “she said that she had lost another baby, a male, towards the twentieth day. I do not know whether that was true”, εἰ ἀληθέα οὐκ οἶδα‘; at Epid. 4.26 (L. 5.170.9), εἰ δὲ καὶ εἶχέ τι νήπιον, οὐκ οἶδα, “whether she was carrying a baby, I do not know”; at Epid. 7, 24 (L. 5.394.5 = Jouanna 66, 2), “I don’t remember which of the two cheeks was red”, ὁποτέρη οὐ μέμνημαι. Not only ignorance, but even mistake is conveyed through the explicit first person.53 Such is the case in Epid. 5, 27 (L. 5.226.10–11 = Jouanna 17, 1–3), τοῦτο παρέλαθέ με δεόμενον πρισθῆναι· ἔκλεψαν 51  Narrator: “the representative of the author in the text (the primary narrator-focaliser)”; Narrator-text: “those parts of the text which are presented by the narrator, i.e. the parts between the speeches”. Focaliser: “the person (the narrator or a character) through whose eyes the events and persons of a narrative are seen”. 52  The dative μοι occurs five times in the seven books, always with forms of δοκέω; the accusative με occurs four times, all used as direct object of verbs of visiting (with reference to the doctor). 53  On admission and discussion of errors in Hippocratic medicine see Lo Presti, R. ‘The physician as teacher. Epistemic function, cognitive function and the incommensurability of errors’, in Horstmanshoff, M. (2010). Hippocrates and the Medical Education, 137–68.

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δέ μευ τὴν γνώμην, (“it escaped my notice that I should trephine; because it failed my understanding . . .”). The effect might be at times merely to express caution, e.g. when giving an approximation on irrelevant facts, as at Epid. 2, 2.18 (L. 5.92.2), “she lived, ὡς ἐγὼ οἶμαι, in Archelaos’ property”; or when reporting unsure details, as in the case of Epid. 7, 42 (L. 5.408.22 = Jouanna 77, 12), “I believe around the fourteenth day”, ὡς οἶμαι. Occasionally, this feature exposes more radical tentativeness: “he was practically without fever and pain, because his seat was inflamed—or so I interpret it”, τοῦτο λέγω (Epid. 4, 41, L. 5.182.15): in this last case, the doctor explicitly puts his hands up as he passes judgment on the patient’s lack of pain and its causes. δοκεῖ (“it seemed (to me) that”) returns here in its capacity as expression of external judgment, and conveys the doctor’s point of view. Consider some examples: at Epid. 1, 13, case 1 (L. 2.682.8–9 = Kühlewein 202, 15–16) τρίτῃ . . . ἔδοξε γενέσθαι ἄπυρος, (“on the third day . . . he appeared to have lost the fever”); or in Epid. 3, 1, case 2 (L. 3.34.8 = Kühlewein 216, 6), πάντα ἔδοξε κουφισθῆναι (“he seemed to be relieved in all respects”); in Epid. 2.3, 13 (L. 5.114.17), μὴ ἑστάναι ἔδοξεν ἀπόστασις (“there seemed to be no apostasis that stayed”); and Epid. 5, 50 (L. 5.236.16 = Jouanna 23, 22), ἔδοξεν ἄμεινον ἔχειν (“it seemed to get better”), as well as in Epid. 7, 25 (L. 5.394.15–16 = Jouanna 66, 13–14), πέμπτῃ πρωΐ ἐδόκει ἠπιώτερος εἶναι (“early on the fifth day the fever seemed milder”); and so on. All these are potentially ambiguous from a syntactical point of view—the patient, in theory, might also be the subject of these impressions. In some cases, however, the reference to the physician as the source of the opinion expressed here appear undoubtedly to be the most plausible: the past tense for the assessments of pathological severity, especially concerning fever; the use of the technical term apostasis, where the aorist expresses the evaluation of the physician and in particular caution at an optimistic prognosis in a case that than develops badly. However, a statement such as “it seemed to get better” must remain open. The focalising role of the physician is explicit in those cases in which a contrast between prevision and outcome is made. See, for instance, Epid. 5, 31 (L. 5.228.20–21 = Jouanna 18, 18–19), καὶ παρέκοψε καὶ ἔθανεν· ἐδόκει δ’ ἂν ἐκφυγεῖν τὸ νόσημα (“he was deranged, and died; while it had seemed he would escape the disease”); or Epid. 4, 3 (L. 5.146.3–4), ἐδόκει ἔμπυος ἔσεσθαι, οὐκ ἐγένετο (“it appeared he would become purulent; he did not”). Ιn this last case, the technical term ἔμπυος reinforces that this is the doctor’s and not the patient’s impression to be disproven by facts. Both examples contain an element of prolepsis as well as one of ‘if-not’ situation that heighten suspense and intensity.54 54  ‘If not’ situation: “there X would have happened, if Y had not intervened”. Often a pathetic or tension-raising device.

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All these elements work as proleptic “seed”55 presented after the outcome, and in negative, with a pathetic effect, thus allowing for a didactic function: the students or colleagues in the audience should beware of interpreting the given sign or ‘seed’ in that way, or univocally in that way. The use of technical terms in association with evaluative expressions, thus, is always a key signal for a physician’s viewpoint. Such is the case at Epid. 5, 87 (L. 5.252.16–17 = Jouanna 40, 2), ἐκ μελαγχολικῶν δοκεόντων εἶναι καὶ τοιούτων καὶ τοσούτων. . . (“after what seemed to be a melancholic affection of that kind and degree . . .”), or explicitly at Epid. 5, 14 (L. 5.212.20–21 = Jouanna 8, 19–20): Ἱπποσθένης περιπλευμονίῃ ἐδόκει τοῖσιν ἰητροῖσιν ἔχεσθαι. ἦν δὲ οὐδαμῶς (“Hipposthenes seemed to the physicians to have peripleumonia; but that was not the case”).56 6.2 Character Language An important indicator is the use of technical as opposed to non-technical language. Hunter remarks that this important and indisputable indicator of a physician’s contribution to the dialogue is increasingly obfuscated in many contemporary patient reports, as nowadays laymen (in Western urban contexts, at least) tend to appropriate language and concepts of science (to what degree of true understanding, is a matter of debate).57 This was not in any way the case for our ancient patients. Hence, the use of terms we can clearly detect as technical should be safely taken as reflective of the doctor as focaliser. The use of expressions that appear to be out of the ordinary, like ἵδρυσις, for instance, a metaphorical usage of a term coming from architecture to indicate composure and calm (e.g. at Epid. 3, L. 3.138.13 = Kühlewein 242, 24), or παρακρούσις, common for derangement in Epidemics and not found much anywhere else: all these contribute to a ‘character language’ typifying the physician, in a way different from what we expect from technical vocabularies, but to a similar effect.

55  Seed: “the insertion of a piece of information, the relevance of which will only later become clear. The later event thus prepared for becomes more natural, logical, or plausible (a form of prolepsis)”. 56  Similar cases are found at Epid. 7, 26 (L. 5.398.5–6 = Jouanna 68, 13), ἐδόκει ῥηγματώδης εἶναι (“he appeared to have some fissuring”), or Epid. 4, 30 (L. 5.174.6–7): ἰσχίου δὲ καὶ σκέλεος, ὑστερικὰ ἦν, δοκέοντα ἀλγήματα εἶναι (“pains that seemed to be related to the state of the womb appeared in her hip and leg”). 57  Hunter, Doctors’ stories, 14: “the existence of these two narratives [the physician’s and the patient’s, i.e.] is obscured by the adoption of the terms of scientific medicine into the folk beliefs of Western culture”.

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6.3 Rhythm58 Rhythm, the way in which the narrative relates to the fabula, to the actual facts, is also a focalising feature that can only stem from a source that posits itself as external and authoritative. Rhythm can be detected in the very chronological frame of the report: the varying choice of which days to observe, and the consequent organisation of anamnestic elements, prognosis, present pathology and post-eventum comments in succession. The use of adverbs and expressions of intensity and the comments denoting progress and deterioration all contribute to imparting structure and pace to the narrative. 6.4 Managing the Patient’s Utterances The references to whether patients speak or not—a matter entirely different from our earlier discussion of what they say—are also worthy of consideration. The decision about which silences and voices deserve mention is an important underlying element of control. Most explicitly so are the questions directly posed to the patient, found also outside the Epidemics: frequent examples come from Prorrh. 2, e.g. 42 (L. 9.72.16), ἐπανερέσθαι οὖν περὶ τῆς τοῦ αἵματος ῥήξιος, “but ask about the blood”. This information on communication or lack thereof points to overt occasions in which the patient has the chance to contribute his or her information to the report, but also marks the reaffirmation of the physician’s strong role as focaliser of the story, since embedded focalisation, the introduction of a viewpoint internal to the story, participates notoriously in both. The given information on speaking or not speaking feeds also into this aspect: the common expressions πολλὰ λέγει, (“s/he says many things”), λόγοι (πολλοί), παραλήρειν or λῆρος, and even φλυαρεῖ (“delirium, s/he talks nonsense”) and, at the other end of the spectrum, the silences and the refusal to talk (σιγή, σιγάω, οὐκ ἀποκρίνετο, ἀναυδίη), but also the refusal to reply:59 all these expose the filter of the physician who decides, at a given moment, to tune the narrative onto the patient and his/her communication, or lack thereof. When, at Epid. 2, 3, 2 (L 5.104.9) the writer says ἐῶ τὰ πλεῖστα, (“I pass over most things”)—not in a patient case however, but here discussing drugs—we have a glimpse of what must be continuously happening in a teaching context where a didactic agenda dictates topics and creates focus. Accordingly, not all

58  Rhythm: “the relation between text-time and fabula-time. An event may be told as a scene (text-time=fabula-time), summary (text-timefabula-time) or ellipsis (no text time matches fabula time)”. 59  Like at Epid. 3, 1 case 2 (L. 3.36.6 = Kühlewein 216, 13–14), διαλέγεσθαι οὐκ ἠδύνατο; Webster 177–179 in this volume.

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information is regarded as valuable. At Prorrh. 2, 3 (L. 9.12.11–12), for instance, the author devotes a section to comment on how one can detect the import of patient disobedience in the case of patients lying ill in a fixed place (ἄνθρωπον κατακείμενον ἐν τῷ αὐτῷ, 10–11): the physician later dismisses ‘confessions’ or reports of petty infractions as preposterous and of no consequence, so irrelevant that he listens and laughs when they are announced to him, τὰς δ’ ἀκριβείας κείνας ἀκούω τε καὶ καταγελῶ τῶν ἀπαγγελλόντων (Prorrh. 2, 4 (L. 9.14.10–11).60 6.5 Professional self-reflectiveness References to the professional frame (such as engagement with colleagues and comments on the medical acts performed) are also significant for our purposes. In several cases, for exemple, the physician makes prognosis (prolepsis, narratologically) or reflects backwards on the ‘roads not taken’ or on previous false impressions (analepsis). Especially in Epid. 2, 4 and 6 this professional and competitive component is very strong.61 The work of colleagues is mentioned, pondered, rated and often plainly criticised. A few good examples can be found in Epid. 7, 123 (L. 5.468.5–6 = Jouanna 118, 4), ὁ ἱητρὸς οὐ ξυνεῖδεν, (“the doctor did not realise” (and the patient died); in Epid. 5, 14 (L. 5.212.20–21 = Jouanna 8, 19–20), “it seemed to the doctors that it was peripleumonia, but it was false”; at Epid. 5, 28 (L. 5.226.20=Jouanna 17, 14), on the other hand, “it was rightly recognised as needing trephination”, ἐγνώσθη ὀρθῶς. One could mention several remarks in which ἐδόκει or analogous expressions refer to the false impressions received by a physician, or to surprising outcomes; implicitly, even a case like the one found in Epid. 5, 46 (L. 234.10 = Jouanna 22, 8, παραδοξότατα ἐσώθη, “he survived against all expectations”) inserts a strong focalisation of the point of view of the professional health provider.62 ἐδόκει can also 60  See also Prorrh. 2, 2 (L. 9.10.13–15) on ‚hearing‛, καίτοι γε ἀκούω καὶ ὁρῶ οὔτε κρίνοντας ὀρθῶς τοὺς ἀνθρώπους τὰ λεγόμενά τε καὶ ποιεύμενα ἐν τῇ τέχνῃ οὔτ’ ἀπαγγέλλοντας, “and indeed I know, both by what I hear and by what I see, that people neither judge correctly what is said and done in medicine, nor report it accurately”. 61  See Manetti, D. (1990). ‘Data-recording in Epid. 2, 2–3: some considerations’, in Potter, P. et al. (1990). La Maladie et les Maladies dans la Collection Hippocratique, 149 on some important questions on the topic, with reference to Epid. 2. 62  The same posture can be conveyed by other means, of course, that we cannot exhaustively review here: even only the particle δέ can bring in a world of disattended prognosis, as in the case of Timocrates in Epid. 5, 2 (L. 5.204 = Jouanna 3, 2–5), ἐν δὲ τῷ ὕπνῳ οὐκ ἐδόκει τοῖσι παρεοῦσιν ἀναπνεῖν οὐδὲν ἀλλὰ τεθνάναι, οὐδ’ ᾐσθάνετο οὐδενὸς οὔτε λόγου οὔτ’ ἔργου· ἐτάθη δὲ τὸ σῶμα καὶ ἐπάγη. ἐβίω δὲ καὶ ἐξήγρετο: the patient “did not seem in his sleep to those who were there to be breathing, but to have died. He perceived nothing, speech or action, and his body was stretched out and rigid. But he survived and waked up”. Within three lines of text three subjectivities appear, kept together by that δέ, which

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underline one’s viewpoint for caution or modesty—“I, for one, thought that . . .”, like at Epid. 5, 95 (L. 5.254 = Jouanna 42, 5–7): ἐδόκει δέ μοι ὁ ἰητρὸς ἐξαιρέων τὸ ξύλον ἐγκαταλιπεῖν τι του δόρατος κατὰ τὸ διάφραγμα. Αλγέοντος δὲ αὐτοῦ, πρὸς τὴν ἑσπέρην ἔκλυσέ τε καὶ ἐφαρμάκευσε κάτω, “it seemed to me that the physician who took out the wood left a piece of the shaft in the diaphragm, and the patient thought that too. The physician gave him an enema towards the evening and a drug by the bowel . . .”. We have here a first narrating physician and his own judgment, a second physician who had underperformed his operation, and a third one at work—whether this last is identical to either of the first two, it is impossible to say; perhaps, as the texts seems to suggest,63 we might even have the viewpoint of the patient in agreement with the narrator. The result is an especially rich example of the narratological complexity these texts can reach. At Epid. 6, 8, 32 (L. 5.356.12–15 = Manetti-Roselli 194, 10–14), instead, the verb of opinion serves the purpose of depicting a medical consensus about the therapy to apply. This move, if it does not entirely lift individual responsibility for the ensuing failure, may make it lighter: ἐδόκει δὲ πᾶσι τοῖσιν ἰητροῖσιν, οἷσι κἀγὼ ἐνέτυχον, μία ἐλπὶς εἶναι τοῦ γυναικωθῆναι, εἰ τὰ κατὰ φύσιν ἔλθοι· ἀλλὰ καὶ ταύτῃ οὐκ ἠδυνήθη, πάντα ποιούντων, γενέσθαι, ἀλλ’ ἐτελεύτησεν οὐ βραδέως, (“it seemed to all doctors, among which I also found myself, that there was only one hope to restore her womanhood, if normal menstruation would occur: but in her case too it was not possible, though we did everything, but she died quickly”). Sometimes the judgment a posteriori is left open (a case of ‘if-not’ situation), as in Epid. 5.15 (L. 5.214.18–19 = Jouanna 10, 7–8), ἐδόκει δ’ ἂν πλείονα χρόνον διενεγκεῖν εἰ μὴ κατὰ τοῦ φαρμάκου τὴν ἰσχύν (“it seemed that he would have survived longer if not for the strength of the medicine”). 6.6 The Third Parties At Epid. 6, 2, 24 (L. 5.290.4–6 = Manetti-Roselli 46, 1–3) we find a list of aspects on which a medical inquiry should be conducted: “what is explained, what kind of things, how it must be accepted; the reasoning/words; what relates to the patient, what relates to those who are present, and to people elsewhere” (ἡ περὶ

convey respectively the lack of consciousness, or sensorial perception, on the part of the patient; the insight of those present; or the narrating physician, who (wrongly) expected death or continuation of the comatose state. 63  Jouanna corrects MV’s δοκέοντος here with ἀλγέοντος, found in MV for the homologous case in Epid. 7, 121 (and kept by Smith); he explains why we should consider Epid. 7 closer to the original in 13–15. See n. 39 above.

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τὸν νοσέοντα οἰκονομίη καὶ ἐς τὴν νοῦσον ἐρώτησις· ἃ διηγεῖται, οἷα, ὡς ἀποδεκτέον, οἱ λόγοι· τὰ πρὸς τὸν νοσέοντα, τὰ πρὸς τοὺς παρεόντας, καὶ τὰ ἔξωθεν).64 There is an additional element in the ways these cases are narrated: the ‘others’, the third parties, who are far from being mute spectators and are important, at times crucial, sources of information, elements of interaction, and actors in the scientific debates or recipient of the doctor’s didactic gestures. This composite internal audience has not often been given the prominence it deserves by scholarship on these cases and on the practice of Hippocratic medicine, which focused more on the so-called “triangle” ’65 that joins disease, patient and physician in a Spiel of effort and counter-effort (ὁ ἱητρὸς ὑπηρέτης τῆς τέχνης· ὑπεναντιοῦσθαι τῷ νουσήματι τὸν νοσεῦντα μετὰ τοῦ ἰητροῦ). The triangle becomes thus rather a ‘quadrangle’, or, in any case, a schema of greater complexity and much less clear internal relationships. A net of competing centres of attention emerges in the background of the Epidemics. First, the family and friends of the patient. For example, at Epid. 1, 13 case 5 (L. 2.694.4–6 = Kühlewein 206, 17–19) the reference to the bystanders as source becomes explicit: Ἐπικράτεος γυναῖκα. . .περὶ τόκον ἐοῦσαν, ῥῖγος ἔλαβεν ἰσχυρῶς, οὐκ ἐθερμάνθη ὡς ἔλεγον (“the wife of Epicrates . . . when near her delivery was set with sever rigor without, it was said, becoming warm . . . ”. In the case of the daughter of Euryanax, the reference to what others said is used rather to express caution, ἔλεγον δὲ γευσαμένην βότρυος, “they said that she suffered this after having eaten grapes”—as the eating of a specific food is proposed as possible cause for an illness with fever and delirium (Epid. 3, 2, case 6 (L. 3.50.11 = 220, 15–16 Kühlewein). Even when the reference is not explicit, however, the contribution of the family is visible. In the reports on sleep, for example, especially when they are daily (or even offered several times a day) and stretch over longer periods the imput of family members must have been necessary. Long anamnestic sections also lead us to third cooperating voices, like in the case of Apollonius in Epid. 3, 17, case 13 (L. 3.140.10 = Kühlewein 243, 9), where the narrative opens with the patient’s suffering, including pieces of information such as “he was ailing for a long time”, or “he adopted a thoroughly bad regimen”, which seem difficult to have been gathered from him, especially as he lay prey to forgetfulness and delirious throughout (διὰ τέλεος). We should, therefore, often count for this additional dimension, that of a co-authoring 64  See Manetti-Roselli ad loc. on this passage as expressive of the importance of the patient’s words. 65  Epid. 1, 5 (L. 2.634.6–636.4 = Kühlewein 189, 24–190, 3–6); cf. the classic D. Gourevitch (1984), Le triangle hippocratique dans le monde gréco-romain: le malade, sa maladie et son médecin.

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internal audience participating in the creation of the main story. Sometimes this audience is illumined as if by a flash of lightning: at Epid. 5, 95 (L. 5.256.2 = Jouanna 42, 9–10), the patient “seemed to the physician and others to be better” (ἐδόκει καὶ τῷ ἰητρῷ καὶ τοῖσιν ἄλλοισι βέλτιον ἔχειν). This is a case where we have already noticed a polemical engagement among physicians, with the narrating voice possibly coming from a third party. We have here possibly the additional presence of a group of bystanders comprising family members or students of the attending physician (οἱ ἄλλοι seems to suggest a categorical difference from ὁ ἱητρός). Another example is a patient we have already mentioned, that of Epid. 5.2 (L. 5.204.13–15 = Jouanna 3, 2–5). He is at the center of a web of perceptions—his own, and that of others: “in sleep he did not seem to those who were present to be breathing, but to have died. He perceived nothing, speech or action, and his body was stretched out and rigid” (ἐν δὲ τῷ ὕπνῳ οὐκ ἐδόκει τοῖσι παρεοῦσιν ἀναπνεῖν οὐδὲν ἀλλὰ τεθνάναι, οὐδ’ ᾐσθάνετο οὐδενὸς οὔτε λόγου οὔτ᾿ ἔργου· ἐτάθη δὲ τὸ σῶμα καὶ ἐπάγη). The patient and οἱ παρέοντες are symmetrical focuses from which the medical scene is observed: lack of sensorial feeling, from the first and corpse-like appearance, in the second case. The case of very young patients is also to the point: in these cases the participation of family is greater and even necessary in the case of smaller children. This intrusion, however, is not always declared. See for example Epid. 7, 117 (L. 5.462.21–23 = Jouanna 114, 7–10): τῷ Δεινίου παιδίῳ ἐν Ἀβδήροισι μετρίως ὀμφαλὸν τμηθέντι συρίγγιον κατελείφθη· καί ποτε καὶ ἕλμις δι’ αὐτοῦ διῆλθεν ἁδρή· καὶ ἔφη, ὅτε πυρέξειε, χολώδεα ὅτι καὶ αὐτὰ ταύτῃ διῄει, “Deinias’ child in Abdera: when a small incision was made at his navel a small fistula was left behind. Once a full-sized worm came through it. And he said that whenever he was feverish actual bilious material came out of it . . . ”. Who is this last speaking part? Not the child, surely. Perhaps it is a parent, if we can attribute to him knowledge and use of the seemingly technical concept of “bilious mate­rial” (χολώδεα); unless, this is a reported information from a relative recasted by the physician in the language of the profession—a case of ‘simultaneous translation’ into professional idiom that is always at work in patient reports (ancient and contemporary), and surely is active everywhere in the texts we are examining, even when not signaled like in this case. Alternatively, the ‘he’ could be a professional interlocutor, another physician the writer is in dialogue with; although no other reference to him is made. A counterexample to such explicit reference to the voice of the patient or his family could be found in Epid. 7, 52 (L. 5.420.20–21=Jouanna 84, 14–16), the case of an infant patient who ἀρρωστέων δὲ αἰεὶ τῇ χειρὶ κατῆγε κατὰ τοῦ βρέγματος. . .οὐκ ἤλγει δὲ τὴν κεφαλήν (“while he was sick he kept drawing down with the hand from the front of his

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head . . . but he had no pain in the head”): the latter is an impossible assumption to make about the behaviors of others and their causes, and all the more in the case of a baby. This additional audience, as mentioned above, is not only a familial one but can be also constituted of students, or colleagues. We have seen mentions of interaction among competing or cooperating physicians. There are also elements of a didactic or epideictic nature that evoke a teaching context, especially in the form of questions. These are especially frequent in Epid. 2, 4 and 6,66 where they are inserted into the discussions of individual patients. One such case is the one at 2, 9 (L. 5.88.11–12), ἐρωτήματα· ἤρεον γὰρ αὐτοὺς ἀεὶ πληροῦσθαι ποτοῦ καὶ σίτου; “question: is it easier always to satiate with drink or with food?”. This question reads like a general reflection, and may be an addition made at a later stage in the redaction of the text, but may also equally have generated from the specifics of the encounter with the patient, with the debate and didactics the visit could include. Likewise, at Epid. 2, 2, 10 (L. 5.88.13–14) the author asks “how can one recognise very serious pains by seeing them?” (ὀδύνας τὰς ἰσχυροτάτας, ὅτῳ τρόπῳ διαγνοίη ἄν τις ἰδών;). If these questions may sound more general, there are also clinical ones attached more tightly to individual cases which evoke more unequivocally the context of the medical encounter, such as Epid. 2, 3, 11 (L. 5.116.8–9= Smith 56, 7–8), if we take, with Smith, the phrase as interrogative: “does such excrement indicate crisis, like in the case of Antigenes?”, τὸ τοιοῦτον ἦ κρίσιμον, ὅτι καὶ τὸ Ἀντιγένεος;). These features of openness and dialectic are absent from Epid. 1 and 3 (as, in general, is explicit professional self-reflectiveness), and echo directly the interaction between a physician and an audience of students—during the visit, at a later stage or both. In this way, the patient cases in books 2, 4 and 6 expose openly the in-and-out traffic, so to say, in the creation of these patient narratives: not only the disease, the patient, and the physician; but also a complication of competing medical voices, professional and belonging to students, as well as coming from family and bystanders of unclear status.

66  See Alessi, R. (2010). ‘Research program and teaching led by the master in Hippocrates Epidemics 2, 4 and 6’, in Horstmanshoff, M. (2010). Hippocrates and Medical Education, 119–36 on the didactic milieu we can reconstruct from Epidemics 2, 4 and 6. See, in addition, Epid. 7, 57 (L. 5.424.5–6 = Jouanna 86, 4–6) (and 5, 77), ἧρά γε ἐν πᾶσι τοῖσιν ἐμπυήμασι καὶ τοῖσι περὶ ὀφθαλμὸν ἐς νύκτα οἱ πόνοι, “is it true that in all suppurations, including these around the eye, the distress comes towards night?”.

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7 Conclusions This analysis has hopefully shown that these texts can in no way be simplistically seen as blind to the point of view of the patient. Yes, they are more explicitely reflective of the systematising intentions of the physician, with his knowledge and agenda. In almost every paragraph of the Epidemics, however, we can find a shift from the physician’s function to the function of the patient which undermines this opposition. In addition, there is a degree of depth and complexity to these texts which involves a third part, a supplementary audience of professionals or family that does not always come to the fore, and yet contributes to the authoring of the narrative to an important extent. Our narratological observations will have served their aim if they have managed to illustrate a more general fact, valid outside the interpretation of the patient cases of the Hippocratic Epidemics: that it is indeed impossible to write about someone’s suffering without the writer making space, in a way or another, for the voice of the suffering individual. This is a hermeneutic model well-known to scholars who have engaged with the recovery of the voice of marginalised groups in various literatures (with feminist and gender studies serving perhaps as the best example). This methodology has been taken on variously, as we have seen, by current studies of patient case taking, bringing together the interpretation of texts as humanistic act and the interpretation of illness stories as practice of medical ethics. Its application to the history of ancient medicine is bound to yield exciting results. Texts Used Hippocrates. Ancient Medicine (Vet. Med.). Ed. and trans. J. Jouanna. Hippocrate. De l’ancienne medicine, Collection des universités de France. Paris: Les Belles Lettres, 1990. ———. The Art; Breaths (Art., Flat.). Ed. and trans. J. Jouanna. Des vents, de l’Art, Collection des universités de France. Paris: Les Belles Lettres, 1995. ———. Diseases 2 (Morb. 2). Ed. and trans. J. Jouanna Maladies 2, Collection des universités de France. Paris: Les Belles Lettres, 1983. ———. Epidemics 1 (Epid. 1). Ed. H. Kühlewein. Hipp. Opera Omnia 1, 180–245 (CMG). Leipzig: B. G. Teubner, 1894. ———. Epidemics 3 (Epid. 3). Ed. H. Kühlewein. Hipp. Opera Omnia 1, 180–245 (CMG). Leipzig: B. G. Teubner, 1894. ———. Epidemics 5 and 7 (Epid. 5, 7). Ed. and trans. J. Jouanna. Epidémies 5 et 7, Collection des universités de France. Paris: Les Belles Lettres, 2000.

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———. Epidemics 6 (Epid. 6). Ed. and trans. D. Manetti, A. Roselli. Ippocrate. Epidemie. Libro sesto. Firenze: La Nuova Italia Editrice, 1982. ———. Epidemics 2 and 4 (Epid. 2, 4). Ed. and trans. W. D. Smith. Hippocrates, vol. 7. The Loeb Classical Library 477. Cambridge, MA: Harvard University Press, 1994. ———. Nature of Woman (Nat. Mul.). Ed. and trans. F. Bourbon. Nature de la femme, Collection des universités de France. Paris: Les Belles Lettres, 2008. ———. Prorrhetikon 2 (Prorrh. 2). Ed. and trans. P. Potter. Hippocrates, vol. 9. The Loeb Classical Library 482. Cambridge, MA: Harvard University Press, 1995. ———. Regime in Acute Diseases, Appendix (Acut. (spur.)). Ed. and trans. R. Joly Du Régime des maladies aiguës, Appendice. De l’aliment. De l’usage des liquids. Cambridge, MA: Harvard University Press, 1972. For all other Hippocratic texts, I have used Littré’s edition (Œuvres completes d’Hippocrate. Ed. and trans. É. Littré, vol. 1–10. Paris: J.-B. Ballière, 1839–61.

References Alessi, R. ‘Research Program and Teaching Led by the Master in Hippocrates Epidemics 2, 4 and 6.’ in Hippocrates and Medical Education, ed. M. Horstmanshoff. Leiden: Brill (2010): 119–136. Baader, G. and Winau, R. (eds.) Die hippokratischen Epidemien: Theorie—Praxis— Tradition. Verhandlungen des 5e Colloque international hippocratique. Veranstaltet von der Berliner Gesellschaft für Geschichte der Medizin in Verbindung mit dem Institut für Geschichte der Medizin der Freien Universität Berlin, 10.–15. 9. 1984. Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989. Brody, H. Stories of Sickness. Oxford: Oxford University Press, 2003. Bruner, J. Actual Minds, Possible Worlds. Cambridge, MA: Harvard University Press, 1986. Cassell, E. J. The Healer’s Art. Philadephia: Lippincott, 1976. De Jong, I. A Narratological Commentary on the Odyssey. Cambridge: Cambridge University Press, 2001. Del Vecchio Good, M.-J. American Medicine: The Quest for Competence. Berkeley: University of California Press, 1995. Eijk, P. van der ‘Towards a Rhetoric of Ancient Scientific Discourse Some Formal Characteristics of Greek Medical and Philosophical Texts.’ in Grammar as Interpretation. Greek Literature in its Linguistic Contexts, ed. E. J. Bakker, 77–129. Leiden: Brill, 1997. Entralgo, P. L. The Therapy of the Word in Classical Antiquity. New Haven: Yale University Press, 1970. Epstein, J. Altered Conditions: Disease, Medicine, and Storytelling. New York: Routledge, 1995.

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Frank, A. W. The Wounded Storyteller. Chicago: University of Chicago Press, 1995. Good, B. Medicine, Rationality, and Experience. Cambridge: Cambridge University Press, 1994. Gourevitch, D. Le triangle hippocratique dans le monde gréco-romain: le malade, sa maladie et son médecin. Rome: Ecole française de Rome, 1984. Graumann, L. A. Die Krankengeschichten der Epidemienbücher des Corpus Hippocraticum. Aachen: Shaker Verlag, 2000. Horstmanshoff, H. F. J. ‘The Ancient Physician: Craftsman or scientist?’ in The Journal of the History of Medicine and Allied Sciences 45, (1990): 176–97. Hühn, P., Schmid, W. and Schönert, J. (eds.) Point of View, Perspective, and Focalization: Modeling Mediation in Narrative. Berlin: Walter de Gruyter, 2009. Hunter, K. M. Doctors’ stories: The Narrative Structure of Medical Knowledge. Princeton: Princeton University Press, 1991. Jori, A. ‘Il medico e il suo rapporto con il paziente nella Grecia dei secoli 5 e 4 A.C.’ Medicina nei secoli. Arte e Scienza 9.2, (1997): 189–222. Jouanna, J. Hippocrates. Baltimore and London; Johns Hopkins University Press, 1999. Kächele, H., Schachter, J., Thomä, H. From Psychoanalytic Narrative to Empirical Single Case Research. New York: Psychosozial-Verlag, 2009. Kächele, H. ‘The Single Case Study Approach as a Bridge Between Clinicians and Researchers.’ Annual Meeting of the Rapaport-Klein Study Group. Austen Riggs Center, Stockbridge, MA, June 3–5, 2011 (http://www.psychomedia.it/rapaport-klein/ Kaechele-2011.pdf, accessed 20.02.2015). Kleinman, A. The Illness Narratives: Suffering, Healing and the Human Condition. New York: Basic Books, 1988. ———. Rethinking Psychiatry. From Cultural category to Personal Experience. New York: Macmillan/The Free Press, 1991. ———. Medical Theories in Hippocrates. Berlin: Walter De Gruyter, 1990. ———. ‘Structure and Genesis of Some Hippocratic Treatises.’ in Magic And Rationality In Ancient Near Eastern And Graeco-Roman Medicine, ed. H. F. J. Horstmanshoff and M. Stol, 219–75. Leiden: Brill, 2004. Lonie, I. M. ‘Literacy and the Development of Hippocratic Medicine.’ in Formes de Pensée dans la Collection Hippocratique, ed. F. Lasserre and P. Mudry, 145–61. Geneve: Droz, 1983. Leven, K.-H. (ed.) Antike Medizin: Ein Lexikon. München: C. H. Beck, 2005. ———. ‘ “Mit Laien soll man nicht viel schwatzen, sondern nur das Notwendige”—Arzt und Patient in der hippokratischen Medizin.’ in “Krumme Touren”—Anthropologie kommunikativer Umwege (Veröffentlichungen des Instituts für Historische Anthropologie e.V., Bd. 10), ed. W. Reinhard, 47–61. Wien, Köln, Weimar: Böhlau, 2007.

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Lo Presti, R. ‘The Physician as Teacher. Epistemic Function, Cognitive Function and the Incommensurability of Errors.’ in Hippocrates and Medical Education, ed. M. Horstmanshoff, 137–68. Leiden: Brill, 2010. Manetti, D. ‘Data-Recording in Epid. 2, 2–3: Some Considerations.’ in La Maladie et les Maladies dans la Collection Hippocratique, ed. P. Potter, G. Maloney and J. Desautels, 143–58. Québec: Éditions du Sphinx, 1990. Miller, G. ‘Literacy and the Hippocratic Art: Reading, Writing and Epistemology in Ancient Greek Medicine.’ Journal of the History of Medicine and Allied Sciences 45, (1991): 11–40. Nutton, V. Ancient Medicine. Oxford: Routledge, 2004. Pigeaud, J. La maladie de l’âme. Étude sur la relation de l’âme et du corps dans la tradition medico-philosophique antique. Paris: Les Belles Lettres, 1981. Porter, R. ‘The Patient’s View: Doing Medical History From Below.’ Theory and Society 14, (1985): 175–98. ———. A Social History of Madness. The World Through the Eyes of the Insane. London: Dutton, 1987. Potter, P. ‘Epidemien 1/3: Form und Absicht der zweiundvierzig Fallbeschreibungen.’ in Die Hippokratischen Epidemien, ed. G. Baader and R. Winau, 9–19. Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989. Rood, T. Thucydides: Narrative and Explanation. Oxford: Oxford University Press, 2002. Smith, W. D. ‘Generic Form in Epidemics 1 to 7.’ in Die Hippokratischen Epidemien, ed. G. Baader and R. Winau, 144–58. Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989. Steger, F., ‘Patientengeschichte—eine Perspektive für Quellen der Antiken Medizin? Überlegungen zu den Krankengeschichten der Epidemienbücher des Corpus Hippocraticum.’ Sudhoffs Archiv 91, (2007): 230–38. Sullivan, S. D. Psychological and Ethical Ideas: What Early Greeks Say. Leiden: Brill, 1995. ———. Aeschylus’ Use of Psychological Terminology: Traditional and New. Montreal: McGill-Queen’s University Press, 1997. ———. Sophocles’ Use of Psychological Terminology: Old and New. Ottawa: McGillQueens University Press, 1999. ———. Euripides’ Use of Psychological Terminology. Montreal: McGill-Queen’s University Press, 2000. Thumiger, C. ‘Mental insanity in the Hippocratic texts: a pragmatic perspective.’ Mnemosyne, (2014): 1–24.

CHAPTER 4

Case History as Minority Report in the Hippocratic Epidemics 1 John Z. Wee Instead of being self-evident depictions of sickness, ancient medical texts were narratives created from certain points of view and for intended purposes. As a guide for the physician travelling to an unfamiliar community of people, the treatise Airs, Waters, Places anticipated “communal” conditions resulting from seasonal changes, while admitting the possibility of “personal” sickness due to individual lifestyles. Even with its geographical situatedness, Epidemics 1 continued to prioritise population narratives, subsuming sickness within the experiences of the anonymous majority whenever possible. In both its constitutions and case histories, however, patients whose conditions deviated from majority expectations were identified for forensic purposes, so that case histories functioned as minority reports rather than exemplars of how sickness behaved. Such reports guarded against surprising deviations from the rules of prognosis, which could present a threat to the physician’s credibility and livelihood as a consequence. Why is there a patient in the medical text? Are patient identities really necessary in medical writing? Large portions of the Hippocratic corpus, in fact, do a coherent job describing the human body without identifying it with any historical patient. The treatise Regimen in Acute Diseases, as we will see, employs the invented persona of a patient for the sake of illustrating how sickness behaves, while avoiding the capricious experiences of actual patients who do not always fall sick in the manner they are expected to.1 This point should give us pause to think about the complexity of using real patients as exemplars in medical writing. In the precise nosological schemes of the Hippocratic Epidemics, for example, where events such as crises, 1  Acut. 46 (L. 2.320.5–324.4 = Joly 56.3–18). The author of Regimen in Acute Diseases acknowledged that the same sickness could manifest itself differently in different regimens and complained about the practice of attaching a new name to every variation of the same sickness. See Acut. 3 (L. 2.228.2–6 = Joly 37.7–10).

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paroxysms, and intermissions are assigned to fixed days, and where their occurrences on even or odd days carry predictive significance, it may not have been that difficult to find patients who broke the rule in one way or another.2 We know today that different patients can respond differently to the same disease, whether due to their individual genetics, immunity histories, allergies, nutrition, or psychological states. To be sure, the notion of the patient as variable is not completely foreign to the Hippocratic writings, though we typically encounter patient groups (e.g. athletes, the elderly, women, and children) rather than named and identified individuals. Perhaps more so than other texts, the fourteen case histories of Epidemics 1 show us how personal narratives can perform important roles in supplementing, or even contradicting, systematised accounts about the behaviour of sickness. 1

Place, Time, and Patient

Modern medical authors have credited the treatises of Airs, Waters, Places and Epidemics 1 and 3 for making the early distinction between ‘epidemic’ and ‘endemic’ disease.3 These writings date to the second half of the fifth century BC, and they were considered authentic Hippocratic works in Erotian’s Glossary.4 The modern impression of Airs, Waters, Places may have been influenced by the words ‘endemic’ and ‘epidemic’ in W. H. S. Jones’ accessible English translation, though, in what may be a typo, ‘endemic’ is curiously used for the Greek expression ἐπιδημεῖ in one instance.5 Many have noted the ambiguity of the term ἐπίδημος itself, which could have referred not only to

2  For discussion on ‘Critical Days’, see Langholf, V. (1990). Medical Theories in Hippocrates: Early Texts and the ‘Epidemics’, 79–118. 3  Buck, C. et al. (1988). The Challenge of Epidemiology: Issues and Selected Readings, 3, 18–19; Wilkinson, L. ‘Epidemiology’, in Bynum, W. F. and Porter, R. (1993). Companion Encyclopedia of the History of Medicine, vol. 2, 1263; Morens, D. M. ‘Epidemiology’ and Parascandola, M. ‘Epidemiology’ and ‘Epidemiology, History of’, in Byrne, J. P. (2008). Encyclopedia of Pestilence, Pandemics, and Plagues, vol. 1, 201, 205. 4  περὶ τόπων καὶ ὡρῶν (line 11) and ἐπιδημίαι ζ´ (line 18) in Nachmanson, E. (1918). Erotiani vocum Hippocraticarum collectio cum fragmentis, 9. 5  See Jones’ translation “endemic” (p. 77) for ἐπιδημεῖ at Aer. 4 (L. 2.20.4 = Jouanna 193.6–7). It is tempting to understand ἐπιδημεῖ here as an error for ἐπιχώρια, which appears in a similar context in Aer. 3 (L. 2.18.1–2 = Jouanna 190.13–14). The reading ἐπιχώρια, however, does not appear as a variant for ἐπιδημεῖ (Aer. 4) in attested manuscripts.

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a ‘visiting’ sickness, but also to ‘visiting’ medical practitioners.6 Our interest here extends beyond the title Ἐπιδημιῶν to the Greek terms appearing in the narrative, which reveal to us the heuristics employed for the identification and classification of sickness. The word that corresponds to ‘endemic’ or ‘native’ conditions in Airs, Waters, Places is ἐπιχώριος, which designates “space” or “place” (χώρα or χῶρος) as its defining factor.7 This variable of geography is, in fact, the primary concern of the treatise, which goes on to set up contrastive dichotomies between north and south, and between east and west. We might suspect that much in such paradigms derives from correlative theory rather than empirical evidence, though the narrative presents its conclusions as self-evident. There is awareness, moreover, that geography alone cannot fully account for all conditions affecting the population: These sicknesses are native (ἐπιχώρια) for them. And, besides, if any communal (πάγκοινον) sickness should take hold due to a change of the seasons, they also share in this (Aer. 3, L. 2.18.15–17 = Jouanna 192.5–8) For the men, these sicknesses are native (ἐπιχώρια). And, besides, [there are] communal ones (πάγκοινον) which take hold due to a change of the seasons (Aer. 4, L. 2.22.1–2 = Jouanna 194.10–12). In the above references to seasonal changes, we do not find the term ὡραῖος (“seasonable”) or any other word that reflects a time aspect. Instead, the word used is πάγκοινος (“communal”), which draws attention to the means by which such sicknesses are recognised. Aristotle famously argued that “one swallow does not make a spring”.8 The single manifestation of a medical condition does 6  Smith, W. D. ‘Generic form in Epidemics 1 to 7’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien, 145; Langholf, Medical Theories in Hippocrates, 78–79; cf. Graumann, L. A. (2000). ‘Die Krankengeschichten der Epidemienbücher des Corpus Hippocraticum. Medizinhistorische Bedeutung und Möglichkeiten der retrospektiven Diagnose’. Med. Diss., Universität Leipzig, 35–36; Eijk, Ph. J. van der ‘Exegesis, explanation and epistemology in Galen’s commentaries on Epidemics, books one and two’, in Pormann, P. E. (2012). Epidemics in Context: Greek Commentaries on Hippocrates in the Arabic Tradition, 29. 7  For ἐπιχώρια as a description of sickness, see Aer. 2 (L. 2.14.4 = Jouanna 188.9); Aer. 3 (L. 2.18.1–2 = Jouanna 190.14; L. 2.18.15 = Jouanna 192.6); Aer. 4 (L. 2.22.1 = Jouanna 194.11). The word also describes ‘native’ winds in Aer. 1 (L. 2.12.7 = Jouanna 187.1); Aer. 4 (L. 2.18.20 = Jouanna 192.12); Aer. 15 (L. 2.62.8 = Jouanna 227.5) and ‘native’ persons in Aer. 22 (L. 2.76.14–15 = Jouanna 238.9). 8  E N 1.1098a.18–19 = Bywater 11.18–19. Of course, Aristotle’s concern here is ethical rather than medical, though the principle articulated is more broadly applicable.

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not link it to any specific time or season. Correlation between sickness and season requires the widespread occurrence of such medical phenomena in the local community at particular times of the year. This supposition also underlies the heuristics recommended at the beginning of Airs, Waters, Places: For if one (the physician) should know these things well, preferably all or at least most of them, when he arrives at a polis with which he is unfamiliar, he would not be unaware of either the native (ἐπιχώρια) sicknesses or the nature of the common ones (τῶν κοινῶν; alternative reading: τῶν κοιλιῶν, “of the bellies”) . . . As time and the year advances, he would be able to tell what communal (πάγκοινα) sicknesses will take hold of the polis, whether in summer or in winter, and what personal ones (ἴδια) will become hazardous to the individual due to a change of lifestyle, Aer. 2 (L. 2.14.1–10 = Jouanna 188.6–189.3). Again, πάγκοινος (and perhaps κοινός) appears as a variable related to time (“whether in summer or in winter”) and distinct from geography (i.e. ἐπιχώριος).9 Furthermore, the ‘communal’ aspect of πάγκοινος stands in contrast to any “personal” (ἴδιος) sickness of specific patients that cannot be adequately attributed to seasonal changes.10 Before the physician arrives at an unfamiliar polis, he may anticipate ‘native’ sicknesses based on the polis’ location and its proximity to the winds and water. Knowing the effects of heat, cold, wetness, and dryness on health, he may also predict how seasonal changes would affect the populace. Such predictions could be later corroborated or refined by the physician’s own encounters with ‘communal’ sicknesses while residing in the polis. Any ‘personal’ conditions unexplained by geography and time, however, depended on interactions with specific patients and could not be addressed beforehand in a preparatory treatise like Airs, Waters, Places. On the other hand, as we will shortly see, the situatedness of Epidemics 1 and its grounding in actual local experiences presented material for the expression of the ‘personal’ in the form 9  Note the use of ξύντροφος instead of πάγκοινος when seasonal changes are not significant (“both in summer and in winter”) at Aer. 7 (L. 2.28.3–4 = Jouanna 200.9–10). Fever is categorised as either κοινός (instead of πάγκοινος) or ἴδιος in Flat. 6 (L. 6.96.23–98.2 = Jouanna 109.5–8). 10  Priority given to the variables of place and time (i.e. seasonal change) in the classification of sickness could even cut across traditional or natural groups within a population. “Being women is a less unifying factor in etiology and nosology than is climatic exposure”, since slave women and men shared similar vulnerabilities due to their exposure outdoors, in contrast to free women who remained indoors. Hanson, A. E. ‘Diseases of women in the Epidemics’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien, 39.

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of case histories. The statements below reveal similar ways of thinking about sickness in Books 1 and 3 of the Epidemics: And it is necessary to learn well the constitution of the seasons, each one11 accurately, as well as (each case of) sickness: any good feature that is common (κοινόν) during the constitution or among (manifestations of) the sickness, any bad feature that is common (κοινόν) during the constitution or among (manifestations of) the sickness . . ., Epid. 3.16 (L. 3.102.2–5 = Kühlewein 1.232.10–14)12 . . . learning from the common (κοινῆϛ) nature of all and the personal (ἰδίηϛ) (nature) of the individual . . ., Epid. 1.10 (L. 2.668.14–670.2 = Kühlewein 1.199.10–11) The first selection implies that the beneficial or harmful quality of a feature in any constitution or sickness can be determined when the feature consistently produces the same effects in repeated cases, so that such effects may be described as “common” (κοινός) among the cases. The injunction “to learn well the constitution of the seasons, each one accurately,” suggests that what is ‘common’ can vary with time and must therefore be re-evaluated at different times. The next selection sets forth a contrast between the ‘common’ (or ‘communal’) and the ‘personal’. Though notions of the ‘communal’ in the Hippocratic Epidemics are not as exclusively associated with seasonal change as in Airs, Waters, Places, temporal variation is included as one of the factors

11  The question is whether ἑκάστην in Epid. 3.16 (L. 3.102.3 = Kühlewein 1.232.11) refers to τὴν ὥρην (“season”) or τὴν κατάστασιν (“constitution”). If the former, this would be a direct implication that what is ‘common’ changes with the season. The latter option, however, might be the more natural grammatical interpretation and finds support in the subsequent pairing of κατάστασιϛ and νοῦσος, Epid. 3.16 (L. 3.102.3–5 = Kühlewein 1.232.12–13). Even if one understands this as an injunction to learn well “each constitution of the seasons” (rather than “the constitution of each season”), it is still more likely that this passage refers to constitutions that change with each season, rather than constitutions that change with each year of seasons. Finally, Littré’s edition reflects the reading τὴν κατάστασιν τῶν ὡρέων ἑκάστης, “the constitution of each of the seasons” (L. 3.102.2–3), where it is unambiguous that “common” conditions vary with seasonal change. 12  My translation reflects the switch in Kühlewein’s edition from νόσημα “(a case of) sickness”, Epid. 3.16 (Kühlewein 1.232.12) to νοῦσος “(manifestations of) the sickness”, Epid. 3.16 (Kühlewein 1.232.13–14) when the author refers to common features shared by separate manifestations of the same kind of sickness. Littré’s edition has the noun νοῦσος in both instances (L. 3.102.3–5).

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accounting for ‘group’ conditions.13 Here again, our physician performs the work of a statistician, reasoning inductively from repeated and widespread observations to general conclusions about their value for medical practice and prognosis. These methods might even account for the eventual formulation of medical aphorisms.14 A good illustration of such means of generalisation is the following rule of thumb: In this constitution, they (the patients) recovered particularly due to four signs—either (1) a good bleeding through the nostrils, or (2) much urine from the bladder having much proper sediment, or (3) bile from disordered bowels at the right time, or (4) by becoming dysenteric, Epid. 1.9 (L. 2.656.7–658.2 = Kühlewein 1.195.21–196.2).15 In antiquity and in modern times, scholars have recognised the affinity between Books 1 and 3 of the Epidemics. Both books clearly demarcate sections of their text by the titles κατάστασις (“constitution”) and ἄρρωστοι (“(case histories of) sickly ones”). Both are meticulous in their attention to date and time references, to the patient’s development even over the period of a month or months, and to the designation of the final outcome as death, crisis, or recovery. For all their similarities, however, the precise relationship between Epidemics 1 and 3 is less clear. Littré considered Books 1 and 3 of the Epidemics to be originally a single work divided into two and proposed that they should be read in the order of “the four annual constitutions one following the other,. . .[and] finally, the forty-two individual histories without interruption”.16 This proposal to disregard manuscript forms and to group together all the constitutions and all the case histories was adopted by Sticker in his translation.17 Deichgräber 13  For a survey of ‘types’ and ‘groups’ in the Epidemics, see Langholf, Medical Theories in Hippocrates, 194–208. 14  Thivel, A. (1981). Cnide et Cos? Essai sur les doctrines médicales dans la collection hippocratique, 148–49; Roselli, A. ‘Epidemics and Aphorisms: Notes on the history of early transmission of Epidemics’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien, 182–90. 15  To be sure, we find aorist optative verbs (αἱμορραγήσαι, ἔλθοι, γενοίατο) in this passage, rather than the ‘gnomic’ or ‘empirical’ indicative aorist forms one might expect for aphorisms in the Epidemics. Langholf, V. ‘Generalisationen und Aphorismen in den Epidemienbüchern’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien, 137–39. 16  Littré, É. (1840). Oeuvres complètes d’Hippocrate, vol. 2, 537–38, 588–89 [translation mine]. 17  Sticker, G. (1923). Der Volkskrankheiten erstes und drittes Buch, 37–85. More recently, all forty-two case histories of Epidemics 1 and 3 were studied as a group without ­differentiation

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drew attention to thematic and perhaps even intertextual links between the Hippocratic work On Prognosis and Books 1 and 3 of the Epidemics, suggesting that On Prognosis was composed prior to the Epidemics.18 Arguing for a progressive development of medical doctrine within Epidemics 1, Lichtenthaeler proposed that Book 3 preceded Book 1, and that On Prognosis followed after both books.19 Dugand relied on this chronological sequence to reconstruct the travels of Hippocrates through Larissa, Meliboea, Abdera, and Thasos (places mentioned in the case histories of Epidemics 3) before his three-year stay at Thasos (the location of the constitutions in Epidemics 1).20 Langholf declared such a reconstruction “too speculative”, and his important study on the Epidemics follows the usual approach today of treating Books 1 and 3 as a single group without specifying their exact relationship with each other.21 All things considered, there may be good reasons to respect existing manuscript forms and to avoid conflating both books of the Epidemics as a single work. In Book 1, each of the three constitutions begins with the label “in Thasos”, while the vast majority of case histories are silent about their locations and seasons of occurrence.22 This silence is remarkable, since the in Hellweg, R. (1985). Stilistische Untersuchungen zu den Krankengeschichten der Epidemienbücher 1 und 3 des Corpus Hippocraticum; Potter, P. ‘Epidemien 1/3: Form und Absicht der zweiundvierzig Fallbeschreibungen’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien, 9–19. 18   Deichgräber, K. (1933, repr. 1971). Die Epidemien und das Corpus Hippocraticum: Voruntersuchungen zu einer Geschichte der koischen Ärzteschule, 17–23. 19  Lichtenthaeler, Ch. (1960). Sur la vocation universitaire de l’histoire de la médicine, leçon inaugurale. Le troisième Épidémique d’Hippocrate vient-il vraiment après le premier?, 40–67; id. (1989). Das Prognostikon wurde nicht vor, sondern nach den Epidemienbüchern 3 und 1 verfasst. Zweiter Beitrag zur Chronologie der echten hippokratischen Schriften, 121–26; id. (1994). Neuer Kommentar zu den ersten zwölf Krankengeschichten im 3. Epidemienbuch des Hippokrates, 16–17. 20  Dugand, J.-E. ‘Hippocrate à Thasos et en Grèce du nord’, in Joly, R. (1977). Corpus Hippocraticum, 233–45; id. (1979). ‘Les adresses de malades d’Épidémies 1 et 3 et les preuves tant archéologiques qu’épigraphiques du séjour d’Hippocrate à Thasos, capitale de l’île de ce nom’, Annales de la Faculté des Lettres et Sciences humaines de Nice 35, 131–55. 21  Langholf, Medical Theories in Hippocrates, 77–78. Skepticism at Lichtenthaeler’s scheme was also voiced by Hankinson, R. J. (1991). Review of Das Prognosticon wurde nicht vor, sondern nach den Epidemienbüchern 3 und 1 verfasst. Zweiter Beitrag zur Chronologie der echten Hippokratischen Schriften by Charles Lichtenthaeler, Isis 82.2, 365–66. Note the opinion that “eine Klärung der Frage nach dem Entstehungsverhältnis dieser Texte allein aufgrund stilisticher Befunde . . . unmöglich” in Hellweg, Stilistische Untersuchungen, 225. 22  Only two exceptions in the case histories (cases 4 and 9) mention “Thasos” and, as we will see shortly, at least three more cases (1, 2, and 10) can be identified with individuals described in the Year #3 constitution of Thasos in Epidemics 1.

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constitutions emphasise the idea that medical conditions were noteworthy to a greater or lesser extent depending on when they occurred. The case histories were likely intended to be read in tandem with their preceding constitution, which supplied the geographical and seasonal background information missing in the case histories themselves. By contrast, the constitution in Book 3 curiously lacks a toponym (“Thasos” or otherwise), while the case histories after this constitution are careful to specify their patients’ locations, moving in rotational order from Thasos, to Larissa, to Abdera, and on to other sites (i.e. Cyzicus or Meliboea).23 One might wonder whether the absence of a single toponym served to portray the constitution in Epidemics 3 as a description of the larger Aegean coastal region, which encompassed the disparate locations mentioned in its case histories. It is clear, in any case, that variables of geography, time, and patient were defined and prioritised differently in Books 1 and 3. Of the two, it is Epidemics 1 that corresponds more fully to the heuristic recommended in Airs, Waters, Places. Instead of understanding Epidemics 1 as a bipartite division of ‘constitutions’ versus case histories, we might do better to view it as a tripartite account of three years at the island of Thasos.24 The usual assumption that the years are consecutive is plausible, especially since the seasonal description at the end of Year #2 (i.e. the return of much rain with northerly winds near the rising of Arcturus) appears again at the beginning of Year #3.25 The constitutions of Years #1 and #2 do not name any patients and include no case histories, while

23  The case histories at the end of Epidemics 3 may perhaps be interpreted in terms of the following cycles: #1) Thasos (cases 1–3 or 4?)—Larisa (case(s) 4? and 5)—Abdera (cases 6–10); #2) Thasos (case 11)—Larisa (case 12)—Abdera (case 13)—Cyzicus (case 14); #3) Thasos (case 15)—Meliboea (case 16). The sequences here are unexpected, because they seem to disregard the close geographical proximity between Thasos and Abdera, and between Larisa and Meliboea. In contrast, the twelve case histories preceding the constitution in Epidemics 3 are largely silent about their location, though it is uncertain how or whether they relate to the constitutions in Books 1 and 3 of the Epidemics. 24  In fact, scholars already tend to assume that the case histories of Epidemics 1 pertain particularly to the Year #3 constitution, rather than to all three constitutions. See, for example, Deichgräber, Die Epidemien und das Corpus Hippocraticum, 11; id. (1982). Die Patienten des Hippokrates: Historisch-prosopographische Beiträge zu den Epidemien des Corpus Hippocraticum, 8–11; Dugand, ‘Hippocrate à Thasos et en Grèce du nord’, 234; Hellweg, Stilistische Untersuchungen, 10; Lichtenthaeler, Neuer Kommentar, 90. 25  Epid. 1.4 (L. 2.616.4–5 = Kühlewein 1.184.15–16); Epid. 1.13 (L. 2.638.8–9 = Kühlewein 1.190.22–23). Note also the mention of a “previous constitution” (τῆς πρόσθεν καταστάσιος) in the Year #1 constitution, Epid. 1.1 (L. 2.598.11 = Kühlewein 1.180.11–12), which has been omitted from Epidemics 1 for rhetorical or other reasons.

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Epidemics I

Year #1

Year #2

Constitution (No Names)

Constitution (No Names)

Year #3 Constitution (Names)

14 Case Histories (Names)

the Year #3 account identifies many of its patients in the constitution and concludes with fourteen case histories of named patients. As we remember, Airs, Waters, Places begins by settling upon a single geographical location, thus eliminating the variable of place and giving definition to what is “native” (ἐπιχώριος). In Epidemics 1, the location chosen is the island of Thasos. Whereas Epidemics 3 seems to portray an itinerant physician in the midst of his travels, both Epidemics 1 and Airs, Waters, Places envision him at the commencement of a residency intended to last for at least a year or years. The seasonal traits given prominence in Aer. 11 (L. 2.52.1–6 = Jouanna 218.13– 219.5) are the same ones that govern the organisation of the constitutions in Epidemics 1, in which each year begins and ends around the season of Arcturus, the equinox and the setting of the Pleiades are major autumnal events, the summer and winter solstices herald constitutional changes, and the Dog Star is linked to the hottest days (i.e. ‘the dog days’) of summer.26 In Airs, Waters, Places, seasonal sicknesses are said to be “communal” (πάγκοινος), because their widespread occurrence at particular times is what suggests the correlation between sickness and season. Conditions of individual patients that cannot be conflated with such communal descriptions are, instead, labelled as “personal” (ἴδιος). In Epidemics 1, the same heuristic is evident in the effort to distinguish medical conditions of ‘the majority’ from those experienced by only ‘some’ or by single named individuals.

26  “The meteorological approach of Epidemics 1 and 3 is considerably more flexible than the one of Airs, Waters, Places (and of On the Sacred Disease); but the traditional method is not criticised; instead, the new method of Epidemics 1 and 3 is formulated in a way that no contradictions to the older one can occur.” Langholf, Medical Theories in Hippocrates, 172–79, 211–12.

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Patterns of Identity and Anonymity

Airs, Waters, Places served as a preparatory guide for the physician who arrives at a polis “with which he is unfamiliar”, Aer. 1 (L. 2.12.9–10 = Jouanna 187.4–5); Aer. 2 (L. 2.14.3 = Jouanna 188.8–9). The absence of “personal” (ἴδιος) accounts agrees with this portrayal of the physician as one who has not yet encountered actual patients in the polis. Epidemics 1, on the other hand, represents a narrative situated in place and time, whereby the physician’s experience of a single year (i.e. Year #3) at Thasos yielded the information needed for the writing of “personal” case histories.27 Indeed, for us to appreciate the local significance of medical signs observed in these histories, we may have to view them in the narrowly prescribed context of their constitution.28 How might Epidemics 1 appear to us if, for a change, we consider it primarily as a physician’s interpretation of the historical incidence of medical phenomena in a single year and at a single place? What if we allow that medical signs in Epidemics 1 need not always concur with the manifestations, distribution, and frequencies of signs known from comparable diseases today or from those of other Hippocratic writings, e.g. the other books of Epidemics and On Prognosis? Three case histories in Epidemics 1, in fact, have been identified with individuals named in the Year #3 constitution, and they reveal how case histories function in the rhetorical context of their constitution.29 Philiscus (case 1) and Silenus (case 2) are the patients named in the following passage: . . . those most likely to recover were those who had good and copious bleeding from the nostrils, and I know no one who died in this constitution, if he had a good bleeding. For Philiscus and Epameinon and Silenus, who died, dripped (only) a little from the nostrils on the fourth and fifth days, Epid. 1.8 (L. 2.642.5–10 = Kühlewein 1.191.19–24).

27  I refer here to the physician in the singular, though of course it is possible that more than one physician was responsible for Epidemics 1, or that the author utilised notes composed by other physicians. 28  Even if one thinks the same author wrote Books 1 and 3 of the Epidemics, “sa tâche propre consiste à adapter ce cadre général aux caractéristiques particulières des maladies dans une constitution donnée.” Demont, P. ‘Les facteurs aggravants de la troisième constitution de Thasos’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien, 204. 29  Deichgräber, Die Epidemien und das Corpus Hippocraticum, 11; Lichtenthaeler, Neuer Kommentar, 90.

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As we noted earlier, repeated observations had suggested the rule of thumb that “a good bleeding through the nostrils” predicted the patient’s recovery, Epid. 1.9 (L. 2.656.7–658.2 = Kühlewein 1.195.21–196.2). The three patients here, however, seemed to question the validity of this rule, since they died even after a nosebleed. The solution was to argue that what happened in the case of Philiscus, Epameinon, and Silenus did not count as a “good bleeding”, but as “a little” dripping. There was, of course, a degree of subjectivity involved in classifying a nosebleed as “good” versus “a little”, and we cannot be certain that such labels were always attached to medical signs before the patient’s final outcome was known. In two other passages of Epidemics 1, instances of nosebleed that ended with the patient’s death were likewise qualified as “a little” dripping.30 In the final logic of the treatise, distinctions on types of nosebleed served to buttress the paradigm of prognosis adopted in the constitution. Another patient, “the Clazomenean” (case 10), is more fully addressed as “Hermippus the Clazomenean” in the constitution: The painful swellings by the ears during fevers, for some, neither subsided nor suppurated when the fever left with a crisis. These were relieved, when they had bilious diarrhea or dysentery or a sediment of thick urine, as in the case of Hermippus the Clazomenean, Epid. 1.9 (L. 2.660.1–5 = Kühlewein 1.196.19–23). The reference to “some” implies that, for most patients, ear swellings did indeed disappear along with their fevers after times of crisis. This impression is confirmed elsewhere in the Year #3 constitution. One passage describes how “near the crisis . . . swellings by the ears disappeared”, Epid. 1.8 (L. 2.646.2–3 = Kühlewein 1.192.21–22). Another text resembles Hermippus’ case even more closely, revealing that “some had (swellings) by the ears, had a crisis on the twentieth day, and, for all these, (the swellings) subsided and did not suppurate, but were diverted to the bladder”, Epid. 1.9 (L. 2.664.12–666.3 = Kühlewein 1.198.3–5). Hermippus the Clazomenean also experienced a crisis on the twentieth day, exactly when one might have expected his ear swellings to subside, but they did not do so until the thirty-first day of his sickness. In short, Philiscus, Silenus, and Hermippus represent instances where the behaviour of sickness deviated from expectations suggested by comparable medical cases. One might have anticipated recovery after nosebleeds by Philiscus and Silenus, but they ended up dying instead. One might have 30  See σμικρὰ ἔσταξεν, Epid. 1.18 (L. 2.654.1 = Kühlewein 1.195.6) and σμικρὰ ἀπὸ ῥινῶν ἔσταξε, Epid. 1.13, case 11 (Kühlewein 1.212.6); ἔσταξε σμικρὰ ἀπὸ ῥινῶν (L. 2.710.3).

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predicted that Hermippus’ ear swellings would subside with his fever, but they remained for at least eleven more days. As a matter of fact, the identification of the patient in such contrary cases is not surprising, for the practice is aligned with patterns of identity and anonymity widely attested in the Year #3 constitution. Let us look at the following examples: Example #1: Women and maidens share all the above-written signs. And those for whom any of these (signs) occurred properly, or copious menstruation appeared, through these (signs) they began to recover and had a crisis. And I know no one who perished, for whom any of these (signs) occurred properly. For the daughter of Philo died despite a violent flow from the nostrils, because she dined unseasonably on the seventh day, Epid. 1.9 (L. 2.658.6–12 = Kühlewein 1.196.6–13). Example #2: For the majority, menstruation appeared during the fevers and, for many maidens, it was the first time then. Some bled from the nostrils. Sometimes both (bleeding) from the nostrils and menstruation appeared at the same time, as in the case of the maiden daughter of Daitharses, where there appeared at that time her first (menstruation) and a violent flow from her nostrils, Epid. 1.8 (L. 2.646.13–648.4 = Kühlewein 1.193.10–16). With the daughter of Philo in Example #1, we are again confronted with the situation where the patient’s nosebleed is followed by death. Unlike the case with Philiscus and Silenus, however, the “violent flow” that issued from this woman’s nostrils could not be easily rationalised as “a little” dripping. Instead, the physician resorted here to the vague explanation that she had “dined unseasonably”, hence vindicating the prognostic value of nosebleed as a sign of recovery under normal circumstances. We should take note that the many “women and maidens” whose medical conditions ratified this prognostic rule are unnamed, whereas the daughter of Philo is identified precisely because she deviated from the rule. The same concern for the atypical is evident in Example #2, where the majority of women who menstruated during fevers are not specified. Even the minority group with nosebleeds instead of menstruation remains unnamed. A subset of women within this minority group, however, who simultaneously experienced nosebleeds and menstruation, finds representation in the person of Daitharses’ daughter (Example #2). Example #3: The majority had bleeding, especially youths and those in their prime. And most of those who did not have bleeding died. But older

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people had jaundice or disordered bowels, as in the case of Bion who lay down at the house of Silenus, Epid. 1.8 (L. 2.644.7–11 = Kühlewein 1.192.10–14). Example #4: For the majority, urine was well-coloured, but thin and having few sediments . . . But I will recall those whose urine was very watery, clear, and thin, but for whom both sediments and other aspects ameliorated after a crisis: Bion who lay down at the house of Silenus, Cratis who lodged with Xenophanes, the slave of Areto, and the wife of Mnesistratus . . ., Epid. 1.8 (L. 2.648.6–650.3 = Kühlewein 1.193.19–194.5). Example #5: The majority had a crisis on the sixth day, an intermission of six days, and a crisis on the fifth day after the relapse. . . . Some had a crisis on the sixth day, an intermission of six days, an attack for three days, an intermission of one day, an attack for one day, and a crisis, as in the case of Euagon the son of Daitharses. Some had a crisis on the sixth day, an intermission of seven days, and a crisis on the fourth day after the relapse, as in the case of the daughter of Aglaïdas, Epid. 1.9 (L. 2.662.3–664.4 = Kühlewein 1.197.7–16). Both nosebleeds and bile from disordered bowels, if we remember, were considered signs that the patient would recover, Epid. 1.9 (L. 2.656.7–658.2 = Kühlewein 1.195.21–196.2). In Example #3, however, the manifestation of one sign over the other seems to have been determined by the age of the patient. The majority were young persons who suffered bleeding on their way to recovery, while the fewer older patients experienced jaundice or disordered bowels instead. No names appear here from the young majority, whereas Bion is mentioned as a representative of the older group. In Example #4, the majority of patients with well-coloured urine are likewise anonymous. The text, on the other hand, meticulously lists the identities of Bion, Cratis, the slave of Areto, and the wife of Mnesistratus, because their “very watery” and “clear” urine marked a departure from the usual observations. Example #5 is interesting for showing the importance of the timing of crises and intermissions in the scheme of Epidemics 1. When compared with others, Euagon and the daughter of Aglaïdas each experienced one additional day of intermission at different points in their sicknesses. This variation was sufficient to warrant the mention of their names, in contrast to the nameless majority who supposedly followed the typical pattern of crises and intermissions. These examples and others show that common medical conditions were described under the rubric of an anonymous “majority” (οἱ πλεῖστοι), whereas

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more unusual or peculiar medical signs were designated as the experiences of ‘some’ or of specifically named individuals.31 Though there are a couple of exceptions to this rule, the general pattern of identity and anonymity is clear.32 To express this in the language of Airs, Waters, Places: Medical conditions that were “communal” (πάγκοινος) could be described anonymously, as occurrences validated by the experiences of ‘the majority’ and thought to derive from seasonal changes. Medical conditions that were “personal” (ἴδιος), however, had greater need for the evidence of individual testimony, whereby the names and identities of patients took on forensic importance. ‘Personal’ sickness, moreover, was linked to individual lifestyle and individual responses to therapy, which could vary from person to person.33 The relationship between the “communal” (πάγκοινος) and the “personal” (ἴδιος) deserves our careful attention. The ‘personal’ is defined by the ‘communal’, and not the other way round. We might even say that the ‘personal’ exists because of its failure to assimilate into the ‘communal’. To be sure, it may appear counterintuitive to say that ‘personal’ case histories derive not only from their individuals’ experiences, but also from those of the community of patients. In the first place, however, the selection of individuals for patient narratives and the choice of content for their case histories were shaped by manifestations of sickness in the wider community. Patients whose conditions could be adequately described in ‘communal’ terms were simply addressed as part of the anonymous majority, rather than given prominence in separate case histories. Conversely, this means that identified patients are by definition 31  The word translated “the majority” in all these cases is not οἱ πολλοί with its possible political overtones, but οἱ πλεῖστοι, which expresses proportion without necessarily suggesting value judgments about majority or minority attestations. 32  We are not certain why Teleboulus’ daughter was mentioned as an example of death after childbirth, Epid. 1.8 (L. 2.646.11–13 = Kühlewein 1.193.7–10), though her case history was evidently not considered noteworthy to be preserved in Epidemics 1. Another passage relates that “the majority died on the sixth day in these sicknesses, as in the cases of Epameinondas, Silenus, and Philiscus the son of Antagoras”, Epid. 1. 9 (L. 2.664.10–12 = Kühlewein 1.198.1–3). These were probably not the same persons as Philiscus and Silenus mentioned earlier: in the case histories, Philiscus is not qualified as “the son of Antagoras”, while Silenus dies on the eleventh, not the sixth, day. In any case, judging by other accounts in the constitution and case histories, “Epameinondas, Silenus, and Philiscus the son of Antagoras” seem to exemplify a situation (i.e. death on the sixth day) that was normative only in a rather prescribed context. 33  Similarly, in Flat. 6.3–7.3ff. (L. 6.96.23–98.16ff. = Jouanna 109.5–111.1ff. ), “common” (κοινός) fevers come from the population’s shared exposure to harmful wind, whereas “personal” (ἴδιος) fevers result from the individual’s bad regimen of food and exercise.

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non-­representative medical cases, at least according to the heuristic schemes of Epidemics 1 and Airs, Waters, Places. We should therefore question the view that the case histories here “may have been conceived as exemplary pieces of evidence for the general exposition of the καταστάσεις” in Epidemics 1.34 Philiscus, Silenus, and Hermippus are known to us from the text, not because they exemplified the behaviour of sickness in its constitution, but because they contradicted majority expectations of how sickness is supposed to behave. As a matter of fact, the labelling of a patient narrative as “exemplar” (παράδειγμα) does occur in Regimen in Acute Diseases, where, perhaps tellingly, a hypothetical rather than a real patient is described:35 It is sufficient to write a certain exemplar (παράδειγμα) of all these things: for, if a certain one, who receives a wound on the lower leg that is neither severe nor slight, . . . is treated immediately from the start while lying down and never raising the leg, . . . he would recover much more quickly than if he wanders about while being treated. If, however, on the fifth or sixth day or later still, he wishes to arise and step forth, he would suffer more than if he had wandered about immediately from the start while being treated . . . Finally therefore, all these things testify (μαρτυρεῖ) with each other, that all things that suddenly deviate much from the mean in either direction are injurious, Acut. 46 (L. 2.320.5–324.4 = Joly 56.3–18). The language of proof (παράδειγμα and μαρτυρεῖ) implies that even the imagined behaviour of a hypothetical patient could present a persuasive argument to the ancient audience. What were the benefits of imagining such a hypothetical patient, rather than quoting from the experience of an actual named individual? Here, anonymity not only took for granted the plausibility of the situation described, it also suggested that the principle illustrated

34  Hellweg, Stilistische Untersuchungen, 10 [translation mine]. Silenus’ case was viewed “as illustration of [the author’s] general description of the third catastasis” in Smith, ‘Generic form in Epidemics 1 to 7’, 147. The question whether case histories served to validate any hypotheses held by the ancient author was considered in Potter, ‘Epidemien 1/3: Form und Absicht’, 17. 35  Perhaps ‘exemplar’ here may recall Thomas Kuhn’s idea of analogical ‘models’ of imagining scientific objects or processes and representative puzzle-solving solutions known as ‘exemplars’. Kuhn, Th. S. (1977). The Essential Tension: Selected Studies in Scientific Tradition and Change, 297–98. These ‘models’ and ‘exemplars’, while certainly relatable to real world situations, may also include clearly hypothetical features such as frictionless surfaces and speed-of-light travel.

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was ­universally valid and not limited to specific named cases. Furthermore, by using a hypothetical narrative, the author could isolate a single point in the patient’s experience (i.e. pain from a leg wound), without concern for a whole array of other medical signs that might unnecessarily—in the author’s view—complicate his argument. These reasons present the flip side to what we observe in Epidemics 1, where patients were named because the behaviour of their sickness could not be taken for granted, and where detailed case histories were preserved in order to fully document such conditions that deviated from the majority of cases. 3

The Imperative of Prognosis

Our methodology has departed from most previous scholarship on the case histories of Epidemics 1 in three important ways. First, in respect for existing manuscript forms, we have focused exclusively on Epidemics 1 as a self-contained narrative, without conflating or grouping it together with Epidemics 3. Secondly, we have adopted a narrowly contextual reading of the medical signs in the case histories, viewing their manifestations, distributions, and frequencies as incidental phenomena of a single historical year (Year #3) at Thasos, while resisting attempts to define them as products of sicknesses known in modern times or in closely affiliated works such as the other books of Epidemics or On Prognosis. Finally, in clarifying the relationship between constitution and case histories, we have avoided the usual practice of emphasizing similarities between the two, as if case histories represent simple illustrations of sicknesses addressed in their constitution. Instead, we have prioritised the differences between constitution and case history, in line with our argument that ‘personal’ case histories exist because they cannot be assimilated with ‘communal’ descriptions in the constitution. All three points are, in fact, related: it is only when we insist on reading the case histories of Epidemics 1 exclusively through the lens of the Year #3 constitution, that it becomes obvious how much dissonance there is between case histories and constitution. The non-representative nature of the case histories in Epidemics 1 explains why scholars have found it so difficult to connect them to the constitution(s). Furthermore, the exact point of relevance between the case histories and their constitution is not always clear. On the one hand, parts of the case histories of Philiscus (case 1) and Hermippus (case 10) play critical roles in the argument of their constitution, providing counterexamples to the experiences of the majority of patients. Parallels in language may even suggest that these case histories or their Vorlagen served as textual sources for the Year #3

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constitution.36 To give one example, the form σμικρόν is used in the constitution and in the case histories to describe “a little” nosebleed by Philiscus, whereas similar constructions elsewhere in Epidemics 1 seem to prefer the form σμικρά.37 On the other hand, the vast amount of detail in these same case histories appears to be of only tangential relevance to the constitution.38 Why record the entire case history of Philiscus, for instance, if the only feature that mattered was his nosebleed? Indeed, there are many patients named in the constitution that do not have their case histories preserved. In the end, we may not be able to give a definite answer. It bears reminding, however, that ‘personal’ (ἴδιος) medical conditions did not arise arbitrarily, but from a specific set and combination of factors in the individual’s life, and therefore required a holistic consideration of the individual’s history.39 After all, the case history of Philiscus was intended not merely as a historical record of past events, but as a pattern that could be consulted for future comparisons. We earlier noted the subjectivity involved in classifying a nosebleed either as ‘good’ or ‘a little’. Imagine a patient with an indeterminate amount of nosebleed on the fifth day. The physician might say, the patient has a good nosebleed that will lead to his or her recovery. Or the physician might say, it is going to turn out the way it happened with Philiscus. Indeed, if the patient 36  Compare the language of τὰ παρὰ τὰ ὦτα . . . οὔτε καθίστατο οὔτε ἐξεπύει, Epid. 1.9 (L. 2.660.1–3 = Kühlewein 1.196.19–21) with τὰ δὲ παρὰ τὰ ὦτα οὔτε καθίστατο οὔτε ἐξεπύει, Epid. 1.13, case 10 (L. 2.706.15–708.1 = Kühlewein 1.211.9–10). Compare also σμικρὸν ἀπὸ ῥινῶν ἔσταξεν, Epid. 1.8 (L. 2.642.9 = Kühlewein 1.191.24) with σμικρὸν ἀπὸ ῥινῶν ἔσταξεν ἄκρητον, Epid. 1.13, case 1 (L. 2.682.14–15 = Kühlewein 1.202.21–22). 37  In descriptions of Philiscus, the form σμικρόν appears as an adjective (modifying ἄκρητον) at Epid. 1.13, case 1 (L. 2.682.14 = Kühlewein 1.202.21), and either as a substantivised adjective or an adverb at Epid. 1.8 (L. 2.642.9 = Kühlewein 1.191.24). The adverbial form σμικρά is preferred in similar constructions at Epid. 1.9 (L. 2.654.1 = Kühlewein 1.195.6); Epid. 1.13, case 11 (L. 2.710.3 = Kühlewein 1.212.6); Epid. 3.17, case 7 (L. 3.122.14 = Kühlewein 1.238.3). See discussion of syntax in Langholf, V. (1977). Syntaktische Untersuchungen zu HippokratesTexten: Brachylogische Syntagmen in den individuellen Krankheits-Fallbeschreibungen der hippokratischen Schriftensammlung, 76. But note the attestation of σμικρόν at Epid. 3.17, case 1 (L. 3.104.5 = Kühlewein 1.233.3). 38  In fact, the case history of Silenus (case 2) omits altogether the crucial point of his nosebleed. 39  Lloyd was correct when he spoke of “seeing the case histories not so much as a resource for generalisation about what particular signs (for example, “thin” urine or “sleeplessness”) might mean but, rather, as underlining the need to take every sign in its collocation, namely, as part of a history to be viewed and interpreted as a whole.” Lloyd, G. E. R. (1995). Review of Neuer Kommentar zu den ersten zwölf Krankengeschichten im 3. Epidemienbuch des Hippokrates by Charles Lichtenthaeler, Isis 86.3, 469.

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also manifests semen-like urine, deep and intermittent breathing, a swollen spleen, and other signs shown by Philiscus, the physician would be able to say on firmer grounds that history (or case history) was repeating itself. The works of Deichgräber and Lichtenthaeler have long drawn attention to the relationship between the Epidemics and the treatise On Prognosis. The characters associated with case histories in Epidemics 3 further testify to the importance of prognosis, since these characters end with either Υ or Θ, which, according to Galen, signified “recovery” (Ὑγείαν) or “death” (Θάνατον).40 It has been argued that case histories served “less to facilitate diagnosis, than to provide information that would help the doctor to predict the outcomes of diseases, especially whether the patient would die or recover”.41 Our imagined scenario with the physician above suggests what is at stake for the medical profession. In the absence of formal medical certification, accurate prognosis was a means of winning the patient’s trust and building the physician’s r­ eputation.42 Unexpected deviations from the usual rules of prognosis, therefore, presented a potential threat to the physician’s credibility and livelihood. This imperative of prognosis may give us a key to understanding the case histories. There are four more case histories in Epidemics 1 that can be meaningfully related to parts of the Year #3 constitution. The two case histories on pregnant women (cases 4 and 5) are natural candidates for the following passage in the constitution, which is specially devoted to the topic of pregnancy, delivery, and post-natal sickness: Many women became sick, though they were fewer than men, and fewer died. The majority suffered in childbirth and fell sick after delivery, and these especially died, as when the daughter of Teleboulus died on the sixth day after delivery. . . . And if those who were pregnant happened to become sick, to my knowledge, all had miscarriages, Epid. 1.8 (L. 2.646.9– 648.6 = Kühlewein 1.193.6–18)43

40  See Jones’ notes (p. 213–15) before his translation of Epidemics 3. 41  Lloyd, G. E. R. (1979). Magic, Reason and Experience: Studies in the Origin and Development of Greek Science, 154. 42  A particularly clear statement of this notion may be found at Progn. 1 (L. 2.110.1–112.11 = Alexanderson 193.1–194.9). On prognosis and the medical profession, see also Jouanna, J. (1999). Hippocrates, trans. M. B. De Bevoise, 100–11. 43  For the medical meaning of ἀπέφθειραν here as “to have a miscarriage”, see also descriptions of “miscarriage” (ἀποφθορά) elsewhere at Epid. 3.1, cases 10 and 11 (L. 3.60.2, 10 = Kühlewein 1.222.6, 14).

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The wife of Epicrates (case 5) offers a challenge to the above description at every level. Though she was seized with strong rigors two days before “she gave birth” (ἔτεκεν), the delivery “went according to plan” (κατὰ λόγον ἦλθε), and the language here seems to imply that the child survived.44 It is not entirely clear how to reconcile this fact with the author’s statement in the constitution that, to his knowledge, “all had miscarriages”.45 Furthermore, though her sickness was aggravated immediately after delivery, she avoided the fate of the majority of women, and experienced a complete crisis after a long period of eighty days. Her case history may have served as a caution to any physician who might prematurely predict the deaths of women in similar condition. More in line with expectations, the wife of Philinus (case 4) fell sick only after delivery and eventually died like the majority of women. The delivery itself, however, was normal, and she was in good condition prior to the sickness. The point of controversy, however, is this: the wife of Philinus appears to have been fitted into the paradigm of death from post-natal sickness, though the first signs of any sickness only occurred fourteen days after the delivery. This is a significant gap when one compares her experience with other women, such as the wife of Dromeades, Epid. 1.13, case 11 (L. 2.708.6–710.11 = Kühlewein 1.211.15– 212.14), the woman by the Liars’ Market, Epid. 3.1, case 12 (L. 3.62.11–66.11 = Kühlewein 1.223.3–224.5), and the woman in Cyzicus, Epid. 3.17, case 14 (L. 3.140.14–142.4 = Kühlewein 1.243.13–25) who all fell sick immediately or a day after delivery, the woman by the Cold Water, Epid. 3.17, case 2 (L. 3.108.5–112.12 = Kühlewein 1.234.3–235.6) who developed acute fever three days after delivery, and the woman at the house of Pantimides, Epid. 3.1, case 10 (L. 3.60.1–8 = Kühlewein 1.222.6–13) and the wife of Hicetas, Epid. 3.1, case 11 (L. 3.60.9–62.10 = Kühlewein 1.222.14–223.2) who both fell sick immediately after their miscarriages. In other words, the case of Philinus’ wife warned against the presumption of well-being, even if a woman’s sickness did not manifest itself for a full thirteen days after childbirth, more than double the time it took the daughter of Teleboulus to die from post-natal sickness! Just as Epicrates’ wife represents the minority experience in the Year #3 constitution, the wife of Philinus

44  It is less likely that the expression κατὰ λόγον ἦλθε (“went according to plan”) refers to the miscarriage of the child in accordance with prognostic expectations. In cases 1.10 and 1.11 of Epidemics 3, the women who had miscarriages are not described as having “given birth” (ἔτεκεν). 45  Was the case history of Epicrates’ wife not taken into account in the composition of the constitution, but included later? Did the author consider sickness to commence only with the onset of acute fever, which occurred the day after the wife of Epicrates delivered?

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illustrates the unusual extent to which the event of childbirth can remain relevant in cases of female mortality. The case histories of Meton (case 7) and Erasinus (case 8) relate to another passage, which includes a description of medical signs remarkably similar to their own: About the equinox until (the setting of) the Pleiades and during winter, though kausos-fevers continued, phrenitics became majority at that time, and the majority of these died. . . . There were signs for those who suffered from kausos-fever at the beginning, for whom the fatal signs concurred. For right from the beginning, there were acute fever, slight rigors, sleeplessness, thirst, nausea, slight sweats . . . much delirium, fears, depression, very cold extremities—toes and especially fingers. The paroxysms were on even days; for the majority, the pains were greatest on the fourth day, . . . Their urine was slight, black, thin, and their bowels were stopped. They did not bleed from the nostrils . . . or else they dripped (only) a little. . . . They died on the sixth day with sweating. Phrenitics shared (alternative reading: did not share) all the above-written (signs), and their crisis was generally on the eleventh day . . ., Epid. 1.9 (L. 2.650.9–654.5 = Kühlewein 1.194.13–195.10). Erasinus (case 8) seems to closely mirror the picture of fatal kausos-fever here.46 He was seized with fever at the beginning of his sickness, experienced sleeplessness, a mild thirst, sweat, delirium and wandering, fear, cold extremities, black urine, and no nosebleeds, though he did pass excrement from the bowels. He had a paroxysm on the second day, became worse on the fourth day, and finally died with sweat and convulsions around the beginning of the sixth day (i.e. around sunset on the fifth day). Meton (case 7) displayed similar signs, but with some at different times. He too was seized with fever from the start, suffered during the night, passed black urine, and had only a little nosebleed. He experienced his paroxysm on the fourth day, but his sickness was instead resolved by a crisis on the fifth day, after which he suffered from sleeplessness, wandering, and frequent nosebleeds. As with Philiscus, Silenus, and the wife of Epicrates, Meton’s history bore certain resemblances with comparable medical cases (i.e. of kausos-fever) but provided an alternative outcome that contradicted prognostic expectations (i.e. he did not die on the sixth day). 46  Note that Philiscus (case 1) too is mentioned in the constitution as suffering from kausosfever, Epid. 1.8 (L. 2.642.4–5, 8 = Kühlewein 1.191.19, 22), and that much of his case history agrees with the description of this sickness here.

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A major difficulty in interpretation stems from the ambiguous manuscript evidence whether or not phrenitics “shared all the above-written (signs)” of fatal kausos-fever.47 All things considered, it is likely that the two conditions were similar to each other: phrenitics either shared all the described signs of those suffering from fatal kausos-fever, or they shared many (but not all) of these signs.48 The case of Erasinus, which otherwise appears to be an unremarkable example of fatal kausos-fever, may therefore take on special significance in the argument of the constitution. We are in a season when cases of phrenitis are “majority”, but when we also need to be reminded that kausosfevers exist. Due to their similarities, kausos-fever was liable to be mistaken for the more common sickness (i.e. phrenitis). In Example #3 earlier, Bion was named not because his condition of “jaundice or disordered bowels” was in itself extraordinary, but because it was less common when compared to the majority of patients who were young and suffered “bleeding” instead, Epid. 1.8 (L. 2.644.7–11 = Kühlewein 1.192.10–14). Likewise, Erasinus is important here not necessarily as a deviant case of kausos-fever, but because kausos-fever represented the minority condition at this time. Indeed, during this season, sufferers of kausos-fever are described as dying on the sixth day, while phrenitics may expect a crisis on the eleventh day. In the case of Erasinus, we may have an example of a sickness that had the potential to be misidentified, and which could therefore lead to a misguided prognosis. Other case histories in Epidemics 1 cannot be related to the Year #3 constitution with the same degree of clarity and, at this stage, it would be too speculative to map every single case history onto the constitution. The account of days thirty to eighty of Cleanactides’ sickness (case 6), for example, seems to focus on the colour and sedimentation of his urine, which happens to be the theme of a distinct section in the constitution (see Example #4 above). Other conditions, however, such as Crito’s painful toe (case 9), worms in stools (case 12), and the nosological pattern of initial fever, intermission on the seventh day, and a crisis on the eleventh day (cases 13 and 14) cannot be definitely linked to parts of the constitution, though the omission of such descriptions in the constitution may indicate that these too represent less typical cases. Furthermore, we 47  See critical apparatus to L. 2.654.3 and Kühlewein 1.195.8–9. Littré has οὐ ξυνέπιπτε in the main body of his edition, while Kühlewein prints συνέπιπτε without the negative particle. 48  The option that phrenitis had nothing or not much in common with fatal kausos-fever fails to satisfactorily explain the following: 1) the implied comparison of the two conditions in the passage, 2) the need for the qualifier πάντα (‘all’), and 3) the absence of any subsequent description of bodily signs of phrenitis other than days of its crises that differed from those for kausos-fever, even though “phrenitics became majority at that time”.

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should remember that the case history of Silenus (case 2) does not even mention the crucial point that he experienced a slight nosebleed on the fourth or fifth day, though the constitution is explicit about the relevance of that detail. Such omissions may indicate that the author was familiar with the patient’s history to an extent that is not always preserved in our textual accounts. The chart below suggests that, up to a point, the case histories in Epidemics 1 appear in an order parallel to the narrative of the Year #3 constitution, though there are still too many gaps here to be absolutely certain of this picture. Regardless of how closely we wish to connect the textual structures of constitution and case histories, it at least seems likely that our case histories functioned as companion texts to their constitution, providing alternative perspectives or counterexamples to general trends of sickness described in the constitution. Case Histories of Epidemics 1 Case Patient

Feature Under Consideration

Related Section in Constitution

Relevance for Constitution

1

Philiscus

A little nosebleed

Epid. 1 8.12–18 = L. 2.642.4–10 = Kühlewein 1.191.19–24

Named in Constitution

2

Silenus

(A little nosebleed)

Epid. 1 8.12–18 = L. 2.642.4–10 = Kühlewein 1.191.19–24

Named in Constitution

3

Herophon

?

?

?

4

Wife of Philinus

Childbirth & sickness

Epid. 1 8.1–15 = L. 2.646.9–648.6 = Kühlewein 1.193.6–18

Topic of childbirth & sickness

5

Wife of Epicrates

Childbirth & sickness

Epid. 1 8.1–15 = L. 2.646.9–648.6 = Kühlewein 1.193.6–18

Topic of childbirth & sickness

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Case Histories of Epidemics 1 Topic of urine colour & sedimentation?

6

Cleanactides

Urine colour & Epid. 1 8.1–12 = sedimentation? L. 2.648.6–650.4 = Kühlewein 1.193.19–194.7?

7

Meton

Signs of kausos-fever/ phrenitis

Epid. 1 9.1–28 = L. 2.650.9–656.1 = Kühlewein 1.194.13–195.14

Topic of kausos-fever / phrenitis

8

Erasinus

Signs of kausos-fever/ phrenitis

Epid. 1 9.1–28 = L. 2.650.9–656.1 = Kühlewein 1.194.13–195.14

Topic of kausos-fever / phrenitis

9

Crito

?

?

?

10

(Hermippus) Ear swellings persisting after the Clazomenean crisis

Epid. 1 9.1–6 = L. 2.660.1–5= Kühlewein 1.196.19–23

Named in Constitution

11

Wife of Dromeades

?

?

?

12

Man

?

?

?

13

Woman

?

?

?

14

Melidia

?

?

?

4

Concluding Thoughts

We conclude our study here with a few final thoughts. First, although the categories of ‘communal’ and ‘personal’ are distinct enough conceptually, the assignment of particular cases to one category or to the other relied on

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the Hippocratic author’s interpretive judgment. Whereas patients identified in the case histories and the Year #3 constitution were acknowledged to be atypical, it does not mean that other patients addressed as part of the anonymous ‘majority’ necessarily conformed to the same degree to majority paradigms. Since the observation of medical signs is a theory-laden enterprise, the tendency would have been to interpret medical phenomena in line with established patterns of sickness behaviour, and to smooth over minor discrepancies wherever possible. Case histories represent instances where, for whatever reasons, the dissonance between observation and expectation proved too difficult to ignore. Secondly, the factors that classified a medical condition either as ‘communal’ or ‘personal’ were its frequency and distribution in the community of patients, rather than the specific mechanism of sickness. In other words, variables of place, time, and patient represent different ways of organizing a narrative about sickness in a local population, rather than different immediate causes of sickness. Though Epidemics 1 is not always explicit about humoral theory, there is nothing here against the view that both seasonal change and individual lifestyle were understood in terms of their effects on bodily humours.49 Thirdly, though the case histories of Epidemics 1 were products of a selection process that emphasised the ‘personal’, this criterion probably applied to the preservation of recorded histories, rather than to their initial composition. Some of the case histories in Epidemics 1 and 3, in fact, span a period of up to forty, eighty, or even a hundred and twenty days, and it is natural to assume that some record was undertaken from the beginning, even when it was not entirely clear how the sickness would develop. It is possible, therefore, that different Hippocratic case histories served various purposes or represent written records at different stages of formulation. We cannot expect all case histories to adhere to the heuristic of those in Epidemics 1, especially when they are not presented together with a constitution as an integrated narrative. That being said, there are several examples in the Epidemics where patients experiencing 49  The term κατάστασις “can be used for the ‘state’ of a disease as well as for the ‘condition’ of the weather”, and “the semantic ambiguity is due to the underlying medical doctrine of a close interrelation between the weather and the diseases, which both form one ‘system’ ”. Langholf, Medical Theories in Hippocrates, 169–70. Cf. Temkin, O. (1928). ‘Der systematische Zusammenhang im Corpus Hippocraticum’, Kyklos 1, 15, 29–31; Demont, ‘Les facteurs aggravants’, 204. Note the mention of “humor” (χυμός) responsible for ear swellings, Epid. 1.8 (L. 2.646.1 = Kühlewein 1.192.20), as well as the implication that this is diverted to the bladder when ear swellings subside, Epid. 1.9 (L. 2.664.12–666.3 = Kühlewein 1.198.3–5).

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different medical signs are nonetheless implied as suffering from versions of the same condition, revealing attempts to account for varied sickness behaviours in systematised ways.50 Finally, our arguments here on case histories as minority reports, which deviate from the experiences of the majority, should enter into larger discussions about the definition and classification of diseases in ancient Greece. The polemic in Regimen in Acute Diseases against the Cnidian Sentences is well known, which includes the complaint about the absurdity of attaching a new name to every variation of the same sickness.51 Galen’s commentary on this work and the nosological treatise of Internal Affections seem to illustrate this practice, with their enumeration of three consumptions, four kidney diseases, four jaundices, and three tetanuses, among other disease categories.52 Viewed in this light, the heuristic in Epidemics 1 may represent an alternative strategy of classification, whereby differences in the manifestation of sickness were attributed, not to variant forms of the same disease, but to the patient instead as the variable. Texts and Translations Used Aristotle. Nicomachean Ethics. (EN). Ed. I. Bywater. Oxford Classical Texts. Oxford: Clarendon Press, 1894. Hippocrates. Œuvres completes d’Hippocrate. Ed. and trans. E. Littré, vol. 1–10. Paris: J.-B. Ballière, 1839–61. ———. Airs, Waters, Places. (Aer.). Ed. J. Jouanna. Collection des universités de France. Paris: Les Belles Lettres, 1996. ———. Airs, Waters, Places. Trans. W. H. S. Jones. The Loeb Classical Library 147. Cambridge, MA: Harvard University Press, 1923. ———. Breaths. (Flat.). Ed. J. Jouanna. Collection des universités de France. Paris: Les Belles Lettres, 1988.

50  Unlike Timenes’ sister, Menander’s vinedresser did not shiver during his crisis on the seventh day because of his upset belly, Epid. 4.25 (L. 5.168.3–5 = Smith 110). In place of the eye problems experienced by other patients, the slave/child of Apemantus’ sister suffered joint problems due to his fatigue, Epid. 4.27 (L. 5.172.1–5 = Smith 114). There are also other cases where differences between patients being compared are not explicitly stated. 51  Acut. 3 (L. 2.228.2–6 = Joly 37.7–10). 52  See, for example, Int. 10 (L. 7.188.26 = Potter 102); Int. 14 (L. 7.202.1 = Potter 118); Int. 35 (L. 7.252.17 = Potter 188); Int. 52 (L. 7.298.11 = Potter, 250).

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———. Epidemics 1. (Epid. 1). Ed. H. Kühlewein. Hippocratis opera quae feruntur omnia, 2 vols. Leipzig: B. G. Teubner, 1894–1902. ———. Epidemics 3. (Epid. 3). Ed. H. Kühlewein. Hippocratis opera quae feruntur omnia, 2 vols. Leipzig: B. G. Teubner, 1894–1902. ———. Epidemics 3. Trans. W. H. S. Jones. The Loeb Classical Library 147. Cambridge, MA: Harvard University Press, 1923. ———. Epidemics 4. (Epid. 4). Ed. W. D. Smith. The Loeb Classical Library 477. Cambridge, MA: Harvard University Press, 1994. ———. Internal Affections. (Int.). Ed. P. Potter. The Loeb Classical Library 473. Cambridge, MA: Harvard University Press, 1988. ———. Prognostic. (Progn.). Ed. B. Alexanderson. Studia Graeca et Latina Gothoburgensia 17. Stockholm: Almquist and Wiksell, 1963. ———. Regimen in Acute Diseases. (Acut.). Ed. R. Joly. Collection des universités de France. Paris: Les Belles Lettres, 1972.

References Baader, G. and Winau, R. (eds.) Die hippokratischen Epidemien: Theorie—Praxis— Tradition. Verhandlungen des 5e Colloque international hippocratique. Veranstaltet von der Berliner Gesellschaft für Geschichte der Medizin in Verbindung mit dem Institut für Geschichte der Medizin der Freien Universität Berlin, 10.–15. 9. 1984. Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989. Buck, C., Llopis, A., Nájera, E. and Terris, M. (eds.) The Challenge of Epidemology: Issues and Selected Readings. Pan American Health Organization, 1988. Deichgräber, K. Die Epidemien und das Corpus Hippocraticum: Voruntersuchungen zu einer Geschichte der koischen Ärzteschule. Berlin, 1933; reprinted Berlin: Walter de Gruyter, 1971. ———. Die Patienten des Hippokrates: Historisch-prosopographische Beiträge zu den Epidemien des Corpus Hippocraticum. Akademie der Wissenschaften und der Literatur, Mainz. Wiesbaden: Franz Steiner Verlag, 1982. Demont, P. ‘Les facteurs aggravants de la troisième constitution de Thasos.’ in Die Hippokratischen Epidemien, ed. G. Baader and R. Winau, 198–204. Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989. Dugand, J.-E. ‘Hippocrate à Thasos et en Grèce du nord.’ in Corpus Hippocraticum: Actes du colloque hippocratique de Mons (22–26 Septembre 1975), ed. R. Joly, 233–45. Éditions universitaires de Mons: Série sciences humaines. Université de Mons, 1977. ———. ‘Les adresses de malades d’Épidémies 1 et 3 et les preuves tant archéologiques qu’épigraphiques du séjour d’Hippocrate à Thasos, capitale de l’île de ce nom.’ Annales de la Faculté des Lettres et Sciences humaines de Nice 35, (1979): 131–55.

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Eijk, Ph. J. van der. ‘Exegesis, Explanation and Epistemology in Galen’s Commentaries on Epidemics, Books One and Two.’ in Epidemics in Context: Greek Commentaries on Hippocrates in the Arabic Tradition, ed. P. E. Pormann, 25–47. Scientia GraecoArabica 8. Berlin: De Gruyter, 2012. Graumann, L. A. ‘Die Krankengeschichten der Epidemienbücher des Corpus Hippocraticum. Medizinhistorische Bedeutung und Möglichkeiten der retrospektiven Diagnose.’ Med. Diss., Universität Leipzig. Aachen: Shaker Verlag, 2000. Hankinson, R. J. Review of Das Prognosticon wurde nicht vor, sondern nach den Epidemienbüchern 3 und 1 verfasst. Zweiter Beitrag zur Chronologie der echten Hippokratischen Schriften by Charles Lichtenthaeler. Isis 82.2, (1991): 365–66. Hanson, A. E. ‘Diseases of Women in the Epidemics.’ in Die Hippokatischen Epidemien, ed. G. Baader and R. Winau, 38–51. Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989. Hellweg, R. Stilistische Untersuchungen zu den Krankengeschichten der Epidemienbücher 1 und 3 des Corpus Hippocraticum. Habelts Dissertationsdrucke: Reihe Klassische Philologie 35. Bonn: Dr. Rudolf Habelt GmbH, 1985. Jouanna, J. Hippocrates. Trans. M. B. DeBevoise. Baltimore: The Johns Hopkins University Press, 1999. Kuhn, Th. S. The Essential Tension: Selected Studies in Scientific Tradition and Change. Chicago and London: University of Chicago Press, 1977. Langholf, V. Syntaktische Untersuchungen zu Hippokrates-Texten: Brachylogische Syntagmen in den individuellen Krankheits-Fallbeschreibungen der hippokratischen Schriftensammlung. Akademie der Wissenschaften und der Literatur, Mainz. Wiesbaden: Franz Steiner Verlag, 1977. ———. ‘Generalisationen und Aphorismen in den Epidemienbüchern.’ in Die Hippokratischen Epidemien, ed. G. Baader and R. Winau, 131–43. Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989. ———. Medical Theories in Hippocrates: Early Texts and the ‘Epidemics’. Berlin: Walter de Gruyter, 1990. Lichtenthaeler, Ch. Sur la vocation universitaire de l’histoire de la médicine, leçon inaugurale. Le troisième Épidémique d’Hippocrate vient-il vraiment après le premier? Sixième étude hippocratique. Genève: Droz, 1960. ———. Das Prognostikon wurde nicht vor, sondern nach den Epidemienbüchern 3 und 1 verfasst. Zweiter Beitrag zur Chronologie der echten hippokratischen Schriften. Stuttgart: Franz Steiner Verlag, 1989. ———. Neuer Kommentar zu den ersten zwölf Krankengeschichten im 3. Epidemienbuch des Hippokrates. Stuttgart: Franz Steiner Verlag Wiesbaden, 1994. Littré, É. Oeuvres complètes d’Hippocrate. 10 Volumes. Paris, 1839–61. Lloyd, G. E. R. Magic, Reason and Experience: Studies in the Origin and Development of Greek Science. Cambridge: Cambridge University Press, 1979.

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———. Review of Neuer Kommentar zu den ersten zwölf Krankengeschichten im 3. Epidemienbuch des Hippokrates by Charles Lichtenthaeler. Isis 86.3, (1995): 469. Morens, D. M. ‘Epidemiology.’ in Encyclopedia of Pestilence, Pandemics, and Plagues, Volume 1, ed. J. P. Byrne, 200–204. Westport, CT: Greenwood Press, 2008. Nachmanson, E. (ed.) Erotiani vocum Hippocraticarum collectio cum fragmentis. Collectio Scriptorum Veterum Upsaliensis, 1918. Parascandola, M. ‘Epidemiology’ and ‘Epidemiology, History of.’ in Encyclopedia of Pestilence, Pandemics, and Plagues, Volume 1, ed. J. P. Byrne, 204–07. Westport, CT: Greenwood Press, 2008. Potter, P. ‘Epidemien 1/3: Form und Absicht der zweiundvierzig Fallbeschreibungen.’ in Die Hippokratischen Epidemien, ed. G. Baader and R. Winau, 9–19. Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989. Roselli, A. ‘Epidemics and Aphorisms: Notes on the History of Early Transmission of Epidemics.’ in Die Hippokratischen Epidemien, ed. G. Baader and R. Winau, 182–90. Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989. Smith, W. D. ‘Generic Form in Epidemics 1 to 7.’ in Die Hippokratischen Epidemien, ed. G. Baader and R. Winau, 144–58. Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989. Sticker, G. Der Volkskrankheiten erstes und drittes Buch. Klassiker der Medizin 28. Leipzig: Verlag von Johann Ambrosius Barth, 1923. Temkin, O. ‘Der systematische Zusammenhang im Corpus Hippocraticum.’ Kyklos 1, (1928): 9–43. Thivel, A. Cnide et Cos? Essai sur les doctrines médicales dans la collection hippocratique. Paris: Les Belles Lettres, 1981. Wilkinson, L. ‘Epidemiology.’ in Companion Encyclopedia of the History of Medicine, Volume 2, ed. W. F. Bynum and R. Porter, 1262–82. London: Routledge, 1993.

CHAPTER 5

Voice Pathologies and the ‘Hippocratic Triangle’ Colin Webster Hippocratic authors frequently utilise silence, babbling, lisping and other verbal signs to diagnose a variety of physical illnesses and predict their course. This chapter examines these ‘voice pathologies’ and evaluates their impact on the dialogue between patients and Hippocratic physicians. In short, Hippocratic authors treat patients’ voices in two dissonant ways. On the one hand, physicians promote some form of discourse, implicitly relying on patients to report internal sensations resulting from illnesses. On the other hand, they develop extensive techniques to diminish and downplay this reliance. As a result, Hippocratic authors treat patients’ mouths not so much as the loci of potential subjective expression, but as orifices secreting verbal discharges. They weaken the distinction between the (sonic) effluvia of the mouth and those of other bodily outlets, thus bringing verbal output into close conceptual proximity with other types of discharge. Words come to be scrutinised for their quantity, quality and consistency as though they were quasi-excreta of the mouth. λέγειν τὰ προγενόμενα, γινώσκειν τὰ παρεόντα, προλέγειν τὰ ἐσόμενα· μελετᾶν ταῦτα. ἀσκεῖν περὶ τὰ νοσήματα δύο, ὠφελεῖν ἢ μὴ βλάπτειν. ἡ τέχνη διὰ τριῶν, τὸ νόσημα καὶ ὁ νοσέων καὶ ὁ ἰητρός· ὁ ἰητρὸς ὑπηρέτης τῆς τέχνης· ὑπεναντιοῦσθαι τῷ νοσήματι τὸν νοσέοντα μετὰ τοῦ ἰητροῦ. Announce what has happened, discern what is happening and foretell what will happen; attend to these things. Practice two things concerning diseases: help or do no harm. The art consists of three parts: the disease, the diseased and the physician; the physician is the servant of the art; the diseased fights against the disease with the physician (Hipp., Epid. 1.5, L. 2.634.6–636.4 = Kühlewein 189, 24–190, 6).1

1  Many thanks to the editors of the present volume, Georgia Petridou and Chiara Thumiger, for their helpful comments and continual patience. All translations are my own unless otherwise noted.

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1 Introduction The famous ‘Hippocratic triangle’ outlined above establishes the three main components that comprise the art of medicine: the disease, the diseased and the physician. Yet, even construing these three elements as a ‘triangle’ implicitly invokes the idea of equilateral angles and shared status. In fact, many scholars interpret this passage as though it were granting all but equivalent agency to both a physician and his patient, constructing them as two subjective agents allied together in combating the disease. Scholars then tend to assume that this type of partnership extends throughout the Hippocratic corpus. Jouanna, for instance, speaks about a “conversation” whereby the physician initiated a dialogue “for the purpose of collecting information about the diagnosis or prognosis of the illness, or possibly about the course of treatment.”2 Likewise, Nutton insists that the doctor’s success in treating the disease was just as dependent on the patient’s cooperation as an “informant” as it was on the patient’s compliance with the doctor’s advice.3 Despite these claims, however, the case studies in Epidemics 1 present patients who are consistently unreliable partners in dialogue, report very little information and are often incapacitated by fevers. To be sure, their verbal emissions are recorded, but mainly insofar as they babble and produce nonsense—or simply remain speechless. In short, patients in this text are constructed primarily as sick bodies emitting verbiage, not as interlocutors contributing speech. As a consequence, if the above passage of the Epidemics were in fact suggesting a triangle, it would need to be deeply acute, rather than equilateral.4 Difficulties surrounding the medical use of patient voices are not unique to the Epidemics. Across the corpus, Hippocratic authors frequently utilise silence, babbling, lisping and other verbal signs—what I call the ‘voice pathologies’—to diagnose a variety of physical illnesses and predict their course. In this paper, I propose to examine the use of these voice pathologies as litmus to test the potential for dialogue between patient and physician and to ­examine 2  Jouanna, J. (1992, rev. ed. 1999). Hippocrates, 135. For similar interpretations of the Hippocratic triangle, see Bourgey, L. ‘La relation du médecin au malade dans l’écrits de l’École de Cos’, in Bourgey, L. and Jouanna, J. (1975). La Collection Hippocratique et son rôle dans l’histoire de la médicine, 215; Gourevitch, D. (1984). Le Triangle Hippocratique dans le monde gréco-romaine: le malade, sa maladie et son médecin. 3  Nutton, V. (2004). Ancient Medicine, 88. 4  Cf. Hipp., Progn. 1 (L. 2.112.1–3 = Alexanderson 194, 1–3), which reflects a similar type of asymmetry, insofar as in this passage it is the physician alone who “fights against” (ἀνταγωνίσασθαι) the disease with his art.

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the construction of the patient within Hippocratic texts. How do ancient physicians use the voice in a medical context? What are the consequences of these practices? To begin to answer these questions, I argue that Hippocratic authors treat the patient’s voice in two dissonant ways. On the one hand, physicians do engage in some form of discourse, implicitly relying on patients as agents who can ‘give voice’ to the internal sensations resulting from illnesses—I call this listening to the patient’s subjective voice.5 In this way, patients provide valuable medical information otherwise hidden from sight. On the other hand, physicians also develop extensive techniques to diminish and downplay this reliance on secondhand testimony. These techniques are quite valuable: they allow physicians to consolidate their own authority and demonstrate their own expertise, while also helping to stabilise what constitutes medically relevant information. We should not underestimate the importance of such codification in a context where multiple healing practices compete with one another, and different traditions disagree over what constitutes a disease in the first place. Hippocratic physicians operate in a world where dreams can be just as medically significant as flatulence, the direction of the wind and the orientation of one’s city. Thus, what information gets brought into the medical arena is far from obvious, and regulating this information is quite important. Yet, while controlling the patients’ subjective voices is useful, it has its consequences, namely, it undermines their agency, thereby rendering them as epistemic objects—diseased bodies to be inspected and examined—rather than true partners in the therapeutic process. We can see this dynamic reflected in the way in which Hippocratic physicians treat patients’ mouths: not as the loci of potential subjective expression, but as orifices secreting verbal discharges. In other words, by constraining the voice’s capacity to relate subjective sensations and focusing instead on the diagnostic usefulness of vocal emissions— what I call the ‘literal voice’6—Hippocratic authors collapse the distinction between the (sonic) effluvia of the mouth and those of other bodily outlets. They thus bring verbal “secretions” into close conceptual proximity with other 5  The subjective voice is identified with the actual linguistic content—that is, the verbal information supplied by the voice. 6  The literal voice encompasses two types of information: 1) the sonic qualities of the voice, such as roughness, smoothness and pitch; and 2) the qualitative and quantitative aspects of how a patient says what he says, what he chooses to say, how much he says, etc. Both aspects of the literal voice relate meta-linguistic information not supplied by the actual verbal content. We could also think of the subjective voice as the message and the literal voice as the medium—with the obvious blurring between the categories to be discussed below.

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types of discharge. Words come to be scrutinised for their quantity, quality and consistency as though they were quasi-excreta of the mouth. 2

Prognosis and Dialogue

As a simple medical practice, ancient physicians must have asked their patients who they were and when they had become ill. Textual evidence confirms this and suggests that sick patients supplied considerable information about symptoms7 to which the physician would not have had direct access. For instance, Hippocratic authors frequently list internal sensations such as dimness of vision, thirst, hunger and heaviness in the limbs and body, and Epidemics 7.45 states that Mnesianax saw sparks around his eyes as he was walking around the marketplace—a detail that the author could not have known if Mnesianax had not himself mentioned it—and indeed, in this instance the author actually flags it as reported information.8 Other Hippocratic texts also occasionally describe pains so specific—some radiating across the left side of the body and into the ear, others shooting along the shoulder blades to the collarbone— that the patients simply must have been the ones describing them.9 Despite often utilizing information derived from patient reports, however, Hippocratic authors only rarely give indication that their data has been collected from secondhand testimony.10 Instead, throughout the corpus authors list symptoms 7   The term symptom comes loaded with conceptual baggage, insofar as it implies that observable afflictions are effects of some underlying disease. The distinction between sign and disease is not always so transparent in the Hippocratic corpus. As such, I use the term symptom, but it should be understood to refer to the perceptible afflictions either accompanying or resulting from disease—in other words, medically relevant data. 8   Hipp., Epid. 7.45 (L. 5.412.19–414.5 = Jouanna 79, 7–80, 5). This entry includes a report from Mnesianax: “He said that at times heat fell upon his hypochondria and sparks followed his eyes” (ἔστι δ᾽ὅτε προσπίπτειν αὐτῷ πρὸς τὰ ὑποχόνδρια θερμασίην ἔφη καὶ τῶν ὀφθαλμῶν μαρμαρυγὰς παρακολουθεῖν). For other patients reporting visual flashes, see Hipp., Epid. 5.83 (L. 5.250.18–252.4 = Jouanna 38, 5–15); Epid. 7.88 (L. 5.444.22–446.6 = Jouanna 102, 9–103, 5). 9   Cf. Hipp., Epid. 2.3.4 (L. 5.106.3–108.6 = Smith 50); Morb. 3.15. (L. 7.136.11–15 = Potter 82, 22–25). An especially marked case of a self-reported affliction is that of Nicanor, who said that he was terrified by the sound of the flute at nighttime symposia; see Epid. 7.86 (L. 5.444.13–16 = Jouanna 101, 10–102, 2). 10  Although examples can be found in other texts, the majority of explicitly marked patient reports comes in Epidemics 5 and 7. In several instances, however, when these reports are mentioned, the Hippocratic authors couch them in the language of ‘seeming to the patient’, which has the effect of distancing the author from the observed data; cf. Hipp.,

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without commenting on whether they were reported by the patients themselves, or simply gleaned by other outward means. In fact, there are a surprising number of symptoms that the physician could have easily learned by simple inquiry, but for which Hippocratic authors employ extensive visual signs. For instance, there are visual, outward signs for discomfort,11 delirium12 and dimness of vision.13 Diagnosing pain is a particular point of anxiety for Hippocratic physicians,14 and while they propose many outward, visible signs, including body position,15 rapidity of breathing,16 sleep patterns,17 drawn-up testicles,18

Epid. 5.21 (L. 5.220.14–19 = Jouanna 13, 18–25); Epid. 5.22 (L. 5.220.20–222.11 = Jouanna 14, 1–18); Epid. 5.43 (L. 5.232.17–22 = Jouanna 21, 11–18); Epid. 7.2 (L. 5.366.10–11 = Jouanna 49, 7); Epid. 7.25 (L. 5.394.15–18 = Jouanna 66, 13–17). Holmes remarks that the use of “it seemed to the patient” (δοκεῖν ἑαυτῷ) does not always imply that the author necessarily thinks the patient is incorrect; see Holmes, B. (2010). The Symptom and the Subject: The Emergence of the Physical Body in Ancient Greece, 149, n. 2; cf. the chapter of C. Thumiger in this volume, 107–137 (Chapter Three). 11  For instance, rather than simply asking the patient how he is feeling, Hipp., Progn. 3 (L. 2.118.7–122.4 = Alexanderson 197, 3–198, 11) provides an elaborate description of how a patient should look if he is feeling healthy—he should be leaning on either of his sides, holding his arms, neck and legs slightly bent and lying in a healthy manner. 12  Hipp., Progn. 3 (L. 2.118.7–122.4 = Alexanderson 197, 3–198, 11); Progn. 5 (L. 2.122.11–17 = Alexanderson 199, 6–11); Progn. 10 (L. 2.134.5–12 = Alexanderson 205, 9–206, 2); Progn. 11 (L. 2.134.13–138.14 = Alexanderson 206, 3–208, 3); Coac. 159 (L. 5.618.9–11 = Potter 140); Coac. 485 (L. 5.694.3–7 = Potter 224); Epid. 6.7.6 (L. 5.340.8–12 = Manetti and Roselli 156, 1–158, 6). The movement of the patient’s eyes is especially telling, for instance at Progn. 7 (L. 2.126.3–8 = Alexanderson 201, 2–9), where rapid eye movements and a throbbing hypochondrium indicate madness; cf. Pigeaud, J. (1987). Folie et cures de la folie chez les médecins de l’antiquité gréco-romaine, 23, 31. Galen, too, notes that madness can be detected from visual signs as easily as from verbal signs. For instance, see Gal., In Hipp. Prorrh. comment. 1.2.53 (K.16.630.13–631.11); cf. Ciani, M. G. ‘The silences of the body: Defect and absence of voice in Hippocrates’, in ead. (1987). The Regions of Silence: Studies on the Difficulty of Communicating, 154. 13  Hipp., Int. 48 (L. 7.284.8–19 = Potter 230–232); Dieb. Judic. 3 (L. 9.300.11–22 = Potter 302–304); cf. Boehm, I. ‘Inconscience et insensibilité dans la Collection hippocratique’, in Thivel, A. and Zucker, A. (1999). Le Normal et le Pathologique dans la Collection hippocratique, 259. 14  Cf. C. Roby’s paper in this collection, which examines Galen’s response to patients reporting their own pain, 304–322 (Chapter Eleven). 15  Hipp., Progn. 3 (L. 2.118.7–122.4 = Alexanderson 197, 3–198, 11). 16  Hipp., Progn. 5 (L. 2.122.11–17 = Alexanderson 199, 6–11). 17  Hipp., Progn. 9 (L. 2.134.5–11 = Alexanderson 205, 9–206, 2). 18  Hipp., Progn. 10 (L. 2.134.5–11 = Alexanderson 205, 8); cf. Coac. 484 (L. 5.694.2–3 = Potter 224).

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patients rubbing their sore parts19 and the sound of flatulence,20 the author of Epidemics 2 still asks how someone would distinguish the strongest pains, for which he offers cowardice and unique, individualised fear as outward signs.21 As was mentioned above, identifying symptoms from within a strict set of prescribed visual signs allows physicians to objectify what could otherwise be unstructured information and to stabilise what constitutes medically relevant information.22 Yet, the extensive use of outward signifiers should also cause us to reconsider what we might have otherwise identified as reported information. Even seemingly straightforward internal sensations are now externalised, objectified and made directly accessible to the physician’s senses. The Hippocratic author of Regimen in Acute Disease reveals his particular anxiety about relying on patients to report their own internal sensations, arguing that collecting such testimony is the mark of an amateur: οἱ συγγράψαντες τὰς Κνιδίας καλεομένας γνώμας ὁποῖα μὲν πάσχουσιν οἱ κάμνοντες ἐν ἑκάστοισι τῶν νοσημάτων ὀρθῶς ἔγραψαν καὶ ὁποίως ἔνια ἀπέβαινεν· καὶ ἄχρι μὲν τοῦτων, καὶ ὁ μὴ ἰητρὸς δύναιτο ἄν ὀρθῶς συγγράψαι, εἰ εὖ παρὰ τῶν καμνόντων ἑκάστον πύθοιτο, ὁποῖα πάσχουσιν· ὁπόσα δὲ προκαταμαθεῖν δεῖ τὸν ἰητρὸν μὴ λέγοντος τοῦ κάμνοντος, τουτῶν πολλὰ παρεῖται, ἄλλ᾽ ἐν ἄλλοισι καὶ ἐπίκαιρα ἔνια ἐόντα ἐς τέκμαρσιν. Those who compiled the so-called ‘Cnidian Sentences’ wrote down correctly what sort of things sick people suffer in each of the diseases, as well as the ways in which some turn out. But this much, even a non-physician would be able to compile correctly, if he should learn from each of the sick people what sort of things they suffered. But all the things the physician needs to understand beforehand without the sufferer saying anything, the majority of these things [the Cnidian authors] omit, some in some cases, others in other cases and some even though they are pertinent for judging from signs (Hipp., Acut. 1, L. 2.224.1–8 = Joly 36, 1–10, emphasis mine). 19  Hipp., Epid. 5.17 (L. 5.216.11–19 = Jouanna 11, 4–14). This visual sign seems to identify when children have pain in their genitals; cf. Aer. 9.4–6 (L. 2.38.13–42.6 = Jouanna 209, 11–211, 11). 20  Hipp., Progn. 11 (L. 2.138.6–10. = Alexanderson 207, 7–10); cf. Coac. 485 (L. 5.694.3–7 = Potter 224). 21  Hipp., Epid. 2.2.10 (L. 5.88.13–14 = Smith 33). The entry also mentions two other signs of serious pain—“solutions” (αἱ εὐπορίαι) and “experiences” (αἱ ἐμπειρίαι)—although what these denote is unclear. 22  On the difficulty of classifying medical information, especially as regards mental afflictions, see Simon, B. ‘ “Carving nature at the joints”: The dream of a perfect classification of mental illness’, in Harris, W. (2013). Mental Disorders in Classical Antiquity, 27–40.

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While this passage clearly denigrates dialogue with the patient for the purpose of gaining insight into their symptoms, it also suggests that not all physicians shunned this practice outright.23 In fact, the author of the ‘Cnidian Sentences’ seems to have engaged in it.24 More than that, however, this passage betrays the author’s somewhat schizophrenic treatment of the patient, insofar as some level of questioning must take place at least in practice if there are any pieces of information that fall outside of the heading ‘things the physician ought to understand beforehand’—which clearly must be the case for the category to have any meaning (i.e. if this were not the case, everything should be understood beforehand). Regardless, this Hippocratic author is suggesting that ideally a physician should recognise most of what patients are experiencing ‘without them saying anything’. Therefore, Hippocratic physicians do not simply disregard the subjective voice altogether, but nevertheless display manifest anxiety about relying on patients to articulate their own experiences. Although this preference for visual signs is displayed across the Hippocratic corpus, the prognostic texts exhibit it most thoroughly.25 They also display a unique response to this anxiety, insofar as they articulate a set of strategies 23  See M. Letts’ paper in this volume (81–103) which examines the great importance given by Rufus of Ephesus to the questioning of patients. The fact that he needs to argue for the benefit of questioning his patients demonstrates that it was not taken for granted as a standard practice. 24  Cf. Hipp., Praec. 2.2–11 (L. 9.254.4–5 = Jones 314), which argues that the physician “should not hesitate to question non-physicians” (μὴ ὀκνεῖν δὲ παρὰ ἰδεωτέων ἱστορεῖν). It is unclear whether these non-physicians are reporting their own past experiences, or those of others. In any case, it shows that some physicians were occasionally willing to ask questions to others and incorporate their answers into the construction of generalities. Nevertheless, it shows that Hippocratic authors did not all assume that asking patients questions was valuable; see G. Ecca (Chapter Twelve, 325–344 in this volume) on the Precepts and the patient-physician relationship described in it. 25  Texts that include prognostic practices: Progn., Prorrh. 1, Prorrh. 2, Coac., Dent., Aph., Aer. and Epid. 2, 4–7. The same type of visual signs also appears in Morb. 1–3. Grmek illustrates that Epidemics 1 and 3 also place an emphasis on prognosis rather than diagnosis; see Grmek, M. (1983). Les maladies à l’aube de la civilization occidentale. Similarly, Nutton, Ancient Medicine, 89, 92 sees Epidemics 1 and 3 as representing an ‘intermediary stage’ between case studies designed to collect prognostic information and a text designed to describe and catalogue various constitutions. For a similar account of the Epidemics, see Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien; Langholf, V. (1990). Medical Theories in Hippocrates, 222–54; Robert, F. ‘La prognose hippocratique dans les livres 5 et 7 des Épidemies,’ in Bingen, J. et al. (1975). Hommages à Claire Préaux, 257–70; Jouanna, J. (2000). Hippocrate, Épidemies 5 et 7. See also J. Wee’s paper in this volume (Chapter Four, 138–165) on cases and constitutions.

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whereby patients confirm rather than describe certain symptoms. This provides the physician with access to valuable diagnostic information, while simultaneously neutralizing the destabilizing effect of actual patient subjectivity within the medical arena.26 These techniques thus control the output of the patient’s voice by filtering it through a set of established questions rather than letting it sound on its own. This leaves the physician as the sole authority narrating the course of a disease. Although it can be found throughout many texts, a single example from Prorrhetics 2 will suffice to illustrate the technique. In the context of a long description of sciatica, the author states: oἷσι δὲ τὸ νούσημα τοῦτό ἐστι μὲν ἐν τῇ ὀσφύι καὶ τῷ σκέλει, βιάζεται δὲ οὐχ οὕτως ὥστε κατακέεσθαι, ξυστρέμματα σκέπτεσθαι μὲν εἴ που ἐν τῷ ἰσχίῳ, καὶ ἐπανερέσθαι εἰ εἰς τὸν βουβῶνα ἡ ὀδύνη ἀφικνεῖται· ἢν γὰρ ταῦτ’ ἔχῃ ἄμφω, χρόνιον τὸ νούσημα γίνεται· ἐπανερέσθαι δὲ καὶ εἰ ἐν τῷ μηρῷ νάρκαι ἐγγίνονται, καὶ ἐς τὴν ἰγνύην ἀφικνοῦνται· καὶ ἢν φῇ, αὖθις ἐρέεσθαι, καὶ ἢν διὰ τῆς κνήμης, ἐπὶ τὸν ταρσὸν τοῦ ποδός. ὁπόσοι δ’ ἂν τούτων τὰ πλεῖστα ὁμολογέωσι, εἰπεῖν αὐτοῖσιν ὅτι τὸ σκέλος σφὶν τοτὲ μὲν θερμὸν γίνεται, τοτὲ δὲ ψυχρόν. For those who have the disease in the loins and leg, but who are not so oppressed that they remain in bed, examine whether there are tumours anywhere in the hip joint and ask whether pain extends down into the groin; for if both are the case, the disease becomes chronic. And ask whether numbness is present in the thigh and extends to the upper leg. And if he says yes, ask again whether it also extends through the lower leg to the bottom of the foot. For all those who answer yes to the majority of these questions, say that their leg will sometimes become hot, sometimes cold (Hipp., Prorrh. 2.41, L. 9.70.20–72.4 = Potter 284). In instances such as this, the patient’s voice is reduced to its capacity to affirm or deny specific symptoms; it does not engage the physician in a general dialogue about the course of the illness. Rather than allowing the subjective experiences of the patient to guide him to a prognosis, the physician uses his own general prognostic framework to structure the appropriate symptoms for the patient to be experiencing. As a result, instead of acting as a true partner, the patient becomes little more than the raw input for the medical formula to calculate. One could say that prognostic techniques supply both the vocabulary 26  It should be said that it is hard to discern whether controlling the patient’s voice in this way reflects a simple textual practice—perhaps an idealised scenario—or a reflection of how medical encounters actually transpired.

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and grammar of suffering, and the patient can only speak according to this rigidly prescribed set of rules. Beyond structuring the patient’s experience of disease, the practices of prognosis claim even more authority over the subjective symptoms to which the patient could have otherwise been expected to ‘give voice.’ As Holmes has shown, Hippocratic patients bear very ambiguous relationships to their own bodies. In fact, Hippocratic authors often attempt to divorce sick individuals from their own somatic sensations and instead assume that they possess a more intimate knowledge of what patients are experiencing than even the patients themselves.27 For instance, Hippocratic prognosis is supposed to reveal not only what will happen to the patient during the course of a disease, but also what he has experienced—as well as what he is currently experiencing. As part of this program, the Hippocratic author of Prognostic 1 states that the physician should foretell “the things that are happening in the present, the things that have happened in the past, and the things that will happen in the future” (τά τε παρεόντα καὶ τὰ προγεγονότα καὶ τὰ μέλλοντα ἔσεσθαι).28 Similarly, the author of Prorrhetics 2.1 mentions that prophecy can be correct about both present and past symptoms (ἐπὶ πᾶσι τούτοισί τε καὶ τοῖσι προτέροισι χρόνοισι προφητίζειν καὶ πάντα ἀληθεύειν).29 The author of the Precepts even seems to remind physicians of the need to make a “display” (ἐπίδειξις) of the relevant signs to the patient, rather than advocating any dialogue or sustained 27  Holmes, Symptom, esp. 167–71. Holmes argues that the physician places himself as the true authority over the sensations that the patient feels (or is supposed to be feeling) and that the patient can only truly experience his or her own body by adopting the role of a physician. My argument aligns with hers in many ways, except insofar as I argue that the ubiquity of the voice pathologies provide a slight difficulty for this account, since in most cases a patient is fundamentally unable to hear his own voice as the physician would. For examples in which authors claim explicit authority over what a patient is actually feeling, see Hipp., de Arte 7 (L. 6.10.15–12.13 = Jouanna 231, 1–232, 11); de Arte 11 (L. 6.18.14–22.14 = Jouanna 237, 4–239, 14); Morb. 1.20 (L. 6.178.5–180.7 = Wittern 54, 15–58, 6). 28  Hipp., Progn. 1 (L. 2.110.2–3 = Alexanderson 193, 2–3). The quotation goes on to say “telling in detail as many as the patients leave out, [the physician] would be more trusted to know the predicaments of the sick” (ὁκόσα τε παραλείπουσιν οἱ ἀσθενέοντες ἐκδιηγούμενος πιστεύοιτο ἂν μᾶλλον γινώσκειν τὰ τῶν νοσεόντων πρήγματα) (Hipp., Progn. 1 (L. 2.110.3–5 = Alexanderson 193, 3–5). This once again demonstrates the schizophrenic treatment of patient reports, which the physicians need in order to understand the basic parameters of most diseases, but which they also try to downplay; cf. Epid. 1.5 (L. 2.634.6–636.4 = Kühlewein 189, 24–190, 6), quoted above. See also Langholf, Medical Theories, 232–54 for the connection between this type of prognosis and divination. 29  Hipp., Prorrh. 2.1 (L. 9.6.13–14 = Potter 216).

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q­ uestions designed to elicit reports from them.30 Even the so-called “recollection” (ἀνάμνησις) of the symptoms in On Ancient Medicine seems to come from the physician rather than the patient.31 In part, as Edelstein suggests, prognosis of this type is used for its ‘psychological effect’, insofar as physicians can demonstrate incredible competence and skill by being able to identify symptoms that the patient is experiencing before actually being told of them. Moreover, they can detect when patients break from their prescribed regimens, much to the astonishment (and perhaps chagrin) of the offending party.32 In short, prognosis garners trust.33 Such trust can be an incredibly powerful tool to attract and keep patients within a crowded marketplace of healers, and it can help ensure that patients adhere to their doctor’s orders, potentially improving the chances of recovery. That being said, the trust gained through visual prognosis has its consequences, namely, that by providing the physician with a set of visible signs to perceive internal sensations, prognosis also continues to remove the patient’s authority over his own body and actions. By privileging visual diagnosis, Hippocratic physicians 30  Hipp., Praec. 11 (L. 9.266.14–15 = Jones 326); cf. Praec. 9 (L. 9.264.8–266.8 = Jones 324–326). 31  Hipp., VM 2 (L. 1.572.9–574.7 = Jouanna 119, 12–120, 15). In this passage, the physician tells the patient what symptoms he suffers, and the patient only ‘recollects’ them (ἀναμιμνήσκειν) after he has heard them described by someone else, pace Wittern, who suggests that ‘anamnesis’ reveals the subjective symptoms of the patient; see Wittern, R. ‘Diagnostics in classical Greek medicine’, in Kawahita, Y. (1987). History of Diagnostics, 69–89. 32  Hipp., Prorrh. 2.1–4 (L. 9.6.1–20.15 = Potter 216–232). 33  Edelstein, L. ‘Hippocratic prognosis’, in Temkin O. and Temkin, C. L. (1967). Ancient Medicine: Selected Papers of Ludwig Edelstein, 87–100. More recently, Nutton, Ancient Medicine, 88–89 takes the same position. While trust can certainly be gained through these prognostic displays—and this is certainly how the Hippocratic author of the Prorrhetics justifies his program cf. Progn. 1 (L. 2.110.1–112.6 = Alexanderson 193, 1–194, 5)—both Edelstein and Nutton paint an overly rosy picture of the potential accuracy of prognosis. That is, the competence that the Hippocratic physician could display through correctly declaring what symptoms patients are suffering surely must be weighed against the danger of getting the symptoms wrong. While correctly identifying present symptoms can gain the patient’s trust, accurate prognosis in the long term—and therefore greater sustained confidence in a physician—could certainly be better served by true and thorough dialogue, rather than simply asking for confirmation of what the physician already feels he knows. For a recent discussion of prognosis and the purpose of the Prorrhetic 2 as a text to gain students, see Stover, T. ‘Form and function in Prorrhetic 2’, in Eijk, Ph. J. van der (2005). Hippocrates in Context, 345–61. See also K. van Shaik’s contribution (Chapter Nineteen, 471–495 in this volume), which explores how prognosis engenders trust, whether in the Hippocratic texts or the indigenous populations of Western Australia.

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elevate visible signs over any declarations of the patient. Authority over the patient’s personal actions is thus granted to the physician, who begins to speak as the true spokesman of the patient’s body.34 Once we acknowledge that prognostic practices devalue questioning and control patient reports, the construction of the patient within the so-called Hippocratic triangle looks very different—especially when we recognise that the author of Epidemics 1, quoted above, advocates the same triad of prognosis—that the physician should announce “what has happened, recognise what is happening and foretell what will happen” (λέγειν τὰ προγενόμενα, γινώσκειν τὰ παρεόντα, προλέγειν τὰ ἐσόμενα)—directly before he establishes that the disease, the diseased and the physician are the three components of medicine. That is, this Hippocratic author introduces the relationship between the physician and his patient only after having endorsed the very practices of prognosis that would have greatly reduced any subjective voice potentially available to the sick party.35 Up to this point, we have examined the anxiety that Hippocratic authors display about using the patient’s subjective voice as an access point to the body. In contrast, Hippocratic physicians frequently utilise the literal voice as a repository of diagnostic information without any such hesitancy. In fact, when articulating his diagnostic method in a well-known programmatic passage, the author of the Epidemics 1 provides a list of the fields that are medically relevant: τὰ δὲ περὶ τὰ νοσήματα, ἐξ ὧν διεγινώσκομεν, μαθόντες ἐκ τῆς κοινῆς φύσιος ἁπάντων καὶ τῆς ἰδίης ἑκάστου, ἐκ τοῦ νοσήματος, ἐκ τοῦ νοσέοντος, ἐκ τῶν 34  At a textual level, therefore, the potential agency of the patient finds expression not through dialogue, but only in troublesome disobedience. Some irony may be found in the fact that employing prognosis in order to gain a patient’s trust implicitly recognises patients as subjective individuals outside the text, insofar as they are seen as capable of choosing another physician or other kinds of healers. In other words, the fact of needing the patient’s trust recognises him as a subjective customer. Yet, at the same time, the very practices used to engage with the patient as a customer and win his trust have the effect of reducing him to an agent-less set of symptoms inside the text, a vector of bodily pains and affections to which he himself no longer has unique access. 35  As a result, ὁ νοσέων in the introductory quotation above ought to be closer identified with a ‘suffering body’ mutely fighting against the disease rather than an ‘embodied sufferer’ able to articulate his own somatic experiences; cf. Holmes, Symptom, esp. 143–47. This is not to argue that we cannot reconstruct moments within the text where patient agency and subjectivity filter through, only that we cannot take this as guaranteed by any hypothetical Hippocratic triangle.

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προσφερομένων, ἐκ τοῦ προσφέροντος—ἐπὶ τὸ ῥᾷον γὰρ καὶ χαλεπώτερον ἐκ τούτων—, ἐκ τῆς καταστάσιος ὅλης καὶ κατὰ μέρεα τῶν οὐρανίων καὶ χώρης ἑκάστης, ἐκ τοῦ ἔθεος, ἐκ τῆς διαίτης, ἐκ τῶν ἐπιτηδευμάτων, ἐκ τῆς ἡλικίης ἑκάστου, λόγοισι, τρόποισι, σιγῇ, διανοήμασιν, ὕπνοισιν, οὐχ ὕπνοισιν, ἐνυπνίοισι, οἵοισι καὶ ὅτε, τιλμοῖσι, κνησμοῖσι, δάκρυσιν, ἐκ τῶν παροξυσμῶν, διαχωρήμασιν, οὔροισιν, πτυάλοισιν, ἐμέτοισι. . .ἐκ τούτων καὶ ὅσα διὰ τούτων σκεπτέον. The things concerning diseases, from which we recognise them, learning from the common nature of all and from the individual nature of each person; from the disease, from the diseased person; from the things being applied, from the one prescribing them—for from this it is either easier or more difficult—from the condition of the whole and according to the parts, from the heavens and from each place; from the character; from the regimen; from practices; from the age of each person; by means of words; mannerisms; silences; thoughts; by their sleeping and not sleeping; by what sort of dreams and when; by pulling out hair; by scratching; by tears; from paroxysms; by bowel movements; by urines; by expectorations; by vomits . . . from these, one ought to examine all the things that occur because of them and all that results because of these fluids (Hipp., Epid. 1.10 (L. 2.668.14–670.15 = Kühlewein 199, 8–200, 2, emphasis mine). We can note that alongside other signs, such as bowel movements and urines, the author mentions “words, mannerisms, silences and thoughts” (λόγοισι, τρόποισι, σιγῇ, διανοήμασιν). Although the consideration of “thoughts” would require some discourse with the patient, the investigation of “words” and “silences” would demand a very different type of listening. That is, for these symptoms the physician would attend to the actual manner in which the patient speaks, while also noting the times at which he does not speak. Epidemics 6 makes this explicit: τὰ ἐκ τοῦ σμικροῦ πινακιδίου· σκεπτέα, δίαιτα γίνεται πλησμονῇ, κενώσει βρωμάτων, πομάτων· μεταβολὴ τούτων ἐξ οἵων οἷα ὡς ἔχει. ὀδμαὶ τέρπουσαι, λυποῦσαι, πιμπλῶσαι, †πειθόμεναι† μεταβολαὶ ἐξ οἵων οἵως ἔχουσι. τὰ ἐσπίπτοντα, ἢ ἐσιόντα πνεύματα [ἢ καὶ σώματα]. ἀκοαὶ κρέσσονες, αἱ δὲ λυποῦσαι. καὶ γλώσσης, ἐξ οἵων οἷα προκαλεῖται. πνεῦμα †τὸ ταύτῃ† θερμότερον, ψυχρότερον, παχύτερον, λεπτότερον, ξηρότερον, ὑγρότερον, πεπληρωμένον, μεῖόν τε καὶ [τὸ] πλεῖον· ἀφ’ ὧν αἱ μεταβολαί, οἷαι ἐξ οἵων, ὡς ἔχουσιν. τὰ ἴσχοντα, ἢ ἐνορμῶντα, ἢ ἐνισχόμενα [σώματα]. λόγοι, σιγὴ, εἰπεῖν ἃ βούλεται· λόγοι, οὓς λέγει, ἢ μέγα, ἢ πολλοί, ἀτρεκεῖς, ἢ πλαστοί.

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Things from the small tablet that one ought to examine: regimen resides in repletion and evacuation of food and drinks; changes in these things—from what to what, and what happens. Smells: pleasant, painful and filling; changes from what things and what happens. The stuff going in or breath going in, or bodily things as well. Noises: stronger, but some painful. And of the tongue, what is called forth from what. Breath: hotter, colder, thicker, thinner, drier, wetter, more filled up, to a greater and lesser degree; what sort of changes result from what sort of things, and what happens; the bodily things that bind or encourage or are bound. Words, silence, saying what he wants; words: which ones he says, either loudly, or many, or accurate or affected (Hipp., Epid. 6.8.7 (L. 5.344.17–346.7 = Manetti-Roselli 166, 1–172, 12, emphasis mine).36 Once again, verbal articulations are listed alongside other bodily affections, including things that either constipate or encourage bowel movements. The voice, however, was considered a uniquely important marker of a patient’s health. When speaking of the development of the fetus, the author of Epidemics 2 claims that “one’s nature is similar to one’s utterances” (ἡ γὰρ φύσις τῇ φθέγξει ὁμοίη),37 and Theophrastus even goes so far as to say that “the majority of signs in sick people are located in the tongue” (. . .σημεῖα πλεῖστα τοῖς κάμνουσιν ἐπ᾽ αὐτῆς εἶναι).38 Still, adopting “words” as a symptom has two major effects. On the one hand, it recognises the role that the voice plays in the construction of the patient as an individual,39 implicitly acknowledging the patient has a set of normal speech patterns against which any current articulations must

36  For other similar statements, see, Hum. 2 (L. 5.478.6–13 = Jones 64–66); cf. Prorrh. 2.3 (L. 9.10.16–14.6 = Potter 220–224). 37  Hipp., Epid. 2.6.4 (L. 5.134.2–5 = Smith 76); I am following Smith’s text; Littré reads λύσις, not φύσις; cf. Montiglio, S. (2000). Silence in the Land of Logos, 229, n. 53. 38  Thphr., Sens. 43. There is a possibility that Theophrastus means this quite literally, although Greek physicians do not promote tongue-diagnostics as extensively as traditional Chinese medicine, and the ‘tongue’ is often used as a metaphor for speech. 39  Montiglio, Silence, focuses on the social aspects of ‘speechlessness’, although she overemphasises the symbolic or cultural meaning of the symptom at the expense of recognizing voice pathologies as fundamentally physical in nature. Holmes, Symptom, 155–62 has a more measured approach, speaking about voice and physical comportment as signs that pertain to the construction of the patient as a social agent, while also acknowledging that these are physical symptoms that allow a window into the internal struggle between the φύσις of the body and the φύσις of the disease.

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be weighed.40 On the other hand, examining the literal voice as a repository of diagnostically valuable information further fractures the possibility of the patient ever acting as such an individual, since the main vehicle for subjectivity, namely his or her words, must now constantly be scrutinised to see whether they betray any pathological significance. Is the patient talking too much? Too little? Is he rambling? Do his words sound distorted in any manner? In this way, the scrutiny of the voice’s potential pathological content would have produced a barrier that prevented any actual dialogue from taking place, since the voice no longer truly belongs to the patient as an individual, but primarily as a diseased body. It therefore must now be run through a medical gamut in the same way as the other effluvia, being tested and examined for signs to which the patient does not himself have access. 3

Voice Pathologies

Having established that Hippocratic authors restrict and devalue the subjective voice in the medical arena while having also emphasised that they utilise the literal voice for both diagnosis and prognosis, we can now turn to examine the conceptual apparatus at work behind the voice pathologies themselves—and indeed, the ubiquity and the diversity of voice symptoms are considerable. While many appear completely comprehensible to a modern reader, others betray significant foreignness.41 Nevertheless, in all cases the voice pathologies 40  Several scholars discuss how symptoms such as changes in voice and behavioural alterations implicitly express the individuality of the patient; see Pagel, W. (1939). ‘Prognosis and diagnosis’, Journal of the Warburg Institute 2.4, 382–98; Diller, H. (1964). ‘Ausdrucksformen des methodischen Bewusstseins in den hippokratischen Epidemien’, Archiv für Begriffsgeschichte 9, 133–50 (repr. in Diller, H., 1971. Kleine Schriften zur antiken Medizin, 106–28, see esp. 136); Hall, T. S. (1974). ‘Idiosyncrasy: Greek medical ideas of uniqueness’, Sudhoffs Archiv 58, 285–90; Bourgey, ‘La relation’, 128, 195–210; Pigeaud, Folie, 23–24; Wittern, ‘Diagnostics’, 86–88; Schubert, C. ‘Menschenbild und Normwandel in der klassischen Zeit’, in Jouanna, J. and Flashar, H. (1996). Médecine et morale dans l’Antiquité, 121–55; Andò, V. ‘La φύσις tra normale e patologico’, in Thivel and Zucker, Le normal, 97–122; Giambalvo, M. ‘Normale versus Anormale?: lo statuto del patologico nella Collezione Ippocratica’, in Thivel and Zucker, Le normal, 55–96; Von Staden, H. ‘Ὡς ἐπὶ τὸ πολύ: “Hippocrates” between generalization and individualization’, in Thivel and Zucker, Le normal, 23–24; Nutton, Ancient Medicine, 89, 92. 41  For example, while we might consider the nasal voice of a cold and the incapacity to articulate a thought as symptoms belonging to two very different medical categories, Hippocratic physicians treat both as pathologies of the voice. “Swearing” (αἰσχρομυθεῖν)

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refer to aspects of the literal voice—in other words, voice pathologies concern the voice as a medium. Ciani has provided the most in depth general taxonomy of such verbal signs,42 and although I follow her approach in many respects, I wish to focus on a few pathologies in particular, even as I slightly recast her categories. For the purposes of this paper, I focus on a set of pathologies dealing with the sonic quality of the voice, such as roughness, smoothness, pitch and clarity of articulation, and a set of pathologies dealing with the verbal quantity of vocal emissions, such as babbling and speechlessness.43 Of course, there is a distinct qualitative element to evaluating the verbal aspects of voice pathologies (i.e. whether what is said constitutes coherent speech) and keeping a strict wall between sonic and verbal pathologies would be misleading, since the Hippocratic physicians use both to the same end (namely, to evaluate the status of the battle being fought inside the patient’s body). Nevertheless, examining the pathologies while using these rough categorisations will allow us to recognise how Hippocratic authors interpret the ‘outflow’ of the voice through a conceptual rubric related to the other bodily effluvia. 4

Sonic/Qualitative Pathologies

4.1 Roughness and Smoothness On the Art 12 names the “clarity and roughness of the voice” (φωνῆς λαμπρότης καὶ τρηχύτης) as the paradigmatic voice pathologies—in fact, the very first symptoms to which a physician has recourse when signs of illness are not is treated as a symptom for those who do not normally use foul language; see Hipp., Epid. 4.1.15 (L. 5.152.20 = Smith 96); cf. Coac. 51 (L. 5.596.11–13 = Potter 116). Yet, because this case takes into consideration the normal behaviour of the individual patient, it does not fall under the typical paradigm of verbal ejections. Some scholars, such as Wittern, ‘Diagnostics’, have argued that the Coan treatises that include these symptoms are thus more ‘patient focused’, whereas the Cnidian treatises are more ‘disease focused’. Langholf, Medical Theories, dismantles such distinctions. 42  Ciani, ‘Silences’. Ciani, however, structures her taxonomy according to modern medical explanations, rather than categories more relevant to the conceptual framework of the Hippocratic texts. See also Gourevitch, D. ‘L’aphonie hippocratique’, in Lasserre, F. and Mudry, P. (1983). Formes de pensée dans la collection hippocratique, 297–305, who deals with ἀφωνίη in particular. 43  An impediment arises from trying to classify and comprehend the voice pathologies, since it is often unclear whether attendant symptoms are supposed to be understood as expressing the cause of the voice pathologies, or whether they should simply be taken as a group of associated signs; cf. Pigeaud, Folie, 21.

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directly visible.44 A scratchy, harsh voice is perhaps the most immediately comprehensible of the voice pathologies, and Hippocratic physicians often associate “rough” (τρηχέα), “hoarse” (βραγχώδης) and “rasping” (ῥέγκος) voices with throat infections.45 Still, voices can be rough by nature rather than simply by disease, and even this natural roughness can help predict diseases46— something which modern physicians might be more hesitant to assert. In addition, the smoothness of the voice can also help forecast the course of an illness. For instance, the author of Coan Prenotions 208 suggests that a “weaker and smoother voice” (ἀσθενεστέρη καὶ λειοτέρη) indicates that a patient will undergo remission,47 while those with naturally soft voices (αἱ μαλακαί) are less prone to certain problems.48 As such, although evaluating the roughness and smoothness of the voice may seem like a comprehensible practice, the way this information is used within the Hippocratic texts already betrays a type of strangeness that becomes even more visible with the other pathologies. 4.2 Pitch Both high- and low-pitched voices can provide valuable diagnostic information as regards both the physical state of the respiratory system and the mental stability of a patient. For instance, speaking in a low-pitched voice (βαρὺ φθέγγεσθαι) is a bad sign, indicating diseases of the lung,49 while “high-pitched” and “shrill” voices are even worse and can indicate psychological disorders, such as mania.50 Yet, even pitch-diagnosed mania should not be seen as a simple mental evaluation. Rather, the symptom is understood within a nexus of 44  Hipp., de Arte 12 (L. 6.24.2–7 = Jouanna 240, 5–6). 45  For examples, see Hipp., Epid. 2.1.8 (L. 5.80.1–4 = Smith 24–26); Epid. 6.8.32 (L. 5.356.8 = Manetti-Roselli 194, 6); Epid. 7.7 (L. 5.378.9 = Jouanna 56, 8); Morb. 2.50 (L. 7.76.10 = Jouanna 186, 13). 46  For example, see Hipp., Epid. 2.1.8 (L. 5.80.1–14 = Smith 24–26). 47  Cf. Hipp., Hebd. 46 (L. 8.663.18–19 = Roscher 69); cf. Dieb. Judic. 2 (L. 9.298.17–19 = Potter 302). 48  Hipp., Epid. 2.1.8 (L. 5.80.3–4 = Smith 26). Similarly, the author of Aer. 5 (L. 2.24.2 = Jouanna 197, 4) suggests that inhabitants of a place where springs face east are “clearvoiced” (λαμπροφονοί), more intelligent and better tempered. 49  Hipp., Morb. 2.48 (L. 7.72.6–13 = Jouanna 183, 5–13); Morb. 3.16 (L. 7.150.21–23 = Potter 50); Prorrh. 2.35 (L. 9.66.11–15 = Potter 278–280); cf. [Arist.], Pr. 11.3, 11.11. 50  Hipp., Coac. 98 (L. 5.604.3–6 = Potter 126); Coac. 252 (L. 5.638.10–12 = Potter 162); Prorrh. 1.17 (L. 5.514.10–12 = Polack 77, 1–3); Prorrh. 1.19 (L. 5.514.14–516.1 = Polack 77, 6–8); Epid. 6.7.6 (L. 5.340.8–12. = Manetti-Roselli 156, 1–158, 6). Prorrhetic 1.47 (L. 5.522.8–9 = Polack 80) makes the broader, and simpler, claim: “a high-pitched, broken voice is a bad sign” (ὀξυφωνίη κλαυθμώδης κακόν).

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bodily affects, since delirium-indicating sharpness of the voice accompanies the tightening of the hypochondrium.51 Indeed, most scholars acknowledge that Hippocratic physicians never establish a strict division between the mind and body, or between mental and physical afflictions, and instead see mental illnesses as part of a larger somatic physiology. In fact, even when authors such as Plato and the author of the Anonymous Londiniensis papyrus articulate a distinction between mental and physical diseases, they still attribute many defects in cognition to underlying somatic causes.52 Thus, by using pitch to determine both physical and mental health, as well as by conceptualizing mental illness as part of a larger psychosomatic continuum, Hippocratic authors illustrate that we should not consider sonic pathologies as bodily and verbal pathologies as mental. Rather, both aspects form a 51  Hipp., Coac. 51 (L. 5.596.11–13 = Potter 116). 52  Pl., Ti. 86b1–2 argues that there are diseases of the body and diseases of the soul; cf. Anon. Lond. 1.36, et al. (see Manetti, D. ‘The role of doxography in the Anonymus Londiniensis’, in Eijk, Ph. J. van der (1999). Ancient Histories of Medicine, 95–141; cf. Hipp., Epid. 6.8.31 (L. 5.354.19–365.3 = Manetti-Roselli 192, 1–194, 5). In all these cases, the authors still attribute “soul-” or “mind-” afflictions to somatic causes, such as excess bile, or heat and cold destabilizing the function of the mind, etc. See also Sassi, M. M. ‘Mental illness, moral error, and responsibility in late Plato’, in Harris, Mental, 413–26, who cites Plato’s distinction as evidence that he essentially ‘invented’ the concept of mental illness; cf. Jouanna, J. ‘The typology and aetiology of madness in ancient Greek medical and philosophical writing’, in Harris, Mental, 97–118. Although Plato certainly contributed to the conception of mental afflictions as disturbances in the soul rather than the body, authors prior to Plato had already begun to mark cognitive/behavioural disorders as a category in their own right, even if they were not yet separated from bodily causes; cf. Harris, W. ‘Thinking about mental disorders in classical antiquity’, in Harris, Mental, 1–23. For general investigations into the emergence of mental illness as a category and the hazy boundary between body/ soul and somatic/psychic afflictions in ancient medical thought, see Pigeaud, J. ‘Quelques aspects du rapport de l’âme et du corps dans le Corpus hippocratique’, in Grmek, M. D. (1980). Hippocratica, 417–33; Singer, P. ‘Some Hippocratic mind-body problems’, in López Férez, J. A. (1992). Tratados Hipocraticos: estudios acerca de su contenido, forma e influencia, 131–43; Gundert, B. ‘Soma and Psyche in Hippocratic medicine’, in Wright, J. P. and Potter, P. (2000). Psyche and Soma: Physicians and Metaphysicians on the Mind-body Problem from Antiquity to the Enlightenment, 13–35; Bartoš, H. (2006). ‘Varieties in the ancient Greek body-soul distinction’, Rhizai 3, 59–78; Eijk, Ph. J. van der ‘Modes and degrees of soulbody relationship in On Regimen’, in Perilli, L. et al. (2011). Officina Hippocratica. Studies in Honour of Anargyros Anastassiou and Dieter Irmer, 255–70; Eijk, Ph. J. van der ‘Cure and (in)curability of mental disorders in ancient medical and philosophical thought’, in Harris, Mental, 307–38; Lo Presti, R. ‘Characterizing epilepsy in Greek scientific discourse’, in Harris, Mental, 195–222; Holmes, B. ‘Disturbing connections: Sympathetic affections, mental disorder, and the elusive soul in Galen’, in Harris, Mental, 147–76.

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larger group of voice signs that collectively address the status of the patient and the disease. For the present, however, it is important to note that by allowing the tenor of a patient’s voice to determine his mental and physical stability, the physician puts up a barrier between himself and the person whom he treats; he no longer listens to the patient’s voice for its verbal content alone, but now scans it instead for its meta-linguistic information. In effect, the patient’s voice ceases to function as a vehicle for subjectivity, but becomes redeployed as a substance whose quality and consistency reveals the inner fight between body and disease. As Ciani states, the voice “becomes an expression of the state of health, the voice of the body, rather than the expression of the thoughts and the mind.”53 Moreover, although the voice certainly can be used to gauge the mental stability of the patient, the delirium associated with shrillness of the voice tends to be linked to certain bowel symptoms as well: “Cases of delirium, shrillness in the voice and spasms in the tongue: when these people also tremble, the person will become beside themselves; constipation is a fatal sign for these people” (αἱ παρακρούσιες, φωνῇ κλαγγώδεες, γλώσσῃ σπασμώδεες, καὶ αὐτοὶ τρομώδεες γινόμενοι, ἐξίστανται· σκληρυσμὸς τούτοισιν ὀλέθριος).54 In fact, this is the first in a series of associations between the ‘excretions’ of the mouth and the effluvia of other orifices, which may allow us to see a greater conceptual link between these different sets of pathologies. 4.3 Trembling Voice (τρομώδης) The connection between voice defects and the bowels is explicit with the trembling of the voice (φωνὴ τρομώδης), which sounds as if the patient is shivering. Coac. 39 claims that this is a “bad sign”,55 and, as if demonstrating this fact, the symptom occurs at Epid. 4.55 shortly before a patient’s death. Like pitch, vocal trembling can be used to evaluate the patient’s mental stability— nevertheless, even when it is associated with delirium, it still remains linked to other bodily effluvia. For instance, Coac. 228 states: “Trembling tongues cause liquidity in the bowels for some; and if their tongues are also black, they signify a quick death; is a trembling tongue a sign of the mind not being settled?” (αἱ τρομώδεες γλῶσσαί τισι καὶ κοιλίην καθυγραίνουσιν· μελανθεῖσαι δ᾽ἐν τούτοισι, ταχὺν θάνατον σημαίνουσιν· ἆρα τρομώδης γλῶσσα σημεῖον οὐχ ἱδρυμένης γνώμης).56 53  Ciani, ‘Silences’, 159. 54  Hipp., Coac. 98 (L. 5.604.3–6 = Potter 126); cf. Prorrh. 1.17 (L. 5.514.10–12 = Polack 77). 55  Hipp., Coac. 39 (L. 5.594.11–14 = Potter 114). 56  Hipp., Coac. 228 (L. 5.634.14–17 = Potter 158); cf. Coac. 253 (L. 5.638.12–13 = Potter 164); Coac. 625 (L. 5.728.19–23 = Potter 264), Coac. 636 (L. 5.732.4–5 = Potter 268). Similarly, Coac. 312 (L. 5.652.9–11 = Potter 178) asks whether trembling is also a bad sign for those

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However strange the association of trembling tongues and diarrhea may seem, Hippocratic authors frequently make connections—both pathological and conceptual—between verbal effluvia and the outflow of the anus. Worman has demonstrated the links between mouth and anus in Athenian rhetorical practices, whereby the two often stand as metonyms for each other, as orators purposefully conflate their respective appetites and excretions.57 And, while the Hippocratic authors never do so explicitly, the pseudo-Aristotelian author of Problemata 11.45 even calls the voice a “flow” (ῥύσις).58 In fact, the Problemata treats the voice pathologies as though they were completely physical symptoms, operating within the same system as the rest of the body’s ailments—so much so that the text explains stammering not as some mental affliction, but as the effect of the voice cooling, cured by the heating action of wine. Such associations can help us understand how the physiological function of the voice operates in close conjunction with the physical, somatic discharges flowing out of the other orifices. 4.4 Stuttering (ψελλός), Mumbling and Lisping (τραυλός) “Stuttering” (ψελλότης) is characterised by the inability to articulate one’s words, especially the incapacity to join one word to the next. It can be caused by paralysis and general weakness,59 or even dryness of the tongue.60 Rather than reflecting defects of either the mind or mouth alone, it belongs to a nexus of physical and psychis systems, just like trembling. To give a few examples, stuttering can signify that a patient will become empyemic and start collecting pus in a given cavity.61 When stuttering occurs in bald people whose “chests are saturated” (κατακορέα τὰ στήθεα), it can indicate mania.62 Baldness is often associated with the voice, and in turn both are connected to the testicles.63

with pains in their loins; cf. Prorrh. 1.42 (L. 5.522.2–4 = Polack 80, 4–7); Prorrh. 1.19 (L. 5.514.14–516.1 = Polack 77). 57  Worman, N. (2008). Abusive Mouths in Classical Athens. 58  [Arist.], Pr. 11.54. Similarly, Pr. 11.12 considers how the sound of the voice is tied to the moisture levels of the body; cf. Pr. 11.30, 35, 36, 38, 54, 55, 60. 59  Hipp., Epid. 7.8 (L. 5.378. 22–23 = Jouanna 56, 23–25). 60  Hipp., Epid. 7.105 (L. 5.456.7–8 = Jouanna 109, 14–15). 61  Hipp., Epid. 2.5.2 (L. 5.128.7–11 = Smith 70); cf. Judic. 43 (L. 9.290.9–11 = Potter 292–93). 62  Hipp., Epid. 2.6.14 (L. 5.136.2–5 = Smith 80); I am here following Smith’s translation of κατακορέα (see Smith, Loeb 81, n. b.); cf. Epid. 2.6.22 (L. 5.136.14–18 = Smith 82). 63  Cf. Hipp., Coac. 160 (L. 5.618.11–15 = Potter 140–42).

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Related to stuttering are “mumbling” (ἰσχνοφωνίη) and “lisping” (τραυλότης, ὑποτραυλότης). These are two separate affections,64 but are often paired together as a set. As with stuttering, lisping can be a congenital disorder, or can be caused during the course of a disease, either by a dry mouth or excessive shouting.65 And, like stuttering, muttering and lisping are associated with a related assortment of symptoms. Mumbling can indicate epilepsy in a child who also has shooting pains in the belly and has recently gotten in an accident,66 while the author of Epid. 2.5.1 states that mumbling can be cured when veins in the testicles enlarge. This latter claim should recall the association of the voice and testicles above, as well as the claim: “when a testicle has swelled from coughing, it is a reminder of the connection between the chest, breasts, genitals, voice” (ὄρχις οἰδήσας ὑπὸ βηχωδέων ὑπόμνημα κοινωνίης στηθέων, μαζῶν, γονῆς, φωνῆς).67 The remainder of the passage at Epid. 2.5.1 goes on to assert that “mumblers” (ἰσχνόφωνος) and “lispers” (τραυλός) are melancholic when they are also bald or hairy. The link between mumblers, lispers and melancholic diseases also appears at Epid. 2.6.1, where a similar set of physical categorisations comes up again, where lispers with large heads and small eyes are “quick to anger” (ὀξύθυμοι). Moreover, the lispers and “fast talkers” (ταχύγλωσσοι) are melancholic and intense, while someone with a small head will neither be a lisper nor bald unless his eyes are grey.68 64  Ciani, ‘Silences’, 149–50 notes how difficult it is to discern the precise semantic ranges of ψελλός, ἰσχνοφωνός and τραυλός. [Arist.], Pr. 11.30 considers “lisping” (τραυλότης) to be the inability to articulate a certain letter, “stuttering” (ψελλότης) the inability to join one syllable to another and “mumbling” (ἰσχνοφωνίη) the inability to control the tongue, as is often the case with children; cf. Schmidt, J. H. H. (1876). Synonymik der griechischen Sprache, 369–73. Ciani identifies these as ‘congenital defects’, but they also occur during the course of an illness and are thus sometimes pathological as well. 65  Hipp., Epid. 7.2 (L. 5.368.3 = Jouanna 50, 1–2); Epid. 7.43 (L. 5.410.11–13 = Jouanna 78, 2–5); Epid. 7.22 (L. 5.393.13–14 = Jouanna 65, 7–9); Epid. 7.11 (L. 5.386.21–22 = Jouanna 61, 23–24). 66  Hipp., Prorrh. 2.10 (L. 9.28.26–30.9 = Potter 242); cf. Coac. 157 (L. 5.618.4–7 = Potter 140). 67  Hipp., Epid. 2.1.6 (L. 5.76.15–16 = Smith 22); cf. Epid. 2.6.2 (L. 5.132.21–22 = Smith 76); Epid. 4.61 (L. 5.196.19–21 = Smith 140); Hum. 10 (L. 5.490.9–16 = Jones 80–82). These connections could reflect the observation that castrated males do not undergo a deepening of the voice during puberty, or could reflect the common idea that the testicles were part of the vascular system, connecting to the veins leading down from the head from which semen was derived; see Hipp., Oss. 14–15, 17 (L. 9.186.17–190.9, 9.192.3–16); cf. Arist., HA 3.1.510a12–35; 3.4.514b29–515a5; GA 2.2.735a29–736a23. Celsus, Med. 6.18.6; 7.22.5 mentions castration, but it is unclear what he thought its consequences were aside from the loss of the capacity to procreate, see König, J. (2013). ‘Ancient Greco-Roman views of the testicle in Celsus and beyond’, Rosetta 13, 104–10. 68  Hipp., Epid. 2.6.1 (L. 5.132.15–21 = Smith 76).

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This association of inherent physical features, cognitive/behavioural afflictions and particular speech pathologies can indicate a patient’s potential susceptibility to certain diseases. For example, the author of Epid. 1 lists a group of people who died in large numbers, including “those who have lived carelessly and are lazy, the mumblers, the rough voiced, the lispers, the passionate” (οἱ εἰκῇ καὶ ἐπὶ τὸ ῥᾴθυμον βεβιωκότες, ἰσχνόφωνοι, τρηχύφωνοι, τραυλοί, ὀργίλοι).69 Lastly, Aphorism 6.32 declares: “lispers will be especially afflicted by terrible diarrhea” (τραυλοὶ ὑπὸ διαρροίης μάλιστα ἁλίσκονται μακρῆς).70 These examples demonstrate that the quality of the patient’s voice belongs to a psychosomatic system of signs and afflictions, where mental disturbances remain tied to a larger physiological conception of the body, one that involves passages, fluids, heat, coldness, wet and dry. Moreover, while the particular physiological relationship remains undefined, the voice pathologies are frequently connected to disrupted bowel movements. That is, the body’s inability to control the outflow of one orifice (the mouth) signifies that the patient is unable to control the outflow of another (the anus). 5

Verbal/Quantitative Pathologies

While many voice pathologies deal with the sonic qualities of articulation, another set deals with the meta-linguistic information related by verbal utterances. On the one hand, these verbal pathologies evaluate certain qualitative aspects, determining whether utterances constitute meaningless, inappropriate speech (e.g. nonsense). On the other hand, the two most prevalent sets of verbal pathologies deal largely with the quantity of speech—that is, whether patients produce speech in excessive amounts, which generally indicates mental and physical instability, or in deficient amounts, through either periodic silence, or physical voicelessness. Scholars have often examined these pathologies within the context of mental illness.71 Nevertheless, while identifying 69  Hipp., Epid. 1.9 (L. 2.656.4–6 = Kühlewein 195, 18–19). 70  Hipp., Aph. 6.32 (L. 4.570.10 = Jones 186). 71  For the most recent examination of the taxonomy of madness, see Thumiger, C. ‘Early medical vocabulary of insanity’, in Harris, Mental, 61–96; cf. Berrettoni, P. (1970). ‘Il lessico tecnico del 1 e 3 libro delle Epidemie ippocratiche. Contributo alla storia della formazione della terminologia medica greca’, Annali della Scuola Normale Superiore di Pisa 39, 27–106, 217–311. The bibliography on ancient mental illness is vast, but for the most recent contributions, see Harris, Mental, many of which have already been cited. For investigations that incorporate the voice and breath in particular, see Clarke, E. (1963). ‘Apoplexy in the Hippocratic writings’, Bull. Hist. Med. 37, 301–14; Pigeaud, Folie, 14–40; Pigeaud, J.

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babbling and nonsense can certainly help establish a patient’s mental state, there are many instances where the psychological implications are far from evident—and, if the mind/body distinction is already unclear for mental illnesses, as mentioned above, we should consider whether the same is the case for mental symptoms. Thus, given the pathological connection between certain voice defects and troublesome excreta, we can also draw a conceptual connection between how symptoms such as rambling and incoherence map onto physiological conceptions of surfeit and lack. 5.1 Nonsense and Excessive Speech Hippocratic authors have a number of different words for ‘nonsense’, and they can include both verbal emissions that are nonsensical by nature and those that are nonsensical in context. In the first category we can include “talking gibberish” (φλυηρεῖν), which seems to occur while a patient is incapacitated by drink,72 deliriousness from pain,73 or in a state of lethargic semi-­ consciousness.74 Similarly, patients can be said to “babble” (λαλεῖν) while in a similar state of lethargy.75 In these instances, the words that come out of the patient’s mouth seem devoid of any particular meaning, and instead operate merely as random phonemes, perhaps even associated with animal noises.76 Along with this type of nonsense, we might also include the symptom listed as “many words” (πολλοὶ λόγοι), or simply as “words” (λόγοι), which again seems to indicate when a patient is producing words of no discernible value, which may however—as in all these cases—include snippets of actual speech. For instance, Silenus, struck by a fever, gets worse on the third day: “feces thin, dark; urine turbid, dark; no sleep at night; many words, laughing, songs; he was unable to hold back” (διαχωρήματα λεπτά, ὑπομέλανα, οὖρα θολερά, ὑπομέλανα, νυκτὸς οὐδὲν ἐκοιμήθη, λόγοι πολλοί, γέλως, ᾠδή, κατέχειν οὐκ ἠδύνατο).77 Similarly, in Thasos, the wife of Philinus suffered complications from birth, and on the fourteenth day: “spasm all over the body, many words, a little bit lucid” (παλμὸς (1989). Maladie de l’âme, 100–07; Duminil, M.-P. “Les maladies ‘frappés’ ”, in Férez López, Tradatos, 215–24. See also Benedetto, V. d. (1986). Il medico e la malattia, 43–50, who examines how voice symptoms function in terms of the soul and perception. 72  Hipp., Morb. 2.22 (L. 7.36.14–38.5 = Jouanna 156, 10–157, 10). 73  Hipp., Morb. 2.67 (L. 7.102.4–25 = Jouanna 205, 17–206, 18). 74  Hipp., Morb. 2.65 (L. 7.100.1–7 = Jouanna 204, 3–10); Coac. 355 (L. 5.658.23–660.3 = Potter 186). For an example of fever correlated with and episode of gibberish, see Hipp., Morb. 3.13 (L. 7.132.18–134.7 = Potter 26). 75  Hipp., Epid. 7.11 (L. 5.382.19–21 = Jouanna 59.5–7). 76  Cf. [Arist.], Pr. 11.30. 77  Hipp., Epid. 1.13, Case 2 (L. 2.686.1–7 = Kühlewein 203, 23–204, 1).

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δι᾽ ὅλου τοῦ σώματος, λόγοι πολλοί, σμικρὰ κατενόει).78 More than babbling or gibberish, when the Hippocratic physicians classify “words” as a diagnostically valuable pathology, they functionally strip the patient’s voice of all linguistic content and instead reduce the emissions of the mouth to a raw material being excreted. Purged of any possible verbal meaning, the voice becomes a crude emission, a substance to be scrutinised and examined. Related to “words” is “nonsense” (λῆρος), as can be seen on the fifth day at Epidemics 1.13, Case 1, where Philiscus has a distressing night with little sleep and suffers from both “words” and “nonsense.”79 Although not exclusively verbal,80 the vast majority of instances of “producing nonsense” (λῆρος, λήρησις, ληρεῖν, παραλήρησις) seem to involve something akin to the babbling that takes place while a patient is asleep. The term appears throughout the Epidemics as a symptom suffered by feverish, disturbed patients whether they are awake, or unconscious.81 For instance, at Epid. 1.13, Case 3, Herophon suffers acute fever, cannot sleep and on the fifth day becomes delirious (παρεφρόνησεν) with a tighter hypochondrium.82 On the sixth day, “he produced nonsense, sweats in the night, chills, the nonsense remained” (ἐλήρει, ἐς νύκτα ἱδρώς, ψύξις, παράληρος παρέμενεν).83 We might consider what it means for the physician to be consistently measuring the level of nonsense the patient produces whether or not he or she is awake. These voice pathologies (or quasi-voice pathologies) such as gibberish and nonsense certainly help determine the mental stability of a patient if he is awake, but if the patient is asleep, nonsense offers a far 78  Hipp., Epid. 1.13, Case 4 (L. 2.692.16–17 = Kühlewein 206, 13–14). 79  Hipp., Epid. 1.13, Case 1 (L. 2.684.3 = Kühlewein 203, 3). 80  Hipp., Epid. 7.85 (L. 5.444.1–12 = Jouanna 100, 16–101, 9) describes Androthales as suffering from ἀφωνίη, ἄγνοια, παραλήρησις, and it is unclear whether these symptoms occur in alternation, or whether the “nonsense” in this case is non-verbal; cf. Epid. 5.80 (L. 5.248.23–250.9 = Jouanna 36, 7–37, 6). Nevertheless, λῆρος and φλυαρία are paired by both Plato (Hp. Ma. 304b5) and Aristophanes (fr. 62, ln. 18, Austin), and like φλυαρία the term λῆρος most often refers to verbal nonsense; cf. Ar., Th. 880, Pl. 518, Nu. 359, Ra. 1497; Pl., Hipp. Maj. 298b8–c1, Tht. 176d4. That being said, Ar., Pl. 589, refers to a wreath as a λῆρον, which suggests that the term could also denote non-verbal instances of nonsense as well. 81  Pigeaud, Folie, 17–18 takes λῆρος as an indication of delirium displayed through speech on par with παραλέγειν. 82  Hipp., Epid. 1.13, Case 3 (L. 2.688.10–16 = Kühlewein 204, 20–205, 2). Given the association seen above at Hipp., Coac. 51 (L. 5.596.11–13 = Potter 116), tight hypochondrium = high-pitched voice = delirium, we might consider whether this case draws on the same supposition. 83  Hipp., Epid. 1.13, Case 3 (L. 2.688.15–16 = Kühlewein 205, 2–3).

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clearer window into the internal fight of the body.84 We could say that while conscious, deranged patients speak gibberish; while asleep, sick bodies secrete nonsense. 5.2 Voicelessness and Silence As seen in the passages above, the authors of both Epidemics 1 and 6 list “silences” alongside words and mannerisms as a symptom with potential medical relevancy. In fact, “voicelessness” (ἀφωνίη) is the most common of all the voice pathologies, appearing 109 times within the Hippocratic corpus.85 For the most part, the symptom indicates devastation of the most severe type, frequently appearing as the last outward sign that the patient displays as he or she nears death.86 The case of Philinus’ wife at Epidemics 1.13, Case 4 could easily serve as a typical example: “Around the fourteenth day there was a spasm all over her body, many words, a little rational, but after a short time deranged again; around the seventeenth becoming voiceless; on the twentieth, death” (περὶ τεσσαρεσκαιδεκάτην ἐούσῃ παλμὸς δι᾽ ὅλου τοῦ σώματος, λόγοι πολλοί, σμικρὰ κατενόει· διὰ ταχέων δὲ πάλιν παρέκρουσεν. περὶ δὲ ἑπτακαιδεκάτην ἐοῦσα ἄφωνος. εἰκοστῇ ἀπέθανε).87 For this reason, Montiglio calls silence the sound of “the state of dying.”88 Nevertheless, while voicelessness is never a positive thing, Montiglio does not emphasise the wide range of illnesses in which it plays a crucial prognostic role. Though they are rare, some cases of voicelessness, or “stopped voice”, represent actual physical constrictions. For instance, at Epid. 7.100, Polemarchus’ 84  Montiglio, Silence, 228 claims that delirium and silence are worrisome, especially since the physician “urgently needs his patients’ words in order to understand the nature of their illnesses.” As we have seen, however, this is an overstatement and the information conveyed by the sign “nonsense” can be just as powerful for prognosis as any patientrevealed information. 85  Related to “voicelessness” ἀφωνίη is “speechlessness” ἀναυδίη. In fact, despite any overlap, Hipp., Epid. 3.17, Case 3 (L. 3.114.3 = Kühlewein 235, 13) lists “speechless, voiceless” (ἄναυδος, ἄφωνος) as consecutive symptoms on both the second and fourth days. Although it is difficult to discern a strict difference between these two pathologies in the Hippocratic corpus, Gal., In Hipp. Epid.1 comment. 3.74 (K. 17a 758.11–16) considers ἀναυδίη to be the paralysis of the tongue and the inability to articulate words, whereas ἀφωνίη is the complete loss of vocal capacity. 86  Montiglio, Silence, investigates the cultural meaning of silence and emphasises the relationship of speechlessness and death in the Hippocratic corpus; cf. Holmes, Symptom, 158; Boehm. ‘Inconscience’, 269. 87  Hipp., Epid. 1.13, Case 4 (L. 2.692.15–694.2 = Kühlewein 206, 12–16). 88  Montiglio, Silence, 229.

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wife suffers post-menopausal pain in her hip, and, after she drank beet juice “her voice was stopped through the night until midday; she heard and was lucid, and signified with her hand that the pain was around her hip” (ἔσχετο ἡ φωνὴ νύκτα καὶ ἐς μέσον ἡμέρης· ἤκουσε δὲ καὶ ἐφρόνει· καὶ τῇ χειρὶ ἐσήμαινεν ἀμφὶ τὸ ἰσχίον εἶναι τὸ ἄλγημα).89 In most instances, however, voicelessness arises from some type of general incapacitation. Often this includes mental incapacitation, sometimes caused by trauma to the head,90 sometimes following a sudden pain,91 sometimes as a result of epilepsy,92 but most often when accompanied by intense fever. In many of these cases, the patient is completely weakened, lethargic and perhaps even functionally unconscious and without senses (ἀναίσθητος).93 Galen even complains that Hippocrates often classifies those who are in a state of torpor (κάρος) as voiceless.94 One such instance occurs at Epid. 1.13, Case 2, on the eighth day of Silenus’ illness: “His extremities warmed up a bit, little sleep, deeply lethargic, voiceless, thin, clear urine” (ἄκρεα σμικρὰ ἀνεθερμαίνετο, ὕπνοι λεπτοί, κωματώδης, ἄφωνος, οὖρα λεπτὰ διαφανέα).95 When reviewing this type of voicelessness, Ciani states that is has “no particular import except in so far as it is connected with the comatose state 89  Hipp., Epid. 7.100 (L. 5.452.25–454.3 = Jouanna 108, 4–8). Hippocratic authors list other peculiar physical signs that occur along with ἀφωνίη, including hiccoughs and jaundice; cf. Hipp., Coac. 194 (L. 5.626.6–10 = Potter 150); Prorrh. 1.32 (L. 5.518.3–8 = Polack 78, 9–13). 90  Cf. Hipp., Epid. 7.32 (L. 5.400.22–402.5 = Jouanna 71, 3–10); Epid. 7.77 (L. 5.434.9–15 = Jouanna 93, 13–94, 4); Epid. 5.50 (L. 5.236.11–20 = Jouanna 23, 15–24, 2); Epid. 5.55 (L. 5.238.11–16 = Jouanna 25, 6–13); Coac. 489 (L. 5.696.2–5 = Potter 226); Aph. 7.58 (L. 4.594.10–11 = Jones 206). 91  Hipp., Morb. 2.21 (L. 7.36.1–13 = Jouanna 155, 10–156, 9); Morb. 2.6 (L. 7.14.8–22 = Jouanna 137, 9–138, 5); Aph. 7.40 (L. 4.588.8–9 = Jones 202); Epid. 4.12 (L. 5.150.14–15 = Smith 94). These cases of speechlessness seem to arise from a stroke or an aneurism, a category which Ciani, ‘Silences’, 152 calls “cerebral disturbances”. Still, we should be weary of normalizing this pathology to fit modern physiological explanations, especially when Aph. 7.40 regards this sudden paralysis of the tongue as a type of melancholic illness. 92  Hipp., Morb. Sacr. 7.2–5 (L. 6.372.4–374.22 = Jouanna 15, 5–22); Morb. Sacr. 10.3 (L. 6.380.4–7 = Jouanna 20, 5–9). 93  Hipp., Epid. 7.1 (L. 5.366.1–6 = Jouanna 48, 15–49, 2); cf. Epid. 7.108 (L. 5.458.13–16 = Jouanna 111, 10–15). At other times, such as Prorrh. 1.83 (L. 5.530.13–532.1 = Polack 85), the voiceless patients remain at least conscious enough to be considered “deranged” (παρενεχθεῖσαι) and continue vomiting. 94  Gal., In Hipp. Aph. comment. 5. (K. 17b 788.7–9); cf. Ciani, ‘Silences’, 155. We should note that being κωματώδης does not mean being outright comatose or unconscious, merely severely lethargic or drowsy; cf. Pigeaud, Folie, 16, n. 13. 95  Hipp., Epid. 1.13, Case 2 (L. 2.688.1–2 = Kühlewein 204, 12–13). Similar cases occur where patients are voiceless after fainting or while attended by tremendous lethargy, ending

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and, therefore, with a more or less drastic drop in the level of consciousness.”96 Despite Ciani’s claim, however, the very fact that Hippocratic physicians describe incapacitated patients as voiceless has considerable import for the way in which the voice is seen as a repository of diagnostic information. That is, it is not being used simply to gauge whether or not the patient is deeply lethargic—this is already known. Rather, a deficiency of the voice is seen as a symptom in its own right. This has considerable consequences, since we could certainly make sense of voicelessness as an affliction caused by incapacitation, especially incapacitation resulting from fever, but it makes little sense to see it as a symptom in addition to incapacitation unless we are already examining the products of the voice for their quantity and quality as a unique and independent marker of illness. This point can be further stressed by recognizing the sheer speed at which patients transition between speaking and becoming voiceless. For instance, consider the case of the woman in Thasos who gave birth to a daughter without an afterbirth: ἑξηκοστῇ. . .κωματώδης· παρέλεγε καὶ ταχὺ πάλιν κατενόει· πρὸς δὲ τὰ γεύματα ἀπονενοημένως εἶχεν· σιηγὼν μὲν ἐπανῆκε, κοιλίη δὲ χολώδεα σμικρὰ διέδωκεν, ἐπύρεξεν ὀξυτέρως, φρικώδης· καὶ τὰς ἐχομένας ἄφωνος καὶ πάλιν διελέγετο. On the sixtieth day . . . comatose; she babbled and was quickly rational again; towards food she was without sense; jaw slack; her bowels producing a little bit of bilious stool; she was acutely feverish, shivering; and on the following days she was voiceless and then conversed again (Hipp., Epid. 3.17.2, L. 3.112.2–9 = Kühlewein 234, 22–235, 3). The rapid transition between coherent dialogue and voicelessness should strike us as at least somewhat strange, especially if the loss of speech denotes outright incapacity, since it seems unlikely that a patient wavers so swiftly between complete verbal incapacitation and coherent dialogue. Coac. 254 alludes to similar rapid transitions: “frequent voicelessness with extreme torpor are early signs of a consumptive attack” (αἱ πυκναὶ ὑποκαρώδεις ἀφωνίαι σύστασιν φθινώδεα προσημαίνουσιν) (emphasis mine).97 Frequently losing and in sleep; cf. Epid. 7.24 (L. 5.394.3–7 = Jouanna 65, 24–66, 4); Epid. 7.118 (L. 5.464.3–11 = Jouanna 114, 14–115, 5). 96  Ciani, ‘Silences’, 154. 97  Hipp., Coac. 254 (L. 5.638.13–14 = Potter 164).

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gaining one’s capacity to speak while continuing to suffer from the same torpor seems odd—one would expect genuine torpor to predicate all but consistent speechlessness. Yet, rapid transitions between silence and verbal outbursts seem to have been a wider culture trope of illness. Euripides’ Medea presents just such a case, insofar as Creon’s daughter, Glauce, swiftly shifts between speaking and silence, as she writhes and screams in agony as a result of the caustic potions of Medea: she suddenly falls speechless (ἄναυδος), then rouses again before death.98 The ‘speechlessness’ in these instances blurs the line between a patient’s inability to speak and a patient’s simple failure to speak, perhaps even for a short duration of time.99 Such rapidity betrays the close attention Hippocratic physicians must have paid to even subtle changes in articulation, as they waited to hear whether and when the patient would speak. This becomes especially clear in cases of “silence” (σιγή, σιγεῖν), which does not seem to denote strict incapacity, but when the patient simply fails to speak. The author of Coac. 65 makes a clear distinction between the two pathologies: “Silent trances in fevers for a patient who is not speechless are fatal” (αἱ ἐν πυρετοῖσιν ἐκστάσιες σιγῶσαι μὴ ἀφώνῳ, ὀλέθριαι).100 Both of these elements come together at Epidemics 7.89, where Parmeniscus, who was periodically afflicted with depression and thoughts of suicide, took to his bed. By operating right on the pivot of psychological and somatic symptoms, this case allows particular insight into the use of the voice as a prognostic tool: ἄφωνος κατέκειτο ἡσυχίην ἔχων, βραχύ τι ὅσον ἄρχεσθαι ἐπιχειρέων προσειπεῖν· ἤδη δέ τι καὶ διελέχθη καὶ πάλιν ἄφωνος. ὕπνοι ἐνῆσαν, ὁτὲ δὲ ἀγρυπνίη· καὶ ῥιπτασμὸς μετὰ σιγῆς καὶ ἀλυσμὸς καὶ χεὶρ πρὸς ὑποχόνδρια ὡς ὀδυνωμένῳ, ὁτὲ δὲ ἀποστραφεὶς ἔκειτο ἡσυχίην ἄγων· ἀπυρετὸς δὲ διὰ τέλεος καὶ εὔπνοος· ἔφη δὲ ὕστερον ἐπιγινώσκειν τοὺς ἐσιόντας. He lay down, voiceless, keeping silent, hardly attempting to begin to say something; then he said something, and again voiceless. Sleep came on, but he was sometimes awake, and tossing in silence and anguish, and his hand on his hypochondrium as though he were in pain. Sometimes, turning away, he lay there keeping silent. He was feverless throughout, and breathing was easy; he later said that he recognised those coming in (Hipp., Epid. 7.89, L. 5.446.9–14 = Jouanna 103, 8–15). 98  Eur., Med. 1183–84. 99  For similar arguments, see Gourevitch, ‘L’aphonie’ 297–305; Ciani, ‘Silences’, 156–57 and Montiglio, Silence, 228–33. 100  Hipp., Coac. 65 (L. 5.598.9–10 = Potter 120).

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The Hippocratic author seems to be careful to distinguish between silence and strict voicelessness, although we might ask how he discerns the difference, especially when the speed of these transitions is taken into consideration. Is the physician or his assistant actually asking the patient to speak, thereby intervening into the display of symptoms? Or is the information gained from Parmeniscus failing to speak just as potentially valuable for prognostic purposes? That is, would the physician ruin potentially valuable medical information by the very attempt to engage the patient in the type of dialogue required for even a bare minimum of partnership? Does any such dialogue only come after the patient has recovered, as the above case seems to indicate? In any case, once the amount of speech and its particular qualities matter as much to the physician, if not more, than any potential subjective information conveyed by the voice, the patient’s verbal emissions become more of a raw material to be scrutinised than the articulations of an interlocutor to be engaged. 6 Conclusion This paper has made two related arguments. First, Hippocratic authors do not treat their patients as true partners in any hypothetical ‘triangle’ and instead maintain a somewhat dichotomous relation to those for whom they care— that is, these authors rely on subjective patient reports at the same time as they construct medical strategies to reduce and eliminate any such dependency. Second, Hippocratic physicians promote the literal voice as a means of detecting another set of pathological information—encoded in the quality of the voice and the amount that flows from the mouth. Value is placed on this second type of information, and, as a result, the (vocal) medium becomes perhaps the primary message. Having demonstrated that the voice pathologies belong to a nexus of physical and mental afflictions, I have also suggested that the conceptual apparatus underlying voice symptoms bears many similarities to the physiology of fluids and discharges: the voice can flow in excess and defect; it can be distorted; it accompanies diarrhea. Words are treated as a raw emission. Nevertheless, it still remains unclear whether sublimating patient testimony is a true diagnostic practice enacted in reality or simple textual practice deployed in writing. It could be quite possible that Hippocratic physicians made substantial use of patient testimony, but simply did not report it. In this way, they could prevent the ‘diseased’ content of the voice from infecting any of the other symptoms that they wished to establish as objective in nature. Yet, we should avoid falling back on this position automatically. We may take it for granted that it is

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­ edically beneficial for a physician to engage his patient in a conversation m about their symptoms. This presumes, however, that both parties hold a considerable amount of knowledge in common. While we may not all be medical experts, the vast majority of westerners have (roughly) similar ideas about what constitutes a disease, what symptoms look like and what type of things medicine can accomplish. This makes asking the simple question ‘what seems to be the problem?’ a potentially useful endeavour. Even still, modern physicians must frequently lament the unruliness of patient reports, which can spiral in all directions and need to be understood within standardised categories in order to be medically informative. Whether it is a textual or diagnostic practice, however, the result is the same: the pathological value of the voice puts pressure on its linguistic content. Although the voice potentially functions as the most important locus of individuality and subjectivity, when the Hippocratic physicians treat it in their texts, noting its abnormalities and measuring its amount, they scrutinise it as a quasi-excretum of the body, as though it were an effluence to be examined for its quantity, quality, consistency and timbre. Texts and Translations Used Anonymous Londiniensis. On Medicine (Anon. Lond.). Ed. D. Manetti. Anonymus Londiniensis, De Medicina. Berlin/New York: Walter de Gruyter, GmbH & Co, Bibl. Script. Graec. et Rom. Teubneriana, 2011. Aristophanes. Clouds (Nu.). Ed. F. W. Hall and W. M. Geldart. Aristophanis, Comoediae, Tom. 1: Nubes, 105–64. New York: Oxford University Press, 1906, repr. 1980. ———. Frogs (Ra.). Ed. F. W. Hall and W. M. Geldart. Aristophanis, Comoediae, Tom. 2: Lysistrata, Thesmophoriazusae, Ranae, Ecclesiazusae, Plutus, Fragmenta, 99–160. New York: Oxford University Press, 1907, repr. 1982. ———. Thesmophoriazusae (Th.). Ed. F. W. Hall and W. M. Geldart. Aristophanis, Comoediae, Tom. 2: Lysistrata, Thesmophoriazusae, Ranae, Ecclesiazusae, Plutus, Fragmenta, 53–98. New York: Oxford University Press, 1907, repr. 1982. ———. Fragments ( fr.). Ed. C. Austin. Comicorum Graecorum fragmenta in papyris reperta, 7–32. Berlin: De Gruyter, 1973. ———. Wealth (Pl.). Ed. F. W. Hall and W. M. Geldart. Aristophanis, Comoediae, Tom. 2: Lysistrata, Thesmophoriazusae, Ranae, Ecclesiazusae, Plutus, Fragmenta, 211–61. New York: Oxford University Press, 1907, repr. 1982. Aristotle. De Generatione Animalium (GA). Ed. H. J. D. Lulofs. Aristotelis, De Generatione Animalium. New York: Oxford University Press, 1965.

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———. Historia Animalium (HA). Ed. L. Ditmeyer. Aristotle, De Animalibus Historia. Leipzig: B. G. Teubner, 1907. Celsus. De Medicina (Med.). Ed. and trans. W. G. Spencer, vol. 2. The Loeb Classical Library 292. Cambridge, MA: Harvard University Press 1938, repr. 1977. Euripides. Medea (Med.). Ed. D. Mastronarde. Euripides, Medea. New York: Cambridge University Press, 2002. Galen. Commentary on Hippocrates’ Aphorisms (In Hipp. Aph. comment.). Ed. C. G. Kühn. Claudii Galeni opera omnia, vols. 17.2, 345–887 and 18.1, 1–195. Leipzig: Knobloch, 1829, repr. Hildesheim: Olms, 1965. ———. Commentary on Hippocrates’ Epidemics 1 (In Hipp. Epid. 1 comment.). Ed. E. Wenkebach. Galeni in Hippocratis epidemiarum librum 1 commentaria 3, 6–151, CMG V, 10.1. Leipzig: Teubner, 1934. ———. Commentary on Hippocrates Prorrhetics 1 (In Hipp. Prorrh. comment.). Ed. H. Diels. Galeni in Hippocratis Prorrheticum 1 commentaria 3, 3–178, CMG V, 9.2. Leipzig: Teubner, 1915. Hippocrates. Œuvres completes d’Hippocrate. Ed. and trans. E. Littré, vol. 1–10. Paris: J.-B. Ballière, 1839–61. ———. Airs Waters Places (Aer.) Ed. and trans. J. Jacques. Hippocrate: Tome 2: Airs, eaux, lieux. Paris: Les Belles Lettres, 1996. ———. Ancient Medicine (VM). Ed. and trans. J. Jouanna. Hippocrate: Tome 1: De l’ancienne médecine. Paris: Les Belles Lettres, 1990. ———. Aphorisms (Aph.). Ed. and trans. W. H. S. Jones. Hippocrates, vol. 4, 97–221. The Loeb Classical Library 150. Cambridge, MA: Harvard University Press, 1953. ———. Coan Prenotions (Coac.). Ed. and trans. P. Potter. Hippocrates, vol. 9, 103–269. The Loeb Classical Library 509. Cambridge, MA: Harvard University Press, 2010. ———. Critical Days (Dieb. Judic.). Ed. and trans. P. Potter. Hippocrates, vol. 9, 271–311. The Loeb Classical Library 509. Cambridge, MA: Harvard University Press, 2010. ———. Diseases 2 (Morb. 2). Ed. and trans. J. Jouanna. Hippocrate: Tome 10.2: Maladies 2. Paris: Les Belles Lettres, 1983. ———. Diseases 3 (Morb. 3). Ed. and trans. P. Potter. Hippocrates, vol. 6, 1–63. The Loeb Classical Library 473. Cambridge, MA: Harvard University Press, 1988. ———. Epidemics 1 and 3 (Epid. 1 and 3). Ed. H. Kühlewein. Hippocratis Opera quae feruntur omnia, Bd. 1, 179–245. Leipzig, 1894. ———. Epidemics 2 and 4 (Epid. 2 and 4). Ed. and trans. W. D. Smith. Hippocrates, vol. 7, 18–91. The Loeb Classical Library 477. Cambridge, MA: Harvard University Press, 1994. ———. Epidemics 5 and 7 (Epid. 5 and 7). Ed. and trans. J. Jouanna. Hippocrate: Tome 4.3: Epidémies 5 et 7. Paris: Les Belles Lettres, 2000. ———. Epidemics 6 (Epid. 6). Ed. D. Manetti and A. Roselli, Ippocrate Epidemie, libro sesto. Firenze: Bibl. di studi sup. 66, 1982.

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———. Humours (Hum.). Ed. and trans. W. H. S. Jones. Hippocrates, vol. 4, 61–95. The Loeb Classical Library 150. Cambridge, MA: Harvard University Press, 1953. ———. Internal Affections (Int.). Ed. and trans. P. Potter. Hippocrates, vol. 6, 65–255. The Loeb Classical Library 473. Cambridge, MA: Harvard University Press, 1988. ———. On the Art (de Arte). Ed. J. Jouanna. Hippocrate: Tome 5.1: De l’art, 165–280. Paris: Les Belles Lettres, 1988. ———. On the Nature of Bones (Oss.) Ed. and trans. P. Potter. Hippocrates, vol. 9, 9–49. The Loeb Classical Library 509. Cambridge, MA: Harvard University Press, 2010. ———. On the Sacred Disease (Morb. Sacr.). Ed. and trans. J. Jouanna. Hippocrate: Tome 2.3: La maladie sacrée. Paris: Les Belles Lettres, 2003. ———. Precepts (Praec.). Ed. and trans. W. H. S. Jones. Hippocrates, vol. 1, 303–33. The Loeb Classical Library 147. Cambridge, MA: Harvard University Press, 1948. ———. Prognostics (Progn.) Ed. B. Alexanderson. Die hippokratische Schrift “Prognostikon”. Stockholm: Studia Graeca et Latina Gothoburgensia 17, 1963. ———. Prorrhetics 1 (Prorrh. 1). Ed. H. Polack. Textkritische Untersuchungen zu der hippokratischen Schrift Prorrhetikos 1. Diss. Hamburg (1954); Hamburg: U. Fleischer, Hamburger philol. Studien. 44, 1976. ———. Prorrhetic 2 (Prorrh. 2). Ed. and trans. P. Potter. Hippocrates, vol. 8, 213–93. The Loeb Classical Library 482. Cambridge, MA: Harvard University Press, 1995. Plato. Hippias Major (Hp. Ma.). Ed. J. Burnet. Platonis Opera: Tom. 3. New York: Oxford University Press, 1903, repr. 1985. ———. Thaeatetus (Tht.). Ed. E. A. Duke. Platonis Opera: Tom. 1, 277–382. New York: Oxford University Press, 1995. ———. Timaeus (Ti.). Ed. J. Burnet. Platonis Opera: Tom. 4. New York: Oxford University Press, 1905.

References Andò, V. ‘La φύσις tra normale e patologico.’ in Le normal et le pathologique dans la Collection hippocratique: Actes du Xème Colloque internationale hippocratique, Nice, 6–8 octobre 1999, 2 vols., ed. A. Thivel and A. Zucker, 97–122. Nice: Publications de la Faculté des Lettres, Arts et Sciences Humaines de Nice-Sophia Antipolis, 2002. Baader, G. and Winau, R. (eds.) Die Hippokratischen Epidemien: Theorie—Praxis— Tradition. Verhandlungen des 5e Colloque international hippocratique. Veranstaltet von der Berliner Gesellschaft für Geschichte der Medizin in Verbindung mit dem Institut für Geschichte der Medizin der Freien Universität Berlin, 10.–15. 9. 1984. Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989. Bartoš, H. ‘Varieties in the Ancient Greek Body-soul Distinction.’ Rhizai 3, (2006): 59–78.

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Benedetto, V. d. Il medico e la malattia. Torino: Giulio Einaudi editore, 1986. Berrettoni, P. ‘Il lessico tecnico del 1 e 3 libro delle Epidemie ippocratiche. Contributo alla storia della formazione della terminologia medica greca.’ Annali della Scuola Normale Superiore di Pisa 39, (1970): 27–106, 217–311. Boehm, I. ‘Inconscience et insensibilité dans la Collection hippocratique.’ in Le Normal et le Pathologique dans la Collection hippocratique: Actes du 10ème colloque international hippocratique, 2 vols., ed. A. Thivel and A. Zucker, 257–69. Nice: Publications de la Faculté des Lettres, Arts et Sciences Humaines de Nice-Sophia Antipolis, 2002. Bourgey, L. ‘La relation du médecin au malade dans l’écrits de l’École de Cos.’ in La Collection Hippocratique et son rôle dans l’histoire de la médicine: Colloque de Strasbourg, ed. L. Bourgey and J. Jouanna, 209–27. Leiden: Brill, 1975. Ciani, M. G. ‘The Silences of the Body: Defect and absence of voice in Hippocrates.’ in The Regions of Silence: Studies on the Difficulty of Communicating, ed. M. G. Ciani, 145–60. Amsterdam: J. C. Gieben, 1987. Clarke, E. ‘Apoplexy in the Hippocratic Writings.’ Bulletin of the History of Medicine 37, (1963): 301–14. Diller, H. ‘Ausdrucksformen des methodischen Bewusstseins in den hippokratischen Epidemien.’ Archiv für Begriffsgeschichte 9, (1964): 133–50 (repr. in Diller, H. Kleine Schriften zur antiken Medizin, 106–28, Munich: C. H. Beck’sche Verlagsbuchhandlung, 1971). Duminil, M.-P. ‘Les maladies ‘frappés’.’ in Tradatos hippocráticos: estudios acerca de su contenido, forma e influencia; actas del 7e Colloque international hippocratique, Madrid, 24–29 de septiembre de 1990, ed. J. A. López Férez, 215–24. Madrid: Universidad Nacional de Educación a Distancia, 1992. Edelstein, L. ‘Hippocratic Prognosis.’ in Ancient Medicine: Selected Papers of Ludwig Edelstein, ed. O. Temkin and C. L. Temkin, 65–85. Baltimore: The Johns Hopkins University Press, 1967. Eijk, Ph. J. van der ‘Modes and Degrees of Soul-body Relationship in On Regimen.’ in Officina Hippocratica. Studies in Honour of Anargyros Anastassiou and Dieter Irmer, ed. L. Perilli, C. Brockmann, K.-D. Fischer and A. Roselli, 255–70. Berlin and New York: Walter de Gruyter, 2011. ———. ‘Cure and (In)curability of Mental Disorders in Ancient Medical and Philosophical Thought.’ in Mental Disorders in the Classical World, ed. W. Harris, 307–38. Leiden: Brill, 2013. Giambalvo, M. ‘Normale versus Anormale?: lo statuto del patologico nella Collezione Ippocratica.’ in Le normal et le pathologique, actes du 10ème Colloque internationale hippocratique, Nice, 6–8 octobre 1999, 2 vols., ed. A. Thivel and A. Zucker, 55–96. Nice: Publications de la Faculté des Lettres, Arts et Sciences Humaines de Nice-Sophia Antipolis, 2002.

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Gourevitch, D. Le Triangle Hippocratique dans le monde gréco-romaine: le malade, sa maladie et son médecin. Rome: École française de Rome, 1984. ———. ‘L’aphonie hippocratique.’ in Formes de pensée dans la collection hippocratique: actes du 4e Colloque international hippocratique, Lausanne, 21–26 septembre 1981, ed. F. Lasserre and P. Mudry, 297–305. Geneva: Librarie Droz, 1983. Grmek, M. Les maladies à l’aube de la civilization occidentale. Paris: Payot, 1983. Gundert, B. ‘Soma and Psyche in Hippocratic Medicine.’ in Psyche and Soma: Physicians and Metaphysicians on the Mind-body Problem from Antiquity to the Enlightenment, ed. J. P. Wright and P. Potter, 13–35. Oxford: Clarendon Press, 2000. Hall, T. S. ‘Idiosyncrasy: Greek Medical Ideas of Uniqueness.’ Sudhoffs Archiv 58, (1974): 285–90. Harris, W. ‘Thinking about Mental Disorders in Classical Antiquity.’ in Mental Disorders in the Classical World, ed. W. Harris, 1–23. Leiden: Brill, 2013. Holmes, B. The Symptom and the Subject: The Emergence of the Physical Body in Ancient Greece. Princeton, New Jersey: Princeton University Press, 2010. ———. ‘Disturbing Connections: Sympathetic Affections, Mental Disorder, and the Elusive Soul in Galen.’ in Mental Disorders in the Classical World, ed. W. Harris, 147– 76. Leiden: Brill, 2013. Jouanna, J. Hippocrates. Trans. M. B. DeBevoise. Baltimore: The Johns Hopkins University Press, 1992, rev. ed. 1999. ———. ‘The Typology and Aetiology of Madness in Ancient Greek Medical and Philosophical Writing.’ in Mental Disorders in the Classical World, ed. W. Harris, 97–118. Leiden: Brill, 2013. König, J. ‘Ancient Greco-Roman Views of the Testicle in Celsus and Beyond.’ Rosetta 13, (2013): 104–10. Langholf, V. Medical Theories in Hippocrates: Early Texts and the ‘Epidemics’. Berlin: Walter de Gruyter, 1990. Lo Presti, R. ‘Characterizing Epilepsy in Greek Scientific Discourse.’ in Mental Disorders in the Classical World, ed. W. Harris, 195–222. Leiden: Brill, 2013. Manetti, D. ‘The Role of Doxography in the Anonymus Londiniensis.’ in Ancient Histories of Medicine, ed. Ph. J. van der Eijk, 95–141. Leiden: Brill, 1999. Montiglio, S. Silence in the Land of Logos. Princeton: Princeton University Press, 2000. Nutton, V. Ancient Medicine. New York: Routledge, 2004. Pagel, W. ‘Prognosis and Diagnosis.’ Journal of the Warburg Institute 2.4, (1939): 382–98. Pigeaud, J. ‘Quelques aspects du rapport de l’âme et du corps dans le Corpus hippocratique.’ in Hippocratica: actes du Colloque hippocratique de Paris, 4–9 septembre 1978, ed. M. D. Grmek, 417–33. Paris: Éditions du Centre national de la recherche scientifique, 1980.

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———. Folie et cures de la folie chez les médecins de l’antiquité gréco-romaine. Paris: Les Belles Lettres, 1987. ———. Maladie de l’âme. Paris: Les Belles Lettres, 1989. Robert, F. ‘La prognose hippocratique dans les livres 5 et 7 des Épidemies.’ in Hommages à Claire Préaux, ed. J. Bingen, G. Cambier and G. Nachtergael, 257–70. Brussels: Éditions de l’Université de Bruxelles, 1975. Sassi, M. M. ‘Mental Illness, Moral Error, and Responsibility in Late Plato.’ in Mental Disorders in the Classical World, ed. W. Harris, 413–26. Leiden: Brill, 2013. Schmidt, J. H. H. Synonomik der griechischen Sprache, vol. 3. Amsterdam: Verlag Adolf M. Hakkert, 1876, repr. 1969. Schubert, C. ‘Menschenbild und Normwandel in der klassischen Zeit.’ in Médecine et morale dans l’Antiquité, ed. J. Jouanna and H. Flashar, 121–55, Entretiens sur l’Antiquité classique 43. Geneva: Fondation Hardt, 1996. Simon, B. ‘ “Carving Nature at the Joints”: The Dream of a Perfect Classification of Mental Illness.’ in Mental Disorders in the Classical World, ed. W. Harris, 27–40. Leiden: Brill, 2013. Singer, P. ‘Some Hippocratic Mind-body Problems.’ in Tratados hippocráticos: estudios acerca de su contenido, forma e influencia; actas del 7e Colloque international hippocratique, Madrid, 24–29 de septiembre de 1990, ed. J. A. López Férez, 131–43. Madrid: Universidad Nacional de Educación a Distancia, 1992. Staden, H. von ‘Ὡς ἐπὶ τὸ πολύ: ‘Hippocrates’ between Generalization and Individualization.’ in Le normal et le pathologique dans la Collection hippocratique: Actes du 10ème Colloque internationale hippocratique, Nice, 6–8 octobre 1999, 2 vols., ed. A. Thivel and A. Zucker, 23–43. Nice: Publications de la Faculté des Lettres, Arts et Sciences Humaines de Nice-Sophia Antipolis, 2002. Stover, T. ‘Form and Function in Prorrhetic 2’ in Hippocrates in Context: Papers read at the 11th International Hippocrates Colloquium, University of Newcastle upon Tyne 27–31 August 2002, ed. Ph. J. van der Eijk, 345–61, Studies in Ancient Medicine 31. Leiden: Brill, 2005. Thumiger, C. ‘Early Medical Vocabulary of Insanity.’ in Mental Disorders in the Classical World, ed. W. Harris, 61–96. Leiden: Brill, 2013. Wittern, R. ‘Diagnostics in Classical Greek Medicine.’ in History of Diagnostics: Proceedings of the 9th International Symposium on the Comparative History of Medicine—East and West, ed. Y. Kawahita, 69–89. Osaka, Japan: The Taniguchi Foundation, 1987. Worman, N. Abusive Mouths in Classical Athens. New York: Cambridge University Press, 2008.

PART 3 Patients and Psychological Illness

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CHAPTER 6

Galen’s Anxious Patients: Lypē as Anxiety Disorder Susan P. Mattern Galen describes a syndrome he associates with an emotion called lypē, with specific symptoms and a course that may lead to humoral imbalance, disease, and death. Lypē is an emotion that encompasses distress at a loss, as the death of a close friend or the destruction of one’s books by fire; but Galen also associates it with chronic worry about a future threat, and a physiology between the emotions of worry and fear (that is, ‘­anxiety’). Lypē can cause a progressive syndrome characterised by insomnia, fever, pallor, and weight loss that can kill patients or degenerate into psychotic illness. This syndrome can be described in modern terms as an anxiety disorder. Studies of psychology in antiquity pay little attention to the idea of anxiety, either as an emotion or as a factor in mental illness.1 Today, anxiety disorders are the most common category of psychiatric disorders in the world, by a wide margin,2 and it would be interesting indeed if pathological anxiety did not exist in antiquity or if medical writers did not address it. But modern schol1  Anxiety appears not to be discussed in any of the works on the emotions in antiquity I am aware of, save that of Konstan, D. (2006). The Emotions of the Ancient Greeks: Studies in Aristotle and Classical Literature, 149–50. It is not specifically addressed in Pigeaud, J. (1981). La maladie de l’âme: Étude sur la relation de l’âme et du corps dans la tradition medicophilosophique antique, or in ead. ‘La psychopathologie de Galien’, in Manuli, P. and Vegetti, M. (1988). Le opere psicologiche di Galeno, 153–84. Stok, F. (1996). ‘Follia e malattie mentali nella medicina romana’, ANRW 2.37.3, 2283–2410 includes a brief section on “Le nevrosi” (2322–24), discussing some potential retrospective diagnoses of neuroticism in modern Western psychiatry, neuroticism is mostly considered a personality factor and is not a diagnosis in the DSM-5 or the ICD-10, although the latter retains a broad category of “Neurotic, stress-related and somatoform disorders”.) Among the articles in Harris, W. V. (2013). Mental Disorders in the Classical World, only one is relevant to the theme of anxiety and anxiety disorders: King, H. ‘Fear of flute girls, fear of falling’, 265–84. She discusses two patients in the Hippocratic Epidemics 5 and 7 who appear to suffer from “phobias”. 2  W HO World Mental Health Survey Consortium (June 2, 2004). ‘Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys’, Journal of the American Medical Association 291.21, 2581–90.

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arship has not discovered any such disorder in ancient medical literature, and has barely addressed the more basic concept of anxiety—the emotion of ‘apprehensive expectation’—at all.3 What do I mean by an ‘anxiety disorder’? In the current, fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (=DSM-5), published in 2013, the category of “anxiety disorders” includes Generalized Anxiety Disorder (GAD), by far the most common diagnosis, and also Social Anxiety Disorder, Panic Disorder, Agoraphobia, Specific Phobias, and certain disorders mostly affecting children.4 Because scientists, clinicians, grant funding agencies, and insurance providers all require a common language for mental disorders, the categories of the DSM are the ones normally used, even by scientists in crosscultural studies. But most scientists agree that, among other problems and controversies, the DSM and the closely related “Mental and Behavioral Disorders” section of the International Classification of Diseases (ICD, now in its tenth edition, = ICD 10) are more useful for industrialised, Western European populations than for other cultures,5 a problem which the DSM-5 tries to address in its section on “Cultural Formulation” (749–59).6 Just as some anxiety disorders may be under-reported in non-Western cultures because they present variations that do not conform well to the criteria of the DSM, we should be sensitive to the idea that these and other mental disorders may have looked different in Galen’s (pre-industrial and pre-Western) world than they do in ours. I will argue that modern cross-cultural research in abnormal psychology provides a new context in which to understand certain problems that Galen described—not as quaint folktales or urban myths, hyperbolic anecdotes or literary traditions, nor even “culture-bound syndromes” (the latter idea has undergone substantial evolution in recent years and is becoming obsolete); 3  ‘Apprehensive expectation’ is often used in psychiatric literature to describe states of anxiety. Thus Generalized Anxiety Disorder is “excessive anxiety and worry (apprehensive expectation), occurring more days than not for a period of at least six months . . .” (DSM-5, 222). MacNally, R. J. ‘Anxiety’, in Sander, D. and Scherer, K. R. (2009). The Oxford Companion to Emotion and the Affective Sciences, 42–44, offers “an aversive emotional state prompted by the prospect of future threat”. 4  The DSM-4 included Obsessive-Compulsive Disorder and Post-Traumatic Stress Disorder among anxiety disorders, but these have been removed and given their own categories in the DSM-5. 5  See e.g. Marques, L. et al. (2011). ‘Cross-cultural variation in the prevalence and presentation of anxiety disorders’, Expert Review of Neurotherapeutics 11.2, 313–22; Lewis-Fernández, R. et al. (2010). ‘Culture and the anxiety disorders: Recommendations for DSM-5’, Depression and Anxiety 27, 212–29. 6  This section replaces the DSM-4’s brief appendix on “Culture-Bound Syndromes”.

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but as manifestations of a common, possibly fundamental or universal response to psychic distress, one that takes different forms depending on cultural context. Psychologists are learning to recognise these culture-specific forms of anxiety or distress disorders, and their findings can provide insight into phenomena opaque to historians with no exposure to them. But also, because research on non-industrialised populations is difficult today, historians of the pre-modern world can contribute to the current understanding of anxiety disorders among psychologists. Although scholars often remark on the attention Galen pays to psychiatric symptoms,7 especially because some of the most relevant stories are in his entertaining and accessible treatise On Prognosis, they have underestimated the precision with which he defines certain conditions. In the example I will discuss here, Galen describes a state of mental distress, perhaps even a specific syndrome, with a dangerous course that can lead to death, recognizable (as I argue) to modern cultural psychologists as a type of anxiety disorder. He associates this syndrome with the emotion he calls lypē (λύπη). I will also suggest that other phenomena described in ancient medical literature, such as hysterical suffocation or lovesickness, might be interpreted as culture-specific forms of anxiety disorders, and I hope to publish on those arguments in the future. When I noticed that modern English translations of Galen’s word lypē did not always capture his full meaning, and that the word ‘anxiety’ might be the best translation in some contexts, I began to appreciate the role of this emotion—something different from fear or worry, but related to both—in Galen’s work. For this reason I begin with a study of the term lypē as Galen uses it. Lypē and its derivatives are extremely common in Greek.8 Most occurrences of the verbal form (lypeō), especially in the active voice, simply mean “to harm,” and Galen often uses it this way—referring for example to the λυπῶν χυμός, the “damaging humor”.9 In the passive or middle voice it can signify a disturbed emotional state—lypeisthai, “to be distressed”. The noun can refer very generically to pain; or it can refer to psychic pain as distinct from physical pain. Thus the sophist Antiphon is supposed to have invented and practiced an 7  On psychiatry in Galen a full bibliography would be quite long; see especially Pigeaud, ‘Psychopathologie’; and more recently Nutton, V. ‘Galenic madness’, in Harris, Mental Disorders, 119–28; and Boudon-Millot, V. ‘What is mental a illness, and how can it be treated? Galen’s reply as a doctor and philosopher’, in Harris, Mental Disorders, 129–46. 8  On psychological meanings of lypē see Konstan, Emotions, 245–46; Harris, W. V. (2001). Restraining Rage: The Ideology of Anger Control in Classical Antiquity, 342–44. 9  E.g. De facult. natur. 2.8; 3.13 (K. 2.113; 192); De sympt. caus. 2.6 (K. 7.197); De loc. aff. 1.4; 3.10 (K. 8.38; 192) and passim; Ad Glauc. de meth. med. 2.4 (K. 11.98), etc.

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art he called alypia, the cure of lypē; a sign he posted at his house near the marketplace of Corinth promised to relieve his clients’ (psychic) distress with words “just as diseases are cured by physicians”.10 The Stoics, by whom Galen’s thoughts on psychology were deeply influenced, divided the emotions (the pathē) into four broad categories, namely lypē; phobos, or fear; epithymia, or desire; and hēdonē, or pleasure.11 Lypē as used by the Stoics and others is often translated into English as “distress” to preserve its generic meaning. But it could also signify more specific emotions, including distress at a loss, especially the death of a loved one, an experience with which Stoics and other Hellenistic philosophical traditions were much concerned. It is therefore often translated as “grief”. Lypē often carries this meaning “grief for a loss” in Galen, although he does not emphasise the death of loved ones in his most substantive discussions of lypē. These discussions occur in his treatises On Diagnosing and Curing the Passions of the Soul (K. 5.37–57) and Avoiding Distress (Περὶ ἀλυπίας).12 In both, Galen purports to respond to someone who marvels that no loss or setback seems to distress him. Here Galen associates lypē mainly with two types of loss: that of property such as animals, money, or slaves, and including intellectual property, as when books burn (Avoiding Distress was written after Galen lost his most precious possessions in the fire that burned the Temple of Peace in 192); and loss of honor or reputation, shading into what we might today call shame.13 Thus we may feel lypē if we fail to live up to the virtues of our noble ancestors (Protrept. 10  [Ps.-Plut.], Vitae decem Oratorum 833 C–D; Harris, Restraining Rage, 343; Furley, W. D. (1992). ‘Antiphon der Athener: Ein Sophist als Psychotherapeut?’, RhM n.s. 135, 198–216. Galen seems to contrast lypē with physical pain in De an. aff. dign. et cur. 7 (K. 5.37): “Lypē, like physical pain (πόνος ἐν τῷ σώματι), seems bad to everyone.” 11  Many works on the Stoic emotions could be cited. For a sophisticated study incorporating modern psychology, see Nussbaum, M. (2001). Upheavals of Thought: The Intelligence of Emotions. Brief introductions include Becker, L. C. ‘Stoic Emotion’, in Strange, S. K. and Zupko, J. (2004). Stoicism: Traditions and Transformations, 250–76; and Brennan, T. ‘Stoic moral psychology’, in Inwood, B. (2003). The Cambridge Companion to the Stoics, 257–94. 12  An edition of the sole surviving manuscript of Περὶ ἀλυπίας, discovered in 2005, is available in Boudon-Millot, V. and Jouanna, J. (2010). Galien, vol. 4: Ne pas se chagriner. 13  De an. aff. dign. et cur. 8 (K. 5.43–44); 9 (K. 5.48–51); De indolentia, passim. De indolentia (1–37) focuses mostly on the loss of material and intellectual property and slaves. In these passages Galen always discusses slaves as lost property, not as lost friends or loved ones, although his attitude toward slavery, and especially toward his enslaved patients, is complex; see Mattern, S. P. (2008). Galen and the Rhetoric of Healing, 116–19, and ead. (2013). The Prince of Medicine: Galen in the Roman Empire, 271–72. Galen mentions doxa at 65 and 81, and other miscellaneous calamities at 72, 74–75, and 78.

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7 = K. 1.12). For this reason, and probably showing a debt to the Epicurean tradition on this point, Galen connects grief with insatiability (aplēstia) and greed (pleonexia) or excessive desire (epithymia); the pursuit of fame, or wealth beyond what is necessary for self-sufficiency, causes distress when these things are unattainable or lost.14 Finally, although Galen does not seem as interested in this kind of grief as some of his contemporaries were, lypē can also be the emotion one feels when someone dies (In Hipp. Progn. comment. 1.4 = K. 18b 19). Citing Chrysippus, Galen writes that lypē is what Achilles felt for Patroclus, for example. Here Galen relates grieving or being distressed (lypeisthai) to weeping, mourning, groaning, and wailing (De plac. Hipp. et Plat. 4.7.26, 44 = K. 5.422, 426).15 It is also possible or likely that Galen used the word lypē to describe the emotion of the mother of Nasutus the Jurist, who died after hearing of the death of her best friend; the passage survives only in Arabic.16 When Nasutus’ mother heard the news, she became unable to sleep, she lost weight, became feverish, and died in four days. Galen does not consider it unusual to die of grief, a point the story of Nasutus’ mother is supposed to illustrate, and he names other examples in the same passage. Among them is a grammarian named Callistus who died after his books perished in the fire of 192: “He grieved because of this and could sleep no more. First a fever began, and then in no long time he wasted away to such an extent that he died.”17 In Avoiding Distress (7), Galen names another, apparently distinct grammarian named Philides who died “consumed by despondency (dysthymia) and grief (lypē)” after the fire. In On the Composition of Drugs, by Type (6.1 = K. 13.861) Galen mentions that some physicians died 14  De an. aff. dign. et cur. 9–10 (K. 5.48–54); De indolentia 42, 48; Boudon-Millot and Jouanna, Galien: Ne pas se chagriner, 56–58. 15  Other places where Galen seems to connect lypē with active mourning such as weeping/ wailing (klaiein, klauthmos) are De san. tuenda 1.8 (K. 6.40) and De difficult. respir. 3.10 (K. 7.941). 16   Wenkebach, E. and Pfaff, F. (1956). Galeni In Hippocratis Epidemiarum: Librum 6 Commentaria 1–8, 2nd Edition (CMG V, 10.2.2), 486–87. Books 6.5.6–8 of In Hipp. Epid. 6 comment. do not survive in Greek and are here translated into German from the Arabic of Hunain ibn Ishaq. The CMG does not print the text of Hunain’s Arabic translation, either here or in Pfaff’s index of Arabic words (Pfaff, F., 1960. Galens Kommentare zu den Epidemien des Hippokrates, Indizes der aus dem Arabischen übersetzten Namen und Wörter = CMG V, 10.2.4). It is clear from this index, however, that Pfaff believed that his word Kummer (50, 17) translated the ancient Greek lypē and that Angst translated the ancient Greek phobos. The Arabic text survives in a single manuscript and has never been published. 17  Wenkebach and Pfaff, 486.

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from grief at the loss of their specially prepared medicines; Galen’s own store of these was also demolished in the fire, along with many of his most precious manuscripts. Grief in Galen is not a passive emotion, but a desperate, agitating force that drives its victims to extremes, like Homer’s Achilles or the dead grammarians.18 The word lypē in Galen does not always signify a reaction to loss. In many cases it appears to signify anxiety about some future contingency (‘apprehensive expectation’). In On Prognosis Galen recounts the story of a slave steward who has lost or embezzled his master’s money and expects to have to give an accounting soon. He is lypoumenos (Galen uses this participle twice in close succession and the verb, in the middle voice, once); he is sleepless because of worry (ὑπὸ τῆς φροντίδος ἠγρύπνει).19 Galen also says he is afraid (phoboito) of the upcoming audit. I am translating phrontis as “worry” throughout this paper (although it can have slightly different meanings in some contexts, discussed further below), agrypnia as “insomnia”, and phobos as “fear”. All of these contrib­ute to the slave’s distress or lypē, which might thus be translated as “anxiety” in this context. Galen very frequently uses the word lypē in close connection with fear, worry, insomnia, or all of these, as in the case of the slave steward.20 Thus in On the Causes of Symptoms, insomnia is often caused by lypai or phrontides (1.8 = K. 7.144). Moreover, in On the Affected Parts, Galen explains that the delusions of melancholia have their origins in fear, but can also be caused by fever, 18  Examples of cross-cultural studies comparing concepts of sadness or grief in Western and other societies include Postert, C. et al. (2012). ‘Beyond the blues: Toward a cross-cultural phenomenology of depressed mood’, Psychopathology 45, 185–92 (on Hmong society) and Schieffelin, E. L. ‘The cultural analysis of depressive affect: An example from New Guinea’, in Kleinman, A. and Good, B. (1985). Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder, 101–33. 19  De praecogn. 6 (K. 14.633–35). 20  Other examples: in De opt. corp. const. 3 (K. 4.742), lypē, insomnia, worry, and exhaustion (kopoi) are listed as examples of external causes of humoral imbalance. In De loc. aff 3.10 (K. 8.185), an over-accumulation of black bile might result from lypē, insomnia, or worry or the combination of these (and cp. De atra bile 6 = K. 5.126). In De praesag. ex puls. 3.8 (K. 9.388), worry, lypē, and chronic insomnia are among the causes of hectic fever (along with labor, famine, travel, and old age). In De cris. 2.3 (K. 9.649), labor, insomnia, worry, and lypai cause too much yellow bile; in De cris. 2.13 (K. 9.698), lypē and worry cause dryness. In De meth. med. 8.3 (K. 10.555), one should treat patients suffering from insomnia, lypē, or worry with moisture and sleep. In In Hipp. Progn. comment. 3.23 (K. 18b 273), lypai and worry are among many external factors causing fever. Many more examples could be given; see also n. 22.

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inflammation of the head, or of the brain (phrenitis), or by phrontis, or lypē, when these are combined with insomnia. In On Crises (2.13 = K. 9.697–700), psychic causes of fever include worry, fear, thymoi, and lypai, here discussed at some length. The idea of phrontis is prominent in Galen, this word and its derivatives occurring more than two hundred times in his work; it means “worry” as well as simply “thought”, and Galen often associates it with intellectual activity more generally.21 In most places where he lists emotions or pathē, Galen is describing agents that imbalance the temperament and thus cause disease. Contrary to philosophical tradition he tends to name phrontis along with lypē, two types of anger (orgē and thymos), fear, sometimes pleasure, and sometimes envy as the basic pathogenic emotions, and also tends to mix psychic causes indiscriminately with ‘somatic’ causes of disease in these lists.22 Insomnia is often closely linked to the emotions of lypē and worry not only as a result of psychic disturbance, but as a cause of temperamental imbalance or disease.23

21  De cris. 2.13 (K. 9.697) (“those worried because of study or contemplation”); and cf. Mattern, Galen and the Rhetoric of Healing, 133. 22  Ars med. 24 (K. 1.371): orgē, lypē, thymos, fear, envy, and worry. De temper. 2.6 (K. 1.633): worry, thymoi, lypai. Thras. 40 (K. 5.885): worry and thymos. De san. tuenda 1.5 (K. 6.28): thymoi, worry, lypai. De san. tuenda 1.8 (K. 6.40): thymos, klauthmos, orgē, lypē, and worry. De cris. 2.13 (K. 9.695–700): lypē, fear, thymos, and worry. De meth. med. 8.2 (K. 10.535): insomnia, thymos, lypē, worry. De meth. med. 8.7 (K. 10.585): lypē, worry, thymos. De meth. med. 10.2 (K. 10.666): thymos, lypē, insomnia, worry. De meth. med. 10.4 (K. 10.679): insomnia, orgē, lypē, worry. De meth. med. 10.6 (K. 10.692): lypai, agōniai, thymoi, and worry. In Hipp. Nat. Hom. comment. 17 (K. 15.162): heatstroke, insomnia, worry, lypai, thymoi, lack of food. In Hipp. Epid. 6 comment. 1.10 (K. 17a 852): insomnia, worry, lypai, thymoi. On these lists see also Manuli, P. ‘Le passione nel De Placitis Hippocratis et Platonis’, in Manuli, P. and Vegetti, M. (1988). Le opere psicologiche di Galeno, 193–97. In his works on the pulse, Galen tends also to include hēdonē (pleasure) among the emotions with a characteristic pulse. Thus in De puls. ad tir. 12 (K. 8.473–74) he discusses pleasure, lypē, and fear; in De caus. puls. 4.2–6 (K. 7.157–62) he discusses anger, pleasure, lypē, and fear. See Manuli, P. ‘Le passione’, 195–201 on the emotions and the pulse in Galen. Finally, in De an. aff. dign. et cur. 5.7 the pathē are thymos, orgē, fear, lypē, envy, and epithymia. At K. 5.24 Galen gives a more traditional list of lypē, orgē, thymos, epithymia, and fear. Worry is not discussed per se in this more philosophical treatise or in De plac. Hipp. et Plat., but is much more prominent when Galen is discussing pathē as causes of disease. Galen seems to use singu­ lar or plural forms of all the pathē interchangeably (he also often writes of ‘insomnias’). On different Greek and Latin words for ‘anger’ and their subtle distinctions, see Harris, Restraining Rage, 50–70. 23  E.g. De san. tuend. K. 6.40, K. 6.217, K. 6.225; and see examples in nn. 20 and 22.

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Lypē is closely related to fear in its physiology. Here Galen’s ideas partly reflect a complex dependence on Stoic concepts of the pathē, in which both fear and lypē are responses to the apprehension of something bad and both are what some would call today avoidance emotions (versus approach emotions). In particular, lypē seems to be a chronic and less intense form of fear. Both lypē and fear will cause blood to retreat to the depths of the body (De praesag. ex puls. 3.7 = K. 9.375). For this reason the skin of those who are afraid may feel cold to the touch, their pulse becomes irregular and small, and they may suffer rigors, or shivering fits; lypai cause similar but less intense symptoms (De sympt. caus. 2.5 = K. 7.191–93).24 While people may die suddenly of fear or, paradoxically, joy,25 lypē takes longer to kill (De loc. affect. 5.1 = K. 8.302), a point we will return to. Furthermore, lypē has exactly the same pulse as chronic fear (De puls. ad tir. 12 = K. 8.474). Compared to phrontis however, lypē is more intense. Thus both worry and lypē will cause weight loss, pallor, and hollowness of the eyes; but these symptoms are more prominent in those afflicted with lypē than in those who are “worried (phrontisantes, here perhaps “stressed” is a better modern translation) from study or contemplation” (De cris. 2.13 = K. 9.698).26 Lypē, worry, and insomnia all have similar effects on the pulse; and the pulse, as Galen adds, is the most accurate way to diagnose any illness caused by emotion, providing the emotion is still present.27 24  In this passage Galen also distinguishes an emotion between anger and fear, with a distinct pulse, which he calls agōnia and which Johnson translates as “anxiety”. Galen uses the word agōnia rarely in his work (about two dozen times), and does not normally include it in lists or discussions of emotional causes of illness. The main exceptions are a passage in De meth. med. 12.5 (K. 10.841), a list of psychic affections that can dissipate or destroy the pneuma; and a passage in De plac. Hipp. et Plat., where Galen’s interlocutor is Chrysippus, who seems to have used the word in his discussion of emotions (3.7 = K. 5.335–36). De Lacy has also translated the word as “anxiety” in the CMG edition of this text (De Lacy, P. (1984). Galen on the Doctrines of Hippocrates and Plato = CMG V, 4.1.2 ad loc.). Galen’s usage in De sympt. caus. and elsewhere suggest a state of disturbance and agitation. ‘Anguish’ may be more accurate than ‘anxiety’, although the concepts are not mutually exclusive, and seem to come together in the story of Justus’ wife at De praecogn. 6 (K. 14.632). 25  De meth. med. 12.5 (K. 10.841); De sympt. caus. 2.5 (K. 7.193). 26  See also Ad Glauc. de meth. Med. 1.2 (K. 11.12); and In Hipp. Epid. 6 comment. 2.47 (K. 17A.998), where insomnia, lypē, fasting, or exhaustion might cause the hollow-eyed appearance of the facies Hippocratica. 27  “We now begin the discussion of the psychic affections, worry and fear and thymos and lypē. If the examination takes place while the affections of the soul remain, try most of all to diagnose them through the pulse, as I have written in the [books] about the pulse; and after this, proceed to the diagnosis from the other things.” On the pulses of the emotions

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Thus Galen sees lypē as an emotion related to worry and fear, but stronger than worry, and both less intense and more chronic than fear. Again, “anxiety” is an appropriate translation, although we should be aware that Galen’s lypē is a more flexible concept, specifically encompassing grief as well. Here it is helpful to remember that distinctions among the emotions in modern psychology are also problematic.28 It is most of all by studying Galen’s case histories that one can appreciate the significance of anxiety in his work. His most famous story is in fact about lypē and not, as he twice insists in an apparently futile effort to explain, about love, as many of his followers believed. For love neither has a characteristic pulse by which it can be diagnosed29 nor, as he seems to say elsewhere, is it a direct cause of disease: rather, love can be an antecedent cause if people become distressed (lypountai) as a result of it, and this will result in the characteristic symptoms of insomnia, wasting, fever, and skin color change (In Hipp. Progn. comment. 1.4 = K. 18b 18–19).30 The case of Justus’ wife (De praecogn. 6 = K. 14.630–33) is one of Galen’s favorite stories, and he refers to it several times in his extant works, comparing himself to Erasistratus, who had made a similar diagnosis in the rather more elevated case of Seleucus’ son Antiochus I.31 According to legend Erasistratus diagnosed the cause of the young prince’s illness as love for his father’s new wife, or in Galen’s version, for his father’s concubine. He did this by feeling the patient’s pulse and detecting a so-called erotic pulse (as mentioned, Galen explains that the legend is wrong, for there is no such pulse).

see also De cris. 2.13 (K. 9.697–98,700); De praesag. ex puls. 1.8 (K. 9.268); Ad Glauc. de meth. med. 1.2 (K. 11.12–13); In Hipp. Progn. comment. 1.8 (K. 18b 39–41). On the pulse see also Orly Lewis, ‘The practical application of ancient pulse-lore and its influence in the patientdoctor interaction’ (Chapter Thirteen) in this volume, 345–364. 28  No consensus has been reached on any of the several theories of the definition and classification of emotions. For a concise discussion, see Scherer, K. R. ‘Emotion theories and concepts (psychological perspectives)’, in Sander, D. and Scherer, K. R. (2009). The Oxford Companion to Emotion, 145–50. 29  De praecogn. 6 (K. 14.635), In Hipp. Progn. comment. 1.8 (K. 18b 40). 30  However, in In Hipp. Epid. 2 comment. (Wenkebach, E. and Pfaff, F., 1934. Galeni In Hippocratis Epidemiarum Libros 1 et 2 = CMG V, 10, 1.1), 208, surviving only in Arabic, Galen names love or “love-grief” as the cause of Justus’ wife’s illness. The main point of the passage in In Hipp. Progn. comment. is to argue that there are no divine causes of illness or death, not even in cases where death is attributed to love. 31  De praecogn. 5 (K. 14.625–26); 6 (K. 14.630–33, 634); 7 (K. 14.640); 13 (K. 14.669); In Hipp. Epid. 2 comment. 206–07 Wenkebach and Pfaff; In Hipp. Progn. comment. 1.8 (K. 18b 40).

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The main symptom from which Justus’ wife suffers is insomnia. Galen decides after questioning her and eliminating other possible causes that she suffers either from depressed mood—dysthymia—caused by black bile, or she is distressed (lypoumenē) by something she does not want to confess. Later he determines from her maid that she is worn out by some grief, lypē. One day someone happens to mention in the patient’s presence that Pylades is dancing in the theater. Galen notices the following symptoms: change of gaze and of the color of her face, and her pulse became suddenly irregular. “The same thing”, he says, “happens to those who are about to contend over something”, using the verb agōnian. He detects not love, but distress, a feeling like the feeling one might have when one is about to compete in a contest, or— as Galen also writes—like the feeling the slave steward had, who was “similarly afflicted” (De praecogn. 6 = K. 14.633). As I have mentioned, Galen argues elsewhere that lypē has a distinct pulse different from the pulses typical of anger or (acute) fear but very similar to those of chronic fear, insomnia, and worry. There is no erotic pulse, but there is an anxious pulse. Lypē can be fatal. Thus Galen tells the story of Maeander the augur, who died after predicting his own death. This passage survives in a portion of his commentary on Book 6 of the Hippocratic Epidemics surviving only in Arabic, and printed in German translation in Wenkebach and Pfaff’s edition.32 Galen writes that He [Maeander] went from the bird-flight area back to the city demolished, wretched and yellow in color, so that everyone who met him asked him whether he had some bodily illness . . . Then he began to lie sleepless at night while distress (Kummer) oppressed him all day, so that he deteriorated entirely. Finally a light, gentle fever appeared. When the fever began, his soul became so disturbed, that he was no longer himself and had to stay in bed. Two months after his birthday he died because his body gradually wasted away to such an extent that he entirely dissolved. Here “distress” (lypē?) leads to insomnia, fever, yellow skin color, weight loss, behavioral changes, and finally to death.33 In this story and in those that follow—an anonymous man in distress after losing money; the mother of Nasutus mentioned above, distressed at the death of her friend; the grammarian Callistus, also mentioned above; and a 32  In Hipp. Epid. 6 comment., 485–86 Wenkebach and Pfaff. On the Arabic text and the word Kummer see above, n. 16. 33  In Hipp. Epid. 6 comment., 485–86 Wenkebach and Pfaff.

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patient whose story Galen tells at greater length in another passage also surviving only in Arabic (this time from his commentary on the second book of Epidemics), namely a man who thought a ghost was calling him by name from a cemetery34—all of these patients show a progression of symptoms similar to those of the slave steward and the wife of Justus. They develop insomnia and fever; they may change skin color (to yellow or pale, possibly a result of the accumulation of hot, dry yellow bile); they lose weight and waste away, sometimes even until they die. As I have mentioned, Galen states many times that lypē, worry, and insomnia (in some combination or all together) can cause disease, particularly humoral imbalance (they cause drying and heating), and fever.35 One female patient from On the Method of Healing, for example, “began to be feverish from insomnia and lypē, and she suffered through most of the winter” (De meth. med. 10.5 = K. 10.687). Lypē and worry can cause other kinds of illness too, such as epilepsy. The grammarian Diodorus suffers seizures when he fasts or works too late at his intellectual labours, or when he becomes angry or suffers from phrontis or lypē.36 It is also possible for lypē to lead to the psychotic form of the disease Galen and other ancient medical writers call melancholia, which might occur if black bile over-accumulated in the brain from any of several causes.37 In On the Affected Parts, in a passage probably indebted to Rufus of Ephesus’ lost work on melancholia, Galen explains how yellow bile, when burnt, can transform into black bile and cause what he calls “bestial hallucinations” and other psychotic symptoms.38 Humoral imbalance leading to melancholia may be caused by diet, or people of certain temperaments may be naturally susceptible to it; but also, Galen writes, “lypai, insomnias, and worry” can be factors (3.10 = K. 8.184–85). Pernicious, chronic melancholy, as he writes, tends to arise in those who have suffered from the burning fever called kausos in Greek, or from 34  In Hipp. Epid. 2 comment., 208 Wenkebach and Pfaff. 35  See above, n. 20 and 22. 36  De san. tuenda 6.14 (K. 6.448–49); De loc. aff. 5.6 (K. 8.340–41); De venae sect. adv. Erasistrateos 9 (K. 11.241–42). 37  I use the word ‘psychotic’ in its technical sense, meaning that the symptoms of delusions, hallucinations, and/or disorganised thought are present. Any over-accumulation of black bile could be called melancholia, and in ancient medical texts the disorder often affects the stomach, but when it reached the brain it was thought to cause bizarre neurological symptoms. 38  3.9 (K. 8.178); “bestial hallucinations” is van der Eijk and Pormann’s translation of θηριώδεις παραφροσύνας in Pormann, P. E. (2008). Rufus of Ephesus On Melancholy, 267. For a comment on this phrase see their footnote 4. On ancient melancholia a large bibliography could be cited, but Pormann’s book is a good, recent introduction.

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an inflammation in the head, or from phrenitis, by which Galen meant delusions or hallucinations accompanied by fever; “or it follows from worries or lypai or insomnias” (3.1 = K. 8.193), probably because these could generate the yellow bile that, when burnt, became the black bile of melancholia. Chronic fear—a condition, as I have argued, that Galen might call lypē— had long been considered a crucial element in melancholia. A Hippocratic aphorism, very influential on ancient ideas of melancholia, states that “if fear or depressed mood (dysthymia) persist for a long time, it is something melancholic” (Aph. 6.23). Galen, commenting on this aphorism,39 distinguishes fear caused by an apparent or obvious reason from fear that is not caused by something obvious—this idea of irrational fear evokes the modern psychological concept of phobia or, perhaps more appropriately in light of Galen’s other descriptions of melancholic symptoms, persecutory delusions. Galen believes that irrational fear has a darker prognosis, but even fears that seem reasonable can signify melancholia, if they are chronic—that is, anxiety in the sense of ‘chronic fear’ can indicate a very serious illness (In Hipp. Aph. comment. 23 = K. 18a 35–36). This, Galen says elsewhere, has happened to one of his patients: the patient worried about Atlas. This patient’s story occurs in Galen’s commentary on the sixth book of Hippocratic Epidemics, in the list of examples of people who died or wasted away from mental distress (the same list that includes the story of Maeander and of the mother of Nasutus); and Galen also tells it elsewhere, in his commentary on the first book of Epidemics. The Atlas patient is an especially fascinating example of an anxiety disorder in antiquity: I know a man from Cappadocia, who had gotten a nonsensical thing into his head and because of that declined into melancholy. The idea that he had got into his head was completely ridiculous. His friends saw him weeping and asked him about his distress (Kummer). At that he sighed deeply and answered, saying that he was worried that the whole world would collapse. His distress was that the king, about whom the poets relate that he carries the world and is called Atlas, because of the long time that he had carried it, would become tired. Thus there was a danger that the sky would fall on the earth and smash it.40 This patient’s totally irrational (in Galen’s view) and presumably chronic anxiety about Atlas gives rise to melancholia, as Galen’s discussion in On the 39  Konstan, Emotions, 149–50 believes Galen is drawing on an Epicurean tradition here. 40  487 Wenkebach and Pfaff. On Kummer see above, n. 16.

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Affected Parts suggests that it might. Galen tells the same story in another passage, in his commentary on the first book of the Epidemics, this time surviving in Greek: For when someone was in our presence in the morning, as was his custom, he said in response to an inquiry of him that he had lain awake the whole night, considering [the question, that] if it should occur to Atlas, being sick, that he could no longer hold up the sky, what would happen? And when he said this, we deduced that this was the beginning of melancholia (K. 17a 213–14). Here Galen considers worrying about Atlas a conclusive sign of melancholia. He probably considered his diagnosis conclusive based on a passage from Rufus of Ephesus, who had also described such a patient. Galen’s On the Affected Parts contains a lengthy discussion of melancholia, based largely on Rufus of Ephesus’ lost work on that subject.41 Patients suffering from melancholia, he writes, will have fearful delusions; one thinks he is a mollusk liable to be crushed underfoot at any time; another crows like a rooster; still another is afflicted by the “fear, that somehow Atlas, who holds up the world, having become tired will shrug it off, and thus he would be smashed himself and we all would perish with him” (K. 8.190). Two medieval sources (the later apparently derivative of the earlier) attribute this passage with its references to rooster, mollusk, and Atlas to Rufus of Ephesus; adding the detail that the Atlas patient was an astronomer.42 One possibility of course is that Galen invented a fictitious patient based on the reference in Rufus. But Galen is consistent and precise about his relationship to the stories he mentions; both his formulation “I know a man” (in the first version of the story above) and his use of the first person (in the second version) normally indicate first-hand experience, and no other cases of his inventing a story are known.43 It seems more likely that 41  De loc. aff. 3.9–10 (K. 8.176–93). This passage is reprinted with editorial revision and translated by P. van der Eijk and P. E. Pormann in Pormann, Rufus of Ephesus, 265–88. 42  Fischer, K.-D. (2010). ‘De fragmentis Herae Cappadocis atque Rufi Ephesii hactenus ignotis’, Galenos 4, 173–83. I am grateful to Pauline Koetschet and Klaus-Dietrich Fischer for drawing my attention to this reference. 43  For an extended discussion of this point see Mattern, Galen and the Rhetoric of Healing, 37–40. A couple of examples of supposedly fictitious case histories in Galen are sometimes adduced, but I address them in that discussion. On the debate over fictitious patients in Galen, see also Pauline Koetschet, ‘Experiencing Madness: Mental Patients in Arabo-Islamic Medicine’, Chapter Seven, 224–244 in this volume.

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Galen met a patient with a delusion similar to what Rufus had described, and made an easy diagnosis from that indicator (as the second version of the story implies); this interpretation would be more difficult if Galen had insisted that his own patient was an astronomer, like the patient in Rufus, but he does not. Does Galen’s idea of anxiety (for him, a condition of chronic fear or intense worry that can unbalance the temperament toward heat and dryness, causing a constellation of progressive symptoms including insomnia, fever, weight loss, a characteristic pulse, and skin color change, and potentially ending in death or psychosis) reflect ideas prevalent in his culture and in ancient medical science more generally? Or did he make it up? While a full discussion of anxiety in Greco-Roman literature cannot be attempted here, I make a few suggestions, some of which may merit further study. a) As I have mentioned above, Galen himself points out that lypē causes symptoms often attributed to lovesickness, apparently holding the view that lovesickness is really a form of lypē. Lovesickness in ancient literary sources often produces wasting, insomnia, and skin color change (although a substantial tradition of a more manic form of lovesickness is also attested).44 Perhaps lovesickness in antiquity should be interpreted as a distress or anxiety syndrome. b) Introducing the story of Maeander, Galen writes that I know a large number of people whom fear of death overcame, and whom this fear first made sick, and then drove to death. Some of them a dream plunged into this fear. In some cases this fear was produced by an idea or an omen or a strange apparition that they had, or by a lightning strike. Some were driven to it by signs that they found in the entrails of sacrificial animals, or by an augury of some kind of bird . . . (In Hipp. Epid. 6 comment., 485–86 Wenkebach and Pfaff). That is, Maeander represents a number of people known to Galen who wasted away and died after their deaths were presaged by dreams or omens. Galen further writes that he knows a large number of people wasted by “grief or a bad state of the soul”, like the mother of Nasutus; “I limit myself to a couple of cases, because their number is too great.” That is, he seems to consider the syndrome he describes rather common. Finally, some of Galen’s examples derive from other sources or from oral traditions. The story of Maeander, who hailed from Mysia and lived in Pergamum, may be a folktale indigenous to Galen’s homeland; the hero of the story about 44  Toohey, P. (1992). ‘Love, lovesickness and melancholia’, Illinois Classical Studies 17, 265–86.

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a man afraid of a ghost was Erasistratus (In Hipp. Epid. 2 comment., 207–08 Wenkebach and Pfaff); Rufus of Ephesus saw a patient worried that Atlas would drop the world, as Galen apparently also did, unless he lifted the story from Rufus. If it is true that Galen’s idea of anxiety and of a progressive anxiety syndrome reflects something in his culture more generally, how should we interpret it? As a literary tradition or folk belief? As a ‘primitive’ psychiatric theory, to be compared to the DSM to see what Galen ‘got right’? Neither of these methods is appealing, but there is another option. Cross-cultural approaches to psychology pioneered by Arthur Kleinman have led to a deeper understanding of how anxiety disorders manifest in different cultures today.45 In particular, phenomena once dismissed as quaint “culture-bound syndromes” and relegated to a brief appendix in the DSM-4 are now studied as culturally specific distress syndromes. In Western culture, for example, Generalized Anxiety Disorder may present as an extended period of worry together with some combination of fatigue, restlessness, irritability, difficulty concentrating, muscle tension and insomnia.46 Someone suffering from neurasthenia in China47 might complain mainly of fatigue along with restlessness, muscle aches, dizziness, headache, irritability, and indigestion. The patient might attribute his or her symptoms to weakened heart or kidneys, and might meet DSM criteria for Generalized Anxiety Disorder (GAD), Panic Disorder, Major Depressive Disorder (MDD), Anxiety Disorder NOS (Not Otherwise Specified, a psychiatric catch-all term), or none of these. A patient suffering from the Korean condition of hwa-byung or fire sickness, on the other hand, which usually afflicts women, might complain primarily of intrusive angry thoughts, sensations of heat, indigestion and abdominal pain, palpitations, or a feeling of stifling or pressure in the chest, and on interview might meet DSM criteria for GAD, MDD, Somatization Disorder, Panic Disorder, some combination of these, or

45  Kleinman has published very prolifically. I cite here his groundbreaking study of 1982, ‘Neurasthenia and depression: a study of somatization and culture in China’, Culture, Medicine and Psychiatry 6.2, 117–90. 46  DSM-5, 222–26. 47  Shenjing shuairuo, weakness of the nerves; the term was introduced from the West in the late nineteenth century and is a psychiatric diagnosis in the current editions of the International Classification of Diseases and the Chinese Classification of Mental Disorders. See Kleinman, ‘Neurasthenia’; Lee, S. and Kleinman, A. (2007). ‘Are Somatoform Disorders Changing with Time? The Case of Neurasthenia in China’, Psychosomatic Medicine 69, 846–49.

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none of these.48 In this case the patient may believe that suppressed anger accumulated over a long time has solidified in the abdomen, leading to somatic symptoms in some ways similar to the “hysterical suffocation” of Greco-Roman antiquity, a condition that probably also should be interpreted as an example of a culturally specific distress syndrome. While the diagnosis of neurasthenia is declining in China in favor of Western diagnoses of anxiety or mood disorders,49 in a parallel movement, psychiatry is recognizing new disease categories based on the study of non-Western disorders, and developing assessments and treatments for them, for example in the case of hwa-byung.50 Non-Western disease categories do not correspond exactly to DSM categories, and may overlap affective disorders, anxiety disorders, and even psychotic disorders. Here it is important to emphasise that despite the pragmatic tradition of referring to DSM categories in cross-cultural research, its system of classification is not considered particularly authoritative. Western psychiatry struggles with the classification of mental diseases, which is the subject of much debate and constantly in flux,51 many crosscultural studies make the point that DSM categories need to be revised in light of their findings. 48  On anxiety disorders across cultures see recently the syntheses of Hinton, D. E. et al. (2009). ‘Anxiety disorder presentations in Asian populations: a review’, CNS Neuroscience & Therapeutics 15, 295–303; Marques et al. ‘Cross-cultural variation’; Lewis-Fernández et al. ‘Culture and the anxiety disorders’. On the comorbidity of hwa-byung see further Min, S. K. and Suh, S.-Y. (July 2010), ‘The anger syndrome Hwa-byung and its comorbidity’, Journal of Affective Disorders 124.1–2, 211–14. The authors find that comorbidity with MDD and GAD is very common but not universal in hwa-byung patients. They suggest creating a category of internalizing distress disorders or of affective disorders, to include MDD, GAD, and anger syndrome. 49  Lee and Kleinman, ‘Are somatoform disorders changing?’ 50  Min, S. K. et al. (2009), 'Symptoms to Use for Diagnostic Criteria of Hwa-Byung, an Anger Syndrome', Psychiatry Investigation 6, 7–12; Roberts, M. E. et al. (2006). ‘Development of a scale to assess Hwa-byung, a Korean culture-bound syndrome, using the MMPI-2’, Transcultural Psychiatry 43, 383–400. 51  For discussions of the problem see e.g. Blashfield, R. K. and Livesley, W. J. ‘Classification’, in Millon, T. et al. (1999). The Oxford Textbook of Psychopathology, 3–28; Widiger, T. A. and Samuel, D. B. (2005). ‘Diagnostic categories or dimensions? A question for the Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition’, Journal of Abnormal Psychology 114.4, 494–504. For comment on this subject by historians of antiquity, see Simon, B. “ ‘Carving nature at the joints’: the dream of a perfect classification of mental illness”, in Harris, Mental Disorders, 27–40; and Hughes, J. C. ‘If only the ancients had had DSM, all would have been crystal clear’, in the same volume, 41–60.

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In many cross-cultural presentations of anxiety disorders, somatic symptoms are more prominent than psychological symptoms such as worry. Somatic symptoms in patients meeting the criteria for GAD, for example, vary substantially and may include items not mentioned in the DSM, such as sweating, indigestion, dizziness, and palpitations. Galen’s patients presented the somatic symptoms of fever, skin color change, weight loss, insomnia, and a weak, irregular pulse; that these are not identical to DSM symptoms associated with GAD or other anxiety disorders is not especially significant in cross-cultural context. Causes of anxiety also vary substantially; for example, worries about physical symptoms vary depending on the perceived cause of the disease (‘ethnophysiology’). Thus Cambodian patients imagining that a buildup or blockage of wind in the body is a dangerous condition will be especially sensitive to, and worried about, symptoms of dizziness, nausea, coldness in the extremities, pain in the neck, or abdominal sensations. Other causes of worry, such as the rebirth status of deceased family members in Buddhist populations,52 are also obviously culture-specific and remind us not to dismiss the fears of Maeander or even of the Atlas patient as folkloric inventions, even if one or both of these particular patients is fictional. Studying Galen’s idea of lypē as a cross-cultural anxiety or distress disorder offers several insights. First, it suggests that anxiety and distress disorders existed in Greco-Roman antiquity, and that Galen’s lypē-syndrome might be best understood as one of them. The Atlas patient, for example, might meet DSM criteria for Generalized Anxiety Disorder and perhaps also for Major Depressive Disorder, which is characterised by prolonged depressed mood or anhedonia and which may involve weight change and sleep disturbance as prominent symptoms. It is interesting to note that GAD and MDD are very often co-morbid today and respond to the same drugs, and it is often suggested that they are aspects of the same disease.53 Galen describes an identical progressive syndrome for people suffering from lypē in the sense of ‘grief’ or ‘sadness’ (the mother of Nasutus) and those suffering from lypē in the sense of anxiety (Maeander; the Atlas patient; the wife of Justus). His taxonomy is arguably more accurate than that of the DSM on this point. Furthermore, the comparative perspective I propose here suggests that other conditions described 52  Hinton, D. E. et al. (2011). ‘Worry, worry attacks, and PTSD among Cambodian refugees: a path analysis interpretation’, Social Science and Medicine 72.11, 1821. 53  E.g. Minenka, S. et al. (1998). ‘Comorbidity of anxiety and unipolar mood disorders’, Annual Review of Psychology 49, 377–412; Watson, D. (2005). ‘Rethinking the mood and anxiety disorders’, Journal of Abnormal Psychology 114, 522–36.

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in ancient sources, such as hysterical suffocation, might be better understood as anxiety syndromes. This perspective also suggests mechanisms for how anxiety disorders worked in Galen’s patients: modern anxiety syndromes create a positivefeedback cycle in which the anxious patient pays more attention to the symptoms believed to be associated with his or her syndrome; these symptoms increase through ‘attention amplification’; the patient becomes more worried, and so forth. Often symptoms are interpreted as indicating, or potentially causing, dangerous conditions such as a weakened heart or an attack of pathogenic wind. These “catastrophic cognitions” amplify the feedback loop.54 Galen and presumably his patients believed that anxiety could be fatal; Maeander becomes intensely distressed at the appearance of the ominous symptom of fever. Also, analysis of Galen’s stories can suggest an important correction to modern psychology, which for the most part has not considered the role of the physician in generating culturally specific expressions of distress. Some of the somatic indicators Galen describes—skin color change, fever, and irregular pulse—are signs, not symptoms; they are observed by the physician, not just reported by the patient. Few Western psychiatrists would examine their patients for any of these signs, but Galen’s conception of lypē predisposed him to look for them and, probably, to find them. To sum up: Galen describes a syndrome he associates with an emotion called lypē, with specific symptoms and a course that may lead to humoral imbalance, disease and death. Lypē is not only a reaction to a perceived danger or an overwhelmed response to the loss of a family member or a professional disaster, although it includes this idea of grief. It is mainly the gnawing, wasting feeling of desolation one gets from worrying about money or love or status, or the exposure of secrets, or work. It is the tense feeling one has before appearing in court or giving an important lecture. It is chronic by nature, unlike fear, which reacts to an immediate threat. It can cause a syndrome characterised by insomnia, fever, pallor, and weight loss that can kill patients or degenerate into psychotic illnesses. Of course, Galen’s description of this lypē-syndrome does not match DSM criteria for any anxiety disorder perfectly; but in a crosscultural perspective, it is subtle, sophisticated and quite plausible. It is clear to me that Galen saw anxiety disorders, and that this lypē-syndrome is what they looked like to him. Furthermore, he saw them a lot. If we were tempted to think that anxiety disorders are the plague of a modern lifestyle, we are disabused. 54  Hinton et al., ‘Anxiety disorder presentations’.

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Texts and Translations Used Eijk, P. J. van der and P. E. Pormann. ‘Appendix 1: Greek Text, and Arabic and English Translations of Galen’s On the Affected Parts iii.9–10’. In Rufus of Ephesus: On Melancholy. Ed. P. E. Pormann, 265–88. Tübingen: Mohr Siebeck, 2008. Galen. Opera omnia. Ed. C. G. Kühn. Leipzig: Cnobloch, 1821–33. ———. On the Doctrines of Hippocrates and Plato. Ed. Ph. De Lacy, 2 vols. CMG V 4.1.2. Berlin: Akademie-Verlag, 1984. ———. Galeni In Hippocratis Epidemiarum Libros 1 et 2. Ed. E. Wenkebach and F. Pfaff. CMG V.10.1. Leizpig and Berlin: Teubner, 1934. ———. Galeni In Hippocratis Epidemiarum: Librum 6 Commentaria 1–8. Ed. E. Wenkebach and F. Pfaff. 2nd edition. CMG V.10.2.2. Berlin: Teubner, 1956. Fischer, Klaus-Dietrich. ‘De fragmentis Herae Cappadocis atque Rufi Ephesii hactenus ignotis’. Galenos, 4 (2010): 173–83. Pfaff, Franz. Galens Kommentare zu den Epidemien des Hippokrates, Indizes der aus dem Arabischen übersetzten Namen und Wörter. CMG V.10.2.4. Berlin, 1960. Rufus of Ephesus. On Melancholy. Ed. P. E. Pormann. Tübingen: Mohr Siebeck, 2008.

References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Washington, D. C.: American Psychiatric Publishing, 2013. Becker, L. C. ‘Stoic Emotion.’ In Stoicism: Traditions and Transformations, ed. S. K. Strange and J. Zupko, 250–76. Cambridge and New York: Cambridge University Press, 2004. Blashfield, R. K. and Livesley, W. J. ‘Classification.’ In The Oxford Textbook of Psychopathology, ed. T. Millon, P. H. Blaney and R. D. Davis, 3–28. Oxford: Oxford University Press, 1999. Boudon-Millot, V. and Jouanna, J. (ed.) Galien. Ne pas se chagriner. Paris: Les Belles Lettres, 2010. Brennan, T. ‘Stoic Moral Psychology.’ In The Cambridge Companion to the Stoics, ed. B. Inwood, 257–94. Cambridge and New York: Cambridge University Press, 2003. Furley, W. D. ‘Antiphon der Athener: Ein Sophist als Psychotherapeut?’ Rheinisches Museum für Philologie n.s. 135, (1992): 198–216. Harris, W. V. Restraining Rage: The Ideology of Anger Control in Classical Antiquity. Cambridge, MA: Harvard University Press, 2001. ———. (ed.) Mental Disorders in the Classical World. Leiden and Boston: Brill, 2013.

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Hinton, D. E., Park, L., Hsia, C., Hofmann, S. and Pollack, M. H. ‘Anxiety Disorder Presentations in Asian Populations: A Review.’ CNS Neuroscience & Therapeutics 15, (2009): 295–303. Hinton, D. E., Nickerson, A. and Bryant, R. A. ‘Worry, Worry Attacks, and PTSD among Cambodian Refugees: A Path Analysis Interpretation’. Social Science and Medicine 72.11, (2011): 1817–25. Hughes, J. C. ‘If Only the Ancients Had Had DSM, All Would Have Been Crystal Clear.’ In Mental Disorders in the Classical World, ed. William V. Harris, 41–60. Leiden and Boston: Brill, 2013. King, H. ‘Fear of Flute Girls, Fear of Falling.’ In Mental Disorders in the Classical World, ed. W. V. Harris, 265–84. Leiden and Boston: Brill, 2013. Kleinman, A. ‘Neurasthenia and Depression: A Study of Somatization and Culture in China.’ Culture, Medicine and Psychiatry 6.2, (June 1982): 117–90. Konstan, D. The Emotions of the Ancient Greeks: Studies in Aristotle and Classical Literature. Toronto: University of Toronto Press, 2006. Lee, S. and Kleinman, A. ‘Are Somatoform Disorders Changing with Time? The Case of Neurasthenia in China.’ Psychosomatic Medicine 69, (2007): 846–49. Lewis-Fernández, R. Hinton, D. E., Laria, A. J., Patterson, E. H., Hofmann, S. G., Craske, M. G., Stein, D. J., Asnaani, A. and Liao, B. ‘Culture and the Anxiety Disorders: Recommendations for DSM-V.’ Depression and Anxiety 27, (2010): 212–29. Manuli, P. ‘Le passione nel De Placitis Hippocratis et Platonis.’ in Le opere psicologiche di Galeno, ed. P. Manuli and M. Vegetti, 193–97. Naples: Bibliopolis, 1988. Marques, L., Robinaugh, D. J., LeBlanc, N. J. and Hinton, D. E. ‘Cross-Cultural Variation in the Prevalence and Presentation of Anxiety Disorders.’ Expert Review of Neuro­ therapeutics 11.2, (2011): 313–22. Mattern, S. P. Galen and the Rhetoric of Healing. Baltimore, MD: Johns Hopkins University Press, 2008. ———. The Prince of Medicine: Galen in the Roman Empire. Oxford and New York: Oxford University Press, 2013. Min, S. K. and Suh, S.-Y. ‘The Anger Syndrome Hwa-byung and Its Comorbidity.’ Journal of Affective Disorders 124.1–2, (July 2010): 211–14. Min, S. K., Suh, S.-Y., and Song, K. J. 'Symptoms to Use for Diagnostic Criteria of HwaByung, a Korean Anger Syndrome.' Psychiatry Investigation 6, (2009): 7–12. MacNally, R. J. ‘Anxiety.’ in The Oxford Companion to Emotion and the Affective Sciences, ed. D. Sander and K. R. Scherer, 42–44. Oxford and New York: Oxford University Press, 2009. Minenka, S., Watson, D. and Clark, L. A. ‘Comorbidity of Anxiety and Unipolar Mood Disorders.’ Annual Review of Psychology 49, (1998): 377–412.

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Nussbaum, M. Upheavals of Thought: The Intelligence of Emotions. Cambridge and New York: Cambridge University Press, 2001. Pigeaud, J. La maladie de l’âme. Étude sure la relation de l’âme et du corps dans la tradition medico-philosophique antique. Paris: Les Belles Lettres, 1981. ———. ‘La psychopathologie de Galien.’ in Le opere psicologiche di Galeno, ed. P. Manuli and M. Vegetti, 153–84. Naples: Bibliopolis, 1988. Postert, C., Dannlowski, U., Müller, J. and Konrad, C. ‘Beyond the Blues: Toward a CrossCultural Phenomenology of Depressed Mood.’ Psychopathology 45, (2012): 185–92. Roberts, M. E., Han, K. and Weed, N. C. ‘Development of a Scale to Assess Hwa-byung, a Korean Culture-Bound Syndrome, Using the MMPI-2.’ Transcultural Psychiatry 43, (2006): 383–400. Scherer, K. R. ‘Emotion Theories and Concepts (Psychological Perspectives).’ in The Oxford Companion to Emotion and the Affective Sciences, ed. D. Sander and K. R. Scherer, 145–50. New York: Oxford University Press, 2009. Schieffelin, E. L. ‘The Cultural Analysis of Depressive Affect: An Example from New Guinea.’ in Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder, ed. A. Kleinman and B. Good, 101–33. Berkeley: University of California Press, 1985. Simon, B. ‘ “Carving Nature at the Joints”: The Dream of a Perfect Classification of Mental Illness.’ in Mental Disorders in the Classical World, ed. W. V. Harris, 27–40. Leiden and Boston: Brill, 2013. Stok, F. ‘Follia e malattie mentali nella medicina romana.’ in Aufstieg und Niedergang der römischen Welt 2.37.3, ed. W. Haase, 2283–2410. Berlin and New York: Walter de Gruyter, 1996. Toohey, P. ‘Love, Lovesickness and Melancholia.’ Illinois Classical Studies 17, (1992): 265–86. Watson, D. ‘Rethinking the Mood and Anxiety Disorders.’ Journal of Abnormal Psychology 114, (2005): 522–36. WHO World Mental Health Survey Consortium. ‘Prevalence, Severity, and Unmet Need for Treatment of Mental Disorders in the World Health Organization World Mental Health Surveys.’ Journal of the American Medical Association 291.21, (June 2, 2004): 2581–90. Widiger, T. A. and Samuel, D. B. ‘Diagnostic Categories or Dimensions? A Question for the Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition.’ Journal of Abnormal Psychology 114.4, (2005): 494–504. World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization, 1992.

CHAPTER 7

Experiencing Madness: Mental Patients in Medieval Arabo-Islamic Medicine Pauline Koetschet This paper focuses on the mental patients in Arabo-Islamic Middle Ages. Patients suffering from mental illnesses generated a lot of interest for Arabo-Islamic physicians. The first objective of this study is to identify who were the mentally infirm and to compare the Arab physicians’ typologies of mental patients to that of their Greek predecessors. The second part of this paper shifts the focus from theoretical descriptions to case histories and biographical sources, in order to understand how the physicians treated their mental patients, and to find out what was the social impact of this medical approach. Finally, because the special provision for the insane is a distinctive feature of the Islamic hospital, the third part of my paper examines whether the main purpose of these hospitals was the patients’ confinement or their treatment. Patients suffering from psychological illness generated a lot of interest in Arabo-Islamic medicine. The Medieval physicians who wrote in Arabic relied strongly on Greek sources, especially on Rufus of Ephesus’ Treatise on Melancholy and his case histories, and on Galen’s writings, especially his treatise On the Affected Parts. This reliance on earlier sources, however, did not prevent these authors from both criticising their predecessors and making substantial progress over them in medical theory and practice. This paper focuses on mental patients, whom I consider here as both individuals and as categories of illness. As individualised bodies and souls, each one of them displays a specific history and a specific range of symptoms. As categories of illness, they form sets of cases grouped together according to the disease they suffer from. Was the role of the patients who suffered from mental illnesses any different, when compared with patients who suffered from physical diseases? What importance did the physicians give to the individual’s body, as well as to the individual history of the mental patients? Islamic hospitals allowed the physicians to make clinical observations on a great number of patients and compare them. What role did this accumulation of cases play in their approach to mental patients? What was the place of the mental patients

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in these medical institutions? This is the main cluster of questions this paper aims to address. The present study puts great emphasis on texts containing clinical observations, and compares them with the encyclopaedic tradition. The main aim is to place the patients, not the disease at the focus point. In order to do so, I must first identify who were the mentally infirm according to the Arab physicians, and compare their typologies of mental patients to the ones constructed by their Greek predecessors. The second part of my paper shifts focus from theoretical descriptions to case histories. While theoretical descriptions are found in encyclopaedic treatises or monographs, case histories inserted in these treatises or gathered in ‘case-notes’ books give us a more direct access to the mental patients themselves. Historical sources, such as biographical dictionaries, also give priority to the person over the illness. This is the reason why I added biographical notes to my sources, in order to understand better what the social impact of the medical approach was. Finally, precisely because the special provision for the insane is a distinctive feature of the Islamic hospital, the third part of my paper examines whether the main purpose of these hospitals was the patients’ confinement or their treatment. At the same time, I am also looking at the epistemological changes the practice of medicine in these institutions entailed. 1

Melancholics and Madmen

To what extent does the label ‘mental patients’ relate to the Arabic sources, despite the fact that the term itself is anachronistic to some degree? Who were the mentally infirm according to Arabo-Islamic physicians? For the Arab physicians, just as for their Greek predecessors, some diseases had prominent psychological effects and causes and affected the rational faculties of the soul. Greek and Arabic physicians traditionally distinguished between three rational faculties of the soul (alternatively referred to as faculties of the rational soul): thought, imagination, and memory, all located in the brain.1 Patients suffering from diseases located in the brain were thought of as having their rational faculties impaired. These patients are the focus of this study. They include, for example, patients suffering from melancholy, φρενίτις, μανία, love-sickness, or impairment of one, two, or all three of the faculties of the rational soul. For example, even though the description of melancholy included a wide range of symptoms and causes that could differ from one physician to the other, Greek 1  See for example al-Rāzī (1979). Introduction to the Art of Medicine, 80–85.

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and Arab physicians all considered as the base-line of this disease the two psychological symptoms already mentioned by the famous Hippocratic aphorism 6.23, that states that the two main symptoms of melancholy are sadness (δυσθυμία) and fear (φόβος).2 Contrary to what the title of this article might suggest, not all patients suffering from one of these illnesses were considered to be mad or insane by every physician. Madness (ǧunūn) is sometimes used by Arab physicians to translate the specific disease called μανία in Greek, or in a more general sense to designate any kind of disease accompanied by delirium. In this article, the term madness (ǧunūn) will be mostly used in this more general sense. Whether all mental patients should be considered as madmen—that is as potentially delirious—is a question with which the Arab physicians engaged deeply. They did not always use madness as a heading, but rather focused on the relationship between melancholy and other psychosomatic diseases. In doing so, they reactivated an interest already displayed by Greek physicians.3 Out of the many Greek treatises that dealt with melancholy and were translated into Arabic, the two texts that had the greatest influence on Arab physicians are Rufus of Ephesus’ treatise On Melancholy and the third book of Galen’s On the Affected Parts. Both treatises address the problem of the affinity between melancholy and madness. Rufus established that there was a strong affinity between madmen and melancholics, and he distinguished between the melancholics who “have melancholy because of their nature and original mixture”, and those who “have acquired this mixture later owing to a bad diet”. The latter kind of melancholic becomes the victim of delirium.4 On the other 2  Hipp., Aph. 6.23, (L. 4.568). On the Arabic reception of this passage, see Pormann, P. E. and Joose, P. ‘Commentaries on the Hippocratic Aphorisms in the Arabic tradition: The example of melancholy’, in Pormann, P. E. (2012). Epidemics in Context: Greek Commentaries on Hippocrates in the Arabic Tradition, 211–49. 3  Many important studies have been devoted to the notion of melancholy in the Greek tradition. See, for example, Flashar, H. (1966). Melancholie und Melancholiker in den medizinischen Theorien der Antike; Pigeaud, J. (1981). La maladie de l’âme: Études sur la relation de l’âme et du corps dans la tradition médico-philosophique antique; and Eijk, Ph. van der ‘Aristotle on melancholy’, in Eijk, Ph. van der (2005). Medicine and Philosophy in Classical Anitquity, 139–68. It should be stressed here that the famous Pseudo-Aristotelian Problemata Physica 30.1, where melancholy and genius are closely related, seems to be absent from the Arabic tradition on melancholy. On this famous tradition, see Pigeaud, J. (1988). Aristote. L’homme de génie et la mélancolie, for a detailed study of this text, see Klibansky, R. et al. (1989). Saturne et la mélancolie: études historiques et philosophiques: nature, religion, médecine et art, 45–61. 4  Pormann, P. E. (2008). Rufus of Ephesus. On Melancholy, 34–35.

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hand, Galen distinguished between two types of black bile: the thick melancholic humour that produces melancholy, and the dark yellow bile that results in bestial hallucinations.5 In addition to bestial delirium, Galen connects melancholy to other psychosomatic diseases. In particular, he brings together melancholy and φρενίτις, and compares the diseases caused by each type of black bile to the two types of φρενίτις caused by pale yellow bile and yellow bile. However, Galen distinguishes phrenetic delirium and melancholic delirium, for phrenetic delirium does not subside when the fever peaks, whereas melancholic delirium can occur with or without fever. Moreover, Galen explains that melancholy and epilepsy are closely related, precisely because epilepsy, which can be produced by the melancholic humour, can turn into melancholy. The affinity between melancholy and epilepsy had already been brought forth by Hippocrates in the sixth book of the Epidemics, where it is stated that: Melancholics usually become epileptics, and epileptics (usually become) melancholics. The direction taken by the disease determines which one of these two states occurs: if it affects the whole body, then it is epilepsy; if it affects the thought, then it is melancholy.6 In his commentary on this passage Galen explains that both diseases are similar because they are caused by the same humour, the black natural humour.7 The Arab physicians’ accounts of the close correlation between melancholy and the other psychosomatic diseases differ substantially from those given by Rufus and Galen. The ensuing discussion of three out of those physicians, Abū Bakr al-Rāzī, al-Kaskarī and Isḥāq ibn ʿImrān, and how they differentiated between the different categories of mental patients will flesh this out.8 To start with, Abū Bakr al-Rāzī lived between the end of the ninth and the beginning of the tenth century in Rayy and in Baghdad (d. 925). His home-town was located near modern Teheran. In Baghdad, the capital of the Abbassid Empire at the time, Abū Bakr al-Rāzī practised medicine at court, but he was also active

5  Gal., De loc. aff., 3. 9 (K. 8.177–78), as quoted in Pormann, Rufus, 266–68. 6  Hipp., Epid. 6.8.31 (L. 5.354–56). Translation by Peter Pormann and Philip van der Eijk, as quoted in Pormann, Rufus, p. 271. On Epidemics 6, see Manetti, D. and Roselli, A. (1982). Ippocrate: Epidemie, libro sesto. Translations, unless otherwise noted, are mine. 7  Gal., In Hipp. Epid. 6 comment., Pfaff, CMG V, 10, 2, 2, 505–06. 8  I focus on these three authors, because they all lived at the same period, roughly between the end of the ninth century and the beginning of the tenth century.

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in the recently established hospital called al-ʿAḍudī.9 Historians of medicine often praise him for the central role qualified and quantified experience played in his medical methodology, and for the numerous case histories he wrote down driven by his high regard for clinical experience.10 Even though his understanding of the different kinds of mental patients relies on Greek sources, such as Rufus and Galen, Abū Bakr al-Rāzī made further distinctions in the categories of mental illness and mental patients found in these sources. In his Comprehensive Book on medicine, which gathers the lecture-notes that al-Rāzī made on his Greek, Syriac and Arabic sources, he argues against the “common people” (al-ʿāmma)’s tendency to characterise any person showing a confused state of mind or behaviour as ‘mad’: Abū Bakr said: the people call epileptics, melancholics and those who are confused “madmen”. And between these three (categories), there is a big difference. This is because epileptics enjoy a good health all the time, except at this time (i.e. at the time of their crisis). Melancholy is not accompanied by insomnia and jumping at people, and the (melancholic) does not speak very confusedly. On the contrary, the difference between (the melancholic) and the healthy people often lies in small things, such as harmful thoughts. If this (disease) lasts for a long time, it provokes an important confusion. However, in every case, (the melancholic) is similar to the intelligent man, and fear, anxiety and worry never leave him. On the other hand, madness is accompanied by jumping on people, rapid and violent movements, insomnia, and constant confusion, without heaviness (of the mind).11 Al-Rāzī rejects the labelling of melancholics as madmen, by ascribing it to the opinion of the common folk. However, equating patients who suffered from melancholia and those who were afflicted by madness was not limited to the laymen and was not simply an expression of medical ignorance. Indeed, the 9  See Ibn ʾAbī ʾUṣaybiʿa (1884). History of physicians, vol. 1, 310. For a general presentation of al-Rāzī’s life and writings, see Daiber, H. ‘Abū Bakr al-Rāzī’, in Rudolph, U. (2012). Philosophie in der islamischen Welt, Band 1, 8.–10. Jahrhundert, 261–89. 10  Iskandar, A. Z. (1962). ‘Al-Rāzī al-ṭabīb al-ʾiklīnīkī’, Al-Mašriq 56, 217–82, trans. Pormann, Z. and Pormann, P. E.: ‘Al-Rāzī, the clinical Physician’, in Pormann, P. E. (2010). Islamic Medical and Scientific Tradition, vol. 1, 207–53. 11  Al-Rāzī (1955–85). The Comprehensive Book, 1.195 = (2013). p. 590. See the passage quoted above (although the author of the treatise does not mention madness in this passage): Hipp., Epid. 6. 8. 31 (L. 5.354–56).

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opinion that melancholy and epilepsy can share common roots was based also on medical theories that go back to the Hippocratic Epidemics. Contrary to Rufus and Galen, al-Rāzī stresses the difference between melancholy and delirium, and argues in favour of a much more limited conception of melancholy that would not include other kinds of mental diseases such as φρενίτις or μανία. In the third chapter of the first book of The Comprehensive Book on Medicine, al-Rāzī denies that melancholy can be provoked by dark yellow bile.12 Dark yellow bile can provoke a form of delirium, but this should not be considered as a type of melancholy, as he explains in his Introduction to the Art of Medicine.13 In the thirteenth chapter of the same book, al-Rāzī deals with the affections of the faculties of the rational soul. In the part devoted to the affections of thought, he uses the term waswās in the general sense of “delirium”, or “confusion of the mind”. Different forms of delirium include melancholy, φρενίτις, or μανία. When the affection has its origin in the brain (as opposed to the whole body) and is produced by yellow bile, this is a case of φρενίτις (sirsām). Black bile, on the other hand, causes “bestial madness” (al-ǧunūn al-sabuʿī). If the confusion has its origin in the body of the brain itself, it will last and will not calm down. This disease is called φρενίτις (qarānīṭis), when the bile that is in the brain is of the kind of yellow bile. When it belongs to the kind of black bile, it provokes bestial madness. When it does not belong to the kind of melancholic black bile truly, but to the kind of melancholic black humour, it provokes the kind of melancholic delirium that the Greek call melancholy.14 Is there a contradiction in the passage quoted above with The Comprehensive Book, where al-Rāzī associated the symptoms of bestial delirium to yellow bile? In the passage from the Introduction to the Art of Medicine, black bile can indeed provoke bestial madness. But this does not necessarily mean that there is an opposition here. Even if al-Rāzī does not mention the origin of the “black bile” that causes bestial madness in this instance, he differentiates between “authentic black bile” (marār ʾaswad bi-l-ḥaqīqa) and “black humour” (ḫilṭ sawdāwī)—just as Galen did in the Affected Parts (3.9). It seems that in essence, always according to al-Rāzī, black bile can indeed derive from burnt

12  Al-Rāzī, The Comprehensive Book, 1.63.3–5 = (2013). p. 341. 13  Al-Rāzī, Introduction, 84. 14  Ibid., 81.

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yellow bile, but in this case, the disease that is provoked should neither be called melancholy, nor be considered as a type of melancholy. In this respect, al-Rāzī disagrees not only with his predecessors, but also with his contemporaries, such as al-Kaskarī and Isḥāq ibn ʿImrān, who both associate melancholy with a wide range of psychological symptoms. Al-Kaskarī was a hospital physician who practiced medicine in the 920s in Baghdad. He is the author of a medical compendium that constitutes an important source for the history of medicine in tenth century Baghdad.15 In the chapter on melancholy of his Compendium, al-Kaskarī bases the assimilation of melancholy to delirium on his interpretation of the passage of the Affected Parts mentioned above: Galen said in his book On the Affected Places: “When the melancholic humour becomes dominant and abundant in the hollow of the brain itself (sic. the ventricles), then the results are melancholic delusion, a confusion (sic. of the intellect, i.e. madness) which is fervent, and a daring resembling that of beasts of prey, especially when caused by the burning of yellow bile”.16 In this passage, the temerity that resembles that of the beasts is one of the symptoms of melancholy. Sadness and fear are the other possible effects of black bile. In the same chapter, al-Kaskarī distinguishes between the natural black humour and the black bile produced by the corruption of other humours. However, the same author states that the natural black humour does not cause any disease, precisely because it is natural. Therefore, the melancholic disease seems to be entirely caused by the harmful black bile, when the latter ascends to the brain. Isḥāq ibn ʿImrān’s (d. 932) interpretation produces roughly the same result, by extending the scope of melancholy to many mental plights. Isḥāq lived in Kairouan (in modern Tunisia) at the court of the Aghlabid sultan Ziyādat Allah III, and is the author of the only surviving monograph on melancholy produced in the Islamic medieval world, the Treatise on Melancholy. In this treatise, melancholy covers an extremely wide variety of symptoms, ranging 15  On al-Kaskarī, see for example Pormann, P. E. (2003). ‘Theory and practice in the early hospitals in Baghdad: al-Kaškarī on rabies and melancholy’, in Zeitschrift für Geschichte der Arabisch-Islamischen Wissenschaften 15, 197–248; and more recently by the same author ‘Al-Kaskarī (10th century) and the quotations of classical authors. A philological study’, in Garofalo, I. and Lami, A. (2009). Sulla tradizione indiretta dei testi medici greci, 105–06. 16  Al-Kaskarī, Compendium of Medicine, chap. 22, §2, ed. Pormann in ‘Theory and practice’, p. 233, trans. p. 240.

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from excessive sadness and fear—the two traditional symptoms attached to melancholy in the sixth book of the Hippocratic Aphorisms17—to extreme forms of madness including bestial madness: The type of melancholy that originates in the brain has two main forms: one is accompanied by acute fever, and occurs especially in case of birsām, which the Greeks call φρενίτις. It results from yellow bile that began to burn, but did not reach the extreme blackness and bad temperament which characterise the nature of black bile. It produces jumpiness, foolishness, and hallucinations of black people or of other things that he (i.e. the patient) imagines to be in front of him, whereas none of them is really there. The second form has in turn two species. The first is caused by natural black humour, when it becomes dominant in the complexion of the brain, and alters its essence. This species of delirium is called “bestial”, because those who suffer from it jump around like beasts, and show temerity, intrepidity and strength similar to that of beasts.18 In this passage, Isḥāq ibn ʿImrān thinks that all forms of bestial delirium can be accommodated under the rubric of melancholy, even if their origin is different: phrenitic melancholy arises from dark yellow bile, whereas ‘pure’ bestial delirium dissociated from melancholy arises from natural black humour, unlike the explanation given by Rufus and Galen. These theoretical distinctions may seem like scholastic quibbling, but they did bear some importance when it came to the diagnosis of mentally disturbed patients. Leaving aside these more theoretical preoccupations, the second part of my paper examines the practical approach to mental patients as displayed in case histories. Case histories offer us a unique insight into the patient’s view, as opposed to the views expressed in more academic texts (like the ones discussed above), where the patient is often overshadowed by taxonomical enterprises. 2

Mental Patients in Case Histories

Case histories play a crucial role in the diagnosis and treatment of mental disease by both Greek and Arab physicians. This is primarily due to the multiplicity of symptoms in which the disease manifests, such as the wide range of

17  Hipp., Aph. 6.23 (L. 4.568). 18  Isḥāq ibn ʿImrān, On Melancholy, 41–42.

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melancholic symptoms, which had already been emphasised by Rufus.19 Isḥāq ibn ʿImrān quotes a passage where the Greek physician expresses his hope that the symptoms he has enumerated will help his reader grasp the other symptoms of the same disease, even if they were not made explicit.20 Isḥāq explains that Rufus did not enumerate all the symptoms of the disease, because this task would have been endless. The main reason for this is that while the physical symptoms of melancholy are not hidden, the exact functioning of the soul remains obscure to physicians and philosophers. Thus, it is difficult to grasp the disorders that affect it. Since it is not easy to understand the different states of the soul, or even the course of the intellect, the physician must at all times pay particular attention to the individual history of the melancholic patient. If somebody is normally hasty, impulsive, talkative and quick-tempered, but then becomes silent, taciturn, and slow, this change reveals that the nature of his soul has been altered, and that he is now sick. On the contrary, if somebody is in the habit of answering questions slowly and being afraid of a multitude of things, and one day the same individual starts acting in an agitated way, and appears to be brave and enterprising, this is an indication that he too has been struck by this illness.21 As a result, in the case of mental diseases in general, and of melancholy in particular, the physician has to pay particular attention to the patient as an individual. The second reason why case studies were so significant for mental diseases is that, as mentioned above, Arab physicians, following the lead of their Greek predecessors, understood mental illnesses as the impairment of one or more rational faculties. In order to identify the mental disease he is confronted with, the physician needs to narrow down the rational faculty that has been impaired. Case histories, thus, helped Galen illustrate which part of the brain was injured in each disease. Case histories offer access to more direct knowledge based on the clinical observations the physicians made on their mental patients, rather than knowledge derived from other medical theories. However, as Cristina Álvarez-Millán has already showed in her earlier articles, which discussed both Graeco-Roman and Arabic sources,22 case histories should be handled with caution, because 19  Pormann, Rufus, F5, 28–29. See also in the same volume Eijk, Ph. van der, ‘Rufus’ on melancholy and its philosophical background’, 175–77. 20  Isḥāq ibn ʿImrān, Melancholy, 44. 21  Ibid., 43. 22  Álvarez-Millán, C. (1999). ‘Graeco-Roman case histories and their influence on medieval Islamic clinical accounts’, SHM 12, 19–33; id. ‘Practice versus theory: Tenth-century case histories from the Islamic middle east’, in Horden, P., and Savage-Smith, E. (2000). The Year 1000. Medical Practice at the End of the First Millenium, 293–306; and id. (2010).

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they do not always reflect actual practice, and because they can become part of the physician’s own story-telling. In the present chapter, I am not concerned with the problem of the veracity of these case histories; rather I consider them as part of the medical discourse, in which the role of the patient is the most prominent. Some of these examples are closely related to Greek medical texts. As a whole, examples and case histories in Arabic sources can be divided into three categories according to their relation to their Greek antecedents: textbook cases, adaptations, and genuine case studies. To these three categories, all of which belong to the realm of medical discourse, a fourth category can be added: the social accounts of melancholics and madmen as found in historical sources. The first category includes case histories extracted from Galen’s or Rufus’ writings, regardless of whether the authors’ name is mentioned or not. For example, in The Comprehensive Book of Medicine (1,4), and in the Introduction to the Art of Medicine, al-Rāzī resorts to the same example of the phrenetic wool worker described by Galen in the fourth book of his treatise On the Affected Parts.23 In the Comprehensive Book of Medicine, al-Rāzī refers to Galen’s text,24 but he does not even mention it in his Introduction to the Art of Medicine.25 In this instance, Galen’s example has somehow become a ‘textbook’ case. Indeed, in the Introduction to the Art of Medicine, analogous examples are employed to show which of the faculties is impaired in the various mental diseases. For a start, al-Rāzī describes a man who had an exact knowledge of things and expressed it correctly, but believed at the same time that drum players were inside the house, and kept asking them to leave. This example is also taken from the same book of the Affected Parts. Then, in order to illustrate the possibility that the imagination remains intact while only the faculty of judgment is impaired, al-Rāzī gives a slightly modified version of the famous Galenic example of the phrenitic man.26 A man sat in a room, and the doors of that room opened out in the street. The same man began throwing the room’s contents out of the door and at a young boy (whereas in Galen’s version, the man wanted to throw out the young boy himself), while simultaneously he named each one of the room’s contents by its correct name. ‘The case stories in medieval Islamic medical literature: Taǧārib and Muǧarrabāt as source’, Medical History 54, 195–214. 23  Gal., De loc. aff., 4.2 (K. 8.226–28). See also Mc Donald, G. (2009). Concepts and Treatments of Phrenitis in Ancient Medicine, Diss., 131–32. 24  Al-Rāzī, The Comprehensive Book, vol. 1, 383–84. 25  Al-Rāzī, Introduction, 81. 26  These two examples are given in al-Rāzī, Introduction, 81. For an analysis of the last Galenic example, see Mc Donald, Concepts, 131–35.

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In the latter case, the imagination of the patient remained intact, but his faculty of judgment was altered; while in the former case, it is quite the opposite: the patient’s faculty of judgment remained intact, but his faculty of imagination was altered. The partial adaptation of earlier case histories from Greek authors or their total appropriation by the Arabic authors constitutes a further degree of endorsement for these authors. For example, in one extract from his treatise On Melancholy, Isḥāq ibn ʿImrān aims at presenting the psychological symptoms that are common to the various types of melancholy. Melancholy, according to the same author, mainly impairs the imagination, and, thus, it also impairs sensation. This passage is a long one, but merits full quotation: Their sensations (i.e. of melancholics) lead them to perceive things that do not exist. (1) For example, one of them saw in front of his eyes hideous, horrible, black and dusty forms. In a similar way, when he was suffering from this sickness, Diocles saw black men, who wanted to kill him, as well as clarinet and cymbal-players, who were playing and leaving dust in the corners of his house. (2) Some of them imagine that they did not have a head. We saw something of the sort close to the city of Kairouan. We burdened his head with a tiara, which we made of lead, and put it on his head in place of a helmet. Then he realised that he had a head. Similarly, Rufus, reported that he saw something of the same kind. (3) Some of them (i.e. melancholics) hear a sound similar to the murmur of water, of wind blowing and of storm, as well as terrifying voices in his ears, and a continuous humming, night and day. Out of these things, nothing is real, but they all correspond to false perceptions. (4) Some of them perceive putrid odours coming from everything, because their sense of smell is corrupted and because it has become defective (5) Some of them have an altered taste of delicious things, to the point that some of them do not enjoy any meal, nor any nourishment, because their sense of taste is corrupted, and because their healthy sense of taste has been altered. (6) Some of them think that their body is rougher than it is in fact. Some think that their body is made out of clay, as did al-Fāḫarānī who was affected by this disease. (7) Some also suffer from the corruption of their judgement and their imagination, such as that (patient) who avoided walking in the open air, because he feared that the sky would fall on him. He said that he believed that God who holds the sky could become weary and let it fall onto the world, thus destroying it. Similarly, many symptoms affect them, to the point that someone who considers the symptoms and observes the signs finds it

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hardly possible to determine them precisely, even if they applies intense attention to this research.27 Amongst the examples given by Isḥāq, only (1) and (2) derive from Greek sources, but all seven show a strong similarity with analogous ones mentioned by Greek sources.28 For example, in (6), Isḥāq mentions the case of a certain al-Fāḫarānī who thought that his body was made out of clay, a case that is similar to the one presented by Galen in the third book of the Affected Parts.29 As Klaus-Dietrich Fischer showed, this case history goes back to Rufus.30 Some Greek examples are also rhetorically adapted to the new context, as in the case of the God who carries the world (7). Thanks to Klaus-Dietrich Fischer, we know that this example also goes back to Rufus, who spoke about an astronomer who feared that the sky would fall on his head, because Atlas no longer carried the world on its shoulders.31 It goes without saying that in addition to these examples directly derived from the Greek sources, genuine case histories can also be found in Arabic sources. Our main source is al-Rāzī’s Book of Experiences, which contains over a thousand case histories. The ensuing case histories come from one of the book’s sections devoted to “melancholy and other forms of madness” (ǧunūn): (1) A young man who had melancholy presented. It was said that he plucked his beard, and amused himself with picking clay from the wall. He (al-Rāzī) ordered that he (the patient) be phlebotomised at the basilic vein, and blood be drawn, as long as it was black, until its colour changed to red. If it was not black, then one should stop immediately. Twice a month, he should be given the epithyme decoction to drink; his head should be submersed in violet oil; and he should be treated exceedingly well (. . .). (2) He ordered a man suffering from a bout of melancholy, (excessive) thinking, terror, and fear, to take the following: black myrobalan from Kabul, the weight of ten dirham; fresh, cooling epithyme, seven dirham; 27  Isḥāq Ibn ʿImrān, Melancholy, 49–51. 28  On passage (1), see Eijk, Ph. van der (2001). Diocles of Carystus, 224. and on (2), see Pormann, Rufus, 36. 29  Gal., De loc. aff. 3.10 (K. 8.190.1–10). 30  Fischer, K.-D. (2010). ‘De fragmentis Herae Cappadocis atque Rufi Ephesii hactenus ignotis’, Galenos, Rivista di Filologia dei Testi Medichi Antichi 4, 182. 31  Fischer, ‘De fragmentis’, 182. On this case, see the article by Mattern (Chapter Six), 203–223 in this volume.

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polypody, three dirham; cassidony, four dirham; and white raisin, the seeds of which have been removed, ten dirham. Macerate the myrobalan and the polypody in a sufficient quantity of water so as to submerge it, after having crushed it, for a day and a night. Pour it into a pot; boil it well, add the cassidony, then the raisins, and the epithyme decoction after having boiled it (i.e. the epithyme) in a sound fashion. Soak it and filter it (. . .). (3) He ordered a woman who spoke confusedly whilst laughing at the same time and was red in her face to have her median vein phlebotomised; [to take] the epithyme decoction; and the soporific drug. He said: “this is safe, because it eases the blood”. (4) A boy presented who was half mad, had a fixed glaze, did not speak nor answer when called upon. He was described as having been suffering from constipation for five days, and then having developed this condition. Moreover, he did not remain still in one place, but rather wandered about in the streets. His urine came out involuntarily each night. He ordered strong enemas for him, and to put wine vinegar, oil of roses, and rose water onto his head in a linen cloth.32 Of these four case histories, I would suggest that only the two first deal with patients al-Rāzī considered to be melancholics. Our first compelling evidence comes from the fact that only in those two cases are the patients called melancholics. Furthermore, only these two cases match al-Rāzī’s description of melancholy given above, and its distinction from madness. The second case matches perfectly the traditional symptoms of the kind of melancholy that is provoked by natural black bile, which is the only true meaning of melancholy according to al-Rāzī. It echoes the passage mentioned above, where worry and fear are the two main symptoms of melancholy. The third case is interesting because it also echoes the fact that in this same passage, disorderly speech is not considered a symptom of melancholy, but of madness. In the last case, speech is also impaired, an indication that those last two patients are deemed mad by al-Rāzī and not melancholics. These four cases can be compared to the only case-study found in the chapter on melancholy in al-Rāzī’s Comprehensive Book on Medicine: By me: melancholy can occur when the mixing of the humours is good. In this case, it does not require drugs at all. It occurs because (the melancholic) 32  Al-Rāzī (2006). Book of Experiences, 105–07 (trans. P. E. Pormann in Rufus, 295–96).

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has some peculiar idea. To cure this type (of melancholy), we have to make this idea disappear. There was a man who came to complain to me, and asked me to cure him from a (kind of) bile that he claimed to be melancholic. I asked him what were his symptoms and he said: “I think about God: where does He come from? How did He create the world?”. I told him that this was a widely spread idea amongst many clever people, and he was immediately cured. He incriminated his intellect so much that he was almost unable to take care of his interests any further. I cured many people by making their idea disappear.33 This passage presents us with a very clever melancholic, who matches the description in al-Rāzī’s distinction between madness and melancholia included in his chapter on madness. According to al-Rāzī, melancholy is primarily and, to an extent, exclusively a disease related to the cognitive faculty of judgement, whereas Isḥāq points that melancholy is also, and perhaps primarily, a disease of the imagination, especially in its second and most violent form (bestial madness). This strong opposition is illustrated by the examples and cases histories put forward by the two physicians. The fourth category of case histories deals with historical accounts of melancholics and madmen. Historical sources, such as biographical dictionaries and chronicles, have not yet been fully studied in the context of the social history of medicine of the Islamic Middle-Ages, despite the fact that they could potentially contribute a great deal to the history of the social representation of madness. In these historical sources, madness is often described as mental confusion (taġyīr ḏihn), and it is closely related to melancholy, or a type (ḍarb) of it. Alternatively, madness may be simply associated with the predominance (ġalb) of black bile (al-mirra al-saudāʾ). These sources focus on the psychological effects of melancholy. Even if the historical understanding of melancholy shares symptoms with its medical description, its scope is much wider. Melancholia is closely related to madness, and brings about sadness, anger, mental derangement to the point of incapacity, suicidal ideas, and death. Thus, melancholics tend to be described, at the pinnacle of their illness, as madmen. See for example, how Ibn Ḫallikān describes the case of al-Ḥasan, one of al-Ma⁠ʾmūn’s viziers: Al-Haṣan continued to act as vizier to al-Ma⁠ʾmūn until he had an attack of black bile (melancholy), caused by excessive grief on learning the murder of his brother Al-Faḍl (we shall narrate this event in the biography of the latter). His melancholy overcame him so far, that he had to be confined to 33  Al-Rāzī, The Comprehensive Book, 1.68.20–69.6; = (2013). 1.352.

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his house, and was unable to fulfil the duties of his office. “In the year 203 (818–19), says aṭ-Ṭabarī in his History, Al-Haṣan Ibn Sahl was overcome by black bile, occasioned by a fit of sickness; this sickness impaired his reason to such a degree, that it was necessary to chain him and confine him in a house. Al-Ma⁠ʾmūn then took for his vizier Aḥmad Ibn Abī Ḫālid.”34 In this story, as in many cases recalled by historical sources, one of the most important elements of the social understanding of mental illness is the fact that mental patients become unfit for the job they previously carried out. In fact, this is the main criterion that distinguishes melancholics from the melancholic madmen from a social perspective. Whereas melancholic madmen become incapable of fulfiling their duties, melancholics have not yet reached this stage, and might never do. This distinction features clearly in a story recalled by Abū Ḥanīfa and quoted by Dols. Three jurists try to evade their duties. The one who claims to be mad does succeed, whereas the one who claims to be melancholic is asked to resume his duty after following medical treatment.35 To sum things up, so far I have pointed out that melancholics are considered as individual cases by physicians, because of the wide range of symptoms they manifest. However, the Arab physician had also at their disposal an institution that had the potential to have dramatic affect on the role the patient play in his own therapy: the Islamic hospital.36 My third and final section focuses on the status and the treatment of the mentally ill in the Islamic hospital. 3

Mental Patients in the Islamic Hospital

Historians of medicine, starting with Michael Dols’ pioneering study of the insane in medieval Islamic society,37 have already emphasised the fact that mental patients were specifically cared for in Islamic hospitals (bīmāristānāt). Indeed, various testimonies attest to the presence of the mentally infirm in 34  Ibn Ḫallikān (1842–71). Biographies of illustrious men; trans. De Slane, vol. 1, 409 (with slight revisions). 35  Al-Huǧwirī (1911). Kašf al-maḥǧūb, trans. R. A. Nicholson, 93–94. Quoted in Dols, M. (1992). Majnūn. The Madman in Medieval Islamic Society, 446. 36  The origins of the hospital as a medical institution have been the focus of numerous studies. See, for instance, the entry ‘Hospital’, in Leven, K.-H. (2005). Antike Medizin. Ein Lexicon, 431–34. 37  Dols, Majnūn, 112–35.

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Islamic hospitals starting from the late ninth century onwards.38 This is also confirmed by material documentation. In an article based primarily on the architectural design of the hospitals, Patricia A. Baker argued that the barred windows overlooking the courtyard in the Arghun bīmāristān in Aleppo marked an important separation between the types of patients, and that they might have been designed to isolate the insane from the rest of the mentally ill. A similar description features in Ibn Ǧubayr’s account of the Nāṣirī hospital in Cairo.39 Although the presence of the insane in the Islamic hospital is well established, it does not necessarily follow that the mentally infirm were systematically brought in hospitals. Indeed, hospitals are mentioned in a small number of anecdotes included in historical sources, which involve mentally ill men and women. It is, of course, possible that many other mentally ill people would have been admitted to hospitals without being mentioned in our sources. Having said that, the cases where hospitals are indeed mentioned show us that even members of the elite could be treated in hospitals for mental illness, not simply the poor. Biographers do not seem to consider the presence of those elite mental patients in hospitals as an odd fact. For example, Ibn Ḫallikān reports the case of the twelfth century poet Šibl al-Daula⁠ʾ: Abū al-Haiǧāʾ (i.e. Šibl al-Daula⁠ʾ) remained but a short time in that city (Baghdad) and then proceeded to Transoxiana, and from there he returned to Ḫurāsān. Having stopped at Herat, he fell in love with a woman of that place and composed a number of poems in her praise. From there he moved to Marw, where he settled. Towards the end of his life, he fell into a melancholic madness and was transported to the hospital, where

38  Cf., for instance, Horden, P., ‘Religion as medicine: music in medieval hospitals’, in Horden, P. (2008). Hospitals and Healing from Late Antiquity to the Middle Ages, 140–43; Horden, P., ‘The late antique origin of the lunatic asylum’, in Rousseau, Ph. and Papoutsakis, M. (2009). Transformations of Late Antiquity: Essays for Peter Brown, 275–76; SavageSmith, E. and Pormann, P. E. (2007). Medieval Islamic Medicine, 98; and Pormann, P. E. ‘Islamic Hospitals in the Time of al-Muqtadir’, in Pormann, P. E. (2010). Islamic Medical and Scientific Tradition, 367. 39  Baker, P. A., ‘Medieval islamic hospitals: structural design and social perception’, in Baker, P. A., Nijdam, H. and Van’t Land, K. (2011). Medicine and Space. Body, Surroundings and Borders in Antiquity and the Middle Ages, 267. See also Tabaa, Y. ‘The functional aspects of medieval islamic hospitals’, in Bonner, M., Ener, M. and Singer, A. (2003). Poverty and Charity in Middle Eastern Contexts, 109–10.

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he died. This event took place on or about the year 505 (AD 1111–12). He ranked among the most accomplished literary scholars of the age.40 Two centuries after this event had taken place, the biographer Ibn Šākir al-Kutubī recalls the story of Ibn al-Ṯarda al-Wāʿiẓ, a preacher at the Umayyad mosque in Damascus who came from Baghdad. He suffered from a black humour that altered his state of mind and made him delirious. His melancholic state was severe enough to join the category of “the wise madmen” (“iltaḥaqa bi-ʿuqalāʾ al-maǧānīn”). He composed great poetry when in this state, and he accused everybody who tried to help him financially of having stolen his books. He died in the year 750 h. (1349) in the hospital Ibn Suwayd.41 As far as mental patients were concerned, it seems that Islamic hospitals were not only used to treat the insane, but also to confine them, as the story of the vizier al-Haṣan ibn Sahl quoted above clearly shows. In fact, the detaining of the mentally impaired in a hospital is attested very early on in Ibn al-Nadīm’s Fihrist, for example, by the 9th century historian al-Balādhūrī, who was restrained (shudda) in a hospital, where he also died.42 Furthermore, various testimonies recall the use of shackles for the insane in hospitals.43 Confinement was probably one of the purposes of the hospital, as far as the mentally ill were concerned, but it did not always induce physical violence. In the following passage, the fifteenth century Egyptian historian Ibn Iyās recalls the unfortunate way in which the governor of Jedda, Abū al-Fatḥ Manūfī, ended his life. After Abū al-Fatḥ had fallen into disgrace, says Ibn Iyās, he became the victim of so many ill behaviours on behalf of the sultan that he became mad, and was arrested in the year 1488. The sultan arrested Abū al-Fatḥ al-Manūfī, the governor of Jedda, and kept him in the Zimām barracks, when he (that is Abū al-Fatḥ) was struck by melancholy and by a bit of madness. Then, he rewarded Ǧāhīn al-Ǧamālī by appointing him as the new governor of Jedda in the place of Abū al-Fatḥ. The sultan ordered that he (Abū al-Fatḥ) should be transferred to the hospital. The reason was that once he was called upon by the sultan, he answered in a way that showed his mind was confused by the question the sultan had posed to him. First, (the sultan ordered) that he should be beaten with a stick. At that point, an emir interceded in his 40  Ibn Ḫallikān, Biographies; trans. De Slane, vol. 3, 413 (with slight modifications). 41  Ibn Šākir al-Kutubī (1974). The passing of the deceases, vol. 2, 463. 42  Ibn al-Nadīm (1872). Catalogue, 113, 6–7; as quoted in Pormann, ‘Hospitals’, 367. 43  Dols, Majnūn, 135.

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favour, and some direct witnesses certified that he was struck by melancholy. As a consequence, (the sultan) ordered that they should take him to the hospital. He was transferred there walking, bareheaded, and wearing a chain around his neck. (The sultan) ordered that they (the doctors) should place him with the insane, which they did. He stayed a few days in the hospital, then somebody intervened on his behalf, and he went back to the Zimām barracks, where he stayed in residency.44 Two places of confinement are mentioned in this passage: the barracks and the hospital, which seems to comprise a section devoted to the insane. Being considered mentally ill saved Abū al-Fatḥ from the beating, but his transfer to the hospital seemed as shameful as if he were brought into prison. By comparison, confinement in the barracks was deemed less harsh. The confinement of the mental patients in hospitals should not overshadow the therapeutic role of these hospitals. Al-Kaskarī, in his Compendium, mentioned his hospital experience as a criterion for the use of remedies against melancholic delusion.45 Islamic hospitals allowed an important epistemological change in the clinical approach to patients in general, and mental patients in particular. The accumulation of case histories from the Islamic hospitals helped Arab physicians improve the remedies they inherited from their Greek predecessors and attack more effectively both mental and physical illnesses. Precisely because many mentally ill people found themselves in these types of asylum, the Arab physicians were able to experiment systematically with alternative treatments. The best example is provided by Abū Bakr al-Rāzī in The Comprehensive Book. At one point of this treatise, Abu Bakr al-Rāzī attempts to study the effect of phlebotomy on patients suffering from φρενίτις (sirsām). He divided the patients into two groups: he treated the patients of the first group by bloodletting, while he intentionally left the other group alone. Then he noted the results his treatment had on each group of patients, and bolstered the conclusions he drew from his observations of the two groups.46 My point here is

44  Ibn Iyās (1960). The Most Beautiful Flowers on the Most Glorious Events, vol. 2, 251. 45  Al-Kaskarī, Compendium of Medicine, chap. 22, §13, ed. Pormann in ‘Theory and Practice’, p. 236, trans. p. 244. 46  Al-Rāzī, The Comprehensive Book, 15.121; Iskandar, A. (1962), ‘Al-Rāzī, the clinical physician’, Al-Mašriq 56, 238–39; trans. Pormann, Z. and P. E., 225–26. See also Pormann, P. E., ‘Medical methodology and hospital practice. The case of tenth-century Baghdad’, in Adamson, P. (2008). In the Age of al-Fārābī: Arabic Philosophy in the Fourth/Tenth Century, 109–11.

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not to claim that al-Rāzī anticipated experiments with placebo, but to highlight the role played by the Islamic hospitals in anticipating an avant-guard medical methodology, with which to confront mental illness, and which prioritised the role of patient. The wide range of symptoms presented by mental patients did not hold back the Arab physicians from experimenting with differential therapy. 4 Conclusion Both the more theoretical and the clinical sources show that the mentally infirm were indeed considered to be a specific category of patients by the Arab physicians. Furthermore, the same physicians strove to make distinctions between the various types of mentally ill patients. Presumably, the most challenging task for the Arab physicians was to examine the ways melancholy is related to madness, an association that was already attested in the Greek sources. Each of these famous physicians proceeded in his own way: al-Rāzī distinguished melancholy from madness, while others, such as Isḥāq ibn ʿImrān and al-Kaskarī, tried to differentiate between different types of madness. Although there is a discrepancy between theoretical and practical approaches to mental patients, case histories were heavily influenced by Greek sources, and they reflect, to the same extent, the distinctions made in those theoretical texts. Case histories along with the historical depictions of madness, as found in biographical dictionaries, provide us with an insight into the social representation of the mentally ill. In this paper, I focused primarily on the Islamic hospital, which we should regard as a specific feature of the social provision made for the clinically insane in medieval times, and as an element that is absent from the Galenic world. In the case of the Islamic hospitals, the role the individual patient played in the diagnosis and treatment of mental diseases, which both Greek and Arab physicians recognised, is linked directly to the collective identity of those patients as constructed by their case histories. Texts and Translations Used Al-Rāzī. Book of Experiences. Ed. Ḫālid Ḥarbī. Alexandria: Dār al-Wafā, 2006. ———. Introduction to the Art of Medicine. Ed. M. Concepción Vázquez de Benito. Salamanca: Ediciones Universidad de Salamanca, 1979. ———. The Comprehensive Book of Medicine. Ed. Hyderabad: Osmania Medical Publication, 1955–1985; new edition by Ḫ. Ḥarbī. Alexandria: Dār al-wafāʾ li-dunya al-ṭibāʿa wa al-našr, 2013.

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Galen. Opera omnia. Ed. C. G. Kühn. Leipzig: Prostat in officina libraria Car. Cnoblochii, 1821–33. Hippocrates. Œuvres complètes d’Hippocrate. Ed. É. Littré, vol. 1–10. Paris: Ballière, 1839– 61, reprint. Amsterdam, 1961–82. Ibn ʾAbī ʾUṣaybiʿa. History of physicians. Ed. A. Müller. Königsberg and Cairo: al-Matba’ah al-Wahbiyah, 1884. Ibn Ḫallikān. Biographies of illustrious men, trans. De Slane. Paris: Oriental Translation Fund of Great-Britain and Ireland, 1842–71. Ibn Iyās. The Most Beautiful Flowers on the Most Glorious Events. Cairo: Būlāq, 1960. Ibn al-Nadīm. Catalogue. Ed. G. Flügel. Leipzig: F. A. Brockhaus, 1872. Ibn Shāker al-Kutubī. The passing of the deceases. Beirut: Dār al-ṯaqāfa, 1974. Isḥāq ibn ʿImrān. On Melancholy. Ed. and trans. in French A. Omrani, Adel. Carthage: Beit al-Hikma, 2009.

References Álvarez-Millán, C. ‘Graeco-Roman Case Histories and their Influence on Medieval Islamic Clinical Accounts.’ SHM 12, (1999): 19–33. ———. ‘Practice versus Theory: Tenth-century Case Histories from the Islamic Middle East.’ in The Year 1000. Medical Practice at the End of the First Millenium, ed. P. Horden and E. Savage-Smith, 293–306, SHM 13.2. Oxford: Oxford University Press, 2000. ———. ‘The Case stories in Medieval Islamic Medical Literature: Taǧārib and Muǧarrabāt as Source.’ Medical History 54, (2010): 195–214. Baker, P. A. ‘Medieval Islamic Hospitals: Structural Design and Social Perception.’ in Medicine and Space. Body, Surroundings and Borders in Antiquity and the Middle Ages, ed. P. A. Baker, H. Nijdam and K. van’t Land, 245–72. Leiden: Brill, 2011. Daiber, H. ‘Abū Bakr al-Rāzī.’ in Philosophie in der Islamischen Welt, Band 1, 8–10. Jahrhundert, ed. U. Rudolph, 261–89. Basel: Schwabe Verlag, 2012. Dols, M. Majnūn. The Madman in Medieval Islamic Society. Oxford: Clarendon Press, 1992. Eijk, Ph. van der. Diocles of Carystus. Leiden: Brill, 2001. ———. ‘Aristotle on Melancholy.’ in Medicine and Philosophy in Classical Antiquity, ed. Ph. van der Eijk, 139–68. Cambridge: Cambridge University Press, 2005. Fischer, K.-D. ‘De Fragmentis Herae Cappadocis Atque Rufi Ephesii Hactenus Ignotis.’ Galenos, Rivista di Filologia dei Testi Medichi Antichi 4, (2010): 173–83. Flashar, H. Melancholie und Melancholiker in den medizinischen Theorien der Antike. Berlin: De Gruyter, 1966. Horden, P. ‘Religion as Medicine: Music in Medieval Hospitals.’ in Hospitals and Healing from Late Antiquity to the Middle Ages, ed. P. Horden, 140–43. Aldershot: Ashgate Variorum, 2008.

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———. ‘The Late Antique Origin of the Lunatic Asylum.’ in Transformations of Late Antiquity: Essays for Peter Brown, ed. Ph. Rousseau and M. Papoutsakis, 259–78. Farnham: Ashgate, 2009. Iskandar, A. Z. ‘Al-Rāzī, the Clinical Physician.’ Al-Mašriq 56, (1962): 217–82; trans. Z. and P. E. Pormann in Islamic Medical and Scientific Tradition, ed. P. E. Pormann, 207–53. London: Routledge, 2011. Klibansky, R., Panowsky, E. and Saxl, F. Saturne et la mélancolie: études historiques et philosophiques: nature, religion, médecine et art. Paris: Gallimard, 1989. Leven, K.-H. Antike Medizin. Ein Lexicon. Munich: C. H. Beck, 2005. Mc Donald, G. Concepts and Treatments of Phrenitis in Ancient Medicine, PhD. Diss. University of Newcastle, 2009. Manetti, D. and Roselli, A. (eds.) Ippocrate: Epidemie, libro sesto. Florence: La nuova Italia ed., 1982. Pigeaud, J. La maladie de l’âme: Études sur la relation de l’âme et du corps dans la tradition médico-philosophique antique. Paris: Les Belles Lettres, 1981. ———. Aristote. L’homme de génie et la mélancolie. Paris: Rivages, 1988. Pormann, P. E. ‘Theory and Practice in the Early Hospitals in Baghdad: al-Kaškarī on Rabies and Melancholy.’ Zeitschrift für Geschichte der Arabisch-Islamischen Wissenschaften 15, (2003): 197–248. ———. Rufus of Ephesus. On Melancholy. Tübingen: Mohr Siebeck Tübingen, 2008. ———. ‘Medical Methodology and Hospital Practice. The Case of Tenth-Century Baghdad.’ in In the Age of al-Fārābī: Arabic Philosophy in the Fourth/Tenth Century, ed. P. Adamson, 95–118. London: The Warburg Institute—Nino Aragno Editore, 2008. ———. ‘Al-Kaskarī (10th century) and the Quotations of Classical Authors. A Philological Study.’ in Sulla tradizione indiretta dei testi medici greci, Atti del II seminario internazionale di Siena, ed. I. Garofalo and A. Lami, 105–06. Rome-Pise: Fabrizio Serra editore, 2009. ———. ‘Islamic Hospitals in the Time of al-Muqtadir.’ in Abbasid Studies 2: Occasional Papers of the School of ‘Abbasid Studies, Leuven, 28 June–1 July 2004, ed. J. Nawas, 337–82. Leuven: Dudley, 2010; repr. in Islamic Medical and Scientific Tradition, ed. P. E. Pormann, 337–82. London: Routledge, 2010. ———. and Joose, P. ‘Commentaries on the Hippocratic Aphorisms in the Arabic Tradition: The Example of Melancholy.’ in Epidemics in Context: Greek Commentaries on Hippocrates in the Arabic Tradition, Scientia Graeco-Arabica, ed. P. E. Pormann, 211–49. Berlin and New York: De Gruyter, 2012. ———. and Savage-Smith, E. Medieval Islamic Medicine. Edinburgh: Edinburgh University Press, 2007.

Part 4 Emotional Aspects of the Patient-Physician Relation

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CHAPTER 8

Interpretations of the Healer’s Touch in the Hippocratic Corpus Jennifer Kosak This paper analyses gender as an aspect of the role of touch in the relationship between doctors and patients, as represented in the Hippocratic Corpus. Touch is an essential aspect of the ancient doctor’s art, but one potentially fraught with concerns over gender: while seeing, hearing, and smelling are also central to the medical encounter, touching is the act that places the greatest demands on the privacy and bodily integrity of the patient. This paper shows—perhaps counterintuitively—that, despite the multiple assertions of gender differences put forward by the authors of the Hippocratic Corpus, these authors make little distinction between touching male and female patients. At the same time, the paper argues that ancient physicians were anxious to avoid the charge that they were harming their patients when they touched them. It demonstrates that male doctors, sensitive as they were to the problems posed by their interactions with female patients, were challenged in different ways when engaging in intimate contact with male patients. The acts of seeing, listening, smelling, tasting and touching have long played essential roles in the encounter between doctors and their patients, but different cultures and historical periods use and privilege each of the five senses for medical purposes in distinctive ways. Thus, for example, Roy Porter describes how doctors in eighteenth century Europe relied heavily on patient reports of symptoms and visual cues to form their diagnoses; close, hands-on inspection of patients was considered unprofessional, an indication of incompetence or the mark of the surgeon.1 By contrast, in the nineteenth century, European physicians expected patients to “assume a corpse-like pose beneath the physician’s probing eyes, ears and fingers”.2 A patient in a modern Western clinic expects 1  Porter, R. ‘The rise of the physical examination’, in Porter, R. and Bynum, W. F. (1993). Medicine and the Five Senses, 182–85. 2  Leder, D. and Krucoff, M. (2008). ‘The touch that heals: The uses and meanings of touch in the clinical encounter’, The Journal of Alternative and Complementary Medicine 14.3, 322.

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the doctor to use a stethoscope to listen to his heartbeat or an otoscope to inspect her ears but would be very surprised if a doctor were to taste his urine or smell her hair, diagnostic activities that are recorded in the Hippocratic Corpus.3 Physicians in the ancient world made use of all their senses in their attempts to diagnose and treat patients, but, as with any medical tradition, the beliefs and expectations of the subculture of medicine itself, as well as the larger cultures within which medicine operated, influenced the ways in which the senses were employed by both doctor and patient. In this paper, I want to explore the use of one sense in particular, touch, in the context of early Greek medical practice. Sander Gilman has posited that touch is at once “the most complex and the most differentiated of the senses,” since it is a function embedded in the skin, itself a multifunctional tissue that encases the entire body.4 Touch, although particularly connected with the hands, is nonetheless mediated through all parts of the body. Moreover, Hans Jonas has argued that touch has a special status in the realm of the senses, in that it “is the sense, and the only sense, in which the perception of quality is normally blended with the experience of force”.5 Indeed, Drew Leder and Mitchell Krucoff, in their article on the use of touch in medicine, emphasise that touch is uniquely gestural (it both communicates and receives communication), impactful (it depends on physical contact) and reciprocal (“to touch another is, in turn, to be touched back”). As they point out, the intimacy of touch is “carefully regulated by social codes,” as humans learn to interpret and differentiate between the loving or hostile touch, the comforting or intrusive touch, the sexual or companionable touch, the investigatory or protective touch.6 Both patients and physicians need to learn the rules and significance of touch in the clinical setting; at the same time, the rules and significance of touch may change depending on the age, gender and social status of both patient and doctor. Touch, like any human activity, gains meaning from context.7 The clinical encounter changes over time as the needs and interests 3  For the tasting of patient’s effluvia, cf. Epidemics 4.43 (L. 5.184.9); for the smelling of the head, Mul. 3.219 (L. 8.422.23–424.13); smelling of the mouth, Mul. 2.146 (L. 8.322.12–13); Nat. Mul. 96 (L. 7.412.20–414.1–3). On the patients’ expectations in Western biomedicine, see also Baker (Chapter Fourteen), 365–389 in this volume. 4  Gilman, S. ‘Touch, sexuality and disease’, in Porter, R. and Bynum, W. F. (1993). Medicine and the Five Senses, 199. 5  Jonas, H. (2001). The Phenomenon of Life: Toward a Philosophical Biology, 147. 6  Leder and Krucoff, ‘The touch that heals’, 324. 7  Leder and Krucoff, ‘The touch that heals’, 325–26; cf. also Edwards, S. C. (1998). ‘An anthropological interpretation of nurses’ and patients’ perceptions of the use of space and touch’, Journal of Advanced Nursing 28.4, 809–17.

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of patients and doctors respond to cultural (and technological) developments, and the role of touch, “the healing hand,” is subject to constant negotiation and cultural reinterpretation.8 Despite the fact that, as Leder and Krucoff note, touch is reciprocal, the communication involved in touching between humans is often shaped by inequality: the person touching and the person touched hold different positions of power.9 The doctor is acknowledged to have information that the patient does not have.10 The doctor’s touch will allow the patient’s body to communicate what the patient himself cannot say or does not know. Furthermore, while the act of touching may provide comfort or even healing to the patient, it may also increase the patient’s pain (e.g. “does it hurt when I touch here?”). In allowing the healer to touch her body, the patient is assuming the healer’s intention is “to help or not to harm” (cf. Epidemics 1.11 (L. 2.634.8–636.1)). However, the idea that healers may harm patients through contact, unintentionally or even intentionally, is acknowledged in many works of the Hippocratic Corpus, such as the Hippocratic Oath, which lays emphasis on purity in action and intention on the part of the healer and prohibits sexual relations between healer and patient.11 Finally, while those who speak of touch in the clinical encounter 8  The essential connection between the hand as the instrument of touch and the medical art is well illustrated in the title chosen for the well-known history of hands-on medicine by Majno, G. (1975). The Healing Hand: Man and Wound in the Ancient World. 9  Ritual acts involving touch emphasise this power dynamic; for example, supplication often uses touch in its exploitation of power on the part of both suppliant and supplicated (cf. the foundational discussion of Gould, J. (1973). ‘Hiketeia’, JHS 93, 74–103 and the extensive study by Naiden, F. S. (2006). Ancient Supplication). The suppliant, unlike the healer, is the one who starts out by acknowledging his lack of power in the face of the superior power of the supplicated; but he also attempts to exert power by touching the supplicated. The healer reveals his power over the patient (and the disease) by touching him, but it is important to note that, in the Greek context (see further below) the healer’s touch is invited implicitly or explicitly by the fact that the patient has asked the healer for help. Nonetheless, in certain situations, hiketeia is closely linked to the notion of healing and healing by hand. In a temple healing context, the incubants are occasionally referred to as suppliants, cf. e.g. Philostr., VA 4.11. Petridou (Chapter Eighteen, 451–470 in this volume) examines an analogous scene, where an oneiric encounter between Asclepius and Aelius Aristides follows the ritual grammar of a supplication. 10  On the knowledge shared or not shared by healers and patients, see Holmes, B. (2010). The Symptom and the Subject: The Emergence of the Physical Body in Ancient Greece, esp. 118–19, 168–74. 11  On the purity of the healer, see Staden, H. von (1996). ‘In a pure and holy way: personal and professional conduct in the Hippocratic Oath’, Journal of the History of Medicine and Allied Sciences 51.4, 404–37.

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typically mean the touch of the healer carrying out his professional task, patients may also touch their healers—some scholars distinguish between the “expressive” touches of patients and “instrumental” or “procedural” touches of healers. Touch, then, is a powerful, though potentially unstable, element in the clinical encounter.12 This paper explores the use of touch in the Hippocratic Corpus in an effort to locate what kinds of touch were culturally acceptable in the healer-patient encounter in the Greek classical period.13 I begin with a brief overview of the use of touch throughout the Corpus, after which I turn to two particular, but related questions: first, I consider to what degree the gender of patient and care-giver may play a role in defining the boundaries of acceptable touch. Gender, after all, is an essential dividing line in so many areas of Greek life, even when the line is continually contested and blurred, and so it might seem natural that physical contact between healers and their patients would be similarly circumscribed by gender rules and expectations. Second, I ask whether the ancient ethical principle of ‘not to harm’ may lie behind the language used in certain Hippocratic treatises out of concern about the patients’ (and the onlookers’) interpretation of touch. Let us briefly survey some evidence in the Hippocratic Corpus for the touching of patients. These healers clearly touch their patients a lot, no matter what the gender or status of the patient. They touch bellies and other body parts to test out whether they are hard, soft, swollen or yielding or to predict what will happen inside the bowels; they touch humors and skin and limbs and pus to test for temperature, moisture, thickness and texture. Sometimes they probe and palpitate; other times they tap to hear the sound.14 Touching is also an important means of ensuring that patients are following the healer’s orders, according to a passage in Prorrhetics 2.3 (L. 9.12.14–15): “next, you are less likely to be deceived if you have touched the belly and vessels (of the patient) with 12  For more on the nuances of touch in care-giving relationships generally, see Peloquin, S. M. (1989). ‘Helping through touch: The embodiment of caring’, Journal of Religion and Health 28.4, 299–322. 13  The Hippocratic Corpus is a collection of treatises that have been dated mostly to the fifth and fourth centuries BC, with a few treatises dating later still. Despite the differences in approach, style and theoretical outlook that can be discerned among these treatises, I use them en bloc as evidence for ideas about medicine prevalent in fifth to early third century BC. 14  Testing the quality of the belly: Prorrh. 2.6 (L. 9.22.7); prediction: Prorrh. 2.23 (L. 9.52.24– 54.1–2), a prediction that diarrhea will cease enabled by touching; touching humors: Nat. Hom. 5 (L. 6.42.3–6); touching skin: Morb. 2.12 (L. 7.20.7–8); touching limbs: Morb. 1.29 (L. 6.198.14–17); touching pus: Morb. 2.47 (L. 7.70.20–22); Morb. 2.60 (L. 7.94.6–8); tapping: Morb. 2.36 (L. 7.52.16–17). All translations, unless otherwise stated, are mine.

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your hands than if you have not touched them” (ἔπειτα τῇσι χερσὶ ψαύσαντα τῆς γαστρός τε καὶ τῶν φλεβῶν ἧσσόν ἐστιν ἐξαπατᾶσθαι ἢ μὴ ψαύσαντα). Healers also employ touch to test out levels of pain, a usage particularly prevalent in the gynecological treatises, where the phrase ἀλγεῖ ψαυομένη (“she feels pain when being touched”) and variants thereof occur repeatedly;15 however, we do find generic (presumably male) patients being tested for pain in works such as Internal Affections.16 This form of touch yields up some precision in diagnosis: in Diseases 3.9 (L. 7.128.6–7), the author notes a distinctive feature of phrenitis: patients not only feel pain in their φρένες but they are unwilling to be touched there; likewise Diseases 2.72 (L. 7.110.1–4) mentions pain in the φρένες as a symptom of phrenitis, adding that this patient is afraid and flees both light and people—perhaps indicating fear of both sight and touch. Another unfortunate patient in Diseases 2.15 (L. 7.28.7), assaulted by violent pain in the head, actually feels pleasure when touched there. One intriguing passage in Diseases of Women notes a woman who “hits back and feels pain” if she is touched (καὶ ἢν ἐπαφήσῃ, ἀντιτυπέει καὶ ἀλγέει (2.177 = L. 8.360.7–8); it is unclear whether the pain derives from her own response to the doctor’s touch or the doctor’s touch itself. The treatise On Wounds in the Head presents a careful set of recommendations on touching for diagnostic purposes, VC 10 (L. 3.214.11–16): the author, arguing that touching or probing (μήλωσις) does not provide all the information about the nature of a head wound, urges the healer to get a full report from the patient on what he has experienced. Healers also provide therapy with touch, by anointing patients with oil or other skin treatments, by putting on bandages and wraps, by pressing down on wounds.17 Although the author of Breaths says that it is healers who suffer from “touching unpleasant things”, θιγγάνει τε ἀηδέων, Flat. 1 (L. 6.90.5),18 many passages in the Corpus indicate what must have been unpleasant, uncomfortable experiences for both healers and patients. And yet, there is little intimation of reticence in touching all parts of the body and all manner of bodily fluids, as multiple passages in treatises such as Fistulas and Hemorrhoids 15  So Mul. 1.61 (L. 8.124.21) and 64 (L. 8.130.24–132.1), Mul. 2.113 (L. 8.242.12); cf. Mul. 1.2 (L. 8.16.21), 1.36 (L. 8.86.4–5), 1.60 (L. 8.120.11); Mul. 2.112 (L. 8.240.7–8), 2.120 (L. 8.262.1–2), 2.122 (L. 8.266.1), 2.146 (L. 8.322.5–6), 2.154 (L. 8.330.2), 2.175 (L. 8.356.22); Nat. Mul. 35 (L. 7.378.4). 16  Int. 1 (L. 7.166.23), 27 (L. 7.236.15–16), 47 (L. 7.282.7); cf. also Epid. 2.2.24 (L. 5.96.1–2). 17  Cf. the discussion of ten cases of patient care drawn from the Hippocratic Corpus in Majno, The Healing Hand, 150–76. 18  This passage is quoted in Lucian (Bis Accusatus 1.35) who ascribes the words to the god Asclepius, as the divine healer complains that he is troubled by the sick.

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demonstrate. Furthermore, healers seem to have touched male and female patients without much differentiation in approach. Scholars have pointed to passages in the gynecological treatises where the women touch themselves, or assistants touch the women, or probes and specula are used in place of the healer’s hands and fingers, but these treatises also indicate that male healers did touch female patients directly.19 Indeed, as Helen King has stated with regard to nursing tasks, the healer had “a strong incentive for carrying them out himself”.20 The Hippocratic Corpus matches up well here with what Susan P. Mattern has observed regarding Galen, “there is little evidence of an ethic against touching certain parts of the patient, for example, genitals”.21 She also notes that Galen “recommends shielding from spectators the patient’s genitalia, anus and (for women) buttocks, chest and pubic region generally”;22 although I have not found this specific type of recommendation in the Hippocratic Corpus, the notion that sick people might wish to shield themselves can be seen in Sacred Disease 12 (L. 6.382.19–24), where the epileptic sufferer covers his head in shame.23 I cannot find evidence that the Hippocratic writers expected male sufferers would feel shame or even any particular reticence about ‘being touched’—anywhere. Nonetheless, the concern for the general comfort of the patient is widespread. The writers of the Hippocratic Corpus are attuned to the pain that their hands-on therapy can provide, although occasionally they express frustration with patients who fear the pain of the therapy more than they embrace 19  Self-touch by women: e.g., Mul. 1.40 (L. 8.98.1–2), Mul. 2.157 (L. 8.332.16–18); other women touch: e.g., Mul. 1.21 (L. 8.60.16–17), Epid. 5.25 (L. 5.224.11–13); probe: Superf. 29 (L. 8.496.5–11). 20  King, H. (1998). Hippocrates’ Woman: Reading the Female Body in Ancient Greece, 168; cf. also 165. The issue of male physicians’ treatment of female patients has been much discussed: cf., in addition to King’s work, e.g., Lloyd, G. E. R. (1983). Science, Folklore and Ideology, 69–76; Hanson, A. E. (1994). ‘A division of labor: roles for men in Greek and Roman births’, Thamyris 1, 157–202; Dean-Jones, L. (1994). Women’s Bodies in Classical Greek Medicine, 33–36; Totelin, L. (2009). Hippocratic Recipes: Oral and Written Transmission of Pharmocological Knowledge in Fifth- and Fourth-Century Greece, 248–57. 21  Mattern, S. P. (2008). Galen and the Rhetoric of Healing, 145. 22  Mattern, Rhetoric of Healing, 145. 23  The writer of Fractures expresses concern about the patient (or maybe the healer?) feeling shame if the legs come out at different lengths due to poor treatment (Fract. 19 = L. 3.482.9–10). The Hippocratic writers do take note of whether patients cover or uncover themselves in the course of disease, but their interest in this phenomenon seems more in the realm of patient comfort than patient shame: cf. Epid. 7.11 (L. 5.382.22–23), 7.25 (L. 5.396.21), 7.59 (L. 5.424.14), 7.83 (L. 5.440.5), 7.84 (L. 5.440.5–7), 7.85 (L. 5.444.8–9); Morb. 3.11 (L. 7.130.21); Int. 36 (L. 7.256.21–22).

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its potential benefits. The author of Joints is notable for his attention to the dispositions of both patients and healers, indicating common concerns about appearances and pain in the course of both injury and treatment. Let us look, for example, at his discussion of nose-breaks in Art. 35–37 (L. 4.158– 66). First, he criticises the practitioner who shows off his dexterity (εὐχειρίη) with fancy bandages, which look good but have little benefit and in fact grow annoying to the patient after a few days. In fact, the bandages turn out to be actively harmful because they place too much weight on the nose and end up distorting it (35). Instead of complex bandages, the author urges a small bandage or a paste made of flour (36). Then the author describes how to put the crushed nose back into a proper shape; most practitioners, he maintains, are too cautious in their approach: “for the healers are negligent (or are foolish) and first grasp [the nose] more gently than is necessary”, καταβλακεύουσιν οἱ ἰητροὶ, καὶ ἁπαλωτέρως τὸ πρῶτον ἅπτονται ἢ ὡς χρή, Art. 37 (L. 4.164.14–15). He recommends placing fingers inside (or outside) the nose and forcing (συναναγκάζειν) it into position from below. Furthermore, he states that the best person to do the shaping is actually the patient himself, “if he is willing to be both careful and daring”, εἰ ἐθέλοι καὶ μελετᾶν καὶ τολμᾶν, Art. 37 (L. 4.166.2). Another possibility, less optimal but still good, is to have a boy or a woman do it, because it is important that the hands are soft (μαλθακάς). The author concludes his remarks by asserting the feasibility of the procedure he has just proposed; the biggest obstacle, he remarks, is people’s inability to be both careful and courageous at once, Αrt. 37 (L. 4.166.12–15). Thus, he clearly recognises that the procedure is going to be painful, but that it has to be done carefully to get good results. He criticises both healers and patients here for squeamishness or daintiness in approach; at the same time, with his recom­mendation about soft hands, he acknowledges the importance of pain management. Indeed, perhaps not surprisingly, surgical treatises such as Fractures and Joints are particularly focused on regulating touch. Authorial tone is confident, stressing that holding, pressing and bandaging the different limbs and joints of the patient must be done ὀρθῶς, ἀξίως, and καλῶς (“properly”, “correctly”, “well”); other adverbs include μαλθακῶς and ἡσύχως (“softly”, “gently”). The treatises also urge the healer to act with moderation, μετριότης (and the adverb μετριῶς is common, too). Such terms align well with the rest of the Corpus, but the surgical treatises are somewhat unusual in their repeated use of the term δίκαιος (“just”). For example, in Fractures and Joints, both nature and the art of healing are referred to by this attribute. Fractures calls attention to its use of the term in its opening sentence: “it is necessary that the healer of dislocations and fractures make the extensions as straight

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as possible; for this is the most proper nature” (ἐχρῆν τὸν ἰητρὸν τῶν ἐκπτωσίων τε καὶ καταγμάτων ὡς ἰθυτάτα τὰς κατατάσιας ποιέεσθαι· αὕτη γὰρ ἡ δικαιοτάτη φύσις, Fract. 1 (L. 3.412.1–2). Yet another passage from Fractures develops a link between hands-on treatment and justice: οὗτος ὁ λόγος ὥσπερ νόμος κεῖται δίκαιος περὶ κατηγμάτων ἰήσιος, ὥστε χειρίζειν χρή, ὥς τε ἀποβαίνει ἀπὸ τῆς δικαίης χειρίξιος· ὅ τι δ’ ἂν μὴ οὕτως ἀποβαίνῃ, εἰδέναι χρὴ ὅτι ἐν τῇ χειρίξει τι ἐνδεὲς πεποίηται, ἢ πεπλεόνασται, Fract. 7 (L. 3.442.1–4). This discourse is laid down as the proper (δίκαιος) rule concerning the healing of fractures, how it is necessary to handle them and how they turn out from the proper handling; but if anything does not work out this way, it is necessary to understand that some deficiency has occurred in the handling or something excessive has been done. In the course of discussing the treatment of club feet, another passage drawn from the surgical treatises emphasises the justice of nature itself: ἁπλῷ δὲ λόγῳ, ὥσπερ κηροπλαστέοντα, χρὴ ἐς τὴν φύσιν τὴν δικαίην ἄγειν καὶ τὰ ἐκκεκλιμένα καὶ τὰ συντεταμένα παρὰ τὴν φύσιν, καὶ τῇσι χερσὶν οὕτω διορθοῦντα, καὶ τῇ ἐπιδέσει ὡσαύτως, προσάγειν δὲ οὐ βιαίως, ἀλλὰ παρηγορικῶς, Art. 62 (L. 4.266.13–17). Put simply, just as in modeling wax, it is necessary to bring the twisted part and the parts contracted against nature into their proper (δικαίην) nature, both having straightened them out thus with the hands and by means of bandaging in a similar way, and to lead them in the right direction not by force but by gentleness. This passage presents a complex entanglement of nature and culture; the analogy established is with wax-modeling (which is rather odd, since wax surely has no naturally defined shape), and yet the healer is urged to sculpt or mold the limbs into the correct, proper or just position, already existing in nature and to do so gently (παρηγορικῶς). To be sure, dikē and related words appear in a number of other treatises in the Hippocratic Corpus, too, including the gynecological treatises, where the phrase κατά γε δίκην occurs twice, indicating how things normally occur;24 a similar phrase, κατά γε τὸ σύμφυτον καὶ τὸ δίκαιον 24  Mul. 1.41 (L. 8.98.15), Mul.1.61 (L. 8.124.3).

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(“at least in accordance with the natural and the just”) also appears twice.25 However, Fractures and Joints use the word most emphatically and repeatedly. Such emphasis, it seems to me, may indicate a concern to avoid claims that the healer is intentionally harming the patient. Thus, we should note the focus not only on justice but also on gentleness in the passage quoted above from Joints 62. Indeed, gentleness and moderation are a common preoccupation in the Hippocratic treatises—as Aphorisms 2.51. (L. 4.484.11.) says, πᾶν τὸ πολὺ τῇ φύσει πολέμιον (“all excess is inimical to nature”)—and there are only rare cases in which the surgical treatises actually recommend a violent treatment.26 So, for example, the author of Fractures discusses how the backward dislocation of the humerus, deemed “the most painful dislocation of all” and potentially fatal in a few days, should be treated with violence if the healer is there right away: ἢν μὲν οὖν αὐτίκα παρατύχῃς, βιάσασθαι χρὴ ἐκτανύσαντα τὸν ἀγκῶνα, καὶ αὐτομάτως ἐμπίπτει. ἢν δέ σε φθάσῃ πυρετήνας, οὐχ ἔτι χρὴ ἐμβάλλειν· κατατείνειε γὰρ ἂν ἡ ὀδύνη ἀναγκαζομένου, Fract. 43 (L. 3.554.9–12). If you happen to be present right away, you should force the elbow into extension, and it falls into place of its own accord. But if he has already become feverish when you get there, you should no longer reduce; for the pain of being forced would kill him. Thus, even in a situation where forceful treatment is indicated, the author recommends caution. Similarly, when discussing improper treatment of an arm, the author of this treatise warns against adding more pain that would be greater than the trauma itself: “if having bound it, he intends the arm to be in this position, he would apply much additional pain, greater than the injury”, εἰ ἐπιδήσας ἔχειν τὴν χεῖρα οὕτως ἔμελλε, πόνους ἂν ἄλλους πολλοὺς προσέτιθει μείζονας τοῦ τρώματος, Fract. 2 (L. 3.422.5–6).27 The concern to avoid causing 25  Mul. 3.217 (L. 8.418.10–11), Superf. 29 (L. 8.494.13). 26  Jacques Jouanna (1992. Hippocrates, 131) suggests that gentleness in treatment is one of the three defining characteristics of the Hippocratic orientation towards patients, the other two being “courtesy toward the patient, and conversation with the patient”. Thus, in some of our earliest texts, we read of the ἤπια φάρμακα of the Greeks (e.g. Hom., Il. 4.218, 11.515; Solon fr. 13.60; Hdt. 3.130.10–11). 27  Cf. also Physician 8 (L. 9.214.18–20) regarding phlebotomy: δοκεῖ δὴ δύο βλάβας φέρειν ἡ τοιαύτη χειρουργίη, τῷ μὲν τμηθέντι πόνον, τῷ δὲ τέμνοντι πολλὴν ἀδοξίην (“indeed such handwork seems to bring two harms, distress for the one who has been cut and much disrepute for the one cutting”).

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pain or harm, although found throughout the Hippocratic Corpus, is repeatedly addressed in these surgical treatises. For an even more explicit discussion of the healer’s ethics of touching, let us turn to the remarks of one of the later treatises included in the Hippocratic Corpus, Physician:28 δίκαιον δὲ πρὸς πᾶσαν ὁμιλίην εἶναι· χρὴ γὰρ πολλὰ ἐπικουρέειν δικαιοσύνην· πρὸς δὲ ἰητρὸν οὐ μικρὰ συναλλάγματα τοῖσι νοσοῦσίν ἐστιν· καὶ γὰρ αὐτοὺς ὑποχειρίους ποιέουσι τοῖς ἰητροῖς, καὶ πᾶσαν ὥρην ἐντυγχάνουσι γυναιξὶv, παρθένοις καὶ τοῖς ἀξίοις πλείστου κτήμασιν· ἐγκρατέως οὖν δεῖ πρὸς ἅπαντα ἔχειν ταῦτα, Medic. 1 (L. 9.206.4–9). [The physician must] be just in every social interaction; for it is necessary in every way that justice helps; and the contracts between the sick and the healer are not small; for the sick place themselves under the hands of the healers, and healers at every time of day encounter women, girls and possessions of great value; therefore they must act with self-control towards all these things. Here, in words that recall the link between justice and healing noted in the passages from Joints and Fractures, we see that the writer urges the healer to practice justice (δικαιοσυνήν) in dealing with his patients, for, he says, “the contracts (συναλλάγματα) between healer and sick people are not small (οὐ μικρά)” and patients “put themselves under the hands (ὑποχειρίους) of the healers”; and, he adds, healers regularly encounter women, young girls and valuable possessions. In his edition of the text, Potter translates συναλλάγματα as “intimacy”, which seems appropriate to the contexts of bodily contact, females, and possessions.29 These situations, says the author, demand that the healer behave with self-control (ἐγκρατέως). The words of the treatise attest to the tremendous delicacy of the healerpatient relationship, with particular reference to the issue of touch. While seeing, hearing, and smelling are also essential to a healer’s art, touching is, 28  Jouanna, Hippocrates, 373–416, provides the scholarly consensus on dates of Hippocratic treatises in a useful appendix; he dates Physician to the “Hellenistic era or beginning of the Christian era”, but notes that “its code of ethics corresponds to that of the oldest treatises” (404). 29  Potter, P. (1995). Hippocrates, Loeb Classical Library 482, 303; Littré (9.207) translates the word as rapports (“ce ne sont pas de petits rapports que ceux du médecin avec les maladies”).

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as noted above, the act that places the greatest demands on the privacy and bodily integrity of the patient. The word ὑποχείριος, used by the writer to describe the hands-on nature of the relationship, draws attention to the power dynamics in play, as well; with a couple of exceptions (such as Odyssey 15.448, where it means “available” or “at hand”), the adjective refers to the submission of one person or group to another, most commonly used in cases of surrender or even enslavement in war; in the Attic orators, it can also describe the arrest or capture of a someone accused of committing injustice.30 The word in the passage from the Physician communicates both the literal action of touching and the loss of power that accompanies someone suffering from a disease. The healers of antiquity recognise the power they have over their weakened patients, and furthermore, they recognise their own status as both servants and masters of the art. As Susan P. Mattern has discussed with regard to Galen, the actions of the healer place him on the level both of household slaves and of the master of the house.31 The writers of the Hippocratic treatises do urge one another to behave respectfully towards their patients, and the author of Physician emphasises the proper treatment of women, girls and possessions within the intimate sphere of the household examination. Furthermore, while, as noted above, they have few qualms about touching their patients, male or female, slave or free, they give plenty of advice about what kinds of touches to give. Such confidence may have been bolstered by the open nature of ancient medical practice: healers in classical antiquity were rarely alone with their patients, but instead practiced their craft in a ‘crowded room’, observed by family members, friends, attendants, neighbors and occasional bystanders (a point to which I shall return below).32 Evidence from Greek tragedy and other literature shows the importance of gender, kinship and social standing when it comes to the rules of physical contact: thus, family members may touch each other, but unrelated persons need to establish their status vis-à-vis each other before touching can occur. Other social norms govern the situations under which male-male bodily contact is acceptable (e.g. the palaistra).33 Perhaps it is the case that, as in the sports 30  LSJ s.v. ὑποχείριος. 31  Mattern, Rhetoric of Healing, 146. 32  On the public nature of medical practice and the concept of the crowded room, see, for example, Jouanna, Hippocrates, 75–100; King, Hippocrates’ Woman, 164–167, and Mattern, The Rhetoric of Healing, practically passim, indicating the significance of this issue for Galen and the medicine of his day. 33  For the theoretical background on cultural codes and bodily interaction, see Bourdieu, P. (1977). Outline of a Theory of Practice, 72–95. On rules of male homosocial interactions

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arena, the codes are long-established and clear. There are at least two essential pieces to the code of physical contact in healing contexts, as evidence from some of the earliest Greek literature suggests. First, the healer must be summoned. So for example, despite the fact that Fractures 42 mentions a quick arrival on the part of the healer, it is nonetheless unlikely that he typically just appears without being asked—healers need to be called for (κλητοί), as a passage from the Odyssey demonstrates: τίς γὰρ δὴ ξεῖνον καλεῖ ἄλλοθεν αὐτὸς ἐπελθὼν ἄλλον γ᾽, εἰ μὴ τῶν οἳ δημιοεργοὶ ἔασι, μάντιν ἢ ἰητῆρα κακῶν ἢ τέκτονα δούρων, ἢ καὶ θέσπιν ἀοιδόν, ὅ κεν τέρπῃσιν ἀείδων; οὗτοι γὰρ κλητοί γε βροτῶν ἐπ᾽ ἀπείρονα γαῖαν· (Hom., Od. 17. 382–86) For who goes himself and summons a stranger from another place, unless he is one of those who are workers for the people, a prophet or a healer of ills or a fashioner of wood (builder) or a divine singer, who delights with singing? For these people are summoned among mortals across the boundless earth. The Odyssey accentuates the desirability of healers and other skilled workers to the detriment of beggars, whom no one invites and who are indeed unwelcome in anyone’s home (even if custom demands their proper treatment). In contrast to beggars, healers are summoned—indeed, the passage states that a person would even “go himself” to bring in a healer from elsewhere. Thus, to gain access to a patient’s body required an invitation, one that a man could issue on his own behalf or on behalf of a member of his household. Women, it seems likely, would not have summoned a healer without at least the tacit permission of a male guardian. The second part of the healer’s code seems clear from a passage in Solon: healers touch. When Solon writes about healers, he mentions the healing touch of the hand as the most successful aspect of the art: πολλάκι δ’ ἐξ ὀλίγης ὀδύνης μέγα γίγνεται ἄλγος, κοὐκ ἄν τις λύσαιτ’ ἤπια φάρμακα δούς· τὸν δὲ κακαῖς νούσοισι κυκώμενον ἀργαλέαις τε ἁψάμενος χειροῖν αἶψα τίθησ’ ὑγιῆ. (Solon, fr. 13, 59–62 West) as displayed in literature, see Sedgwick, E. K. (1985). Between Men: English Literature and Male Homosocial Desire. For a study of touch between men in Greek literature, see Kosak, J. C. (1999). ‘Therapeutic touch and Sophokles’ Philoktetes’, HSCP 99, 93–134.

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Often from a small pain great pain arises, and someone could not relieve it having given soothing drugs: but the person distressed by evil and painful diseases, having touched him with his hands he [the healer] straightaway makes healthy. In this passage, we see that the “soothing drugs” (ἤπια φάρμακα) are less effective than the quick touch of the healer’s hands.34 The code as established outside the medical texts thus indicates that, once called, the healer may use his hands to touch the patient.35 It is therefore understood that the sick person will be touched, once the healer is summoned. And such touch, although compulsory, is understood to be helpful, not offensive. The author of The Art provides a parallel to this idea in his description of medicine as an art form that compels nature to respond, by force but without incurring a penalty. He writes that when the patient’s symptoms do not provide clear information to the healer, the art of medicine still has found a way: “When nature herself is unwilling to release these revelations, [medicine] has discovered ways of compulsion by which nature without penalty is compelled to give (the information) up”, ὅταν δὲ ταῦτα τὰ μηνύοντα μηδ’ αὐτὴ ἡ φύσις ἑκοῦσα ἀφίῃ, ἀνάγκας εὕρηκεν ᾗσιν ἡ φύσις ἀζήμιος βιασθεῖσα μεθίησιν, de Arte 12 (L. 6.24.7–9).36 But did the invitation to heal mean that access to the body had no further limits, other than prohibitions against sexual interactions such as the kind mentioned in the Hippocratic Oath? In Athenian law, for example, the body of the citizen is sacrosanct, as a passage in Demosthenes indicates: καὶ μὴν εἰ θέλετε σκέψασθαι τί δοῦλον ἢ ἐλεύθερον εἶναι διαφέρει, τοῦτο μέγιστον ἂν εὕροιτε, ὅτι τοῖς μὲν δούλοις τὸ σῶμα τῶν ἀδικημάτων ἁπάντων ὑπεύθυνόν ἐστιν, τοῖς δ᾽ ἐλευθέροις, κἂν τὰ μέγιστ᾽ ἀτυχῶσιν, τοῦτό γ᾽ ἔνεστι σῶσαι. (D. 22.55) Indeed, if you wish to consider what distinguishes the slave and the freeman, you would find this is the most important thing, that for slaves the

34  On the hand as an important part of the healer’s craft, see Cambiano, G. ‘Le médecin, la main et l’artisan’, in Joly, R. (1977). Corpus Hippocraticum, 220–32. 35  For a study demonstrating the significance of the trope of the healing touch in Greek tragedy, see Marchant-Louët, I. (2009). ‘Les gestes des malades dans le théâtre d’ Euripide: l’ exemple de l’ Oreste’, Bulletin de l’Association Guillaume Budé 2, 92–109. 36  In his commentary on the treastise, Jouanna (ad loc. n. 5) notes the judicial language prevalent in this chapter and the contrast made between slaves who are compelled to testify by torture and citizens who give oaths.

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body is liable for all their offences, while for freemen, even they are most unfortunate, it is possible to protect [their bodies]. Various Athenian laws govern the violation of the body through unacceptable physical contact (i.e. the δίκη αἰκείας, the law governing assault and battery without the intention to dishonor, and the γραφὴ ὕβρεως, the law governing assaults with intent to humiliate or dishonor); yet another law is the γραφὴ τραύματος ἐκ προνοίας, which governs intentional wounding of another’s body with an instrument in non-combat situations.37 But the codes of medical practice were established through persuasion, repetition, tradition and performance: there were neither agencies that established official medical credentials nor any formal malpractice laws governing the practice of medicine in Greek society in the classical period.38 The healer established his own bona fides through his work (though in any given case, additional factors, such as the teacher that he had and the theoretical orientation he espoused, could also play a role in the process), and his concern for his reputation and his eagerness to avoid blame are well known.39 Thus, it seems possible that the concern to establish the justness of the healer’s behavior is particularly acute when it comes to the area of touch, an area governed by a variety of laws outside medicine. And it may be even more acute in situations when the patient has already suffered trauma, as is the case in the surgical treatises. It may also be significant that the surgical treatises feature on-lookers who are called upon to assist and elaborate instruments (such as the Hippocratic bench).40 The work described in these treatises seems especially public. Perhaps a healer might be concerned to make sure his own work with instruments on another person’s 37  For the distinctions among these laws, see Phillips, D. D. (2007). ‘Trauma ek pronoias in Athenian law’, JHS 127, 74–105. 38  The question of laws governing medical malpractice per se is complex; for a discussion that argues that physicians could be subject to the Athenian laws on homicide and assault, see Amundsen, D. (1977). ‘The liability of the physician in classical Greek legal theory and practice’, Journal of the History of Medicine and Allied Sciences 32.2, 172–203. 39  Cf. the overview of this issue in Jouanna, Hippocrates, ch. 5. 40  For apparent bystanders who are asked to help out, cf. Fract. 8 (L. 3.444.16–17) τῶν ἀνδρῶν ὄστις ἐρρωμένος [. . .] καταναγκαζέτω; Fract. 13 (L. 3.462.4–5) and 15 (L. 3.470.10–11), where two men are enlisted to help out with holding and extending the patient’s limbs or helping hold him in a particular contraption; cf. Art. 43 (L. 4.186.5–8), but also note Art. 47 (L. 4.206.6–7), where the writer mentions that the assistant should be “not untrained” (μὴ ἀμαθής). For the Hippocratic Bench, see Fract. 13 (L. 3.460–66) and Art. 72 (L. 4.296–300). For susceptibility (and resistance) to public pressure, see e.g. Fract. 16 (L. 3.476.8–10) and Art. 1 (L. 4.78.9–80.1).

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body in a non-combat situation open to public view was clearly marked as just and appropriate, intended to help and not to harm. In conclusion, there is not much evidence in the Hippocratic Corpus for significant gender differences in expectations on the part of either the healer or the patient regarding physical contact, even if the writers voice special concerns about avoiding sexual intimacy with female patients. Indeed, although the writers of the Hippocratic Corpus certainly differentiate between male and female physiologies, at the same time they assimilate sick men to women: they considered disease to be caused by excess, and not only is excess pathological, it is also typically female. Thus, healers whose ideas are represented in the Hippocratic Corpus develop cures based on female models of excess: balance is male, lack of balance is female, and the methods to restore balance are influenced by or even derived from the model of the female, whom nature regulates through monthly purging. That is, the bodies of men who are sick cannot successfully perform their masculine roles, and as sick people they are treated to some extent as females. This is even true in cases of traumatic injury, where the individual physiology of a given male patient cannot be faulted, at least initially. At the same time, it is precisely in the treatises dealing with traumatic injuries that we see the language of proper conduct appearing most conspicuously, and although women, too, may be subject to such traumatic injuries, it is injured men that the healers are most concerned about when it comes to justice. I suggest that the anxiety, hinted at from time to time throughout the Hippocratic Corpus, about healers being blamed for hurting their patients and thus being potentially liable to legal sanctions may be at work here. The trauma of the injury and the potential trauma of the treatment itself are not, the healers seem to be saying, the same. Healers, they insist, are asked to treat their patients; and once asked, they take on a position of power, which, they hasten to assure their patients, they shall not abuse. Texts and Translations Used Hippocrates. Œuvres complètes d’Hippocrate. Ed. Littré, É., vol. 1–10. Paris: Ballière, 1839–61, reprint. Amsterdam: A. Hakkert, 1961–82. ———. Aphorisms. (Aph.). Ed. W. S. Jones. The Loeb Classical Library 150. Cambridge, MA: Harvard University Press, 1953. ———. De l’art. (de Arte). Ed. J. Jouanna. Collection des Universités de France, Tome 5.1, 165–280. Paris: Les Belles Lettres, 1988. ———. Barrenness. (Mul. 3). Ed. P. Potter. The Loeb Classical Library 520. Cambridge, MA: Harvard University Press, 2012.

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———. Diseases 1. (Morb. 1). Ed. P. Potter. The Loeb Classical Library 472. Cambridge, MA: Harvard University Press, 1988. ———. Diseases 3. (Morb. 3). Ed. P. Potter. The Loeb Classical Library 473. Cambridge, MA: Harvard University Press, 1988. ———. Epidemics 1. (Epid. 1). Ed. W. S. Jones. The Loeb Classical Library 147. Cambridge, MA: Harvard University Press, 1948. ———. Epidemics 2. (Epid. 2). Ed. W. D. Smith. The Loeb Classical Library 477. Cambridge, MA: Harvard University Press, 1994. ———. Epidemics 4. (Epid. 4). Ed. W. D. Smith. The Loeb Classical Library 477. Cambridge, MA: Harvard University Press, 1994. ———. Epidemics 5. (Epid. 5). Ed. W. D. Smith. The Loeb Classical Library 477. Cambridge, MA: Harvard University Press, 1994. ———. Epidemics 7. (Epid. 7). Ed. W. D. Smith. The Loeb Classical Library 477. Cambridge, MA: Harvard University Press, 1994. ———. On Fractures. (Fract.). Ed. E. T. Withington. The Loeb Classical Library 149. Cambridge, MA: Harvard University Press, 1948. ———. Internal Affections. (Int.). Ed. P. Potter. The Loeb Classical Library 473. Cambridge, MA: Harvard University Press, 1998. ———. On Joints. (Art.). Ed. E. T. Withington. The Loeb Classical Library 149. Cambridge, MA: Harvard University Press, 1948. ———. La maladie sacrée. (Morb. Sacr.). Ed. J. Jouanna. Collection des Universités de France, Tome 2.3. Paris: Les Belles Lettres, 2003. ———. Maladies 2. (Morb. 2). Ed. J. Jouanna. Collection des Universités de France, Tome 10.2. Paris: Les Belles Lettres, 1983. ———. Les Maladies des Femmes 1. (Mul. 1). Ed. É. Littré. Oeuvres complètes d’ Hippocrate, Tome 8. Paris: Ballière, 1853, repr. Amsterdam: Hakkert, 1962. ———. Les Maladies des Femmes 2. (Mul. 2). Ed. É. Littré. Oeuvres complètes d’ Hippocrate, Tome 8. Paris: Ballière, 1853, repr. Amsterdam: Hakkert, 1962. ———. Nature of Women. (Nat. Mul.). Ed. P. Potter. The Loeb Classical Library 520. Cambridge, MA: Harvard University Press, 2012. ———. Physician. (Medic.). Ed. P. Potter. The Loeb Classical Library 482. Cambridge, MA: Harvard University Press, 1995. ———. Prorrhetics 2. (Prorrh. 2). Ed. P. Potter. The Loeb Classical Library 482. Cambridge, MA: Harvard University Press, 1995. ———. The Sacred Disease. (Morb. Sacr.) Ed. W. H. S. Jones. The Loeb Classical Library 148. Cambridge, MA: Harvard University Press, 1952. ———. Superfetation. (Superf.) Ed. P. Potter. The Loeb Classical Library 509. Cambridge, MA: Harvard University Press, 2010. ———. Des vents. (Flat.) Ed. J. Jouanna. Collection des Universités de France, Tome 5.1. Paris: Les Belles Lettres, 1988.

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———. On Wounds in the Head. (VC). Ed. E. T. Withington. The Loeb Classical Library 149. Cambridge, MA: Harvard University Press, 1948. Iambi et Elegi Graeci, vol 2. Ed. M. L. West. Oxford: Oxford University Press, 1972.

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Marchant-Louët, I. ‘Les gestes des malades dans le théâtre d’ Euripide: l’ exemple de l’ Oreste.’ Bulletin de l’Association Guillaume Budé 2, (2009): 92–109. Mattern, S. P. Galen and the Rhetoric of Healing. Baltimore, MD: Johns Hopkins University Press, 2008. Naiden, F. S. Ancient Supplication. Oxford: Oxford University Press, 2006. Peloquin, S. M. ‘Helping through Touch: The Embodiment of Caring.’ Journal of Religion and Health 28.4, (1989): 299–322. Phillips, D. D. ‘Trauma ek pronoias in Athenian Law.’ Journal of Hellenic Studies 127, (2007): 74–105. Porter, R. ‘The rise of the physical examination.’ in Medicine and the Five Senses, ed. R. Porter and W. F. Bynum, 179–97. Cambridge: Cambridge University Press, 1993. Sedgwick, E. K. Between Men: English Literature and Male Homosocial Desire. New York: Columbia University Press, 1985. Staden, H. von. ‘In a Pure and Holy Way: Personal and Professional Conduct in the Hippocratic Oath.’ Journal of the History of Medicine and allied Sciences 51.4, (1996): 404–37. Totelin, L. Hippocratic Recipes: Oral and Written Transmission of Pharmacological Knowledge in Fifth- and Fourth-Century Greece. Leiden: Brill, 2009.

CHAPTER 9

Patience for the Little Patient: The Infant in Soranus’ Gynaecia Lesley Bolton Despite advocating perpetual virginity and viewing childbirth as inherently injurious to female health, Soranus’ attitude towards the infant in Book 2 of the Gynaecia is remarkably positive. In fact, it is only towards the infant that Soranus displays such consistently positive attitude. This compassionate approach is evident both in the content and the language employed, which is characterised by a striking occurrence of diminutives. His preference here for authorities such as Thracians and Scythians rather than illustrious ones, along with his ‘language of the nursery’, points to an oral, rather than literary, tradition. Soranus seems to have been the first to write so extensively on childcare; freed from the influence of any earlier tradition, he engaged in a more nuanced vision of childhood, seeing it as a ‘blank slate’ both physically and mentally, untouched by the faults of adulthood. While the content of Book 2 has been mined for information concerning the practicalities of child-care, it has not been evaluated in terms of its differences from the rest of the Gynaecia, which are significant. 1 Introduction Pregnancy is unhealthy; it brings atrophy, atony and untimely old-age to child bearers. So Soranus would have us believe, according to the Gynaecia.1 In fact, he observes, were childbearing not necessary for the continuity of the human race, perpetual virginity would be better, both for men and for women.2 So perhaps, one might think, it would be with some reluctance that Soranus devotes almost a third of the Gynaecia to the delivery and subsequent care of infants, and that the account would be tinged by, at best, some ambivalence towards *  All translations of Greek and Latin texts are my own. 1  Sor., Gyn. 1.42.5. 2  Ibid., 1.32.3.

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this health-destroying individual. I will argue here, however, that Soranus is remarkably and consistently positive in his attitude towards the infant; furthermore, I will suggest that this positive representation is exceptional in two respects: firstly, within the Gynaecia itself, in that we encounter this positive attitude only in relation to the infant; and secondly, in the larger context, that this depiction is unlike that of any other author. 2

Contraception, Miscarriage, Abortion and Infanticide

Soranus is certainly a keen advocate of contraception; better, he says, not to conceive in the first place than to resort to drastic measures later.3 On the matter of abortion, Soranus is quite clear, allying himself with those who do indeed proscribe abortifacients, but only with discrimination; that is, not to those desiring an abortion because of adultery or vanity, but only to those who would be endangered by the birthing process.4 As soon as conception is confirmed, Soranus advocates every measure should be taken to preserve what 3  Ibid., 1.61.1. Contraceptives include barrier and rhythm methods, a form of withdrawal method in which the woman pulls back at the time of ejaculation, and vaginal pessaries composed of materia medica with contracting, cooling and styptic properties. 4  Ibid., 1.60.2. Soranus notes the discord between those who reject the use of abortifacients, citing Hippocratic injunctions, and those who prescribe them with discrimination; we have no means of identifying these opposing groups. While the Hippocratic Oath forbids the physician from giving an abortive pessary, the treatise Diseases of Women (Mul. 1.78) includes a number of recipes for expellant drinks, salves and fumigants, in addition to expellant pessaries; most are specifically aimed at driving out a dead or seriously maimed foetus, but some cases are less clear; for example, χαλβάνην ὅσον ἐλαίην τρίψας ἐν κεδρίνῳ ἐλαίῳ προσθέσθω· τοῦτο δύναται διαφθείρειν καὶ ἐκβάλλειν τὸ νωχελές (L. 8.184, 17–19) “Grind all-heal, the size of an olive, in cedar-oil and apply. This is strong enough to destroy and to produce an abortion.” The physician author of On the Nature of the Child (Nat. Puer. 13 = L. 7.490) recommends leaping, bringing the heels to the buttocks, as a means of dislodging an unwanted embryo; Sor., Gyn. 1.60.1 notes that some see a distinction between this type of physical expellant, not considering it a true abortifacient, and a pharmaceutical one. Among those closer to Soranus’ time, both Dioscorides and Pliny the Elder record the contraceptive and/or abortive properties of materia medica; see Riddle, J. M. (1992). Contraception and Abortion from the Ancient World to the Renaissance, 31–56, 82–84. Riddle also suggests that Scribonius Largus, an opponent of abortion, unwittingly supplies information on abortifacients by describing emmenagogues, 84–85. King, H. (1998). Hippocrates’ Woman: Reading the Female Body in Ancient Greece, 145–46 challenges this view that menses-inducing measures are hidden abortifacients; see also Totelin, L. M. V. (2009). Hippocratic Recipes: Oral and Written Transmission of Pharmacological Knowledge in Fifth- and Fourth-Century Greece, 214–24. On methods of

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has been conceived, and when faced with impending miscarriage, encourages that every attempt should be made to prevent it, noting considerable success in the past: δεῖ μέντοι μὴ ἀποπτυσθέντος εὐθέως τοῦ σπέρματος τῇ συλλήψει συνεργεῖν, ὡς ἐν ἀρχαῖς ὑπεδείξαμεν. φθορᾶς δὲ προσδοκωμένης ἔσεσθαι [. . .] πρὸς μὲν τὴν ἔκκρισιν ἀποσυνεργοῦντα δεῖ πολλὴν ἡσυχίαν ἄγειν καὶ ἀναρρόπως κατακλίνειν καὶ σπόγγους ἀποτεθλιμμένους ἐν ὀξυκράτῳ περιβάλλειν ἐφηβαίῳ καὶ ὀσφύι, πολλάκις γὰρ οὕτως ἔκτρωσις ἐκρατήθη.5 However, if the seed has not been spit out straightaway, one should aid pregnancy, as we showed in the first [chapters]. And if miscarriage is threatening to occur . . . one should try to thwart the separation and to order much rest, and to lie her down in a slightly raised position, and to apply sponges squeezed in vinegar to the pubes and loins, for very often miscarriage has been overcome in this way. But his concern extends beyond mere preservation; having stipulated what things the pregnant woman must avoid in order to ensure retention of the seed (including excessive exercise, wine, pungent food, intercourse and mental upset),6 he sternly censures those who believe that the mere avoidance of miscarriage is adequate. Even before it merits the name of embryo, Soranus’ apprehension about its wellbeing, both physical and spiritual, is apparent:

abortion and associated legal aspects, see Kapparis, K. (2002). Abortion in the Ancient World, 7–31, 167–94. 5  Sor., Gyn. 3.48.2 (Ilberg 126.12–20). 6  Ibid., 1.46.2. (Ilberg 32.22–33.4). The list is extensive: “It is necessary, therefore, once conception has occurred, to guard against every excess and change, both bodily and spiritually. For the seed is discharged through fear, grief, sudden joy and, generally, by severe disturbance; also through violent exercise and forcible holding of the breath, coughing, sneezing, blows and falls, especially those on the hips; through lifting heavy weights, leaping, hard chairs, purgatives, the application of pungent substances and sternutatories; through lack of food, indigestion, drunkenness, vomiting, diarrhoea, and through bleeding from the nose, haemorrhoids or from other places; through slackening from things having the power to cause heat, and through excessive fever, shivering, spasms and, in general, everything bringing on violent motion through which a miscarriage (ἔκτρωσις) is produced.” Elsewhere, Soranus advocates the opposite course of action, i.e. actively employing these measures, during the first thirty days after conception as early stage abortifacients; ibid., 1.64.1.

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μηδεὶς δὲ ὑπολαμβανέτω, διότι, κἂν παραβαινούσης τινὸς ἔνια τῶν εἰρημένων ἢ πάντα μὴ γίνηται τοῦ συλληφθέντος ἔκτρωσις, οὐχὶ πάντως ἠδίκηται τὸ συλληφθέν. βέβλαπται γὰρ ὥστε καὶ ἀτονώτερον γίνεσθαι καὶ ἀναυξητότερον καὶ δυστροφώτερον καὶ τὸ κοινὸν εὐαδίκητον εὐάλωτόν τε τοῖς βλάπτουσιν καὶ κακόμορφον καὶ κατὰ ψυχὴν ἀγενές.7 And let no-one assume, just because miscarriage of the thing conceived does not occur, even with her transgressing some or all of the things ordered, that the thing conceived is not harmed at all. For it has been harmed, in such a way that it becomes weaker and more retarded in growth and more difficult to nourish and, in general, easily injured and susceptible to things that harm, and it becomes misshapen and ignoble in soul. The subject of rearing children, Soranus tells us, is both broad and manifold;8 the entirety of the second book of the Gynaecia, as we have it in Ilberg’s edition, is given over to normal delivery, infant care and children’s diseases.9 Careful consideration must first be given, he tells us, as to which offspring are worth rearing;10 the mother must have spent the pregnancy in good health, the offspring must have been born at its due time,11 it must cry with vigour and 7  Sor., Gyn. 1.47.1 (Ilberg 34.16–21). 8  Sor., Gyn. 2.9.1. 9   Book 1 deals largely with female anatomy, sexual function and pregnancy, Book 2 with normal delivery, infant care and children’s diseases, Book 3 with women’s conditions that are cured by regimen, and Book 4 with the conditions requiring surgery and drugs, including difficult labour. 10  Sor., Gyn. 2.10.1–2.10.5. 11  Ibid., 2.10.3 (Ilberg 57.26–27) “[Birth is] best, then, in the ninth month and later if it should happen; but, in the seventh month as well.” μάλιστα μὲν τὸν ἔννατον μῆνα καί, εἰ τύχοι, βράδιον, ἤδη δὲ καὶ τὸν ἕβδομον. On the theory that infants born after eight months were doomed, while those born at seven months were viable, see Hipp., Vict. 1.26 (L. 6.498); Hipp., Carn. 19 (L. 8.612); Arist., GA 772b 6–10; Hanson, A. E. (1987). ‘The eight months’ child and the etiquette of birth: obsit omen!’, Bull. Hist. Med. 61, 589–602; Reiss, R. E. and Ash, A. D. (1988). ‘The eight-month fetus: classical sources for a modern superstition’, Obstetrics and Gynecology 71.2, 270–73. If Soranus holds back from full-scale endorsement of the doomed eight months’ child’s fate, Mustio, who revised Soranus’ Gynaecia in late antiquity, is not as reserved; in answer to the question “in what months children able to survive are born” he answers, “particularly, indeed, in the tenth or ninth, after that in the seventh; thus it is difficult to turn out well any who are born in the eighth month.”

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be perfect in all its parts. Having outlined the criteria by which the midwife can make a favourable judgement, he concludes that “from the opposites of those things mentioned, the one unfit for rearing is recognised” (ἐκ δὲ τῶν ἐναντίων τοῖς εἰρημένοις τὸ πρὸς ἀνατροφὴν επιτήδειον).12 But he is silent as to what action, if any, should be taken; certainly there is no mention of disposal in the manner indicated by Seneca “we even drown children if they are born weak and deformed”,13 nor is any distinction made between the sexes.14 Soranus also roundly chastises those people who use the trial by cold water method of separating the fit infant from the unfit, putting the newborn into cold water to test their resilience, concluding that “just because it did not tolerate the harm well, does not prove it was unable to live if left unharmed” (οὐ μὴν ἐπεὶ τὴν βλάβην οὐκ ἤνεγκεν, ζῆσαι μὴ βλαβὲν οὐκ ἠδύνατο).15 Quibus mensibus vitales nascuntur? maxime quidem decimo et nono, secundo ordine septimo. unde difficile est aliquos evadere qui octavo mense nascuntur, Mustio 77 (Rose 28, 15–18). 12  Sor., Gyn. 2.10.5 (Ilberg 58.7–8). 13  Sen., De Ira 1.15.2. 14  For discussion of the topic of extensive infanticide in the Graeco-Roman world, see Harris, W. V. (1982). ‘The theoretical possibility of extensive infanticide in the Graeco-Roman World’, CQ NS32.1, 114–16; Harris, W. V. (1994). ‘Child-exposure in the Roman empire’, JRS 84, 1–22; Boswell, J. (1988). The Kindness of Strangers: the Abandonment of Children in Western Europe from Late Antiquity to the Renaissance, 53–179. On the possibility of extensive female infanticide, see Golden, M. (1981). ‘Demography and the exposure of girls at Athens’, Phoenix 35.4, 316–31; Engels, D. (1980). ‘The problem of female infanticide in the Greco-Roman world’, CPh 75.2, 112–20; Ingalls, W. (2002) ‘Demography and dowries: perspectives on female infanticide in classical Greece’, Phoenix 56.3/4, 246–54. For a more nuanced approach, addressing the distinction between infant abandonment and infanticide, see Corbier, M. ‘Child exposure and abandonment’, in Dixon, S. (2001). Childhood, Class and Kin in the Roman World, 52–73; Evans Grubbs, J. ‘Hidden in plain sight: Expositi in the community’, in Dasen V. and Späth, T. (2010). Children, Memory, and Family Identity in Roman Culture, 293–310; Evans Grubbs, J. ‘The dynamics of infant abandonment: Motives, attitudes and (unintended) consequences’, in Mustakallio, K. and Laes, C. (2011). The Dark Side of Childhood in Late Antiquity and the Middle Ages: Unwanted, Disabled and Lost, 21–36; Vuolanto, V. ‘Infant abandonment and the christianization of medieval Europe’, in Mustakallio and Laes, Childhood, 3–19. On early Christian attitudes to infanticide and exposure, see Gray, P. (2001). ‘Abortion, infanticide and the social rhetoric of the Apocalypse of Peter’, JECS 9.3, 313–37; Bakke, O. M. (2005). When Children Become People: The Birth of Childhood in Early Christianity, 110–51. 15  Sor., Gyn. 2.12.2 (Ilberg 59.20–21).

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Compassion for the Infant

Many of the topics addressed in Book 2, despite giving a fascinating insight into Roman practice, are largely commonplace; the cleansing, swaddling, and feeding of children, their bedding, teething, colds, sore throats, itches and diarrhoea—exactly as you might expect nowadays in a treatise on childcare. All these are presented with a great deal of what we could label as ‘common sense’. But it is in his presentation that Soranus displays extraordinary compassion, tenderness, and even affection for his health-destroying individual. Consider, for example, these instructions on breastfeeding: πλὴν οὐχ ἕως πλείονος κλαίειν ἀνετέον αὐτό [. . .] οὐ διὰ μόνην ἔνδειαν κλαυθμυρίζει τὸ βρέφος, ἀλλὰ καὶ διὰ σφίγξιν ἢ θλίψιν κακῶς ἐσχηματισμένον, ἢ διὰ δῆξιν περισσωμάτων καὶ ζῴου τινὸς ἢ νυγμόν, ἢ πλῆθος τροφῆς ἐπιβαρούσης τὸν ὄγκον, ἢ ῥῖγος, ἢ κα τὸ μὴ δύνασθαι διαχωρῆσαι σκληροτέρου παρεγκειμένου τοῖς ἐντέροις περισσεύματος, ἢ διὰ δυσαρέστησιν ἄλλην ἢ νόσον [. . .] τὸ δὲ τῆς τροφῆς ὀρεγόμενον διὰ τοῦ μηδενὸς τῶν εἰρημένων παρόντος τὰ χείλη μὲν σαλεύειν, τὸ δὲ στομάτιον ἀνοίγειν [. . .] φυλάττεσθαι δὲ καὶ μετὰ τὸ πληρωθῆναι τοῦ γάλακτος εὐθέως αὐτὸ κινεῖν. πολλῷ δὲ μᾶλλον τὸ ἀκμὴν νήπιον διά τε τὴν τρυφερίαν τοῦ σώματος [. . .] εἰ δὲ ἐπιμόνως κλάοι τὸ βρέφος ἀπὸ τῆς γαλακτοποσίας, ἐν ταῖς ἀγκάλαις αὐτὸ διακρατείτω ἐρεθισμοῖς τισιν καὶ ψελλίσμασιν καὶ φωναῖς προσηνέσιν παρηγοροῦσα τὸν κλαυθμόν, μήτε δὲ ἐκφοβοῦσα μήτ’ ἐπιταράττουσα ψόφοις τισὶν ἢ ἄλλαις ἀπειλαῖς· ἡ γὰρ ἀπὸ τῶν τοιούτων ἔκπληξις αἰτία παθῶν γίνεται ποτὲ μὲν σωματικῶν, δὲ ψυχικῶν.16 Except one must not let it cry for too long . . . the infant does not cry only because of hunger, but also because of being uncomfortably positioned by constriction or pressure, or because of the soreness caused by biting of faeces, or the bite or sting of some animal, or an excess of food weighing down the body, or cold, , or because it cannot pass the faeces lying in the bowels since they are too hard, or because of some other distress or sickness . . . and that it is yearning for nourishment [we will recognise] because, with none of the aforementioned things being present, it moves its lips and opens its little mouth . . . and [one must] beware of moving it straightaway after feeding with milk to the full . . . much more so the very small infant, because of the tenderness of the body . . . but if the infant should cry continually after nursing, she should cradle it in bent arms and soothe the weeping by distractions and babblings and 16  Ibid., 2.39.1–40.4 (Ilberg 81.24–83.14).

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gentle tones, without alarming it or disquieting it by certain noises or other threats. For the consternation from such things becomes the cause of diseases, sometimes of the body, sometimes of the soul. There are three striking features in this passage, which I would like to consider in turn: Soranus’ concern for the infants’ physical comfort, his concern for its emotional wellbeing, and an emphasis on the fragility of the infant and the tenderness with which it should be treated. 3.1 Physical Comfort First, Soranus is concerned with the infant’s physical comfort and freedom from pain; the carers must ensure it is not cold, hot, hungry, suffering indigestion or constipation, that it is not bound too tight or endangered by pests. The reader encounters the same concerns elsewhere in Book 2; here, Soranus gives instruction on the cutting of the umbilical cord, troubling himself not only with the efficiency of the task, but with the deed causing the least possible distress to the infant: δεῖ. . .ἀποκόπτειν τὴν ὀμφαλίδα διά τινος ἐπάκμου χάριν τοῦ μηδεμίαν γενέσθαι περίθλασιν [. . .] συμπάθεια γένηται καὶ διαγανάκτησις, ἄμεινον ἀδεισιδαιμονέστερον σμιλίῳ μᾶλλον τὸν ὀμφαλὸν κόπτειν [. . .] τὸ γὰρ λίνον ἐντέμνον τὴν τρυφερίαν τῶν σωμάτων δυσυπομονήτους ἀλγηδόνας ἀποτελεῖ [. . .] τὰ γὰρ ἐπικαέντα περιωδυνίας καὶ φλεγμονὰς σφοδρὰς ὑπομένει.17 One must cut the cord . . . by means of something sharp so that no bruising may occur . . . [and lest] sympathetic affection and irritation occur, it is better and less superstitious to cut the cord with a knife . . . for a linen cord cutting into the tenderness of bodies, causes pains which are hard to abide . . . for cauterised parts undergo excessive pains and vehement inflammations. Then, he rebukes the method of binding the infant within a hollowed-out log lined with hay: δυσκαρτέρητος δὲ καὶ ἀπηνὴς ὁ τρόπος οὗτός ἐστιν τῆς διαδέσεως.18 But this [Thessalian] method of bandaging is hard to endure and cruel. 17  Ibid., 2.11.1–5 (Ilberg 58.12–59.4). 18  Ibid., 2.14.2 (Ilberg 61.4–5).

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While he encourages continuing to swaddle the infant until the body is firm and free from distortion, he is willing to dispense with this if there is a chance of injury, or if the infant suffers discomfort: ἐὰν δὲ ἀκμὴν σπαργανούμενον τὸ βρέφος ἑλκωθῇ διὰ τὴν τῶν τελαμώνων παράτριψιν ἢ δι’ ἄλλην τινὰ ποιητικὴν ἑλκώσεως αἰτίαν, παραιτεῖσθαι δεῖ τὰ σπάργανα καὶ ἁπλοῦν αὐτῷ περιτιθέντα χιτωνάριον ἀποθεραπεύειν τὰ ἕλκη.19 But if the infant, while still swaddled, suffers from sores from the chafing of the bandages, or because of some other cause producing soreness, one must give up the swaddling clothes and, dressing it in a simple little shirt, heal the wounds. And, chastising those who insist on bedding that is too hard, too soft, or too fragranced, he advises a middling course: τὸν οἶκον δὲ δεῖ καθαρὸν εἶναι καὶ συμμέτρως θερμὸν καὶ μήτε ἄγαν ἔχοντα πληκτικὴν ἀποφορὰν μήτε περιαύγειαν, παρ’ ὃ καὶ οἰκεία τῆς ἀναψυχῆς ἀφθονία καὶ κωνωπίων ἡ περίθεσίς ἐστιν.20 And the room [in which the infant is placed] ought to be clean and moderately warm and without overwhelming odours nor should there be too much light; and besides, plenty of ventilation and the putting up of mosquito nets is appropriate. The infant must even be protected from its caregivers, since they too can be a danger to its physical health, even to its survival. Here, are some instructions for the inexperienced, or even careless, wet-nurse: καθεζέσθω μὲν οὖν οἷον ἐπινενευκυῖα, ἐπειδήπερ ὑπτιωμένης αὐτῆς ἢ καταρρόπου ἐσχηματισμένης δυσκολωτέρα γίνεται ἡ κατάποσις, ὥστε ποτὲ μὲν ἀνταποδίδοσθαι τὸ πινόμενον, ποτὲ δὲ καὶ πνιγμοῦ γίνεσθαι παραίτιον [. . .] μὴ συγκοιμάσθω δὲ τὸ βρέφος αὐτῇ, καὶ μάλιστα ἐν ἀρχαῖς, ἵνα μὴ ἀπροόπτως ἐπικυλισθεῖσα περιθλάσεως ἢ πνιγμοῦ γένηται παραιτία [. . .] πάντων δὲ χαλεπώτατον καὶ εἰς προφυλακὴν τοῦ μηδ’ ὅλως αὐτὸ κλαῦσαι τὴν θηλὴν διὰ τοῦ στόματος καταλιπεῖν αὐτοῦ κοιμωμένου· θλιβομένων γὰρ τῶν μυξωτήρων

19  Ibid., 2.42.4 (Ilberg 84.25–28). 20  Ibid., 2.16.4 (Ilberg 63.21–24).

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καὶ ἀποφρασσομένου τοῦ στόματος καὶ βαρυνομένου τοῦ φάρυγγος ἔσθ’ ὁπότε τοῦ γάλακτος χωρὶς ἐκμυζήσεως ἐπιρρέοντος τὸ νήπιον πνίγεται.21 So, then, she should sit as if nodding forward, since, if she positions herself bending backwards or leaning downwards, swallowing becomes too difficult, so that sometimes, indeed, what is drunk is brought back up again, and sometimes even becomes the cause of choking . . . and the infant should not sleep with her, especially in the beginning, lest having rolled over unaware, she should be the cause of crushing or suffocation22 . . . and cruellest of all is to leave the nipple in its mouth as it sleeps as a guard against it crying altogether; for, with the nostrils compressed and the mouth blocked and the throat crushed, sometimes the milk flows without sucking and the infant chokes. 3.2 Emotional Wellbeing The second feature of interest in our passage on breastfeeding, is Soranus’ concern for the infant’s emotional,23 even spiritual, wellbeing—although we must recall, of course, that for Soranus the soul has corporeal substance—and for the infant’s pleasure. The infant that cries for no apparent reason should not be chastened by threats, rather it must be comforted by close physical contact and soothed by affectionate chatter; nor should it be subjected to the unexpected, or to the unaccustomed which can damage both body and soul. Again, we can see these elements in other parts of Book 2; sudden change must be avoided, as it is upsetting to the infant:

21  Ibid., 2.37.1–2.38.4 (Ilberg 80.7–81.19). 22  Co-sleeping of infant and parent/caregiver continues to be a controversial subject; even this past month has seen medical opinions published favouring pro-, anti- and middleof-the road positions. See Bergman, A. B. (2013). ‘Bed sharing per se is not dangerous’, JAMA Pediatrics 167.11, 998–99; Carpenter, R. et al. (2013). ‘Bed sharing when parents do not smoke: is there a risk of SIDS? An individual analysis of five major case-control studies’, BMJ Open 3.5, 1–11; Moreno, M. A. (2013). ‘The controversial but common practice of bed sharing’, JAMA Pediatrics 167.11, 1088. 23  For the Methodist belief that emotional disorder can cause, or be a symptom of, bodily disease, see Horstmanshoff, H. F. J. ‘Les émotions chez Caelius Aurelianus’ in Mudry, Ph. (1999). Le traité des Maladies aiguës et des Maladies chroniques de Caelius Aurelianus, 259–90.

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φυλάσσεσθαι [δὲ] δεῖ τὰς τῶν ἐθῶν μεταβολάς, ἐχούσας τι δυσάρεστον ἐκ τῆς ξενοπαθείας.24 And one must guard against changes of habits which are somewhat hard to take because of the strange feeling [they provoke].25 Distress caused by change can even lead to the infants’ developmental decline: ὁπηνίκα τῇ ἀλλαγῇ τοῦ γάλακτος ποτὲ μὲν ξενοπαθοῦν λυπεῖται τὸ νήπιον, ποτὲ δὲ καὶ παντελῶς ἀποστρεφόμενον λιμῷ διαφθείρεται.26 At which time, because of the change in milk, sometimes the infant, sensing something strange, is distressed, while sometimes, turning away from it entirely, it is destroyed by starvation. Sometimes the mishandling of an infant’s emotional state can even lead it into physical danger: καὶ ἄλλως μανιώδεις εἰσὶν αἱ θυμούμεναι καὶ φόβῳ κλαυθμυρίζον ποτὲ τὸ βρέφος ἐπισχεῖν μὴ δυνάμεναι ῥιπτοῦσιν ἐκ τῶν χειρῶν ἢ καταστρέφουσιν ἐπικινδύνως.27

24  Sor., Gyn. 2.48.1 (Ilberg 87.8–9). 25  The idea of ξενοπαθέω is difficult to capture in translation—“having a strange/alien/foreign sensation/feeling/emotion” or “having a sensation/feeling/emotion in response to something that one is unused to”. It is unclear whether it encompasses both a physical and emotional response. The concept that a change to something unaccustomed produces a detrimental “strange feeling” is repeated several times in this work, four times in relation to the infant; Sor., Gyn. 2.12.2 (re. exposing to cold); 2.20.3 (re. changing the wet nurse); 2.42.2 (re. removing swaddling); 2.48.1 (re. changes in habit). There is one instance in relation to women, 1.26.3 (Ilberg 17.5–7) (re. menopause), where the concept is explained more fully—πᾶν γὰρ τὸ αἰφνίδιον ἐν μεταβολῇ, κἂν ἐπὶ τὸ βέλτιον [ἢ] μεταφέρηται, διὰ ξενοπάθειαν λυπεῖ τὸν ὄγκον· οὐκ ἐπιγινώσκεται γὰρ τὸ μὴ προμελετηθέν, ἀλλ’ ὡς ἄηθες δυσαρέστημά τι σύνεστιν. (“for every sudden change distresses the body because of the strange feeling, even if the body is altered for the better. For that to which the body is not accustomed is not tolerated, rather it is as if it is a strange malaise”). The noun ἡ ξενοπάθεια, “strange feeling”, is found only in Soranus. 26  Sor., Gyn. 2.20.3 (Ilberg 69.3–5). 27  Ibid., 2.19.14 (Ilberg 68.17–19).

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And besides, when taken by anger, women may fall prey to mania and sometimes, being unable to restrain an infant that is crying from fear, they fling it from their hands or turn it over in a dangerous way. Nor should we neglect the happiness of the infant, making bathing pleasurable: καταντλεῖν διὰ τῆς δεξιᾶς χειρὸς ὕδωρ θερμόν τε καὶ εὔκρατον ὡς πρὸς τὴν τοῦ βρέφους εὐαρέστησιν.28 [She ought to] pour warm water with her right hand that is well-tempered to the pleasure of the infant. And, ensuring time for amusement and play: κἂν φύσει δὲ βορὸν ᾖ τὸ νήπιον καὶ πλείονος ὀρεγόμενον τροφῆς ἧς δύναται κρατεῖν, ἀποπερισπᾶν τὴν διάνοιαν αὐτοῦ ψυχαγωγίαις τισὶν καὶ παιγνίαις.29 And if the infant is greedy by nature and grasping at more food than it can digest, one should divert its attention with some amusements and games. 3.3 Fragility of the Infant The third striking feature from our passage on breastfeeding is the emphasis on the tenderness and fragility of the infant body, and the delicacy with which we must treat it. This element, too, is well represented elsewhere in Book 2 of the Gynaecia. Here are just a few examples: “So that it may rest tenderly (τρυφερῶς)30 . . . for a linen cord cutting into the tenderness (τὴν τρυφερίαν) of bodies31 . . . the physique is still slack and very weak (βρυώδης ἀκμὴν καὶ ἀσθενής)32 . . . but the newborn being tender (τρυφεροῦ)33 . . . place it gently (πρᾴως) on the middle of the umbilicus34 . . . put the newborn down

28  Ibid., 2.31.2 (Ilberg 76.20–21). 29  Ibid., 2.48.5 (Ilberg 87.20–23). 30  Ibid., 2.6.5 (Ilberg 55.8). 31  Ibid., 2.11.3 (Ilberg 58.25). 32  Ibid., 2.13.1 (Ilberg 60.6). 33  Ibid., 2.13.1 (Ilberg 60.8). 34  Ibid., 2.13.4 (Ilberg 60.25).

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gently (πρᾴως)35 . . . then she should take soft (τρυφερούς) woolen bandages, soft (τρυφερούς) so as not to cause bruises when covering bodies which are still delicate (τρυφεροῖς)36 . . . the newborn, being as yet very slack (βρυῶδες)37 . . . the extraordinary tenderness (τρυφερίαν) of its body38 . . . the natural ducts which are as yet delicate (τρυφερούς).”39 Associated with this feature of tenderness is Soranus’ use of diminutives, which in Book 2 is quite striking. We saw in the passage above how he talked of the infant opening its little mouth (τὸ στομάτιον),40 but he also instructs the caregivers in wrapping up its little hands (τὰ χέρια),41 placing its little head (τὸ κεφάλιον)42 in a raised position, waiting until the little body (τὸ σωμάτιον)43 has recovered, how they should treat its little sore (τὴν ἑλκύδριον),44 how to apply a little piece of lint (τὸ πτυγμάτιον)45 soaked in oil to the umbilicus, how they should put it to sleep in bed so that it peeps out and inclines forward as in a little chair (τῷ καθεδρίῳ),46 how they should dress it a simple little shirt (τὸ χιτωνάριον)47 and how even it should exercise by means of a little handcart (τῶν χειραμαξίων).48 With the exception of τό κεφάλιον ‘little head’, these terms are used exclusively in Book 2; in fact, whilst not completely unattested to, these terms are fairly rare elsewhere.49 As to τὸ κεφάλιον, it does occur 35  Ibid., 2.14.3 (Ilberg 61.20). 36  Ibid., 2.14.4 (Ilberg 61.16). 37  Ibid., 2.26.1 (Ilberg 72.30). 38  Ibid., 2.31.2 (Ilberg 76.23). 39  Ibid., 2.35.2 (Ilberg 79.16). 40  Ibid., 2.39.10 (Ilberg 82.22). 41  Ibid., 2.15.14 (Ilberg 62.16). 42  Ibid., 2.16.2 (Ilberg 63.14–15); also 2.15.5; 2.33.4; 2.33.5; 2.50.2. 43  Ibid., 2.48.7 (Ilberg 87.29); also 2.43.1. 44  Ibid., 2.41.1 (Ilberg 83.29). 45  Ibid., 2.13.4 (Ilberg 60.21). 46  Ibid., 2.37.5 (Ilberg 80.24). 47  Ibid., 2.42.4 (Ilberg 84.28). 48  Ibid., 2.48.5 (Ilberg 87.20). 49  τὸ στομάτιον and τὸ χειραμάξιον appear only in Soranus; τὸ πτυγμάτιον and τὸ καθέδριον occur in Soranus and in the medical compilers such as Oribasius of Pergamum, Aëtius of Amida and Paul of Aegina (see, for example, Orib., Med. Coll. 44.7.17 (Raeder 122, 10); 46.11.3 (Raeder 219, 32); Aët., Libr. Medic. 4.3 (Olivieri 360, 18); 4.19 (Olivieri 367, 10); 7.37 (Olivieri 289, 14); 7.71 (Olivieri 321, 9); 8.38 (Olivieri 455, 1); 8.48 (Olivieri 471, 14); Paul. Aeg., Med. Epit. 6.8.1 (Heiberg 51, 21); 6.8.1 (Heiberg 51, 22); 6.8.2 (Heiberg 52, 20); 6.25.2 (Heiberg 64, 11); 6.31.2 (Heiberg 68, 19); 6.59.1 (Heiberg 98, 10); 6.90.4 (Heiberg 139, 10); 6.96.2 (Heiberg 150, 10); 6.99.2 (Heiberg 152, 14).

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repeatedly in Book 4, in the description of the extraction of a dead fetus. Here, it is combined with τὸ οστάριον, ‘little bone’: προεκκριθέντος γὰρ τοῦ ἐγκεφάλου συμπίπτει τὸ κεφάλιον. τὰ χείλη δὲ τῆς διαιρέσεως ἀποστρέφειν καὶ συνθραύειν τὰ ὀστάρια . . .50 For with the brain removed, the little head collapses; and (one ought) turn aside the edges of the divided part and break the little bones into pieces . . . Not only do these diminutives evoke the language of the nursery, perhaps originating from female sources, but they also exemplify the sense of affection, tenderness and fragility, perhaps indulgence, perhaps even pathos.51 There is good evidence to suggest these diminutives are hypocoristic in tone, rather than ‘true diminutives’ since we find examples where they are linked with adjectives denoting size; it is merely the paucity of diminutives in the English language that makes for an awkward translation. Here τὸ κεφάλιον is combined with μέγας ‘large’: εἰ δὲ μείζονος τοῦ κεφαλίου ὑπάρχοντος ἡ σφήνωσις ἀποτελοῖτο . . .52 If the obstruction is caused by its (little) head being too large . . . And here with μικρός ‘small’: εἰ δὲ μικροῦ τοῦ κεφαλίου τυγχάνοντος . . .53 And if the (little) head happens to be small . . .

50  Sor., Gyn. 4.11.4 (Ilberg 142.18–19): τὸ κεφάλιον also 4.8.6; 4.11.3; 4.11.6; 4.12.1; 4.12.5; 4.12.6. 51  On diminutives and children, see Golden, M. ‘Baby talk and child language in ancient Greece’, in De Martino, F. and Sommerstein, A. H. (1995). Lo Spettacolo delle Voci, 11–34; see also Petersen, W. (1910). Greek Diminutives in—ion; Luciani, V. (1943). ‘Augmentatives, diminutives and pejoratives in Italian’, Italica 20.1, 17–29; Swanson, D. C. (1958). ‘Diminutives in the Greek New Testament’, JBL 77.2, 134–51. 52  Sor., Gyn. 4.11.3 (Ilberg 142.10–11); also 4.12.1. 53  Ibid., 4.8.6 (Ilberg 138.29–30).

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Soranus and Adults

It would seem, then, that Soranus’ compassion, tenderness and concern for his little patient are evident from these passages. This however begs the question as to whether this is just an expression of Soranus’ attachment to any patient and to people in general. I would venture that it is not. Certainly, there are some occasions in which he displays empathy for the mother as patient, where he is eager to allay her fears and anxious to spare her embarrassment,54 but he also suspects her of drunkenness, adultery, vanity, and idleness, and of being ignorant and careless in child rearing.55 We rarely get even a glimpse of the non-parturient patient, with the notable exception of the sufferer of semen-flux, who must give up looking at paintings of attractive figures and listening to saucy tales, and console herself instead with gloomy pastimes and sombre reading.56 As for those who surround the patients, their good qualities are often tempered by the possibility of bad ones; the midwife may be greedy, scheming, superstitious and unskilled,57 the wet nurse lewd, drunken and unsympathetic to her charge.58 The father of the infant, before or after birth, is largely absent, except as an occasional shadowy nuisance making conjugal demands on his pregnant partner.59 Other medical authorities are, of course, universally wrong.60 Only the infant is presented consistently in a positive way. 5

Paediatric Treatises

So, was there a tradition of writing about infants in this particular way that Soranus inherited, or was he actually the first to have done so? The evidence of the Gynaecia suggests that he may well have been the first to write so exten54  For example, he reluctantly allows the pica-stricken woman to partake in a small amount of the unusual food she craves in order to avert despondency, Sor., Gyn. 1.53.2; he advises the assistance of women helpers for the parturient, as they can provide encouragement and allay fears, ibid., 2.5.1; he instructs the midwife to avert her gaze from the parturient’s genitals, lest she become embarrassed and contract her body, ibid., 2.6.2. See Porter, ‘Compassion in Soranus’ Gynecology’, 285–303 in this volume. 55  For example, Sor., Gyn. 1.39.2–3; 1.46.2; 1.60.3; 2.19.2; 2.44.2. 56  Ibid., 3.46.4. 57  On the qualities of the good midwife, ibid., 2.19.1–2.20.3; bad qualities, ibid., 2.19.11–2.19.15; 2.51.4. 58  On the qualities of the good wet nurse, ibid., 3.46.4; bad qualities, ibid., 1.3.3; 1.4.4; 2.11.1. 59  Ibid., 1.56.3. 60  Ibid., 2.5.3; 2.14.1; 2.18.1; 2.18.2; 2.28.5; 2.29.1; 2.48.2.

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sively on childcare. Never one to shy away from criticizing other authorities, of the more than forty mentioned throughout the Gynaecia on ninety-six separate occasions,61 in Book 2 Soranus cites only eight physicians, mentioned in just nine instances.62 This is dramatically fewer than in any of the other three books.63 In Book 2 there is no mention at all of authors who, as Soranus tells us elsewhere, have written specifically on gynaecology or obstetrics, namely the Hippocratics,64 Herophilus65 and Diocles,66 references to whom litter the other three books of the Gynaecia, nor to Cleophantus67 or Alexander Philalethes.68 Nor does Soranus mention his countryman and contemporary Rufus of Ephesus, who is believed to have written a treatise on childcare,69 nor the Romans Pliny the Elder70 or Celsus,71 who certainly made some, however limited, observations on the topic. In fact, when it comes to the actual practicalities of childcare, those that Soranus turns to for his examples (generally, for what not to do) are not the illustrious authorities, but ‘the barbarians’, 61  Fourteen authors are named more than once; the top five are Herophilus/Herophileans with fifteen occurrences, Diocles with eleven occurrences, Hippocrates/Hippocratics with ten occurrences, Themison with six occurrences, and Asclepiades with five occurrences; see also Eijk, Ph. J. van der. ‘Antiquarianism and criticism: Forms and functions of medical doxography in methodism (Soranus, Caelius Aurelianus)’, in id. (1999). Ancient Histories of Medicine: Essays in Medical Doxography and Historiography in Classical Antiquity, 406. 62  Heron (on the placement of the midwife) Sor., Gyn. 2.5.3; Antigenes (on Thessalian swaddling) 2.14.1; Damastes (on breastfeeding) 2.18.1; Apollonius Biblas (on breastfeeding) 2.18.2; Mnesitheus (on the regimen of the wet nurse and on weaning) 2.28.5 and 2.48.2; Moschion (on the regimen of the wet nurse) 2.29.1; Aristanax (on weaning) 2.48.2; Demetrius (on the semiotics of siriasis) 2.55.1. 63  Book 1: twelve authorities are mentioned in twenty-six instances; Book 2: eight authorities mentioned in nine instances; Book 3: twenty-four authorities mentioned in thirty six instances; Book 4: seventeen authorities mentioned in twenty-five instances. 64  Sor., Gyn. 1.60.1. 65  Ibid., 3.3.4; 4.1.3. 66  Ibid., 3.2.1. 67  Ibid., 4.1.3. 68  Ibid., 3.43.1. 69  See Ullmann, M. (1975). ‘Die Schrift des Rufus “De infantium curatione” und das Problem der Autorenlemmata in den “Collectiones medicae” des Oreibasios’, MHJ 10.3, 165–90. 70  On childcare, see Plin., HN 7.68–69; 20.17; 20.123; 20.126; 20.129; 20.148; 20.161; 20.191; 20.211; 20.253; 21.140; 22.31; 22.59; 22.65; 22.82; 22.121; 22.158; 23.74; 23.148; 24.50; 24.83; 24.106; 24.128; 24.140; 26.79; 26.141; 28.39; 28.66; 28.71–72; 28.123; 28.257–59; 29.39; 29.41; 30.135–39; 32.24; 32.137–38; 33.84; 34.151; 37.162. The number of occurrences seems extensive, but most are merely casual references. 71  On childcare, see Celsus, Med. 2.1.17–19; 2.7.7; 3.7.1; 6.11.3–5; 7.20.1.

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‘the Egyptians’, ‘the Germans’, ‘the Scythians, ‘the Hellenes’, ‘the Thracians’, ‘the Macedonians’, and ‘the Syrians’—peoples who, with the exception of the Hellenes, make no other appearance in the Gynaecia.72 Their inclusion in Book 2 may well be an indication that Soranus is tapping into more of an oral tradition than a literary one as regards to childcare, perhaps even using female sources. 6

Patience for the Little Patient—Discussion and Conclusion

So why does Soranus show such extraordinary patience for his little patient, when it seems fleeting at best for others? I would like to suggest two reasons. Firstly, the infant is a ‘blank slate’,73 both physically and mentally, untouched by the faults of adulthood. I do not propose this in a Christian context of children as paradigms for adults, but in the sense that Galen expressed it in the De sanitate tuenda,74 namely that if one can take an infant (τὸ παιδίον) from the beginning, and keep it from harm, it will be healthy throughout its life. However, we cannot totally ignore the possibility that, by Soranus’ time in the second century AD, times were ripe for a more nuanced vision of childhood.75 Thus, much of Book 2 of the Gynaecia is devoted to the physical and emotional wellbeing of the infant—even to its physical attractiveness,76 since we are also instructed how to create an attractive belly-button,77 how best to swaddle 72  ‘The barbarians’, Sor., Gyn. 2.12.1; ‘the Egyptians’, 2.6.4; ‘the Germans’, 2.12.1; ‘the Scythians’, 2.12.1; ‘the Hellenes’, 2.12.1; ‘the Thracians’, 2.16.1; ‘the Macedonians’, 2.16.1; ‘the Syrians’, 2.51.4. 73  With its origins in Aristotelian philosophy (De an. 430a), the idea of the infant mind as tabula rasa was formulated by Locke in the seventeenth century in An Essay Concerning Human Understanding. Most modern developmental theories reject this extreme form of behaviourism, arguing for a much more nuanced and interaction-based concept of early cognition; see, for example, Legerstee, M. ‘The developing social brain: Social connections and social bonds, social loss, and jealousy in infants’, in Legerstee, M. et al. (2013). The Infant Mind: Origins of the Social Brain, 223–47; Gopnik, A. et al. (1999). The Scientist in the Crib: Minds, Brains, and How Children Learn. 74  Gal., De san. tuenda 1.7, 6.32 (K, = CMG V, 4,2, 1.7.1–13). 75  But see Gourevitch, D. ‘The sick child in his family’, in Dasen V. and Späth, T. (2010). Children, Memory, and Family Identity in Roman Culture, 273–92 for Galen’s approach to children as patients. 76  See Gourevitch, D. ‘Comment rendre à sa veritable nature le petit monstre humain?’, in Eijk, Ph. J van der et al. (1995). Ancient Medicine in its Socio-Cultural Context, 239–60. 77  Sor., Gyn. 2.13.4 Ilberg.

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and massage it to create a comely form,78 how to prevent the infant becoming hunchbacked,79 how to avoid it developing a squint,80 even how to correct its ‘Roman nose’.81 All of which are, of course in the hands of the caregivers, primarily the midwife and wet-nurse, so it is no surprise that Soranus places such emphasis on, indeed obligation of, selecting the best. For, particularly with regards to the wet-nurse, not only is she capable of physical harm through negligence and even disaffection, but may also cause developmental harm, since being herself harmed through drunkenness she triggers sluggishness, stupor, tremors and convulsions, and emotional damage in the infant via her milk,82 since by nature the infant grows sullen if its wet-nurse is ill-natured.83 My second point concerns the nature of the Gynaecia itself. We saw that in Book 2 Soranus made far fewer references to other medical authorities, and more references to groups of ‘other peoples’, than he did in the rest of the work, making Book 2 quite different from the rest of it. This, I suggested, may indicate that there was less of a literary tradition and more of an oral one about childcare; I believe this allowed Soranus greater freedom in his writing on this topic, whether consciously so or not. Conversely, following a long tradition of writings on women’s matters, he was most likely influenced by their format and style of these texts, which was, to, a large extent, removed and impersonal. Furthermore, with the exception of the discussion of the actual delivery of the infant, much of the content related to women is restricted to theory, or to the detached cataloguing of recipes for poultices and pessaries, and therefore perhaps removed from the practical and personal. Topics related to the infant, instead, are extremely practical and ‘hands-on’, and this may have facilitated and/or encouraged Soranus’ approach. Soranus exhibits considerable compassion, tenderness and affection toward his little patient; in fact, extraordinary compassion, tenderness and affection, all of which flies in the face of Soranus’ own professed assertion that, overall, pregnancy is a bad thing. Perhaps we should concur with Tertullian who, in his assessment of some of the famous medics before his time, valued Soranus as

78  Ibid., 2.15.2; 2.33.1–2.34.5. 79  Ibid., 2.43.1. 80  Ibid., 2.37.5. 81  Ibid., 2.34.3. 82  Ibid., 2.19.12. 83  Ibid., 2.19.14.

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“the gentler Soranus”.84 Surely the infant of antiquity could have had no better advocate than him. Texts and Translations Used Aetii Amideni Libri medicinales I–IV. Ed. A. Olivieri. CMG VIII, 1. Leipzig et Berlin: Akademie-Verlag, 1935. Aetii Amideni Libri medicinales V–VIII. Ed. A. Olivieri. CMG VIII, 2. Berlin: AkademieVerlag, 1950. Hippocrates. Oeuvres complètes d’Hippocrate. Ed. E. Littré, vol. 1–10. Paris: Baillière, 1839–61. Mustio. Gynaecia. Ed. V. Rose, Sorani gynaeciorum vetus translatio Latino, nunc primum edita cum additis Graeci textus reliquiis a Dietzio repertis atque ad ipsum codicem Parisiensem nunc recognitis a Valentino Rose. Leipzig: Teubner, 1882. Oribasii Collectionum medicarum reliquiae, libri XXIV–XXV. XLIII–XLVIII. Ed. J. Raeder. CMG VI, 2,1. Leipzig et Berlin: Akademie-Verlag, 1931. Paulus Aegineta, Libri I–IV. Ed. J. L. Heiberg. CMG IX, 1. Leipzig et Berlin: AkademieVerlag, 1921. Paulus Aegineta, Libri V–VII. Ed. J. L. Heiberg. CMG IX, 2. Leipzig et Berlin: AkademieVerlag, 1924. Soranus. Gynaecia. Ed. J. Ilberg, Sorani Gynaeciorum libri 4, De Signis Fracturarum, De Fasciis, Vita Hippocratis secundum Soranum (CMG IV). Leipzig and Berlin: Teubner, 1927.

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de colloque de Lausanne 1996, ed. Ph. Mudry, 259–89. Nantes: Institut Universitaire de France, 1999. Ingalls, W. ‘Demography and Dowries: Perspectives on Female Infanticide in Classical Greece.’ Phoenix 56.3/4, (2002): 246–54. Kapparis, K. Abortion in the Ancient World. London: Duckworth, 2002. King, H. Hippocrates’ Woman: Reading the Female Body in Ancient Greece. London: Routledge, 1998. Legerstee, M. ‘The Developing Social Brain: Social Connections and Social Bonds, Social Loss, and Jealousy in Infants.’ in The Infant Mind: Origins of the Social Brain, ed. M. Legerstee, D. Haley and M. Bornstein, 223–47. New York: Guilford Press, 2013. Luciani, V. ‘Augmentatives, Diminutives and Pejoratives in Italian.’ Italica 20.1, (1943): 17–29. Moreno, M. A. ‘The Controversial but Common Practice of Bed Sharing.’ JAMA Pediatrics 167.11, (2013): 1088. Petersen, W. Greek Diminutives in—ion: a Study in Semantics. Weimar: R. Wagner Sohn, 1910. Reiss, R. E. and Ash, A. D. ‘The Eight-Month Fetus: Classical Sources for a Modern Superstition.’ Obstetrics & Gynecology 71.2, (1988): 270–73. Riddle, J. M. Contraception and Abortion from the Ancient World to the Renaissance. Cambridge, MA: Harvard University Press, 1992. Swanson, D. C. ‘Diminutives in the Greek New Testament.’ Journal of Biblical Literature 77.2, (1958): 134–51. Totelin, L. M. V. Hippocratic Recipes: Oral and Written Transmission of Pharmacological Knowledge in Fifth- and Fourth-Century Greece. Leiden and Boston: Brill, 2009. Ullmann, M. ‘Die Schrift des Rufus “De infantium curatione” und das Problem der Autorenlemmata in den “Collectiones medicae” des Oreibasios.’ Medizinhistorisches Journal 10.3, (1975): 165–90. Vuolanto, V. ‘Infant Abandonment and the Christianization of Medieval Europe.’ in The Dark Side of Childhood in Late Antiquity and the Middle Ages: Unwanted, Disabled and Lost, ed. K. Mustakallio and C. Laes, 3–19. Oxford: Oxbow Books, 2011.

CHAPTER 10

Compassion in Soranus’ Gynecology and Caelius Aurelianus’ On Chronic Diseases Amber J. Porter Compassion is considered an important quality for a successful physician today, but did ancient physicians display and value this emotion? How did they feel when faced with the pain and suffering of their patients? How did their patients’ emotions affect their own? Many ancient physicians are not well-known for expressions of compassion in their writings; however, this seems to change in the second century AD. One medical writer who exemplifies this change is Soranus of Ephesus (c. 98–138 AD). In his Gynecology, there are a number of passages where compassion is addressed or expressed (such as the chapters on the qualities of the best midwife, the symptom of pica, childbirth, and superstition). The same points can be made of Soranus’ On Chronic Diseases, preserved to some extent by the Latin version and adaptation by fifth century AD medical writer Caelius Aurelianus (see, for example, the chapters on chronic headache, mania and elephantiasis). Soranus and Caelius display compassion, understanding, and flexibility of approach when dealing with patient issues; they show themselves willing to change their medical technique when they see that it is doing more harm or discomfort than good. In Soranus and Caelius, we have an image of a physician who acknowledges and is aware of their patients’ emotions, beliefs and attitudes, and who exhibits compassion for them. Compassion, the emotion of feeling care for another person who is suffering and desiring to relieve his or her suffering, is sometimes synonymous with sympathy, pity or condolence. It is a key concern for those in healthcare fields, and much energy and consideration have been spent on determining the role of this emotion in a nurse’s or doctor’s repertoire of skills.1 But did ancient Greco-Roman physicians display and value this emotion? Compassion is not 1  Relatively recently a scholarly interest in the history of emotions has developed, for example: Rosenwein, B. H. (2002). ‘Worrying about emotions in history’, The American Historical Review 107.3, 821–45; id. (2010). ‘Problems and methods in the history of emotions’, Passions

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necessarily the first emotion that comes to mind when one thinks of Greek and Roman culture, so how did ancient physicians respond to their sick patients?2 How did they feel when faced with the pain and suffering of their patients? How did their patients’ emotions affect their own? Did they make them objects of compassionate treatment? Did they care about their comfort and emotional states? Or were they simply viewed as diseases in need of cures? Soranus of Ephesus and Caelius Aurelianus, a fifth-century Latin writer who engaged with Soranus’ works, will be the focus of this paper, which will illustrate these two writers’ acknowledgement and awareness of patients’ emotions, beliefs and attitudes, and how they exhibit compassion within the construct of the patient-physician relationship. Soranus and Caelius have quite specific terms for compassion, which help greatly in directing our analysis. Soranus uses terms such as συμπαθής and συμπάσχω (“sympathetic” and “to be sympathetic”); παραμυθία and παραμυθέομαι (“encouragement” and “to encourage”); and εὐαγγελίζομαι (“to speak kindly to”). Caelius uses terms such as humanitas (“humanity”) and consensus (“agreement”) to convey his advocacy of compassion. There are, as well, an interesting range of terms used by other authors. For example, Scribonius Largus, the first century AD pharmacological writer, also uses humanitas and misericordia with reference to the compassion felt by the physician; Aretaeus of Cappadocia, finally, uses the verb συνάχθομαι when lamenting the inevitable death of tetanus patients. In addition, these writers will also use opposite concepts in order to censure those who are not

in Context: Journal of the History and Philosophy of the Emotions 1, 1–32; Toohey, P. (2011). Boredom: A Lively History; for scholarship on emotion in the ancient Greco-Roman world specifically, see: Konstan, D. (2006). The Emotions of the Ancient Greeks: Studies in Aristotle and Classical Literature; Fulkerstone, L. (2013). No Regrets: Remorse in Classical Antiquity; Barton, C. A. (1995). Sorrows of the Ancient Romans: The Gladiator and the Monster; Kaster, R. A. (2005). Emotion, Restraint and Community in Ancient Rome. For how historians might practice empathy in their research, see Harris, W. V. (2010). ‘History, empathy and emotions’, A&A 56, 1–23. 2  Some scholars have addressed compassion and similar emotions in the ancient world, for example: Konstan, D. (2001). Pity Transformed; id. (2000). ‘Altruism’, Transactions of the American Philological Association 130, 1–17; Blowers, P. M. (2010). ‘Pity, empathy, and the tragic spectacle of human suffering: Exploring the emotional culture of compassion in late ancient Christianity’, JECS 18.1, 1–27; Alford, C. F. (1993). ‘Greek tragedy and civilization: The cultivation of pity’, Political Research Quarterly 46.2, 259–80; Kosak, J. ‘A crying shame: Pitying the sick in the Hippocratic Corpus and Greek tragedy’, in Hall Sternberg, R. (2005). Pity and Power in Ancient Athens, 253–76; Ferwerda, R. ‘Pity in the life and thought of Plotinus’, in Runia, D. T. (1984). Plotinus Amid Gnostics and Christians, 53–72.

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compassionate towards others. Soranus discusses insensitive nurses who act “οὕτως . . . ἀπαθῶς” (“so unfeelingly”) and Caelius contrasts curandum (“treatment”) with destituendum (“abandonment”3) when voicing his disapproval of the desertion of elephantiasis patients by physicians. These various terms, along with a close reading of the textual contexts, can be used to localise passages where these writers express compassion. Soranus of Ephesus’4 most well-known surviving treatise, Gynecology, which covers gynecological medicine from pregnancy to birth to women’s diseases, focuses on the physical as well as emotional comfort of the female patient and presents the image of a compassionate and considerate physician. I have selected four passages from this work to examine, which all refer to the pregnant woman’s psychological condition and the need to quell harmful emotions, such as fear, anxiety and despair. In the citation to follow, Soranus lays out the qualifications an excellent and compassionate midwife should have, and stresses various important aspects not only of her personal comportment (her hands and nails, her physical strength, etc.), but also her personality, including her emotional disposition and intellect: ἀτάραχον, ἀκατάπληκτον ἐν τοῖς κινδύνοις, δεξιῶς τὸν περὶ τῶν βοηθημάτων λόγον ἀποδιδόναι δυναμένην, παραμυθίαν ταῖς καμνούσαις πορίζουσαν, συμπάσχουσαν καὶ οὐ πάντως προτετοκυῖαν, ὡς ἔνιοι λέγουσιν, ἵνα συνειδήσει τῶν ἀλγημάτων ταῖς τικτούσαις συμπαθῇ, μᾶλλον γὰρ τετοκυίας5 She will be unperturbed, unafraid in danger, able to state clearly the reasons for her measures, she will bring reassurance to her patients, and be sympathetic. And, it is not absolutely essential for her to have borne children, as some people contend, in order that she may sympathise with the mother, because of her experience with pain; for is more characteristic of a person who has given birth to a child.6

3  ‘Treatment’ and ‘abandonment’ according to Drabkin’s translation. 4  Soranus of Ephesus was a Greek Methodist physician who lived, wrote and practiced in the late first and early second centuries AD. For a thorough background, see Hanson, A. E. and Green, M. H. (1994). ‘Soranus of Ephesus: Methodicorum Princeps’, ANRW 2.37.2, 968–1075. 5  Sor., Gyn. 1.4.3–4, Ilberg 4.18–23 6  Temkin, O. (1956). Soranus’ Gynecology, 6.

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The terms παραμυθίαν, συμπάσχουσαν, and συμπαθῇ highlight the important role of compassion in this passage. Although a midwife’s physical abilities and intellect are obviously important in Soranus’ opinion, as we can see that he does not neglect her ability to be compassionate as well: she brings “reassurance” (παραμυθίαν) and is “sympathetic” (συμπάσχουσαν). In addition, Soranus rejects the idea that a sympathetic midwife has to have also given birth herself, which is apparently advocated by others. He appears to consider compassion a personality trait, something innate, as opposed to something gained by experience or learned from others. Regardless, it is a necessary emotion for a midwife of excellent quality and, in the following chapter, a favourable characteristic for a wet nurse as well. Soranus’ compassionate attitude is also illustrated in the following passage. He writes that, although it is best that a child be nursed by its own mother,7 sometimes it is necessary to choose a wet nurse, who “should be self-controlled, sympathetic (συμπαθής) and not ill-tempered . . .”.8 Here, συμπαθής9 characterises the wet nurse’s compassionate behaviour towards the child, as Soranus explains: συμπαθῆ δὲ καὶ φιλόστοργον, ἵνα καὶ τὰ τῆς ὑπηρεσίας ἀόκνως παρέχῃ καὶ ἀγογγύστως. ἔνιαι γὰρ οὕτως ἔχουσιν ἀπαθῶς πρὸς τὸ γαλουχούμενον, ὥστε μηδὲ ἐπὶ πολὺ κλαυθμυρίζοντος αὐτοῦ ποιήσασθαι πρόνοιαν, ἀλλὰ μηδὲ σχηματίσαι τὸ κείμενον, ἐᾶσαι δ’ ἐφ’ ἑνὸς σχήματος, ὥστε πολλάκις διὰ τὴν θλίψιν προκακοπαθοῦν ναρκᾶν τε καὶ φαύλως διατίθεσθαι τὸ νευρῶδες.10 “Sympathetic” and affectionate, that she will fulfill her duties without hesitation and without murmuring. For some wet nurses are so lacking in sympathy towards the nursling that they not only pay no heed when it cries for a long time, but do not even arrange its position when it lies still; rather, they leave it in one position so that often because of the pressure the sinewy parts suffer and consequently become numb and bad.11 7  Specifically, he says, ἄμεινον γὰρ τῶν ἄλλων ἐπ’ ἴσης ἐχόντων τῷ μητρῴῳ γάλακτι τρέφεσθαι τὸ νήπιον· τοῦτο γὰρ οἰκειότερον αὐτῷ, καὶ πρὸς τὰ γεννηθέντα συμπαθέστεραι μᾶλλον αἱ μητέρες γίνονται . . . (Sor., Gyn. 2.18., Ilberg 65.16–18), “to be sure, other things being equal, it is better to feed the child with maternal milk; for this is more suited to it, and the mothers become more sympathetic towards the offspring . . .” (Temkin, Soranus, 90). This opinion is also expressed by Plutarch who says that mothers should breastfeed their own children in order to create an emotional bond with them. (Plut. Mor. De lib. ed. 3c–d.) 8  Temkin, Soranus, 90. 9   Sor., Gyn. 1.19.13–14, Ilberg 68.10. 10  Ibid., 2.19, Ilberg 68.10–15. 11  Temkin, Soranus, 93.

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Here we have a focus on compassion for the newborn. For Soranus, then, compassion can be a bonding agent: it creates an “affectionate” (φιλόστοργος) connection between the nurse and the infant which is necessary so that the infant is properly nurtured. Like the midwife from the previous passage, not every nurse is naturally compassionate and some act “so unaffectedly” (οὕτως. . .ἀπαθῶς) that they do not have the correct emotional response towards the infant and therefore neglect it. The term ἀπαθής is used here in order to criticise the lack of compassion, which emphasises the importance Soranus places on this emotion as an essential aspect of the nurse’s and midwife’s work. Sentiments of a similar compassionate nature are echoed further on, when Soranus discusses the birth of the child. The midwife and her assistants are held to the same standards when attending to the parturient, especially if she experiences difficulty with the birth: εἰ μὲν ἀσθενὴς εἴη ἡ κυοφοροῦσα καὶ ἄτονος, τὴν μαίωσιν ἐπὶ κατακειμένης αὐτῆς ποιητέον, ὅτι ἀσκυλτότερος οὗτος ὁ τρόπος καὶ ἀφοβώτερος [. . .] τρεῖς δὲ γυναῖκες ὑπηρέτιδες ἔστωσαν προσηνῶς δυνάμεναι τὸ δειλὸν παραμυθεῖσθαι τῆς κυοφορούσης, κἂν μὴ πεπειραμέναι τῶν τοκετῶν τυγχάνωσιν [. . .] εἶτα καλὸν καὶ τὴν ὄψιν τῆς κυοφορούσης φαίνεσθαι τῇ μαίᾳ, ἥτις παραμυθείσθω τὸ δειλὸν αὐτῆς εὐαγγελιζομένη τὸ ἄφοβον καὶ τὴν εὐτοκίαν [. . .] φυλασσέσθω δὲ ἡ μαῖα τὸ εἰς τοὺς γυναικείους κόλπους τῆς τικτούσης τὸ πρόσωπον ἐνατενίζειν, ὅπως μὴ αἰδουμένης συσταλῇ τὸ σῶμα12 . . . if the gravida is weak and toneless one must deliver her lying down since this way is less painful and causes less fear . . . There should be three woman helpers, capable of gently allaying the anxiety of the gravida even if they do not happen to have had experience with birth . . . Furthermore it is proper that the face of the gravida should be visible to the midwife who shall allay her anxiety, assuring her that there is nothing to fear and that delivery will be easy . . . The midwife should beware of fixing her gaze steadfastly on the genitals of the laboring woman, lest being ashamed, her body become contracted.13 Here again we see the use of παραμυθέομαι, meaning to encourage, speak soothingly, or comfort, and this demonstrates Soranus’ level of compassion for the woman in birth and that he expects midwives and attendants to convey this as well. He almost prescribes lines for her to say when he uses the word

12  Sor., Gyn. 2.4.3–2.6.2, Ilberg 53.6–54.24. 13  Temkin, Soranus, 75.

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εὐαγγελιζομένη, which gives a sense of announcing good news, and insisting that they should be face-to-face reinforces this. This positioning allows for more eye contact, which is an important way for individuals to communicate and create intimacy, especially in a medical setting, and a technique used in healthcare today to promote what researchers call “clinical engagement”.14 In this case, the midwife can judge the parturient’s emotional state and react accordingly, and she can also express compassion to her patient directly through encouragement (παραμυθέομαι), by focusing on a “good birth” (ἡ εὐτοκία) and lessening the woman’s fear (ἄφοβος). Inappropriate gazing is addressed in Soranus’ text, too, however, when he writes that the midwife should avoid looking directly at the genitals of the parturient because she may become αἰδουμένης (“embarrassed” or “ashamed”) and clench reactively.15 Here again he takes into account how the woman might feel and provides advice on how the midwife should behave in order to avoid an unwanted reaction. Coincidentally, a mid-second century AD relief on a tomb from Ostia’s Isola Sacra contains an image of this sort of scene. The tomb contains two terracotta reliefs and an inscription by the commissioner of the tomb, Scribonia Attice, who, as she tells us, erected this structure for herself, her husband, and other family and freedmen.16 Both her own and her husband’s professions are depicted on the reliefs to each side of the doorway: a physician and a midwife, respectively. The midwife relief illustrates a birthing scene: a parturient sits in a chair (most likely a birthing chair17) while being held by an assistant and examined physically by a midwife.18 Soranus’ instructions during labour all involve feeling and touching the woman—not looking—and the gesture of the midwife in this relief supports this: she crouches in front of the seated parturient and extends one hand between her legs in what can be assumed to be a gesture of examination. As we have seen in the above passage, Soranus gives 14  See MacDonald, K. (2009). ‘Patient-clinician eye contact: Social neuroscience and art of clinical engagement’, Postgraduate Medicine 121.4, 136–44. 15  For gaze and shame in ancient Rome, see Barton, C. A. ‘Being in the eyes: Shame and sight in ancient Rome’, in Fredrick, D. (2002). The Roman Gaze: Vision, Power, and the Body, 216–35. 16  IPOstie-A, 00222 = ISIS 00133 = Gummerus-01, 00186. 17  Soranus describes a birthing chair at Sor., Gyn. 2.3, Ilberg 52–55. 18  The relief reads: “Scribonia Attice has built for herself and for Marcus Ulpius Amerimnus, her husband, for Scribonia Callityche, her mother, for Diocles and for her freedmen with their descendants, with exception of Panaratus and Prosdocia.” Scribonia Attice’s husband appears to have been a physician, judging by the matching relief on the other side of the tomb’s entrance, which shows a man performing a venesection on another man’s leg with medical tools in the background.

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Midwife birthing scene from the tomb of Scribonia Attice, Isola Sacra, Ostia. Mid-second century AD. Terracotta. Mal585-01_14311,02.jpg from www.arachne .uni-koeln.de.

advice on the midwife’s gaze, too: she should not look directly at the woman’s genitals so as to avoid causing feelings of shame in the patient, and instead she should make direct eye contact so that she can reassure her. The recommended eye contact is not present (she looks outward towards the audience); however, this relief appears both as a ‘snap-shot’ of a birthing scene and a presentation of Scribonia Attice’s profession to the audience.19 The midwife simultaneously avoids inappropriate staring (as recommended by Soranus) and engages the audience with her outward gaze.20 Soranus’ chapter on pica (or kissa, as it is sometimes called) provides a final illustration of compassionate behaviour. Pica is a condition of pregnancy involving upset stomach combined with dizziness, headache, vomiting, digestive issues, and, according to Soranus, the desire to eat “things not customary 19  20 

Kampen, N. (1981). Image and Status: Roman Working Women in Ostia, 74; Kampen describes the relief as “heraldic”. This also fits with the fact that Scribonia Attice is the dedicator of the inscription and therefore the ‘voice’ of both it and the image.

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like earth, charcoal, tendrils of the vine, unripe and acid fruit”.21 The concept of pica today is more general, being applied to women (pregnant and not) and to men, and it is complicated by modern categories of mental illnesses, such as obsessive compulsive disorder.22 But pica as a symptom of pregnancy is still being studied today in such places as Saudi Arabia, Kenya, Tanzania and Mexico.23 Soranus suggests a regime for pica which should help remove or at least control the condition; however, it appears to be a psychologicallyconsuming craving, since for some women the hunger for these strange substances does not abate. He says to first attempt to reason with the pregnant woman, but if this does not work, to allow her eventually to eat what she wants, even if this entails, presumably, substances such as dirt or charcoal: ταῖς δὲ πρὸς τὰ βλαβερὰ τῶν κυουσῶν ἐπιθυμίαις τὸ μὲν πρῶτον ἐνστατέον διὰ λόγων, ὡς τῆς ἀπ’ αὐτῶν βλάβης [καὶ] τῶν τὰς ἐπιθυμίας πληρούντων παραλόγως ᾗ καὶ τὸν στόμαχον κακούσης, οὕτως δὲ καὶ τὸ κατὰ γαστρός [. . .] εἰ δ’ ἀνιαρῶς ἔχοιεν, κατὰ μὲν τὰς πρώτας ἡμέρας οὐδὲν προσενεκτέον, ὕστερον δὲ καὶ μετά τινας ἡμέρας, μὴ τυγχάνουσαι ὧν θέλουσιν τῇ δυσθυμίᾳ τῆς ψυχῆς ἀπισχνοῦσιν καὶ τὸ σῶμα.24 One must oppose the desires of pregnant women for harmful things [i.e., earth, charcoal, etc.] first by arguing that the damage from the things which satisfy the desires in an unreasonable way harms the fetus just as it 21  Sor., Gyn.1.48, Ilberg 35.14–16: καὶ τῶν ἀσυνήθων ὄρεξις οἷον γῆς, ἀνθράκων, ἑλίκων ἀμπέλου καὶ ὀπώρας ἀώρου τε καὶ ὀξώδους. 22  The DSM-4-TR does not make a gender distinction when defining pica (307.52) and lists it under ‘Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence’; other researchers have suggested it may have more in common with obsessive-compulsive spectrum disorders; cf. Stein, D. J. et al. (1996). ‘Pica and the obsessive-compulsive spectrum disorders’, South African Medical Journal 86.12, 1586–92; Rose, E. A. et al. (2000). ‘Pica: Common but commonly missed’, The Journal of the American Board of Family Practice 13.5, 353–58. 23  For modern examples of pregnant women eating dirt and stones, and the possible nutritional reasons behind it, see al-Kanhal, M. A. and Bani, I. A. (1995). ‘Food habits during pregnancy among Saudi women’, International Journal of Vitamin and Nutrition Research 65.3, 206–10; Ngozi, P. O. (2008). ‘Pica practices of pregnant women in Nairobi, Kenya’, East African Medical Journal 85.2, 72–79; Nyaruhucha, C. N. (2009). ‘Food cravings, aversions and pica among pregnant women in Dar es Salaam, Tanzania’, Tanzania Journal of Health Research 11.1, 29–34; Simpson, E. et al. (2000) ‘Pica during pregnancy in low-income women born in Mexico’, Western Journal of Medicine 173.1, 20–24. 24  Sor., Gyn. 1.53.1–2, Ilberg 38.21–30.

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harms the stomach . . . If, however, they feel wretched, though one should offer them none of these things during the first days, some days later one should do so; if they do not obtain what they want, even the body, through the despondency of the soul, grows thinner.25 Soranus’ consent of these unusual and potentially damaging eating habits makes apparent his promotion of compassionate behaviour. After attempting to explain why she should not eat the damaging item and waiting for a few days (presumably to see whether the craving abates), Soranus says to allow τὰ βλαβερά—“the harmful things”, that is, the earth, charcoal, tendrils of the vine, unripe and acid fruit which he mentions at the beginning of the chapter. His reason for this is psychological: not being able to satisfy the craving will cause the woman to “feel wretched” (ἀνιαρός) and become subject to “despondency” (δυσθυμία), and this emotional state will affect her health in a correspondingly negative way.26 According to Soranus, this psychological frame of mind is less favourable than whatever the woman might want to eat and therefore it should be permitted. Thus, rather than single-mindedly forbidding her bizarre cravings, Soranus sees beyond the symptom to the woman’s mental health and values it more highly than the possible damage her craving might cause. These passages from Soranus’ Gynecology reveal a physician who expected a high level of compassion to be provided to women at various stages in their pregnancies.27 He gives instructions on how to be sensitive and sympathetic to patients; how to make them comfortable and secure; and how to encourage and reassure them during difficult situations. The fact that Soranus puts forth these ideas so clearly and consistently throughout his work must mean he valued them greatly. Soranus’ other treatise, On Chronic Diseases, only survives in Greek in a few fragments; however, he was a respected physician within his own lifetime and even after his death, and so there was an effort made by later ancient medical writers and physicians to preserve his work and translate it into Latin 25  Temkin, Soranus, 53–54. 26  δυσθυμία is a word associated with melancholy and mental health in ancient medical literature: e.g., Gal., De loc. aff. 3.9 (K. 8.179.9); 3.10 (K. 8.190.19); 3.10 (K. 8.192.7); 6.1 (K. 8.378.9); 6.1 (K. 8.380.11); 6.5 (K. 8.433.1). For its limited use as ‘depression’ associated with melancholia in the Hippocratic Corpus, see Thumiger, C. ‘The early Greek medical vocabulary of insanity’, in Harris, W.V. (2013). Mental Disorders in the Classical World, 63; For Susan P. Mattern’s discussion of this term as ‘distress’ and its connection to mental disease, see her chapter (Chapter Six) in this volume, 203–223 ‘Galen’s anxious patients: lype as anxiety disorder’. 27  And one example outside of pregnancy at Sor., Gyn. 3.42.3, Ilberg 121.26–31.

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for a wider audience.28 In Roman North Africa in particular, a “Latin medical culture”29 developed which included Caelius Aurelianus, a fifth-century Methodist physician who lived and worked in this area.30 Caelius preserved in Latin the Greek texts of Soranus, creating what scholars used to treat as “translations”31 of his Gynecology, On Acute Diseases and On Chronic Diseases, but are now considered to be rather “adaptations” or “redactions”, as Nutton calls them.32 I have selected four passages from Caelius’ text which will illustrate its compassionate quality.33 Chronic headache, what we might describe as migraine, is addressed by Caelius, as well as other writers such as Aretaeus.34 The following passage occurs early on in the chapter when Caelius discusses how the pain travels and what compassionate therapeutic approaches the physician should take: si autem dolor ad dentes tetenderit, mulsum calidum uel oleum damus, quod in ore sine ullo motu contineat, nisi quis hoc horrescens in nauseam fuerit prouocatus. At si uehementius dolor conualuerit et maiora exegerit adiutoria, permittentibus uiribus in ipsa diatrito uel ante ipsam sanguis erit detrahendus phlebotomia scilicet. sed totum caput dolentibus ex eo brachio, quod facilius fuerit, detractio facienda. at si altera pars capitis doluerit, ex eius contraria detractionem faciemus, quo longius adiutorii commotio a parte patienti remota uideatur.35

28  Caelius is mentioned in: Tert., De anim. 6; August., Cont. Jul. 51; Paul. Aeg. 6.59, Heiberg CMG IX. 29  Following Nutton, V. (2004). Ancient Medicine, 4. 30  The fifth century is the most commonly accepted time period for Caelius, based on a comparison of his Latin with that of Cassius Felix, a mid-fifth century medical writer (Drabkin, I. E., 1950, Caelius Aurelianus: On Chronic and Acute Diseases). Caelius gives Sicca Veneria, Numidia as his location. 31  How much of Caelius’ text is an exact translation of Soranus’ original is unknown; however, most scholars believe it to be very much Soranus’ text with some omissions and additions by Caelius (Hanson and Green, ‘Soranus’, 1034; Neuburger, M., 1910. History of Medicine, 309) while others defend it more as basically Caelius’ work (Pigeaud, J. ‘Pro Caelio Aureliano’, in Sabbah, G., 1982. Memories 3: Médecins et Médecine dans l’Antiquité, 105–17.) Little else is known about Caelius apart from these works and a fragmentary dietetic question-and-answer text. 32  Nutton, Medicine, 195. 33  One other example may be found in Cael. Aur., TP 1.1.25–27. 34  Aret., Caus.Ac. 1.5, Hude 2.15–16. 35  Cael. Aur., TP 1.10–11, Bendz CML VI, 434.20–28.

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But if the pain reaches to the teeth, give the patient warm mead or olive oil to keep in his mouth without any motion. But do not use this treatment if the patient is upset and nauseated by it. Now if the pain becomes even worse and requires more powerful remedies, withdraw blood by venesection, if the patient’s strength permits, at the end of the three-day period or even before that time. In cases where the whole head is in pain, withdraw the blood from the arm where it is easier. But if only one part of the head is in pain, withdraw the blood from the opposite arm, so that the disturbing effect of the remedy may be far removed from the part affected.36 Here, Caelius suggests warm mead or olive oil because the pain is in an awkward area, the mouth; however, holding a liquid in the mouth might cause the patient to become distressed (horrescens) and suffer nausea (in nauseam . . . provocatus) which is not acceptable, according to Caelius, as he suggests forgoing the treatment if this happens. By understanding that not all patients may be able to cope with this treatment and being willing to veto it, if it causes discomfort, Caelius exhibits the ability to take on the point of view of another and understand how that person feels, and be compassionate. This is not a treatment that will cure the patient; it is simply meant to ease the pain in the teeth. Thus, if it simply trades one discomfort for another, Caelius chooses to refrain from it entirely. The same approach is applied to venesection: if the pain is localised to one side, Caelius recommends applying the treatment to the opposite side to avoid commotio (“agitation”). Regardless of whether this has any real effect on the patient, the point is that Caelius believes that it does and this means he intends to always choose the least painful and distressing version of his recommended therapy; in other words, he consistently selects the compassionate choice. Likewise, in his chapter on mania, Caelius describes a treatment which can be characterised, by and large, as gentle and soothing, which focused very much on the mental and physical comfort of the patient. In a word, it is compassionate. He gives instructions on how to handle a manic individual and his aberrations, and who should and should not be in contact with him. He writes: erunt praeterea multorum ingressus prohibendi et maxime ignotorum. mandandum quoque ministris ut eorum errores quodam consensu accipientes corrigant, ne aut omnibus consentiendo augeant furorem, eorum uisa confirmantes, aut rursum repugnando asperent passionis augmentum, sed 36  Drabkin, Caelius, 447.

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inductiue nunc indulgeant consentientes, nunc insinuando corrigant uana, recta demonstrantes. ac si exsilire coeperint, ut difficile teneantur, uel solitudine potius exasperantur, oportebit plurimis uti ministris et praecipere aegros latenter retineri ad articulorum fricationem, quo minime prouocentur. si etiam uisu hominum fuerint commoti, erit adhibenda ligatio sine ulla quassatione . . .37 Do not permit many people, especially strangers, to enter the room. And instruct the servants to correct the patient’s aberrations while accepting (them) with a certain fellow-feeling. That is, have the servants, on the one hand, avoid the mistake of agreeing with everything the patient says, corroborating all his fantasies, and thus increasing his mania; and, on the other hand, have them avoid the mistake of objecting to everything he says and thus aggravating the severity of the attack. Let them rather at times lead the patient on by yielding to him and agreeing with him, and at other times indirectly correct his illusions by pointing out the truth. And if the patient begins to get out of bed and cannot easily be restrained, or is distressed especially because of solitude, use a large number of servants and have them covertly restrain him by massaging his limbs; in this way they will avoid upsetting him. If the patient is excited when he sees these people, bind him without [any] injury.38 His advice for how the servants should behave in the presence of the patient is interesting for its rationality and gentleness, that is, its compassion. He directs that they should avoid upsetting him either by agreeing with his delusions and thereby affirming his erroneous thoughts (ne . . . augeant furorem,39 “in order not to increase his mania”), or by disagreeing with him which would upset the patient (asperent passionis augmentum, “aggravating the severity of the attack”). He also says that corrections should be made quodam consensu accipientes—what I have rendered here as “while accepting (them) with a certain fellow-feeling”, which Drabkin translates as “while giving them a sympathetic hearing”. The aim appears to be that of avoiding distressing the patient in any way, while guiding him towards reality. Even restraining him is meant to be done in a non-confrontational way, by massage. Caelius’ prescribed treatment in this chapter would have been a fine line for servants and family members to walk; they would have needed to be closely instructed on how to respond to 37  Cael. Aur., TP 1.156–57, Bendz CML VI, 522.23–33. 38  Drabkin, Caelius, 543. 39  In Latin, mania and furor are equivalent concepts.

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the patient’s delusions. This kind of therapy is indicative of Caelius’ focus on the mind of the patient and how best to calm and persuade it toward reason. This is not the only therapy—the chapter focuses half on physical treatment and half on mental—but the fact that Caelius mentions this demonstrates his awareness of how easily aggravated a manic person’s mind can be and the sort of behaviour required on the caregiver’s part to avoid this. The gentleness, sensitivity and non-confrontational method of this therapy illustrate that it is compassionate. Caelius continues to endorse the humane treatment of patients who suffer from mania further on in the same chapter. Throughout his work, he discusses (and usually refutes) the prescribed therapies of other physicians; in this chapter he condemns what he sees as harsh and unnecessary treatment of the patients at the hands of some physicians. He writes: non enim uere admittenda aut credenda sunt ea, quae suspicantur, quibus ipsi insanire potius quam curare uideantur [. . .] iubent praeterea uinculis aegrotantes coerceri sine ulla discretione, cum necessario deuinctae partes quatiantur et facilius aegros ministrantium manibus quam inertibus uinculis retinere. cupiunt etiam certis medicaminibus somnos altos efficere, papauere fouentes et pressuram potius atque grauationem capitis, non somnum ingerentes [. . .] alii flagellis aiunt coercendos, ut quasi iudicio mentis pulso resipiant, cum magis tumentia caede lacessendo faciant asperiora et adueniente lenimento passionis, cum sensum recipiunt, plagarum dolore uexentur. uel certe, sicut ratio poscit, uicinis magis ac patientibus locis adiutoria sunt adhibenda; coguntur ergo, ut ori uel capiti plagas imponant [. . .] His igitur omnibus experimentis inanibus conferta est furiosorum curatio.40 Indeed, we cannot agree to, or accept, the conjectures of these writers who seem themselves to be insane rather than able to cure . . . These physicians also prescribe indiscriminately that the patients be kept in bonds. But, in fact, the parts that are bound must suffer injury; moreover, it is easier to restrain patients by having servants use their hands than by applying bonds improperly. And these same physicians try to produce a deep sleep with certain drugs, fomenting the patient with poppy and causing stupor and drowsiness rather than natural sleep . . . Some say he should be flogged, apparently so that he may regain his sanity by a kind of whipping of his reason. But the raining of blows upon the inflamed parts will 40  Cael. Aur., TP 1.172–178, Bendz CML VI, 532.12–14, 18–23; 534.10–15; 536.16–17.

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only aggravate these parts; and, when the attack is over and the patient recovers his senses, he will still be assailed by the pain from these blows. Indeed, reason would require that such remedies be applied in particular to the affected parts and those near them; and so these physicians would have to strike their blows at the face and head . . . And so the treatment of insanity is marked by all these futile and haphazard procedures.41 Caelius judges these medical writers quite harshly with the line “these writers [who seem themselves to be insane rather than able to cure]”.42 While feeling compassion for patients suffering the symptoms of mania, he exhibits no compassion for those of his colleagues who advocate what he sees as inhumane treatment. Bonds are to be avoided since they cause injury, and we have seen this already in the previous passage. Hurting the patient is what Caelius tries to avoid: so, tying the patient down, or beating the patient goes against the type of treatment he promotes. Drugging the patient into sleep is viewed negatively, and he disapproves especially of flogging since he sees it not only as hurtful to the patient, but also ineffective and illogical as a therapy. In general, he describes the majority of the treatments of other medical writers as experimenta (“experiments”) and inanes (“futile”)—two terms which would certainly not be consistent with compassionate behaviour. Similarly, Caelius’ discussion of the disease of elephantiasis also affirms the importance of compassionate treatment and is a defense of the humanitarian nature of medicine. Elephantiasis was a chronic disease and difficult to cure for ancient physicians, which apparently caused some to resort to seclusion: Item alii aegrotum in ea ciuitate, quae numquam fuerit isto morbo uexata, si fuerit peregrinus, caedendum43 probant, ciuem uero longius exulare aut locis mediterraneis et frigidis consistere ab hominibus separatum, et inde revocari, si meliorem receperit ualetudinem, quo possint ceteri cives nulla istius passionis contagione sauciari. sed hi aegrotantem destituendum magis imperant quam curandum, quod a se alienum humanitas approbat medicinae.44

41  Drabkin, Caelius, 555; 557; 559. 42  Drabkin translates this, slightly more dramatically, as “they seem to be the madmen themselves rather than the physicians of madmen.” 43  Bendz takes this word as caedendum (Cael. Aur., TP 4.13, Bendz CML VI, 782.2), while Drabkin takes it as cludendum, which he translates as “imprisoned”. 44  Cael. Aur., TP 4.13, Bendz CML VI, 782.1–7.

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Some assert that if a case of elephantiasis occurs in a city in which the disease has never occurred before, if the patient is a foreigner he should be killed45; if a citizen, he should be sent into distant exile or made to stay in cold, inland places away from other people, and should be brought back only if he regains his health. Their purpose is to protect the rest of the citizens from injury through contact with the disease. But their prescription for the patient amounts to abandonment rather than treatment, and such a view is foreign to the humanitarian principles of medicine.46 Judging by other descriptions of elephantiasis from authors such as Aretaeus of Cappadocia,47 this disease was horrific in nature and would have frightened many people, especially in its final stages. This is emphasised in Caelius’ description since he suggests that people believed it to be contagious, and imprisonment48 and exile were employed in order to limit the citizenry’s exposure to the disease. As a physician, Caelius objects to this reasoning because it is a form of destituendum (“abandonment”) rather than curandum (“treatment”) and he calls upon the “humanitas . . . medicinae” (“humanitarian principles of medicine”) as the reason why this is wrong, thereby opposing the true goal of the physician, which is to cure the patient, with the concept of abandonment. Doing nothing is not acceptable, even with regards to extremely difficult and severe diseases such as elephantiasis. Caelius’ compassion for patients is brought out in this passage by contrast with the uncompassionate actions of others. He does however demonstrate more understanding of the point of view of the perpetrators than in the previous passage. Perhaps this is because those criticised are not physicians or medical writers (or at least he does not tells us; I believe he would tell us since he makes this obvious in his other chapters when discussing treatment). Caelius believes, to repeat, that physicians should follow this “humanitas . . . medicinae” which he states here, and inherent in it is the compassionate treatment of patients. This concept of humanitas is present in the text of Scribonius Largus49 as well and deserves consideration here. In the preface to his Compositiones, 45  Altered to reflect Bendz’s word choice (note 44). 46  Drabkin, Caelius, 823. 47  Aret., Caus.Chr. 2, 13 Hude 85–90. 48  Cf. note 44. If cludendum is meant, it is an unsympathetic approach; however, if caedendum is meant, whereby the foreigner is beaten or killed, then this is a particularly uncompassionate and cruel method with which to deal with an ill individual. 49  Scribonius Largus flourished ca. 14–54 and was a Roman physician whose only surviving text, Compositiones, is a pharmacological text covering a large number of diseases and

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Scribonius gives a defense of the use of drugs in the medical profession, which subsequently evolves into a discussion of medical ethics and the responsibilities of the physician. He talks of the physician’s humanitas and how it is an important aspect of what it means to be a healer. Humanitas can be difficult to conceptualise. It can be translated as ‘humanity,’ ‘humaneness’ or ‘gentleness’; it is, however, basically grounded in the idea that we are all human beings, we all suffer and we all deserve to have this suffering relieved, if possible.50 This internal feeling appears to drive Scribonius’ sense of professionalism and what it means to be a physician, someone who has the potential capacity to relieve suffering. This feeling motivates the physician to focus on the goals of preserving the life of the patient and relieving his or her suffering; he must use everything available to him to do so. This use of humanitas is very similar to the way in which Caelius uses it here. He believes that the physician should help, not abandon, the patient suffering from elephantiasis based on this concept of humanitas, for to not do so is alienum to the humanitas . . . medicinae. Soranus and Caelius both endorsed the compassionate treatment of the sick and suffering, and terms such as συμπαθής, παραμυθία and humanitas reveal to us these physicians as concerned with treating their patients with compassion, patience, and attention. They were worried for their patients’ comfort, advocated humane therapies, and were themselves persistent in doing whatever they could, even when confronted by difficult diseases. Moreover, there are indications that Soranus and Caelius were not alone. Aretaeus of Cappadocia and Scribonius Largus had similar outlooks and approaches. Scribonius Largus, for example, was concerned with how compassion fits into a physician’s professional ethics and makes him a more devoted doctor51; Aretaeus their drug-related cures. The preface to his text is a letter addressed to the freedman of the emperor Claudius, Gaius Julius Callistus, who appears to have commissioned Scribonius’ text. Scribonius also thanks him for showing his medications to the emperor. He references humanitas at Scrib. Comp. ep(3).2–ep(4).1 and ep(5).1–6. 50  For Giulia Ecca’s discussion of φιλανθρωπία as an essential qualification for a good physician in the Hippocratic Praecepts, see her chapter (Chapter Twelve) of this volume, 325–344. ‘The Μισθάριον in the Praecepta: the Medical Fee and its Impact on the Patient’. As an example of the permeability of technical terms between genres of this time period, a surprising comparison can be found in Chariton’s Callirhoe, where φιλανθρωπία, as a Greek equivalent of humanitas, can be taken to mean ‘compassion’ or ‘humanity.’ E.g., Charit.1.12.1; 1.13.10; 2.5.3; 3.4.9; 6.5.10. 51  Many scholars have written on the medical ethics of Scribonius Largus, as he outlines it in his Professio Medici, the short essay which precedes his Compositiones. See Deichgräber, K. (1950). Professio Medici: zum Vorwort des Scribonius Largus; Pellegrino, E. D. and Pellegrino, A. A. (1988). ‘Humanism and ethics in Roman medicine: Translation and commentary on a text of Scribonius Largus’, Literature and Medicine 7.1, 22–38; Hamilton, J. S.

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also advocated much along the same lines as Soranus and Caelius, promoting the comfort of the patient and compassionate treatment.52 Thus, very prominent physicians of the first and second century (including here evidence from Caelius Aurelianus, who relies on Soranus’ work to an important extent) demonstrate a particular—if not necessarily novel—interest in how patients are treated, advocating compassion and humanity in their interactions with them. Texts and Translations Used Aretaeus of Cappadocia, De causis et signis acutorum morborum (Caus.Ac.); De causis et signis diuturnorum morborum (Caus.Chr.). Ed. by C. Hude. Leipzig: In aedibus Academiae Scientiarum, 1958 (CMG II). Caelius Aurelianus. Akute Krankheiten Buch 1–3. Chronische Krankheiten Buch 1–5. Ed. G. Bendz. (CML VI). Berlin: Akademie Verlag, 1990. ———. Aus den Medicinales Responsiones des Caelius Aurelianus. Ed. V. Rose. Anecdota Graeca et Graecolatina, 163–280. Amsterdam: Verlag Adolf M. Hakkert, 1870. ———. On Acute Diseases and On Chronic Diseases. Ed. and trans. I. E. Drabkin. Chicago: University of Chicago Press, 1950. Scribonius Largus. Ed. S. Sconocchia. Scribonii Largi Compositiones. Leipzig: B. G. Teubner, 1983. Soranus of Ephesus. Gynaeciorum libri 4. Ed. J. Ilberg. (CMG IV). Leipzig: In aedibus Academiae scientiarum, 1927. Soranus’ Gynecology. Trans. O. Temkin. Baltimore: Johns Hopkins University Press, 1956.

References al-Kanhal, M. A. and Bani, I. A. ‘Food Habits During Pregnancy Among Saudi Women.’ International Journal of Vitamin and Nutrition Research, 65.3 (1995): 206–10. Alford, C. F. ‘Greek Tragedy and Civilization: The Cultivation of Pity.’ Political Research Quarterly 46.2, (1993): 259–80. (1986). ‘Texts and documents: Scribonius Largus on the medical profession’, Bull. Hist. Med. 60.2, 209–16; Baldwin, B. (1992). ‘The career and work of Scribonius Largus’, RhM 135, 74–82; Nutton, V. (1995). ‘Scribonius Largus, the unknown pharmacologist’, Pharmaceutical Historian 25.1, 5–8. Although my focus is the emotion of compassion itself, as displayed by ancient medical writers, the concept of medical ethics naturally comes into play as well. 52  Aretaeus exhibits a very pronounced emotional reaction to the pain and suffering of patients, with one very good example in his chapter on tetanus: Aret., Caus.Ac. 1.6.7–9, Hude 7.3–23.

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Baldwin, B. ‘The Career and Work of Scribonius Largus.’ Rheinisches Museum für Philologie 135, (1992): 74–82. Barton, C. A. Sorrows of the Ancient Romans: The Gladiator and the Monster. Princeton: Princeton University Press, 1995. ———. ‘Being in the Eyes: Shame and Sight in Ancient Rome.’ in The Roman Gaze: Vision, Power, and the Body, ed. D. Fredrick, 216–35. Baltimore: Johns Hopkins University Press, 2002. Blowers, P. M. ‘Pity, Empathy, and the Tragic Spectacle of Human Suffering: Exploring the Emotional Culture of Compassion in Late Ancient Christianity.’ Journal of Early Christian Studies 18.1, (2010): 1–27. Deichgräber, K. Professio Medici: zum Vorwort des Scribonius Largus, Abhandlungen der Akademie der Wissenschaften und der Literatur. Mainz: Steiner, 1950. Ferwerda, R. ‘Pity in the Life and Thought of Plotinus.’ in Plotinus Amid Gnostics and Christians, ed. D. T. Runia, 53–72. Amsterdam: Free University Press, 1984. Fulkerstone, L. No Regrets: Remorse in Classical Antiquity. Oxford: Oxford University Press, 2013. Hamilton, J. S. ‘Texts and Documents: Scribonius Largus on the Medical Profession.’ Bulletin of the History of Medicine 60.2, (1986): 209–16. Hanson, A. E. and Green, M. H. ‘Soranus of Ephesus: Methodicoruum Princeps.’ in Aufstieg und Niedergang der römischen Welt 2.37.2, ed. W. Haase, 968–1075. Berlin and New York: Walter de Gruyter, 1994. Harris, W. V. ‘History, Empathy, and Emotions.’ Antike und Abendland 56, (2010): 1–23. Kampen, N. Image and Status: Roman Working Women in Ostia. Berlin: Mann, 1981. Kaster, R. A. Emotion, Restraint and Community in Ancient Rome. Oxford: Oxford University Press, 2005. Konstan, D. ‘Altruism.’ Transactions of the American Philological Association 130, (2000): 1–17. ———. Pity Transformed. London: Duckworth, 2001. ———. The Emotions of the Ancient Greeks: Studies in Aristotle and Classical Literature. Toronto: University of Toronto Press, 2006. Kosak, J. ‘A Crying Shame: Pitying the Sick in the Hippocratic Corpus and Greek Tragedy.’ in Pity and Power in Ancient Athens, ed. R. Hall Sternberg, 253–76. Cambridge: Cambridge University Press, 2005. MacDonald, K. ‘Patient-Clinician Eye Contact: Social Neuroscience and Art of Clinical Engagement.’ Postgraduate Medicine 121.4, (2009): 136–44. Neuburger, M. History of Medicine. Trans. E. Playfair, vol. 1. London: H. Frowde, 1910. Ngozi, P. O. ‘Pica Practices of Pregnant Women in Nairobi, Kenya.’ East African Medical Journal 85.2, (2008): 72–79. Nutton, V. Ancient Medicine. London: Routledge, 2004.

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———. ‘Scribonius Largus, the Unknown Pharmacologist.’ Pharmaceutical Historian 25.1, (1995): 5–8. Nyaruhucha, C. N. ‘Food Cravings, Aversions and Pica Among Pregnant Women in Dar es Salaam, Tanzania.’ Tanzania Journal of Health Research 11.1, (2009): 29–34. Pellegrino, E. D. and Pellegrino, A. A. ‘Humanism and Ethics in Roman Medicine: Translation and Commentary on a Text of Scribonius Largus.’ Literature and Medicine 7.1, (1988): 22–38. Pigeaud, J. ‘Pro Caelio Aureliano.’ in Memories 3: Medecins et Medecine dans l’Antiquite, ed. G. Sabbah, 105–17. Saint-Étienne: Publications de l’Université de Saint-Étienne, 1982. Rose, E. A., Porcerelli, J. H. and Neale, A. V. ‘Pica: Common but Commonly Missed.’ The Journal of the American Board of Family Practice 13.5, (2000): 353–58. Rosenwein, B. H. ‘Worrying about Emotions in History.’ The American Historical Review 107.3, (2002): 821–45. ———. ‘Problems and Methods in the History of Emotions.’ Passions in Context: Journal of the History and Philosophy of the Emotions 1, (2010): 1–32. Simpson, E., Mull, J. D., Longley, E. and East, J. ‘Pica During Pregnancy in Low-income Women Born in Mexico.’ Western Journal of Medicine 173.1, (2000): 20–24. Stein, D. J., Bouwer, C. and Heerden, B. van ‘Pica and the Obessessive-compulsive Spectrum Disorders.’ South African Medical Journal 86.12, (1996): 1586–92. Thumiger, C. ‘The Early Greek Medical Vocabulary of Insanity.’ in Mental Disorders in the Classical World, ed. W. Harris, 61–95. Leiden: Brill, 2013. Toohey, P. Boredom: A Lively History. New Haven: Yale University Press, 2011.

CHAPTER 11

Galen on the Patient’s Role in Pain Diagnosis: Sensation, Consensus, and Metaphor Courtney Roby Pain might be a powerful diagnostic tool, but it is at the same time an intensely private and subjective experience that represents a formidable problem in the communication between physician and patient. Galen addresses (principally in De locis affectis) the problem of constructing a consistent and univocal terminology for different pain sensations, rejecting the system proposed earlier by Archigenes on the grounds that he relies on metaphorical descriptors which indiscriminately incorporate terms belonging to information generated by all the senses, fails to conform to patient testimony, and refers to ambiguous concepts. Galen sets himself the task of developing a system of proper or literal (kyrios) terms for pain sensations, even despite the apparent ineffability of certain sensations and laymen’s imprecise self-analysis and description of their suffering. His pain vocabulary, developed through a combination of consensus between patients and physicians’ expert descriptions of their own pain, promises to link terminology univocally to sensation, turning patients’ testimony about their subjective experience of pain into universally applicable diagnostic guidance. 1 Introduction The pain suffered by a patient appears at first glance to represent a powerful diagnostic tool, a chance for a physician to access events in the patient’s interior, which otherwise lie largely inaccessible.1 However, pain also creates a host of diagnostic challenges: it must be mediated by the testimony of the patient, and there is no guarantee that a suffering layman will describe his sensations in terms that will guide the physician along a clear diagnostic path. Pain is, furthermore, notoriously resistant to verbal description; Scarry notes the vivid 1  On the mysteries of the ‘cavity’, see Holmes, B. (2010). The Symptom and the Subject: The Emergence of the Physical Body in Ancient Greece, particularly 121–30, 138–47.

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contrast between pain’s inescapability for a patient and its verbal inaccessibility to anyone else.2 Galen is particularly concerned in De locis affectis with the problem of establishing a consistent and transparent terminology for pain sensations. The solution to this problem requires information deriving from both the physician’s expertise and the patient’s direct experience; both must be disciplined by terminological precision. Verbalizing bodily sensations of pain seems to require some intermediate step of cognitive processing: in order to become describable, bodily pain must somehow be conceptualised in the mind.3 In De placitis Hippocratis et Platonis Galen argues the broader point that sense perception itself requires some kind of cognitive processing. The sensation-enabling processing done by the hēgemonikon, the “ruling part” of the mind, is specifically the realisation that alteration has occurred in some part of the body.4 If the realisation does not happen, in Galen’s model pain sensation cannot truly be said to have occurred. He classifies certain patients as beblammenoi, “stricken”: they would feel pain if their mental faculties had not suffered so as to render them incapable of processing it.5 In De locis affectis he records two similar, yet crucially different, cases of youths suffering from epilepsy. The first patient is able to narrate how his affliction moved upward from the lower leg on one side, eventually reaching the head, at which point he was unable to observe it anymore. The second patient, whose mental faculties were not damaged by the attack (Galen describes him as ouk aphrōn) has a very different experience. He was “better able to explain (hermēneusai)”, articulating that he felt like a cool breeze was rising up to his head.6 In the first case, as with the patients Galen calls beblammenoi, the patient loses the ability to discern the sensation associated with his condition, at the moment when the attack seems to move to the brain. The second patient maintains his faculty of discernment throughout the attack, so that he feels what is happening to him even when the attack moves to the head and can put it into words for the benefit of his doctors. The ability to verbalise sensation is a most valuable diagnostic tool, and must not be taken for granted. 2  Scarry, E. (1985). The Body in Pain: The Making and Unmaking of the World, 4, 13. 3  Plato’s Philebus proposes several possibilities for the level of cognitive processing associated with pain; these are analyzed in Evans, M. (2007). ‘Plato and the meaning of pain’, Apeiron: A Journal for Ancient Philosophy and Science 40.1, 71–94. 4  Gal., De plac. Hipp. et Plat. (K. 5.635 = De Lacy 468.15). 5  Ibid. (K. 5.637 = De Lacy 468.25). 6  Gal., De loc. aff. (K. 8.194). On this episode see also Pigeaud, J. (1999). Poésie du corps, 137–38.

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Pain is of particular importance for this question because, as Scarry observes, unlike other sensations it lacks an external object, so the patient’s translation of his experience into words is of special diagnostic value.7 Some diagnostic cues, however, may elude verbalisation. Galen asserts that “certain peculiar and unspeakable (arrhēta) [signs] precede the speakable symptoms, verifying the diagnoses of the affected parts” (De loc. aff. 8, 339 K.).8 While the latter can, he says, be discovered on one’s own, he promises to explain how a dedicated observer can also become acquainted with the attributes of the symptoms that cannot be spoken. Galen can obviously not articulate these in his text; he can only recommend the path of study by which the physician will acquire the tacit knowledge he needs to recognise them in the field. What form could knowledge of ‘unspeakable’ attributes take? While Galen often emphasised the distinction between Stoic epistemology and his own, it may be useful to compare Stoic views on the connection between verbally articulated and perceptual knowledge to Galen’s own.9 Brittain observes that Stoic “concepts” (ennoiai) seem to be connected to perceptual impressions, memory, and experience;10 hence the image attributed to Aëtius, of the hēgemonikon as a blank piece of paper upon which ennoiai are written, first through sense, then (after the aggregation of memories) through experience.11 In this view, Hood observes, “Stoic ennoiai arise from clear phainomena, from our senses”.12 However, Brittain notes that “it seems necessary that the proper content of each concept should be a unique lekton”,13 suggesting that ‘unspeakable’ content might present problems. So what Galen has in mind when he mentions the role of arrhēta in diagnosis is perhaps not quite the same as the 7  Scarry, Body in Pain, 163 ff.; Holmes, Symptom, 119 n. 141. 8  On these ‘unsayables’ see Reinhardt, T. (2011). ‘Galen on unsayable properties’, Oxford Studies in Ancient Philosophy 40, 297–317. 9  A broader comparison between Galen’s views and those of the Stoics can be found at Gill, C. (2007). ‘Galen and the Stoics: Mortal enemies or blood brothers?’, Phronesis: A Journal for Ancient Philosophy 52.1, 88–120; more extended analysis in id. (2010). Naturalistic Psychology in Galen and Stoicism. 10  Brittain, C. ‘Common sense: Concepts, definition and meaning in and out of the Stoa’, in Frede, D. and Inwood, B. (2005). Language and Learning: Philosophy of Language in the Hellenistic Age, 170. 11  Aëtius, Placita 4.11 = SVF 2.83, von Arnim; see also Brittain, ‘Common sense’, 168–69; Hood, J. ‘Galen’s aristotelian definitions’, in Charles, D. (2010). Definition in Greek Philosophy, 460–61. 12  Hood, ‘Definitions’, 461. 13  Brittain, ‘Common Sense’, 174.

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Stoic ennoia; at the same time, direct perceptual encounters remain crucially important to their discovery. To elicit understanding of these ‘unspeakable’ elements is a matter of expertise and experience, requiring the doctor to negotiate the patient’s verbal testimony as well as a host of nonverbal cues in order to extract a diagnosis from pain. 2

Archigenes’ Pain Terminology

In order to turn pain experiences into useful diagnostic information, Galen argues, a consistent and unambiguous terminology must be developed. Galen enters upon a scene with some pain terminology already available. Archigenes of Apamea, a figure from the early second century AD, dominates Galen’s discussion of the pre-existing terminology, as Archigenes appears already to have embarked on the project of identifying sources of pain with characteristic terms (De loc. aff. 70). Little is known of Archigenes’ life; some fragmentary texts survive, and he is cited by Oribasius a few times, most often on pharmacological questions, but the vast majority of surviving information about him is found in Galen’s many comments on his work, which are mostly unflattering. The terminology chosen by Archigenes is, unsurprisingly, unacceptable to Galen, depending as it does upon terms for pain that “cannot be pointed out when they appear nor comprehended when they are spoken of” (De loc. aff. 87). These include “drawing” (holkimos), “harsh” (austēros), “sweet” (glykos), “salty” (halykos), and “astringent” (styphos) pains. Galen attributes some of these terms to Archigenes himself; others are apparently the products of other authors, as Galen earlier refers to types of pain other than those described by Archigenes.14 Whoever their originator might be, they are problematic, for a variety of reasons. After his initial critique, Galen goes on to say that he has already run into terms incapable of teaching anything, in trying to diagnose based on the pulse.15 He aims to solve this problem, since “all scientific instruction requires 14  For Galen’s opinions about the verbal precision of ‘Hippocrates’ (overall much more positive than his evaluation of Archigenes), see Sluiter, I. ‘The embarrassment of imperfection: Galen’s assessment of Hippocrates’ linguistic merits’, in Eijk, Ph. van der et al. (1995). Ancient Medicine in its Socio-Cultural Context, 519–35. 15  Galen’s reference does not make quite clear which work he refers to; material on pulse terminology is found throughout the surviving works on that topic, though the material most relevant here comes from De differentia pulsuum, De dignoscendis pulsibus, and De praesagitione ex pulsibus.

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proper (kyrios) names” (De loc. aff. 87).16 In diagnosing from the pulse, as from pain, Galen’s stated aim is to establish a vocabulary which can be used to distinguish fine shades of a physiological phenomenon, so that physicians can be reasonably sure that they mean the same thing by a given term as their fellow practitioners. It is therefore not surprising to find that diagnosis from the pulse presents similar problems to diagnosis from pain.17 De praesagitione ex pulsibus emphasises the problems with transferring terms from one sense to another: “just as each individual one of the various words clarifies a thing for all Greeks”, so they designated the qualities appropriate to each sense with unambiguous terminology.18 White, red, grey, and so forth belong to sight and no other sense; harsh and salty to taste alone, and hot and soft only to touch. Colours, tastes, temperatures, and pressures: all of these have their proper sense, and are inaccessible to the others. As von Staden observes, Galen frequently claims that the ‘primary’ or literal ( prōtos or kyrios) sense of a word is associated with its target by the agreement of all Greeks.19 Customary usage and common assent will turn out to play an important role in establishing pain terminology as well. Galen proceeds in this passage to introduce the term ‘metaphor’ for the alternative to the word’s ‘primary’ sense, which is constructed “according to some likeness and analogy” (κατ᾿ ὁμοιότητά τινα καὶ ἀναλογίαν).20 He acknowledges that ordinary speakers often metaphorically transfer terms from one sensory domain to another in casual language use, but argues that transferred terms cannot furnish adequate scientific terminology. Part of the problem with metaphorical terms stems from the role of accidents (contingent attributes) in their creation. In another work on the pulse he observes that people use words like “hard” (sklēros) to describe objects as 16  The requirement here that epistēmonikē didaskalia be equipped with kyria is extended to didaskalia of technical subjects at Gal., De diff. puls. (K. 8.675). 17  On diagnosis from the pulse, see also in this volume Lewis, ‘Ancient Pulse-Lore in Practice: “the art” of the pulses and its role in patient-doctor interaction’ (Chapter Thirteen, 345–364). 18  Gal., De praesag. ex puls. (K. 9.2.367–68.). 19  Staden, H. von (1995). ‘Science as text, science as history: Galen on metaphor’, Clio Medica 28, 504. Von Staden collects references to several such instances at n. 15. Galen’s stipulations for ‘the usage of the Greeks’ are outlined at Morison, B. ‘Language’, in Hankinson, R. J. (2008). The Cambridge Companion to Galen, 143–47. 20  The parallel problems of metaphors for the pulse in Chinese medicine, and their connection to the idea that each sense has its proper objects, are discussed in Kuriyama, S. (1999). The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine, particularly 165 ff.

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diverse as law and wine.21 He explains the reasons for these individual usages of the word, but more importantly the overarching generative principle behind such metaphors: they are reflections of the things that can happen “accidentally” (kata sumbebēkos) to various bodies which are hard, and of a “transfer” (metaphora) from some likeness. This passage expands on the ideas expressed in De praesagitione ex pulsibus: the creation of metaphors from ‘likenesses’ between two phenomena is preserved, but the additional, more alarming, possibility of their creation from accidents is brought in as well.22 These accidents might proliferate unbounded, producing a swarm of ambiguous meanings which would make finding one’s way back to the causal trigger of a sensation nearly impossible.23 To discipline the field of terminology, Galen proposes a four-element progression of types of definition, ranging from the kind that “fully and clearly tells the concept (ennoia) of the subject” to the kind that teaches its “essence (ousia)”, plus two intermediate stages.24 The first type has the advantage of being intelligible to all those who speak the language, but misses out on the essence of the thing concerned and so does not provide what Hood calls “a fully scientific, essential” grasp of the concept.25 Galen evaluates ennoematic definitions as explaining (hermēneuein) nothing more than what everyone knows.26 He warns that some relatively inexperienced doctors may err by thinking they have arrived at an essential definition, when in fact they have not progressed beyond the ennoematic definition. Ennoematic definitions, as Galen represents them here, seem to pose the very same risk as metaphor, in that they pick out accidental features of the object rather than grasping its essence.27 They correspond to common impressions, rather than expert knowledge precisely expressed through proper terminology. The usual demands on such terminology, for all kinds of technē, are clarity and univocality.28 Naval terminology (the so-called sermo nauticus) offers 21  Gal., De diff. puls. (K. 8.690–91). 22  On this possibility see Staden, ‘Science as text’, 508. 23  On this type of ambiguity more generally in Galen, see Morison, ‘Language’, 148–52. 24  Gal., De diff. puls. (K. 8.704); on this passage see Hood, ‘Definitions’, 452–55. 25  Ibid., 464. 26  Gal., De diff. puls. (K. 8.709); Brittain, ‘Common sense’, 192–93. Brittain cautions that Galen’s typology of definitions here should not be identified with the difference between Stoic ‘preliminary definitions’ and genuine definitions. 27  Brittain, ‘Common Sense’, 200. 28  The connection between the qualities labeled σαφήνεια or perspicuitas and technical vocabulary is discussed at Fögen, T. ‘Metasprachliche Reflexionen antiker Autoren zu den Charakteristika von Fachtexten und Fachsprachen’, in Horster, M. and Reitz, C. (2003).

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Latin parallels to the development of specialised technical terminology from everyday words. The verb escendere, for example, narrows its everyday meaning of “climb” to the special significance in the sermo nauticus of “climbing into the lookout to scan for fish or find one’s own location”.29 A technē requires terminology that is tightly and unambiguously paired with the concepts the terms describe, and that is the common possession of all its practitioners. In the development of such terminology from ordinary language, the narrowingdown process used on escendere provides appropriate terminology, whereas metaphorical broadening does not. The added complication in the case of pain is that while it is the physician who (objectively) feels the pulse, it is the patient who (subjectively) feels the pain, and who must be the one to verbalise it in order to bring his sensations into the diagnostic domain.30 Unhappily, the terminology developed by Archigenes is in Galen’s opinion useless for this task of verbalisation; he accuses Archigenes of arriving at a terminological “nowheresville” (atopia), inaccessible even to his own students (De loc. aff. 114). Once again, Galen emphasises that each perceptual system has terms proper to it, and these cannot be exchanged willy-nilly at the risk of unintelligibility: so ‘astringent’ and ‘harsh’ should be applied to taste, not to pain sensations. Extension to other senses is disallowed, as it is for the pulse; Galen here scoffs that Archigenes’ terms convey no more knowledge than ‘blue’ or ‘red’ pain would. Archigenes does not play by the rules Galen has established to legitimate the metaphorical transfer of terms between different domains of meaning.31 The inexplicability of Archigenes’ terminology apparently stems from his failure to recognise that every sensible quality only has one expression; even if several qualities seem to be present in a single essence, still only one proper quality results (De loc. aff. 114). Certain pain sensations, for example, may be Antike Fachschriftsteller: Literarischer Diskurs und sozialer Kontext, 38. On the mechanisms for forming technical terminology in Greek, see Schironi, F. ‘Technical languages: Science and medicine’, in Bakker, E. (2010). A Companion to the Ancient Greek Language, 338–53. Schironi briefly discusses metaphor in medical terminology; the emphasis there is squarely on metaphors of spatial resemblance, e.g. sykon for a “fig-like excrescence” (344). 29  Krenkel, W. ‘Sprache und Fach-Sprache’, in Horster, M. and Reitz, C. (2003). Antike Fachschriftsteller: Literarischer Diskurs und sozialer Kontext, 12. 30  This is not to say that pain’s hard-to-describe attributes are due to this subjectivity itself, as Reinhardt points out (Reinhardt, ‘Unsayable properties’, 302). 31  Jackie Pigeaud argues contra Galen that medicine in fact requires such metaphorical transfers, that “la médecine devient ainsi herméneutique du discours du malade”, suggesting that metaphor in fact has a particular value for medicine, and that Galen’s suggestions sacrifice nuance for clarity (Pigeaud, Poésie, 129).

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circumstantially coupled, though they really ought to be separated, as is the case for those Galen calls “irritation” and “ulcerous”. He asserts that the latter “differs clearly” from the feeling of irritation, but adds that often irritation precedes the feeling of ulceration, the one sensation giving way to the other, and that “because of this Archigenes wrote about them indiscriminately and vaguely, as though not precisely distinguishing the causes of the two conditions” (De loc. aff. 107–108). Archigenes’ failure to distinguish the phenomena from one another indicates a more serious failure in mapping from cause to perceptible effect. He does not distinguish the effects properly, so he must not understand the causes properly. Galen offers similar criticism for Archigenes’ term “drawing (holkimos) pain”: chief among its problems is that it has been defined in so many different ways that it effectively carries no information at all (De loc. aff. 112). The confusion emerging from Archigenes’ failure to link terminology unambiguously to its object, or effect to cause, can better be appreciated in light of the Stoic doctrine of cataleptic impressions. A cataleptic impression must have a referent in the real world and must represent its object accurately (this requirement is sometimes framed in terms of clarity or distinctness).32 Third, it “must be such that no impression indistinguishable from it could ever occur which did not derive from the object in question”.33 This third requirement was evidently introduced by Zeno to answer sceptical objections that an impression meeting only the first two criteria might be confused with a false impression. It equally seems to address Galen’s objection that Archigenes’ terminology invokes concepts of sensation whose relationships to their antecedent causes are unclear or ambiguous. So, while Galen does not use the Stoic language of cataleptic impressions to distinguish his pain terminology from that of Archigenes, he does distinguish a set of desirable properties for such a terminology that seem to correspond loosely to Stoic cataleptic impressions: the verbal enunciation of a concept of pain should be univocally connected to an actual and clearly distinguished cause. The knowledge the physician requires to properly and precisely diagnose and treat based on a patient’s pain experience—the kyrios term, the 32  Frede, M. ‘Stoics and skeptics on clear and distinct impressions’, in id. (1978). Essays in Ancient Philosophy, 159–62; Reinhardt, ‘Unsayable properties’, 297–300. 33  This particular formulation is given by Hankinson, R. J. ‘Natural criteria and the transparency of judgement: Antiochus, Philo and Galen on epistemological justification’, in Inwood, B. and Mansfeld, J. (1997). Assent and Argument, 168–69, 177–80. For the twoelement definition of cataleptic impressions, see Diogenes Laertius, Vitae 7.46. The third requirement is attributed to Zeno by Cicero at Lucullus 77.

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essential definition, the unambiguous link between referent and concept— demands devoted effort and practiced expertise. 3

What Patients Know

Galen asserts that the uselessness of Archigenes’ terminology is confirmed by none other than the patients themselves: because patients asked about their pain “never mention rough, harsh, ceaseless or drawing pain, this kind of instruction once again turns out useless” (De loc. aff. 117). Galen acknowledges that patients may sometimes use terms different from those favoured by experts. However, if patients never use Archigenes’ terms at all, those terms are obviously useless as a diagnostic tool. What makes patient testimony so important? As it turns out, ‘drawing’ pain provides a clue. Archigenes apparently tries to associate this term with disease of the liver, but Galen objects that “the term ‘drawing’ (holkimos) is unusual for Greeks, so it is not easy to find out what it means. For discovery of meanings comes from extensive use” (De loc. aff. 111). Likewise, the terms “astringent” (­styphon) and “harsh” (austēros) are to be used “in the manner usual for Greeks” (De loc. aff. 116). Obtaining a critical mass of reports in which a given term is used is as vital for building a terminology for pain as it is for finding one’s way through the risky ambiguities of metaphor. Patients are the source of these reports: Galen asserts that before Archigenes, no doctor attempting to establish a typology of pains “dared to use terms different from the usual ones, and those which they could hear from the patients themselves” (De loc. aff. 116). So the same group whose vocabulary indicts Archigenes’ system is ultimately responsible for the creation of its replacement (in collaboration, of course, with the doctors who communicate these reports to one another). Galen reports that patients typically use descriptors such as feeling as though they were being pierced by a needle, or trepanned, or bruised, or torn apart, and argues that these expressions are perfectly comprehensible, unlike Archigenes’ terminology (De loc. aff. 116). Where Archigenes by and large tries to map adjectival descriptions of states onto pain experiences, the patientgenerated expressions Galen prefers instead map experiences onto experiences. Some of them offer access to subjective pain sensations in terms of common sensations such as being bruised; this appeal to common experience adds to their transparency. Other descriptors are commonly employed despite referring to uncommon experiences, like being trepanned. Galen does not dismiss these explanations on the grounds that the patients had not experienced the comparison event (indeed, he uses the trepanning comparison to

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describe his own pain at De loc. aff. 81). Such comparisons retain their explanatory power even today, as Shafer observes of patients who compare their pain to “a knife sticking in my back”.34 Dismissing patient testimony in formulating terms for pain is dangerous, Galen argues; without it any discussion of pain becomes “long and futile” (De loc. aff. 116). What kind of knowledge do patients possess that is valuable enough for a doctor to listen to a layman’s testimony? Galen privileges the knowledge that comes from the patients’ own sensory perceptions, even if it is subject to occasional breakdowns in the senses’ natural reliability.35 More broadly, Galen allows for a set of natural criteria of knowledge that he identifies as common to everyone.36 Natural criteria, including perceptual criteria, are indeed vital to the development of any kind of technē.37 Even if the expert’s knowledge requires refinement and certainty beyond what can be provided by the natural criteria, they are the necessary starting-point for developing these more precise distinctions. In the case of diagnosis from pain, because there is no external object for the doctor to observe, knowledge based in sensory perception must (at least in part) begin with the patient, and its reliability will be affirmed when it conforms to common experience. This is not to say that patient reports of pain sensations are an unproblematic source of information. Patients are laymen, whose sphere of experience cannot compare to that of a professional who sees many different cases. Their lay status also affects their ability to verbalise precisely what they feel, since they only have perceptual knowledge, which is apt to yield something closer to an ennoematic than an essential definition: “it is impossible for those who only know it by perception to arrive at terms suitable for instruction” (De loc. aff. 117). Furthermore, their powers of expression may be hampered by mental or physical weakness (De loc. aff. 89). This recalls the patients Galen describes as beblammenoi and others with similar problems, who by virtue of their suffering itself cannot express what is happening to them. Both in their level of experience and in their ability to verbalise that experience, patients present serious limitations. More serious still is another familiar stumbling block to collecting accurate information from patients: sometimes they lie, or at least

34  Shafer, A. (1995). ‘Metaphor and anesthesia’, Anesthesiology 83.6, 1339. 35  Evidence for this view is widely scattered in the Galenic corpus; a good collection is at Hankinson, ‘Natural criteria’, 199–205. 36  Ibid., 206–10; Gal., De plac. Hipp. et Plat. (K. 5.722 = De Lacy 540, 22–552,7). 37  Ibid. (K. 5.725).

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withhold information.38 Reticence and misdirection create a particular problem for pain, which provides no external object for the physician to compare to the patient’s claims. However, there are other signs that Galen says will be exhibited by a patient in genuine pain, including cold in the extremities, pale appearance, a weak pulse, and sometimes cold sweats.39 Medical experience and reasoning can compensate for the problems with patients’ perceptions, verbalisations, and honest reports of their pain experiences, even though the physician lacks the patient’s immediate experience. Ideally, the physician should be able to combine his experience with on-thespot deductions: “a combination of medical experience with the results of ordinary reasoning is useful in the diagnosis of extreme pain”.40 The patient has insight into his internal, subjective pain sensations, while the physician has the experience and expertise needed to put those sensations into context and make accurate judgements about their significance. Experience and logical reasoning combine to allow the physician a kind of virtual access into the experiences of a patient whose actual sensations he cannot share.41 Indeed, according to Galen, the best observations are made by a patient who is also a physician, thus neatly eliminating the need to rely on others. Galen’s ideal observer is a physician with personal experience of the pain he describes, who is able to observe his suffering with mental faculties unimpaired (De loc. aff. 89). The process recommended here seems quite demanding: the physician should seize upon the opportunity to observe his own pain, being careful to apply his physiological expertise to maximise his understanding of the significance of the sensations he undergoes, while keeping his mind unclouded by the suffering itself. One obstacle, of course, is the lamentable fact that any given physician can only hope to experience a subset of all possible kinds of pain; the physician’s personal experience is doomed to be as narrow as his patients’. Galen thus questions whether Archigenes could possibly have experienced every kind of pain he described, disapproving that “he recounted the experiences as though they 38  For example, the well-known case of the lovesick woman at Gal., De praecogn., (K. 14.632); Mattern, S. P. (2008). Galen and the Rhetoric of Healing, 135. See also on this topic Mattern’s chapter in this volume, ‘Galen’s anxious patients: Lypē as anxiety disorder’ (Chapter Six, 203–223). 39  Gal., De morb. simulant. (K. 19.7). 40  Ibid. 41  On the gradual transition to expertise, for the physician and the Stoic sage, see Reinhardt, ‘Unsayable properties’, 300.

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were his own, when in fact he could not have been so sickly” (De loc. aff. 89). In particular, Galen notes sardonically, whatever Archigenes’ personal ­history of illness is, it is unlikely that he experienced any uterine troubles, though he describes these too in a way that suggests first-hand knowledge of the sensations involved (De loc. aff. 117). The inevitable gaps in personal sensory experience create a real barrier to understanding, as Galen argues that what we do not suffer ourselves, we cannot know (De loc. aff. 117). The case of Archigenes’ improbable uterine suffering reveals that defining pain specific to women represents a special problem, which Galen does not discuss in further detail here. This passage does suggest that women were at any rate among the patients solicited for descriptions of their pain sensations, as Galen proceeds immediately to compare Archigenes’ description of uterine pain unfavourably to patient descriptors. Even if the reasoning used to develop that terminology had been correct, says Galen, Archigenes’ results are still useless because they do not match up to patient reports (De loc. aff. 117). Galen ultimately does have the opportunity to compare other patients’ reports with his own experience of a certain kind of pain, and the match is quite close. The condition he describes involved the sensation of “pain as if I were pierced by a trepan deep in the abdomen” (De loc. aff. 81), which Galen says he first identified as the likely result of a stone in the ureter. After this medical drama has played itself out, however, he finds upon examination of the substance excreted (which he describes as “glassy”, hyalōdēs) that the affected part was in this case actually the intestines. Pain in the large intestine, he says, is reported by patients to feel as though one is being impaled on a sharp stick or drilled by a trepan, but it cannot be distinguished from the pain caused by a stone “before one has watched the whole sequence of events” (De loc. aff. 82–83). This is an ideal description of pain: Galen, a professional physician, observes his experience carefully, judging all through the process of suffering how the pain’s perceived location and qualities correlate to other emerging evidence about the part affected. His accurate correlation is owing to the fact that he observes the process until its very end, not allowing himself to jump to conclusions based on his initial perception that the problem lay with the urinary system. The precise descriptors he chooses for the pain—being bored by a trepan or pierced by a stake—are perhaps problematic in light of his later claim that we are ignorant of pain we do not suffer ourselves. However, this objection is evidently trumped by the fact that other patients had described pain similarly.

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Sensations without Names

Even armed with experience and reason, the physician may still face some difficulties in recognizing useful terminology. To assemble the pool of data on pain experiences into a reliable set of definitions means trusting the patients who provide the data in the first place. However, the patient may be unable to understand his experience because of some mental infirmity (dia malakian psychēs). He may alternatively understand his suffering but be unable to verbalise it because of his physical weakness or the pain’s ‘unspeakability’ (De loc. aff. 88–89). Von Staden traces the history of concepts labelled “nameless” (anōnymos) in Greek as far back as Democritus, though it is of course in Aristotle that they are most developed.42 Galen occasionally uses this label as well, but more often refers to “unspeakable” (arrhētos) concepts.43 These include some sensory experiences: for example, because names have not been established for the attributes of smells, Galen acknowledges that metaphor might be used to import descriptive terminology that properly belongs to other senses.44 When trapped in this unfortunate situation, Galen says, one should not resort to metaphor straightaway, but rather to logos, in order to explain (hermēneuein) the concept, provided instruction rather than idle chatter is the goal.45 Galen clarifies the didactic meaning of logos by acknowledging a special case when the use of metaphor is acceptable. If one has, through logos-explanation, previously gained acquaintance with a phenomenon for which there is no literal name, it afterward becomes admissible to apply a metaphorically-derived term for the sake of concision.46 Patients’ pain descriptors such as ‘being pierced by a needle’ or ‘being trepanned’ seem to be just this type of explanation. These descriptors may not allow the concision of single-word metaphors like ‘salty’ pain, but they provide the explanatory clarity those expressions lack. Communication between patient and physician, as communication between

42  Staden, ‘Science as text’, 510 n. 32. 43  Reinhardt, ‘Unsayable properties’, 301. Reinhardt here observes that Galen avoids other synonyms like aphrastos and aneklalētos. 44  Gal., De diff. puls. (K. 8.692). For discussion and translation of book 3, section 7, of Galen’s Differences between Pulses see von Staden, ‘Science as Text’, 510 and n. 33. 45  Ibid. (K. 8.675). For discussion and translation of book 3, section 6, see von Staden, 511 and n. 36. 46  Ibid. (8, 675 K., especially line 9—συντόμου δηλώσεως ἕνεκεν).

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non-expert and expert, has more in common with the ‘didactic’ circumstances Galen refers to here than with communication between experts already acquainted with a phenomenon, who could therefore use metaphorical terms with lower risk of semantic drift. Expertise provides additional ways to deal with ‘unspeakable’ concepts. Reinhardt offers the example of a certain shade of yellow pallor that might be linked to a disease of the liver or spleen (De loc. aff. 355).47 Experienced physicians could in this case point out to one another important and diagnostically useful nuances of the colour even if they cannot describe its particular attributes in words. The same applies to diagnosis from pain. Complaining of Archigenes’ use of ‘dull’ as a pain descriptor, Galen alleges that the term is unclear, and like all unclear terms cannot be explained “unless someone who himself understands the matter attempts to reconcile it to the term” (De loc. aff. 106–107). If the attempt at reconciliation succeeds, the expert’s explanation can supplement the gaps in comprehension the term itself imposes. 5

Common Sensations

Common experience offers another way to diagnose from pain sensations even when they cannot be verbalised. Galen asserts that suffering is largely standardised from one person to another. This means that even a type of pain that is especially hard to express in words can still be communicated as long as that pain is a common experience. Such is the case with the sensation Galen calls haimōdia, which had apparently been used by Archigenes (inappropriately, of course) to indicate an affliction of some kinds of membranes. Galen reclaims this term for a certain type of oral problem: For we know an affection ( pathos) that affects only the mouth, and not even the whole mouth, but the teeth and gums; we call it haimōdia, and it is not possible to explain it verbally. However, there is a precedent that a certain affection in the teeth and gums follows a diet of harsh and sour food. We know that the same thing occurs for everyone, seeing that for the most part similar affections happen to us, so that we suffer the same things from the same causes (De loc. aff. 86–87). The term haimōdia is impossible to verbalise and yet it is rendered semantically accessible because the kind of suffering it represents is common: ineffability is 47  Reinhardt, ‘Unsayable properties’, 304.

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overcome by inclusivity. Galen establishes several other types of pains which do not require any special explanations because they are so widely known: All of us know (nooumen) pricking (nygmatōdēs) [pain], stretching (diateinōn), and others expressed similarly to these, and even more so the violent (sphodros), powerful (ischyros), forcible (biaios), constant (synechēs), and intermittent (dialeipōn), because they have been explained by terms that are part of common usage and happen daily to everybody (De loc. aff. 118). Here is an important distinction between Archigenes’ scheme and Galen’s. Galen critiques Archigenes for using terms like holkimos that have too much semantic baggage to be of diagnostic use, or terms like austēros that would be inappropriately over-determined if used to describe pain. On the other hand, terms like ischyros and synechēs, even if they are already in common use, are diagnostically valuable because they describe such universal experiences that they can easily be mapped onto particular sensations of pain. This mapping between sensation and cause is crucial. Hence the failure of Archigenes’ term “harsh” (austēros) as compared with terms whose sensory targets are more common and less ambiguous: For some of those who are ill say they suffer nausea of the stomach, which is obviously clear to us through having experienced it; likewise ‘being restless’ (to aluein), for this is also clear because of having experienced it. ‘Harsh’ pain, on the other hand, cannot be understood as described by Archigenes even if one has experienced it, on account of not knowing what thing it is upon which he confers this term (De loc. aff. 118). In the case of ‘harsh’ pain, even if one has the personal experiential knowledge of which Galen approves, Archigenes’ term still fails because the referent for the concept is ambiguous. That commonly suffered pains can be identified and diagnosed, even when they are impossible to express in words, represents an application of Galen’s identification of the natural criteria of knowledge with criteria that are common to all. Acknowledging common assent as a source of knowledge, particularly by comparison with the strict demands of cataleptic impressions, raises questions about what kind of concept can be defined in this way. The distinction Galen seems to be making might be compared to a point made by Cicero in his De oratore about how arguments from definition work. Sometimes they work by investigating each thing’s defining attribute, but others study what is

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“as it were impressed upon the common mind (communis mens)”.48 Brittain distinguishes Cicero’s use of communis mens from “what comes from ordinary thought (ex opinione hominum)”, because the former crucially involves some kind of “preconception shared by everyone”.49 In this case, as in the common pains Galen refers to (haimōdia, to aluein, ischyros pain, and so forth), there is an object of knowledge that experience instils in us all. Not every concept of a sensation meets this criterion; the ungraspable ambiguity of Archigenes’ socalled ‘harsh’ pain signifies that it lacks such a common conceptual referent. The role played here by the transmission of common pain experiences has ramifications for the broader discussion of metaphorical terminology in Galen’s work. It will be recalled that Galen connects proper or literal (kyrios) terminology with universal assent or customary usage among Greeks, and likewise that he allows for the use of metaphorical terms in technical practice only on condition that the interlocutors have already been acquainted with the phenomena involved through some other explanatory means. The collaborative development of understanding and universal assent is the road to understanding sensations like haimōdia, or ‘being ill at ease’, and so forth, which are otherwise difficult to verbalise. In keeping with this is the astonishing frequency of first-person plural verbs and pronouns in this passage. Asper alludes to the use of the Greek first-person plural for an anonymous “persona auctoris”,50 a form of ‘integrative we’, which Asper argues has a particular power to elide the distance between author and reader and create a sense of collaboration.51 Galen seems to deploy first-person plural forms to similar effect in the passages on hard-to-describe forms of pain. Even though it is not possible to find literal descriptors of these sensations, the emphasis that ‘we all know’ these kinds of pain, as ‘we’ have all suffered them, offers the stability of experiential consensus. This adds a new wrinkle to the inclusivity of knowledge about pain. Galen insists that practitioners walk the fine line between capitalizing on patients’ experiential knowledge of their own pain, and erring because of those same patients’ limited knowledge of pain sensations and the bodily conditions they may indicate. Archigenes’ complex

48  Cic., De or. 3.115; Brittain, ‘Common sense’, 204–05. 49  Cic., De inv. 2.53; discussion at ibid., 206. Brittain identifies Cicero’s preconceptions with Stoic common conceptions, which are capable of providing a preliminary definition that can serve as the basis of reasoning. 50  Asper, M. (2007). Griechische Wissenschaftstexte: Formen, Funktionen, Differenzierungs­ geschichten, 333. 51  Ibid., 128.

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terminological system is underdetermined, in constant danger of metaphorical drift, because it is separated from the patient’s experiential knowledge. 6 Conclusion For pain to become diagnostically useful, it must be appropriately processed into a verbal form that can be shared with the physician somehow. In the ideal case, this processing is done by a physician who is intellectually and emotionally equipped to name and describe the pain with maximum accuracy, pinpointing its precise location in a complex landscape of different pains. However, this is a rare confluence of circumstances, so the next best situation is a pain with a proper or literal (kyrios) term that all Greek speakers use in the same way. When this is not possible, a more lengthy explanation (logos) may replace that single term, and this appears to be the category into which Galen’s approved patient descriptors of pains in terms of processes fall. What should be avoided at all costs is the kind of metaphorical terminology beloved by Archigenes, which makes up for in vagueness what it offers in concision. Metaphor is not completely off the table even for Galen, however: metaphors for sensations are grudgingly admitted as long as a logos of explanation has been established. His texts on the pulse reveal a close parallel diagnostic process, where the rules of metaphor are more explicitly theorised than in the texts on pain. Galen puts these complex questions about the univocality of technical terminology, and the rules of metaphorical transfer by which such terms must play, to work in the service of the clinical problem of diagnosis from pain. The patient’s account of the experience of suffering is essentially all the physician has to work with; the diagnostic work is done not on the pain itself (which remains the exclusive property of the patient), but on the patient’s verbalisation. The patient’s pain experience, based on perceptual criteria and articulated in the terms the patient is able and willing to provide, can at least provide a starting point for the development of the precise terminology needed for diagnosis. Certain kinds of pain tap into a field of common conceptions; such experiences can be communicated even when it is difficult to formulate terminology for them. Galen’s concern with terminology, then, is not (merely) petty criticism of a rival medical author, but a genuine concern to keep this chain of transformations tethered as tightly as possible to its cause. Galen promises that this endeavour will yield relatively reliable diagnostic information, without the dangerous instability Archigenes’ terminology represents.

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Texts and Translations Used Aëtius. Placita. In Stoicorum Veterum Fragmenta, ed. Arnim, H. F. A. von. Lipsiae: In aedibus B. G. Teubneri, 1903. Cicero, Marcus Tullius. De inventione (De inv.). In M. Tulli Ciceronis scripta quae manserunt omnia, ed. E. Stroebel, vol. 2.2. Lipsiae: Teubner, 1915. ———. De oratore (De or.) In M. Tulli Ciceronis Rhetorica, ed. A. S. Wilkins. Oxonii: E Typographeo Clarendoniano, 1902. Galen. Opera omnia. Ed. C. G. Kühn. Leipzig: Cnobloch, 1821–33. ———. De differentia pulsuum. (Diff. puls.) In Opera omnia, ed. K. G. Kühn, vol. 8, 493– 765. Lipsiae: prostat in officina libraria Car. Cnoblochii, 1821. ———. De locis affectis. (De loc. aff.) In Opera omnia, ed. K. G. Kühn, vol. 8, 1–152. Lipsiae: prostat in officina libraria Car. Cnoblochii, 1821. ———. De placitis Hippocratis et Platonis (On the Doctrines of Hippocrates and Plato). (De plac. Hipp. et Plat.) Ed. Ph. De Lacy. CMG V, 4,1,2. Berlin: Akademie-Verlag, 1978. ———. Quomodo morborum simulantes sint deprehendendi. In Galens Kommentare zu den Epidemien des Hippokrates, ed. K. Deichgräber, F. Kudlien, and F. Pfaff. Berolini: Akademie-Verlag, 1960.

References Asper, M. Griechische Wissenschaftstexte: Formen, Funktionen, Differenzierungs­ geschichten. Stuttgart: Franz Steiner Verlag, 2007. Brittain, C. ‘Common Sense: Concepts, Definition and Meaning in and out of the Stoa.’ in Language and Learning: Philosophy of Language in the Hellenistic Age, ed. D. Frede and B. Inwood, 164–209. Cambridge: Cambridge University Press, 2005. Evans, M. ‘Plato and the Meaning of Pain.’ Apeiron: A Journal for Ancient Philosophy and Science 40.1, (2007): 71–94. Fögen, T. ‘Metasprachliche Reflexionen antiker Autoren zu den Charakteristika von Fachtexten und Fachsprachen.’ in Antike Fachschriftsteller: Literarischer Diskurs und Sozialer Kontext, ed. M. Horster and C. Reitz, 31–60. Wiesbaden: Franz Steiner Verlag, 2003. Frede, M. ‘Stoics and Skeptics on Clear and Distinct Impressions.’ in Essays in Ancient Philosophy, ed. M. Frede, 151–76. Minneapolis: University of Minnesota Press, 1987. Gill, C. ‘Galen and the Stoics: Mortal Enemies or Blood Brothers?’ Phronesis: A Journal for Ancient Philosophy 52.1, (2007): 88–120. ———. Naturalistic Psychology in Galen and Stoicism. Oxford: Oxford University Press, 2010.

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Hankinson, R. J. ‘Natural Criteria and the Transparency of Judgement: Antiochus, Philo and Galen on Epistemological Justification.’ in Assent and Argument: Studies in Cicero’s Academic Books : Proceedings of the 7th Symposium Hellenisticum (Utrecht, August 21–25, 1995), ed. B. Inwood and J. Mansfeld, 161–213. Leiden and New York: Brill, 1997. Holmes, B. The Symptom and the Subject: The Emergence of the Physical Body in Ancient Greece. Princeton N.J.: Princeton University Press, 2010. Hood, J. ‘Galen’s Aristotelian Definitions.’ in Definition in Greek Philosophy, ed. D. Charles, 450–66. Oxford and New York: Oxford University Press, 2010. Horster, M. and Reitz, C. (eds.) Antike Fachschriftsteller: Literarischer Diskurs und Sozialer Kontext, Palingenesia 80. Wiesbaden: Franz Steiner Verlag, 2003. Krenkel, W. ‘Sprache und Fach-Sprache’, in Antike Fachschriftsteller: Literarischer Diskurs und sozialer Kontext, ed. M. Horster and C. Reitz, 11–30, Palingenesia 80. Stuttgart: Franz Steiner Verlag, 2003. Kuriyama, S. The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine. New York: Zone Books, 1999. Mattern, S. P. Galen and the Rhetoric of Healing. Baltimore: Johns Hopkins University Press, 2008. Morison, B. ‘Language.’ in The Cambridge Companion to Galen, ed. R. J. Hankinson, 116–56. Cambridge and New York: Cambridge University Press, 2008. Pigeaud, J. Poésie du corps. Paris: Payot, 1999. Reinhardt, T. ‘Galen on Unsayable Properties.’ Oxford Studies in Ancient Philosophy 40, (2011): 297–317. Scarry, E. The Body in Pain: The Making and Unmaking of the World. New York: Oxford University Press, 1985. Schironi, F. ‘Technical Languages: Science and Medicine.’ in A Companion to the Ancient Greek Language, ed. E. J. Bakker, 338–53. Chichester, West Sussex, U.K. and Malden, MA: Wiley-Blackwell, 2010. Shafer, A. ‘Metaphor and Anesthesia.’ Anesthesiology 83.6, (1995): 1331–42. Sluiter, I. ‘The Embarrassment of Imperfection: Galen’s Assessment of Hippocrates’ Linguistic Merits.’ In Ancient Medicine in its Socio-Cultural Context: Papers Read at the Congress held at Leiden University, 13–15 April 1992, ed. Ph. J. van der Eijk, H. F. J. Horstmanshoff and P. H. Schrijvers, 519–35. Amsterdam: Rodopi, 1995. Staden, H. von ‘Science as Text, Science as History: Galen on Metaphor.’ Clio Medica 28, (1995): 499–51.

Part 5 Material Aspects, Diagnostic Techniques and their Impact on the Patient-Physician Relationship

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CHAPTER 12

The Μισθάριον in the Praecepta: The Medical Fee and its Impact on the Patient Giulia Ecca The brief collection of deontological guidelines entitled Praecepta is one of the most important literary evidence regarding the fee of the ancient physician. This chapter focuses on three passages from the Praecepta, which offer us a wealth of information on this topic. Some technical terms used in the text, such as the term μισθάριον, show clearly that the author intends both to provide guidelines for the ideal bedside manners and to defend the repute of the physicians from the widespread charge of greed. In some regards, the author of the Praecepta depicts medicine as a ‘liberal’ art: the good physician disdains monetary gain as the main goal of his service, and aims to safeguard the social status and reputation of the medical profession. On the other hand, the author of the Praecepta enlightens his readers on the bad behaviour of both charlatan physicians and bad-mannered patients. The Praecepta (Παραγγελίαι)1 is a brief collection of deontological guidelines included in the Corpus Hippocraticum. Although some prudence in dating this treatise is required, the style of the text and some elements of the society depicted in the work allow us to date it plausibly around the first or second century of the Common Era.2 The work has not attracted enough scholarly attention, possibly due to its obscure style, its late date and non-technical medical content. Nevertheless, the Praecepta offers a unique insight into the social ­context of ancient medicine. Its deontological guidelines, quite possibly directed 1  This paper is part of my PhD, which was financed by the Alexander von Humboldt-Stiftung and supervised by Prof. Dr. Philip van der Eijk, to whom I express my gratitude. The result of my PhD thesis will be the publication of a new critical edition with German translation and commentary on the Praecepta. Special thanks for comments and suggestions are due to Matteo Martelli, Georgia Petridou and Chiara Thumiger. 2  A proper discussion of these questions may be found in my own edition: Ecca, G. (in print). Corpus Hippocraticum. Praecepta. Kritische Edition, Übersetzung und Kommentar. Mit Anhang: Ein Scholion zu Praec. 1. Cf. Fleischer, U. (1939). Untersuchungen zu den pseudohippokratischen Schriften. Παραγγελίαι, Περὶ ἰητροῦ und Περὶ εὐσχημοσύνης, 9–18. © koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_014

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to students of medicine, tell us as much about the physician’s relationship with his patients, his colleagues, as they do about his reputation in the society. In particular, the Praecepta is one of the most important pieces of evidence regarding the salary of the ancient physician, and for this reason it is often quoted in scholarly discussions of the physician’s social status. I do not intend here to address the more general question of the ancient physician’s salary, for which I refer the reader to previous studies.3 Rather, I would like to offer an overview of the issue as it emerges from a close reading and an in-depth analysis of three key passages from the Praecepta.4 More particularly, I focus my attention on the self-representation of the good physician and his interaction with his patients with respect to the medical fee. The first passage is about the initial phase of encounter between patient and physician. This phase is marked as an important one, because it affects the psychological disposition of the patient and consequently the overall course of the therapy: παραινέσιος δ’ ἂν καὶ τοῦτ’ ἐπιδεηθείη τῆς θεωρίης· εἰ γάρ ἄρξαιο περὶ μισθαρίων (ξυμβάλλει γάρ τι τῷ κειμένῳ παντί),5 τῷ μὲν ἀλγέοντι τοιαύτην 3  The bibliography on the social status of the ancient physician and his fees is quite extensive. Some of the most important studies include: Cohn-Haft, L. (1956). The public physicians of ancient Greece; Koelbing, H. M. (1977). Arzt und Patient in der antiken Welt; Kudlien, F. (1979). Der griechische Arzt im Zeitalter des Hellenismus; id. (1986). Die Stellung des Arztes in der römischen Gesellschaft; Horstmanshoff, H. F. J. (1990). ‘The ancient physician: Craftsman or scientist?’, JHM 45, 176–97; Nutton, V. ‘Healers in the medical market place: Towards a social history of Graeco-Roman medicine’, in Wear, A. (1992). Medicine in Society. Historical essays, 15–58; Pleket, H. W. ‘The social status of physicians in the Graeco-Roman world’, in Eijk, Ph. J. van der et al. (1995). Ancient Medicine in its Socio-Cultural Context, 27–33; Marasco, G. ‘Les salaires des médecins en Grèce et à Rome’, in Thivel, A. and Zucker, A. (2002). Le normal et le pathologique dans la Collection hippocratique, 769–86. 4  I refer here both to my own edition (Ecca, Praecepta) and to Heiberg’s edition (CMG I, 1, 1927, 30–35). I will mark out in the footnotes, only where necessary, the differences between my own edition and the text printed by Heiberg. The Praecepta is transmitted only by the branch of the Marcianus graecus 269 (M), but in some cases it was necessary to take into account some readings from a second relevant manuscript, the Parisinus graecus 2140 (I), and from some recentiores. Explanations regarding textual and palaeographical questions do not belong here. A detailed analysis of the entire manuscript tradition can be found in Ecca, Praecepta. All translations, unless otherwise stated, are mine. 5  I accept here the reading κειμένῳ πάντι (sic: correxi in παντί) of the manuscript Baroccianus 204 (O), whereas the main manuscripts give the word ξύμπαντι, printed by all editors. I understand τὸ κείμενον as ‘deposit from both parties to this agreement’ that requires not only the doctor’s efforts to heal but also the patient’s obligation to recompense the professional physician for his efforts.

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διανόησιν ἐμποιήσεις τὴν, ὅτι οὐκ6 ἀπολιπὼν αὐτὸν πορεύσῃ, μὴ ξυνθέμενος δὲ,7 ὅτι ἀμελήσεις καὶ οὐχ ὑποθήσῃ τινὰ τῷ παρεόντι. ἐπιμελεῖσθαι οὖν δεῖ περὶ στάσιος μισθοῦ· ἄχρηστον γὰρ ἠγεύμεθα ἐνθύμησιν ὀχλεομένου τὴν τοιαύτην, πουλὺ δὲ μᾶλλον ἢν ὀξὺ νόσημά τι. νούσου γὰρ ταχυτὴς καιρὸν μὴ διδοῦσα ἐς ἀναστροφὴν οὐκ ἐποτρύνει τὸν καλῶς ἰητρεύοντα ζητεῖν τὸ λυσιτελές, ἔχεσθαι δὲ δόξης μᾶλλον. κρέσσον οὖν σωζομένοισιν ὀνειδίζειν ἢ ὀλεθρίως ἔχοντας προμύσσειν (Ecca 114,7–17 = Heiberg 31,16–25= L. 9.254,14–256,7). Also this part of the exhortation would need reflection: for if you begin with a modest fee (you make in this way a sort of contract for the entire deposit), you will give the patient the following impression, that you will proceed [scil. with the therapy] without abandoning him; but if you have not agreed, [scil. you will make him think] that you will be neglectful and you will not give him any medicament. One needs then to take care of fixing the fee:8 in fact, we consider this to be a needless worry on the part of the troubled patient, all the more if there is an acute disease. For the quickness of the disease, since it does not give the chance for turning back, urges the good physician not to seek the profit, but rather to retain his own reputation. It is then better to reproach those patients you are saving than to extort money from those who are in danger of death. The physician should determine the amount of his payment at the beginning of the medical visit before starting the treatment, in order to deter the patient from contemplating the possibility that the physician might abandon him and fail to provide him with the essential remedies. Fixing the physician’s fee (στάσις μισθοῦ)9 emerges in this passage as a very important aspect of the

6  All the manuscripts have οὐκ. Some editors (among them Littré, Jones and Heiberg) delete it, because they believed that beginning a treatment by discussing the salary could lead the patient to think that the physician could later abandon him. The text carries actually the opposite meaning: if the doctor opens the meeting addressing the issue of his salary, the patient is reassured that he will not have to worry about it during the course of the treatment. 7  I accept the correction δέ transmitted by the Vaticanus gr. 277 (R), instead of the reading καί transmitted by the main manuscripts. 8  Many scholars follow Littré, Jones or Heiberg in understanding that beginning the discussion with the issue of the physician’s fee would be troublesome for patient (see above n. 6). Some of them even follow Littré and Jones in adding a negation in the sentence and read ἐπιμελεῖσθαι οὖν οὐ δεῖ περὶ στάσιος μισθοῦ “so one must not be anxious about fixing a fee” (Jones), or, similarly with Korais, ἐπιμελεῖσθαι δὴ οὐ περὶ στάσιος μισθοῦ. 9  The term στάσις has here the literal meaning of ‘weighing’, in the sense of establishing the right amount of money for the fee. For the word μισθός in reference to liberal or ‘banausic’

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patient-physician relationship. Some words used here have a juridical meaning: συμβάλλομαι (“to make a contract”) and συντίθημι (“to agree”) are two significant termini technici, which denote the oral agreement between patient and physician, an agreement that seems to be binding for both sides for the duration of the treatment. Similarly, the participle τὸ κείμενον refers to a sort of deposit put down from both sides: the patient offers a certain amount of money and the physician stakes his own reputation.10 The use of the diminutive μισθάριον to indicate the fee agreed between physician and patient is rather significant for our purposes. The term occurs mostly in comedy. Aristophanes, for instance, uses it ironically in the Vespae, putting it in the mouth of the chorus of popular judges, who complain about their small salary.11 There are also a few instances in some later authors, such as Plutarch and Diogenes Laertius, in which the term refers primarily to stoic criticism directed against the sophists: the μισθάριον denotes there indignation against the ‘selling out’ of the liberal arts for an exorbitant fee, when these arts should be practiced exempt from all charges.12 In Latin, the equivalent term (often used in a negative sense) is mercedula. The word occurs in a remarkable passage from Seneca’s De beneficiis, where it is said that, apart from the modest fee, the patient owes just gratitude and respect to the physician: nec medico quicquam debere te nisi mercedulam dicis nec praeceptori, quia aliquid numeraveris; atqui omnium horum apud nos magna caritas, magna reverentia est (Ben. 6.15.1). This passage is very important, because it also addresses the issue of the patients’ gratitude, which cannot be reduced to mere monetary payment.13 Here the diminutive does not carry ironic overtones, but it does stress how small the amount of money required by a good physician really is, arts see Schulthess, O. (1932). ‘Μισθός’, in RE 15. 2, 2078–95, and Will, E. ‘Notes sur ΜΙΣΘΟΣ’, in Bingen, J. et al. (1975). Le Monde Grec. Pensée, littérature, histoire, documents, 426–38. 10  For the contractual aspect of the relationship between physician and patient, see Kudlien, F. (1979). ‘Die Unschätzbarkeit ärztlicher Leistung und das Honorarproblem’, MHJ 14, 3–16, especially 7–8. Even if Kudlien was not aware of the reading κειμένῳ παντί instead of ξύμπαντι, he still referred to a sort of deposit, in which the physician offered as guarantee to the patient his own reputation: “Bei der ‘liberalen’ Form des Arzt-PatientKontrakts konnte die regelrechte Pfandhinterlegung von Seiten des Arztes offenbar ersetzt werden durch die Garantie des ärztlichen Rufes”. 11  Ar., V. esp. 300–01. The diminutive occurs also in later comic playwrights: see, for instance, Diphilos, fr. 42 K.-A. and Eupolis, fr. 470 K.-A. 12  Plut., Mor. 1044a; D. L. 10.4. 13  On the portrayal of the physician in Seneca, see Pisi, G. and Torti G. (1983). Il medico amico in Seneca, in particular 20–22, esp. n. 32: “il diminutivo mercedula ‘compenso’ per prestazioni di scarso valore [. . .] sottolinea in contrapposizione alla caritas e alla reverentia l’inadeguatezza della remunerazione in denaro”.

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when compared to the invaluable service he offers to the patient by saving his life. The use of the term μισθάριον in the Praecepta seems to be very similar to that of Seneca’s: the author of our text uses the diminutive to refer to the medical fee, in order to emphasise further the importance of the physician’s work. In the Praecepta, the doctor seems to care about the suffering of the patient, who is described as ἀλγέων and ὀχλεόμενος. However, the physician is mainly concerned about the negative influence the patient’s thoughts and worries may have on the therapy. Both the adjective ἄχρηστον “needless”, which alludes to what is unhelpful for the therapy, and the reference to the acute disease, which requires a certain promptness, show that the physician’s concern with the patient’s psychology is purely functional and not related to personal feelings of pity and compassion. The author then claims that a good physician is expected not to aim for profit (τὸ λυσιτελές), but to preserve his good reputation (δόξα). This opposition of profit and reputation is very significant for the purposes of this analysis, because it underlines that high earnings were one of the most important sources of infamy for the ancient physician. The charge of greed (φιλαργυρία), which reduces the goal of the medical practice to the physician’s μισθός, is typically attributed to physicians from the classical era onwards.14 At the end of the section the author considers even the possibility of reproaching his patients (σωζομένοισιν ὀνειδίζειν). Even though it is not clear what the author means exactly, the context suggests that the physician could reproach patients if they did not want to pay the previously agreed amount of money. The author claims that the physician, in order to safeguard his reputation, should make rightful claims about his payment at the end of a successful therapy rather than extort money (προμύσσειν) from the patients who are still in danger of death. He uses here a very colloquial expression. The compound verb προμύσσω is attested in Plutarch with its literal meaning of “to snuff” 14  For an overview of this charge, which became a literary topos, see Mazzini, I. (1982–84). ‘Le accuse contro i medici nella letteratura latina e il loro fondamento’, QLF 2, 75–90 (with some illuminating examples of accusations against physicians who were said to have ‘extorted’ money from their patients); Gourévitch, D. (1984). Le triangle hippocratique dans le monde gréc-romain, 400–06; Marasco, ‘Les salaires’, 773–74; Samama, E. (2003). Les médecins dans le monde grec. Sources épigraphiques sur la naissance d’un corps médical, 45–47. See especially the ‘Hippocratic’ Letter 11 (Smith 60,2–5 = L. 9.326,18–20), where Hippocrates refuses the money offered by the Abderites, asserting that medicine is a free art and should not be enslaved: ἐᾶτε ἐλευθέρης τέχνης ἐλεύθερα καὶ τὰ ἔργα. οἱ δὲ μισθαρνεῦντες δουλεύειν ἀναγκάζουσι τὰς ἐπιστήμας, ὥσπερ ἐξανδραποδίζοντες αὐτὰς ἐκ τῆς προτέρης παρρησίης, “leave free the work of a free science. People who put their knowledge out for hire require it to be slavish, exchanging its earlier freedom of speech for fetters” (trans. by W. D. Smith).

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(i.e. a lamp), and its synonym προβύω “to trim” (i.e. the wick of a lamp) appears in the same sense in Aristophanes’ Vespae.15 The simple form μύσσομαι means “to blow the nose” and as such it is used in medical texts.16 With reference to money, the verb προμύσσειν has therefore the meaning of “extort money” from the patient. It reflects the perspective of the patient: it is almost as if the author is trying to anticipate and reject potential criticism from patients by using the same words they would use. The author of the Praecepta defends the reputation of the physicians against this customary charge of greed and employs intentionally colloquial vocabulary, which evokes that of ancient comedy. In fact, the charge of greed against physicians was widespread especially in popular ethics and in comedy.17 Another passage from the Praecepta reveals much about the ideal code of conduct between the ancient physician and his patients. In particular circumstances, the physician ought to treat his patients free of charge and provide gratuitous care for foreigners and poor people. His kind and benevolent behaviour toward the patient will have a positive effect on the course of the therapy itself, and therefore it becomes essential for good medical practice. παρακελεύομαι δὲ μὴ λίην ἀπανθρωπίην ἐσάγειν, ἀλλ’ ἀποβλέπειν ἔς τε περιουσίην καὶ οὐσίην, ὁτὲ δὲ προῖκα ἀναφέρων μνήμην προτέρης18 εὐχαριστίης ἢ παρεοῦσαν εὐδοκίην. ἢν δὲ καιρὸς εἴη χορηγίης ξένῳ τε ἐόντι καὶ ἀπορέοντι, μάλιστα ἐπαρκέειν τοῖσι τοιουτέοισιν· ἢν γὰρ παρῇ φιλανθρωπίη, πάρεστι καὶ φιλοτεχνίη. ἔνιοι γὰρ νοσέοντες ᾐσθημένοι τὸ περὶ ἑωυτοὺς πάθος μὴ ἐὸν ἐν ἀσφαλείῃ καὶ τῇ τοῦ ἰητροῦ ἐπιεικείῃ εὐδοκοῦσι19 μεταλλάσσοντες ἐς ὑγιείην. εὖ δ’ ἔχει νοσεόντων ἐπιστατέειν ἕνεκεν ὑγιείης, ὑγιαινόντων τε φροντίζειν ἕνεκεν ἀνοσίης, φροντίζειν καὶ ὑγιαζόντων20 ἕνεκεν εὐσχημοσύνης (Ecca 116,10–118,7 = Heiberg 32,5–13 = L. 9.258,6–15).

15  Cf. Plut., Mor. 798a–b and Ar., V. 249 (with the ancient scholia ad loc.). 16  See e.g. Vict. 3.70.1 (Joly-Byl 202,6 = L. 6.606,16). 17  See Gourevitch, Le triangle hippocratique, 400–06. 18  I accept Fleischer’s conjecture (Untersuchungen, 38), who corrects the accusative προτέρην transmitted by all the manuscripts with the genitive προτέρης. 19  The manuscripts Marcianus gr. 269 and Parisinus gr. 2140 transmit the reading εὐδοκιμέουσι, which refers to the good reputation of the patients, and therefore does not fit in this context. I prefer εὐδοκοῦσι (a correction made by a later hand on the Marcianus), which picks up on the earlier εὐδοκία and stresses the importance of the social reputation for the physicians. 20  I take Zwinger’s conjecture ὑγιαιζόντων as certain, whereas the manuscripts transmit the untenable reading ὑγιαινόντων; εὐσχημοσύνη in medical writings refers, almost invariably, to physicians, not to patients.

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I recommend introducing [scil. into patient’s room] not too much unfriendliness, but paying attention to the financial and social status [scil. of the patient], and sometimes even [scil. providing medical care] free of charge, if one recalls a memory of a past gratitude or a present sign of esteem. When given the opportunity to assist generously a foreigner and a person in need, I especially recommend helping such people: for if there is kind helpfulness toward men, there is also a good practice of the art. For some patients, although they realise that their own illness is at a risky stage, take comfort in the fairness of the physician and in this way they change into a healthy condition. It is good to assist the sick for the sake of their health, to care about the healthy for the sake of preventing them from illness, but also to care about healers for the sake of their decorum. The physician is exhorted not to keep too much ‘distance from the patient’ (ἀπανθρωπίη), probably in the sense that he has to show consideration, in a friendly manner, for the individual situation of each patient. He has to evaluate the patient’s economic and social condition (περιουσίη καὶ οὐσίη),21 perhaps also to ask for a reduced payment and to meet the patient’s financial abilities. Although a public social welfare that guaranteed gratuitous medical assistance for everyone did not exist in antiquity, it is nevertheless well demonstrated that the ancient physician could decide to provide treatment for free.22 Much more interesting still is the reason for doing so, as given in the Praecepta: it is a “memory of a past gratitude or a present sign of esteem” (μνήμην προτέρης εὐχαριστίης ἢ παρεοῦσαν εὐδοκίην), which would urge the physician to offer his services pro bono. In this passage, the logic of the reciprocal exchange of favours, which is typical for liberal arts, prevails: the doctor may offer his medical assistance in exchange for signs of gratitude and esteem given to him in

21  The two words περιουσία and οὐσία seem to be complementary here. They denote the financial and social status of the patient respectively. Very similar is the combination of the two words fortuna and persona in Scribonius Largus, Comp. praef. 4 (Sconocchia 2,16– 18), who, nevertheless, formulates the idea in a different way: medicine does not look at the social and economical conditions of the patients, but treats everybody equally: medicina non fortuna neque personis homines aestimat, verum aequaliter omnibus implorantibus auxilia sua succursuram se pollicetur. 22  More on this topic in Cohn-Haft, The public physician and Kudlien, Der griechische Arzt, 11–13. In honorary inscriptions set up for doctors, we often find adverbs like προῖκα and δωρεάν meaning “for free”. For προῖκα see e.g. nos. 245,10 and 290,17 Samama; for δωρεάν, see e.g. nos. 7,18–19; 35,30; and 166,11–12 Samama.

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the past or in the present.23 The term εὐχαριστίη implies the notion of χάρις “favour”, while εὐδοκίη evokes δόξα “reputation”. Both concepts constitute the real currency of the liberal arts, as opposed to the vulgar materialism of monetary payment, which is characteristic of the ‘banausic’ arts.24 The closest parallel to our passage is that by Seneca (Ben. 6.15.1, quoted above), where caritas and reverentia are said to be the real wage for the good physician. Although medicine in antiquity was not stably counted amongst the liberal arts,25 the author of the Praecepta wishes clearly to present it as such, perhaps aiming at increasing its social status. In this same regard I would like to bring into focus the word χορηγίη, which takes us into the high level of tragedy and away from the colloquial language of comedy evoked by the previous passage. In the classical period, the term indicated the activity of the choregos, the citizen who financed the chorus in dramatic festivals, and effectively sponsored the plays. Choregos was a prestigious honorary title in the fifth-century Athenian society, and a role that only a rich and well-respected man could afford to play. Demetrios of Phaleron abolished the office during his government (317–307 BC) and in Hellenistic and Roman times we find the word used only metaphorically denoting “abundance of means” or “assistance”, and mostly within a historical or ethical context. In a medical context, the word χορηγίη (and correspondingly the verb χορηγέω and the noun χορηγός) is used with the same metaphorical meaning denoting either “providing” or “abundance”.26 In the Praecepta then χορηγίη denotes the 23  Massar, N. (2005). Soigner et servir. Histoire sociale et culturelle de la médecine grecque à l’époque hellénistique, 94, speaks here of “logique du don et du contre-don”. This principle is also put in the mouth of Hippocrates’ son (Epist. 27.8: Smith 120,19–20 = L. 9.422,15–16): ἠπίστατο γὰρ χάριτι χάριτα μετρεῖσθαι, “for he knew that one measures a favor by a favor” (trans. W. D. Smith). 24  Cf. Visky, K. (1959). ‘La qualifica della medicina e dell’architectura nelle fonti del diritto romano’, Iura 10, 24–66, who explains that the “salary” of the artes liberales was not the merces, but the honorarium, which was not subject to the norms of locatio-conductio. The artes liberales were based on a sort of ‘friendship’s relation’, in which any exchange of services was effectively an exchange of favours. In return to a service given for free, the receiver may ‘pay’ with a particular currency: gratitude, which could take the form of a gift or of honour. 25  On medicine as a liberal art, see in particular Kudlien, F. (1976). ‘Medicine as a ‘liberal art’ and the question of the physician’s income’, JHM 31, 448–59; Kudlien, ‘Unschätzbarkeit’ and Pisi, Il medico amico, 12–14. The first attempts to include medicine amongst the liberal arts are to be found in a lost canon by Varro, but the majority of our evidence dates to the first century AD. 26  The verb χορηγέω meaning “to provide” occurs for example in Gal., De fac. nat. 3.15 (Helmreich 254,16–17 = K. 2.211,8). On the noun χορηγία meaning “abundance”, see for instance Gal., De meth. med. 4.4 (K. 10.260,7).

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activity of a benefactor and it must be read here in conjunction with φιλανθρωπίη (on which see below), a term that indicates the inclination and availability to help people. In fact, in many texts the two activities occur together and share a strong social import.27 We can assume that the χορηγίη describes a physician’s generous helpfulness to treat foreigners or poor patients (ξένῳ τε ἐόντι καὶ ἀπορέοντι)28 for free, and possibly also his subsidising the expenses required by the treatment. In this context, χορηγίη indicates not the private generosity of an individual, but the doctor’s benevolence, which has a distinct social relevance. Being a choregos aims at establishing a good reputation for doctors in the societal context, and reinforcing the positive image of the physician as saviour (σωτήρ) or benefactor (εὐεργέτης).29 I turn now to what is perhaps the most famous sentence of the entire work: “where there is φιλανθρωπίη, there is also φιλοτεχνίη”. It is not surprising that this beautiful aphorism found its way into many modern studies of medical ethics: in particular, it was the notion of φιλανθρωπία that attracted the greatest scholarly attention. It is now widely accepted, that the Greek ‘philanthropy’ has little to do with the feeling of private charity expressed later by Christianity; rather, it indicates a kind of ‘benevolence’, which is given from someone, who is able to help from a position of superiority and is directed to someone else, who requires assistance and is in a position of inferiority.30 The term φιλανθρωπία was originally used with reference to the concessions offered by gods and kings to needy individuals. Later the same term was also 27  E.g.: D., De Chers. 70, where the τριηραρχία and the χορηγίας are represented as φιλανθρωπίαι; cf. also D. S. 13.58.3. 28  I take these two terms as two different substantivised participles. My interpretation is further substantiated by the ensuing pronoun τοιουτέοισιν. I do not agree with other scholars, who take ἀπορέοντι as adjectival participle qualifying the word ξένῳ and meaning “a stranger who is without means”. It was Zwinger (in his edition of Hippocrates) and after him Kudlien (Der griechische Arzt, 10–11), who first noticed a parallel with the Homeric ξεῖνοί τε πτωχοί τε (Hom., Od. 6.208). Cf. also Deichgräber, K. (1933). ‘Die ärztliche Standesethik des hippokratischen Eides’, QGMed 3, 35. 29  More on these titles in Massar, N. (2001). ‘Un savoir-faire à l’honneur. “Médecins” et “discours civique” en Grèce hellénistique’, Revue belge de philologie et d’histoire 79.1, 175–201. 30  On φιλανθρωπία and its complementary qualities see Tromp de Ruiter, S. (1931). ‘De vocis quae est ΦΙΛΑΝΘΡΩΠΙΑ significatione atque usu’, Mnemosyne 59, 271–306; Bolkestein, H. (1939). Wohltätigkeit und Armenpflege im vorchristlichen Altertum; Hands, A. R. (1968). Charities and Social Aid in Greece and Rome, 131–45. On medical φιλανθρωπία, see Edelstein, L. ‘The professional ethics of the Greek physician’, in Temkin, O. and Temkin, L. C. (1967). Ancient Medicine. Selected Papers of Ludwig Edelstein, 319–22; Amundsen, D. W. and Ferngren, G. B. ‘Philanthropy in medicine: Some historical perspectives’, in Shelp, E. E. (1982). Beneficence and Health Care, 1–31; Temkin, O. (1991). Hippocrates in a World of Pagans and Christians, 18–35.

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used to denote the benevolence politicians and judges demonstrated towards people in need. For this reason, φιλανθρωπία is often connected to other personal qualities such as “kindness” (εὔνοια) and “gentleness” (πραότης), but also related to qualities with a greater social import, such as “piety” (ἔλεος) and “justice” (δικαιοσύνη). The basis of such benevolence, however, implied a sort of reciprocal exchange between the giver and the receiver: in exchange for their generosity the φιλάνθρωποι expected to receive gratitude or honour from their beneficiaries. In the aforementioned passage from the Praecepta, φιλανθρωπίη defines, along with χορηγίη, the social virtue of helping generously others and, thus, gaining a good reputation as prescribed by the norms of an ars liberalis. In this sense, the notion of φιλανθρωπίη stands in opposition to the preceding ἀπανθρωπίη,31 and gets further elucidated by the ensuing (ἐπιεικείη) “fairness”. The φιλανθρωπία encompasses not only all the acts of ‘liberality’ listed above with respect to the physician’s fee (sensitivity to the financial conditions of the patients, gratuitous medical care, special attention to foreigners and financially disadvantaged people), but it also denotes the sort of friendly bedside manners, which could contribute to the patients’ recovery. Even though the notion of φιλανθρωπία is usually interpreted as an element of stoic influence,32 I do not think that in the Praecepta it has specific philosophical connotations. In fact, not only φιλανθρωπία had become quite a widespread notion in ethics since the Hellenistic time,33 but it had also been closely associated (already in classical times) with medicine, with the good physician being prominently pictured as a φιλάνθρωπος.34 The same characterisation appears also in certain medical texts, such as the ‘Hippocratic’ treatise De medico,35 in Galen, who defined medicine as a τέχνη οὕτω 31  See Pisi, Il medico amico, 25: “la φιλανθρωπία, in opposizione all’ἀπανθρωπία (‘mancanza d’umanità’) consiste nella sensibilità ai problemi, anche economici, del paziente”. 32  See, for instance, Edelstein, ‘The professional ethics’, 329–35; cf. also Mudry, Ph. ‘Éthique et médecine à Rome: La Préface de Scribonius Largus ou l’affirmation d’une singularité’, in Flashar, H. and Jouanna, J. (1997). Médecine et Morale dans l’Antiquité, 311–15. 33  Even if the notion of φιλανθρωπία coupled together with the feeling of human sympathy belongs to the realm of Stoic ideas, the occurrence of this term in the Praecepta does not necessarily indicate stoic influence. In fact, the same concept appears in Epicurean treatises (see, e.g., D. L. 10.10) too. Therefore, it is preferable to think of it as belonging to a common deposit of Hellenistic and Roman philosophical ideas. 34  See Pl., Symp. 189c–d, where the god Eros is said to be “the most φιλάνθρωπος of the gods” (θεῶν φιλανθρωπότατος) and therefore is compared to a physician, who gives happiness to people. 35  Medic. 1 (Heiberg 20,11–12 = L. 9.204,11–12): τὸ δὲ ἦθος εἶναι καλὸν καὶ ἀγαθόν, τοιοῦτον δ’ ὄντα πᾶσι καὶ σεμνὸν καὶ φιλάνθρωπον, “he must be a gentleman in character, and being this he must be grave and kind to all” (trans. W. H. S. Jones).

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φιλάνθρωπος,36 as well as in some honorary inscriptions.37 In this way also the connection with φιλοτεχνίη becomes much clearer. In the past, this occurrence of the term φιλοτεχνίη in the Praecepta has been interpreted in various ways: some scholars have read the term in the light of the next sentences, which speak about the value that patients attach to such benevolence, and have understood it as the ‘love for the art’ felt by the patient.38 Others have understood φιλοτεχνίη as the ‘love for the art’ felt by the physician himself in the sense of his zeal for practising the art, which is the usual meaning of the term.39 This last interpretation of ‘good professional practice’, or ‘professional competence’, also attested in some medical inscriptions,40 befits better our passage from the Praecepta: the two qualities of φιλανθρωπίη and φιλοτεχνίη define the good physician by underlining his gentleness, helpfulness, and professional competence.41 This combination of medical virtues—the first concerning the physician’s behaviour and social conduct, the second referring to his professional competence—are also found together in a close parallel from the ‘Hippocratic’ De articulis. It is there that we read that the physician who does not wish to gain vulgar money (δημοειδὴς κιβδηλίη) is described as a “good man” (ἀνδραγαθικώτερος) and a “good craftsman” (τεχνικώτερος).42 Furthermore, 36  Galen claims that φιλανθρωπία is the goal of medicine and holds Hippocrates as the ideal physician in this respect: De plac. Hipp. et Plat. 9. 5. 4–6 (De Lacy 564,21–30 = K. 5.751,10–52,1); Quod opt. med. 2.5–6 (Boudon-Millot 287,7–18 = K. 1.56,10–57,3). For this last passage see also Wenkebach, E. (1933). ‘Der hippokratische Arzt als das Ideal Galens’, QGMed 3, 363–83. On the Galenic use of φιλανθρωπία, see Jouanna, J. ‘La lecture de l’ethique hippocratique chez Galien’, in Flashar, H. and Jouanna, J. (1997). Médecine et Morale dans l’Antiquité, 238–40. 37  See e.g. no. 224,13–14 Samama: προσ-/ενεχθεὶς φ[ι]λανθρώπως πᾶσι τοῖς πολείταις; and no. 245,8 Samama: ζῶντα καλῶς ἐπιεικῶς καὶ φιλανθρώπ[ω]ς. 38  Cf. e.g. Edelstein, ‘The professional ethics’, 321, n. 4. 39  See, for instance, Pl., Cri. 109c and D. S. 1.98.9. 40  See e.g. no. 67,13–14 Samama: φιλοτέχνως ἐπιμε[λό]-[με]νος. 41  This was very aptly put by Koelbing, Arzt und Patient, 130: “behält der Satz von der Menschenliebe und der Liebe zur Kunst seinen einfachen, unkomplizierten Sinn: menschlich anständige Gesinnung und das Bestreben, eine gute Medizin auszuüben, gehen Hand in Hand. Ihre Verbindung kennzeichnet den wahren Arzt”. A peculiar interpretation of the passage is given by Lain Entralgo, P. (1969). Arzt und Patient. Zwischenmenschliche Beziehungen in der Geschichte der Medizin, 23–30, who introduced the concept of “friendship” (φιλία) with “nature” (φύσις) in order to explain the combination of φιλανθρωπία and φιλοτεχνία in the patient-physician relationship. 42  Art. 78 (Kühlewein 236,18–237,2 = L. 4.312,3–5): καὶ γὰρ ἀνδραγαθικώτερον τοῦτο καὶ τεχνικώτερον, ὅστις μὴ ἐπιθυμέει δημοειδέος κιβδηλίης, “this is more honourable and more in accord with the art for anyone who is not covetous of the false coin of popular advertisement” (trans. E. T. Withington).

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in some Roman medical writings, and in particular in those of Celsus and Scribonius Largus, we find ethical rules very similar to those prescribed in our passage from the Praecepta.43 In Celsus the word amicus occurs with reference to the physician. If the physician is friendly with the patient and gains his trust, he will succeed more easily in treating him, provided that he also has a solid grasp of medical knowledge (scientia).44 In Scribonius the physician is expected to be endowed with misericordia and humanitas to comply with the professional requirements (secundum ipsius professionis voluntatem).45 In both cases we find helpful behaviour and competence placed side by side, just as φιλανθρωπίη and φιλοτεχνίη occur together in the Praecepta. The final sentences of the passage are also relevant, as they refer to the three parties that are of immediate interest for the physician: the sick, the healthy, and the doctors themselves, who have to care about their own “decorum” (εὐσχημοσύνη). The word εὐσχημοσύνη means literally the ‘good shape’, in which a physician presents himself to the society, that is, his social conduct. The same term appears among the guidelines and even in the title of yet another treatise of medical ethics (De decenti habitu), in which it occurs in conjunction with the notions of δόξα (“fame”) and εὐδοξία (“good reputation”, 43  As far as medicine is concerned, some scholars have emphasised a difference between Greek (or more vague ‘Hippocratic’) and Roman medicine from the ethical point of view. Such approach was first adopted by Mudry, Ph. (1980). ‘Medicus amicus. Un trait romain dans la medicine antique’, Gesnerus 37, 17–20; see also id. (1986). ‘La déontologie médicale dans l’Antiquité grecque et romaine. Mythe et réalité’, RMS 106, 3–8, who stressed the fact that a benevolent attention to the patients’ psychology and suffering is to be found in particular in the Roman medical literature. Mudry has revised his position in regard to this passage of the Praecepta over the years. In his ‘Medicus amicus’, he clearly contrasts the vaguely-defined ‘Hippocratic’ ethics of the Praecepta with the Roman ethics, whereas in the article ‘Éthique et médecine à Rome’ (1997) he adopts more cautious positions underlining a certain similarity between the Praecepta and some Roman medical writings. For the Roman medical ethics, see also Pigeaud, J. ‘Les fondements philosophiques de l’éthique médicale: Le cas de Rome’, in Flashar, H. and Jouanna, J. (1997). Médecine et Morale dans l’Antiquité, 255–96. 44  Celsus, Med. praef. 73 (Marx 29,13–14): ideoque, cum par scientia sit, utiliorem tamen medicum esse amicum quam extraneum. The term utilitas corresponds exactly to the Greek χρήσιμον, which is the goal of medical care. Mudry (‘Medicus amicus’, 18) identified a “relation personnelle d’amitié entre le médecin et le malade” as a typical feature of Roman medicine. 45  Scrib. Larg., Comp. praef. 3–4 (Sconocchia 2,11–13): tum praecipue medicis, in quibus nisi plenus misericordiae et humanitatis animus est secundum ipsius professionis voluntatem, omnibus diis et hominibus invisi esse debent. For this passage see Deichgräber, K. (1950). ‘Professio Medici. Zum Vorwort des Scribonius Largus’, AAWM 9, 860–61 and Mudry, ‘Éthique et medicine’.

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“esteem”).46 The correspondent adjective (εὐσχήμων) and adverb (εὐσχημόνως) feature also in some honorary medical inscriptions describing the professional competence of certain physicians.47 εὐσχημοσύνη is then (along with εὐδοκίη, χορηγίη and φιλανθρωπίη) closely connected with physician’s reputation and his social cachet. The third and final passage from the Praecepta, although it comments directly on the issue of the medical fees and its impact on the patientphysician relationship, has been neglected by the majority of scholarly works on the topic. After having criticised the quack doctors (ἀνίητροι: Ecca 118,8–13 = Heiberg 32,14–19 = L. 9.258,16–260,3), who are ignorant of medicine and try to profit from rich patients without healing them, the author of the Praecepta shifts his attention to the bad-mannered patients and describes their behaviour towards medical fees. πολυτελείης γὰρ ἀπορέουσιν οἱ νοσέοντες κακοτροπίῃ προσκυνεῦντες καὶ ἀχαριστέοντες ξυντυχίῃ·48 δυνατοὶ ἐόντες εὐπορέειν διαντλίζονται περὶ μισθαρίων, ἀτρεκέως ἐθέλοντες ὑγιέες εἶναι εἵνεκεν ἐργασίης τόκων ἢ γεωργίης ἀφροντιστέοντες περὶ αὑτέων49 λαμβάνειν50 (Ecca 120,8–14 = Heiberg 32,28–33,3 = L. 9.262,1–4).

46  Decent. 1 (Heiberg 25,10–11 = L. 9.226,11–12): τέχνην δὲ τὴν πρὸς εὐσχημοσύνην καὶ δόξαν, “provided that it be an art directed toward decorum and good repute”; ibidem 3 (Heiberg 25,21–23 = L. 9.228,8–10): ἔκ τε γὰρ περιβολῆς καὶ τῆς ἐν ταύτῃ εὐσχημοσύνης καὶ ἀφελείης, οὐ πρὸς περιεργίην πεφυκυίης, ἀλλὰ μᾶλλον πρὸς εὐδοξίην, “dress decorous and simple, not overelaborated, but aiming rather at good repute”; ibidem 18 (Heiberg 29,29–30 = L. 9.244,1–2): τοιουτέων οὖν ἐόντων τῶν πρὸς εὐδοξίην καὶ εὐσχημοσύνην τῶν ἐν τῇ σοφίῃ καὶ ἰητρικῇ καὶ ἐν τῇσιν ἄλλῃσι τέχνῃσι, “such being the things that make for good reputation and decorum, in wisdom, in medicine, and in the arts generally” (trans. W. H. S. Jones). 47  See e.g. no. 62,2 Samama: τήν τε ἀναστροφὴν εὐσχήμονα καὶ πρέπου[σ]αν καὶ [κ]αταξίαν τῆς εὐτεχνίας ποιεῖται; no. 69,12 Samama: πεπ]οίηται καλῶς καὶ εὐσχημόνως; no. 163,9–10 Samama: τὴν ἀναστροφὴν εὐσχήμονα καὶ τῆς [τ]έχνης ἀξίαν. The notion is discussed also by Roselli, A. ‘Il medico nelle città ellenistiche. Le iscrizioni onorarie per i medici e i trattati deontologici ippocratici’, in Boudon-Millot, V. et al. (2007). La science médicale antique. Nouveaux regards. Études réunies en l’honneur de Jacques Jouanna, 368–70. 48  The reading ξυντυχίῃ is my own conjecture, whereas the main manuscripts transmit the infinitive ξυντυχεῖν. 49  Heiberg printed αὐτέων, a reading of both the main manuscripts, but I prefer here the reading of a later hand of the Marcianus gr. 269, which corrected the spiritus from lenis to asper, so offering a reflexive pronoun. 50  The verb λαμβάνειν seems to be superfluous here, because the expression ἀφροντιστέοντες περὶ αὑτέων “they do not care about themselves” does not need any further supplement. The verb has furthermore no organic connection to the following paragraph of Praecepta.

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For patients are in need because they spent a fortune [scil. for their medical treatment],51 prostrating themselves before dishonest physicians and remaining unsatisfied with their condition. Even if they are comfortably able to pay, they exhaust themselves by worrying about a modest fee, whereas in reality they wish to become healthy for the sake of their monetary profits or agricultural business, and consequently neglect themselves. Although the Greek of this passage is quite obscure, the meaning seems to be fairly clear. The author seems to distinguish between two kinds of inappropriate behaviour on the part of the patients. Some patients are ready to spend a big amount of money demanded by unqualified physicians (the abstract noun κακοτροπίη “badness of habits” seems to refer to the behaviour of fraudulent physicians) without receiving proper treatment. Other patients, although they have sufficient financial means to pay the physician’s fee (δυνατοὶ ἐόντες εὐπορέειν), still grieve over the amount of money they have to spend in exchange for medical expertise. These antithetical types of behaviour are portrayed by means of contrasting the nouns πολυτελείη and μισθάριον on one hand, and the verbs ἀπορεῖν and εὐπορεῖν on the other. Those incompetent physicians, who require large fees from their patients without treating them appropriately and perform their duties with the sole aim of monetary gain, are characterised as charlatans. The diminutive μισθάριον occurs here for the second time, referring (as in the first passage) to the honest and relatively small compensation the physician receives in exchange for his invaluable service. This relatively small fee is the compensation of the competent physician, who, nonetheless, must occasionally deal with rich but miserly patients. Wealthy patients are then portrayed as “exhausting themselves” (διαντλίζονται) by worrying about the small fee they have to pay. The verb διαντλίζονται (a hapax legomenon) may derive from διαντλέω (‘to exhaust’ or ‘to endure to the end’). The simple form ἀντλέω means literary “to bale a ship”, or more generally “to draw water”; while the middle-passive form διαντλίζομαι However, considering the redundant style of the text, I preferred not to expunge the verb. In any case, it does not affect the meaning of the sentence. 51  I follow the interpretation given by Jones, who translates “for the patients are in need through heavy expenditure”. The genitive indicates here the cause of the lack of money. For a similar use of ἀπορέω with genitive, see Xen., Mem. 1.3.5. Littré corrects the text of the manuscripts as follows: πολυτελεῖς γὰρ ἀπορέουσιν ἐόντες; and translates “ils sont dans l’opulence et ils manquent”.

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seems to denote the patients, who feel “drained” of their own money. It is with irony that the author describes their avarice and the ridiculous psychological turmoil they experience over the medical fees. Making money is for them the sole goal in life and they want to recover not because they care about themselves, but in order to get back to their businesses.52 The author responds to the bad reputation the physicians had been given, because of their alleged greediness, by attacking in return the tightfistedness of their patients. Thus, the author of the Praecepta seems to be claiming that it is not the physicians who ask for too much money; instead, it is the patients who, because of their avarice, do not want to part with a reasonable amount of money as a medical fee. To sum things up, the passages quoted above provide an insight into the social reputation of the physician and the ‘hot’ topic of the ancient physician’s fees. As the terminology used in the Praecepta reveals, its author seems to be conscious of the widespread ill repute of the physicians on account of their greed, which could conversely affect the reputation of the medical art tout court. To defend physicians against such an allegation, our author insists on the one hand on the relatively small amount of fees required by good physicians, and contrasts that with the invaluable service of saving the patients’ life. In this respect, the diminutive μισθάριον does not say much about the real amount of money gained by the author of the Praecepta, nor does it reveal much about his financial status. In short, the term μισθάριον is used to defend the physicians against any future charge of greed.53 On the other hand, the author defends the social relevance of the medical art by restoring its reputation and counting it among the liberal arts, at least in certain circumstances. The fact that similar attempts to elevate (at least theoretically) the social status of medicine and its practitioners, are detectable in other texts of the first and second century AD54 seems to support our dating of the Praecepta to the first centuries of the Roman Empire.55 In the Praecepta, the figure of the patient emerges primarily from the perspective of the physician: the patient’s pain, thoughts and psychological 52  The final sentence “they neglect themselves” refers to a common criticism in popular ethics against the foolish people, who keep themselves busy with various activities, whilst neglecting to look after their own health. 53  For the wide spectrum of social and financial status of ancient physicians in the Roman Empire see Pleket, ‘The social status’, and Nutton, ‘Healers’, 38–49. 54  See above n. 25. 55  See above n. 2.

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turmoil are described through the eyes of the physician himself. The author of the treatise also paints a picture of the bad-mannered patient, who is to be blamed either for not recognizing a good physician and trusting charlatans, or for being tight-fisted when asked to pay the comparatively modest fee of the skilled doctor. Even the physician’s concern about the psychological distress of the patient is closely linked to the success of the therapy and, consequently, aims at safeguarding the reputation of the physician himself. In fact, the patient’s anguish seems to be taken into consideration by the physician, primarily in so far as it could affect the result of the medical treatment. The point of view of the patient is in this way rather eclipsed by the perspective of the physician, who remains indeed the towering figure of the medical encounter as it emerges from the Praecepta. Texts and Translations Used Aristophanes. Aristophane. Ed. V. Coulon. Paris: C. U. F. Collection Budé, vol. 1–5, 1923–30. Cornelius Celsus. Cornelii Celsi quae supersunt. Ed. F. A. Marx (CML I). Leipzig: B. G. Teubner, 1915. Corpus Hippocraticum. Praecepta: Kritische Edition, Übersetzung und Kommentar. Mit Anhang: Ein Scholion zu Praec. 1. Ed. G. Ecca. Wiesbaden: Reichert Verlag, in print. Demosthenes. Démosthène. Harangues. Tome 2. Ed. M. Croiset. Paris: C. U. F. Collection Budé 1968. Diodorus Siculus. Diodore de Sicile, Bibliothèque historique. Fragments, Tome 1. Ed. Aude Cohen-Skalli. Paris: C. U. F. Collection Budé, 1998. Diogenes Laertius. Lives of Eminent Philosophers. Ed. T. Dorandi, Cambridge, New York: Cambridge University Press, 2013. Galen. Galien. Introduction générale; Sur l’ordre de ses propres livres; Sur ses propres livres; Que l’excellent médecin est aussi philosophe. Ed. V. Boudon-Millot. Paris: C. U. F. Collection Budé, 2007. ———. Galeni De placitis Hippocratis et Platonis. Ed. Ph. De Lacy. CMG V, 4,1,2. Berlin: Akademie Verlag, 2005. ———. Claudii Galeni Pergameni Scripta Minora. Ed. G. Helmreich, vol. 3. Leipzig: B. G. Teubner, 1893. ———. Claudii Galeni opera omnia. Ed. K. G. Kühn, vol. 1–20. Leipzig: Cnobloch 1821–33. Hippocratis Indices librorum, Iusiurandum, Lex, De arte, De medico, De decente habitu, Praeceptiones. Ed. J. L. Heiberg. CMG I, 1. Leipzig: B. G. Teubner, 1927.

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Hippocratis De diaeta. Ed. R. Joly and S. Byl. CMG I, 2,4,2. 2. Aufl. Berlin: Akademie Verlag, 2003. ———. Ed. and trans. W. H. S. Jones, vol. 1. The Loeb Classical Library 147. Cambridge, MA and London: Harvard University Press, 1923. ———. Ed. and trans. W. H. S. Jones, vol. 2. The Loeb Classical Library 148. Cambridge, MA and London: Harvard University Press, 1923. ———. Ed. E. T. Withington, vol. 3. The Loeb Classical Library 149. Cambridge, MA and London: Harvard University Press, 1928. ———. Hippokratus To Peri Aerōn, Hydatōn, Topōn Deuteron ekdothen meta tēs Gallikēs metaphraseōs. Ed. A. Korais. Paris: Ι. Μ. Εveratou, 1816. ———. Hippocratis Opera quae feruntur omnia. Ed. H. Kühlewein, vol. 2. Leipzig: B. G. Teubner, 1902. ———. Œvres complètes d’Hippocrate. Ed. E. Littré, vol. 1–10. Paris: J.-B. Baillière, 1839–61. ———. Pseudepigraphic Writings. Letters—Embassy—Speech from the Altar—Decree. Ed. W. D. Smith. Leiden—New York—København—Köln: Brill, 1990. Hippocratis Coi [. . .] viginti duo commentarii tabulis illustrati. Ed. Th. Zwinger. Basileae, 1579. Homerus. Homeri Odyssea. Ed. H. van Thiel, Zürich, New York: Hildesheim, 1991. Platon. Platonis Opera. Ed. I. Burnet, vol. 1–5, Oxford 1900–07. Plutarchus. Plutarch, Œuvres morales. Tome 11, 2e partie. Ed. J.-Cl. Carrière. Paris: C. U. F. Collection Budé, 1984. ———. Plutarch, Œuvres morales. Tome 15, 1ère partie. Ed. M. Casevitz. Paris: C. U. F. Collection Budé, 2004. Poetae Comici Graeci. Ed. R. Kassel and C. Austin, vol. 1–8. Berlin: W. De Gruyter, 1983–2001. Samama, É. Les médecins dans le monde grec. Sources épigraphiques sur la naissance d’un corps médical. Genève: Droz, 2003. Seneca. Sénèque, Des bienfaits. Ed. F. Préchac. Paris: C. U. F. Collection Budé, vol. 2, 1926–27. Scribonius Largus. Scribonii Largi Compositiones. Ed. S. Sconocchia. Leipzig: B. G. Teubner, 1983. Xenophon. Mémorable. Ed. M. Bandini. Paris: C. U. F. Collection Budé, vol. 2, 2000–11.

References Amundsen, D. W. and Ferngren, G. B. ‘Philanthropy in Medicine: Some Historical Perspectives.’ in Beneficence and Health Care, ed. E. E. Shelp, 1–31. Dordrecht: D. Reidel, 1982.

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Bolkestein, H. Wohltätigkeit und Armenpflege im vorchristlichen Altertum. Utrecht: Oosthoek, 1939. Cohn-Haft, L. The public physicians of ancient Greece. Northampton: Smith College Studies in History, 1956. Deichgräber, K. ‘Die ärztliche Standesethik des hippokratischen Eides.’ Quellen und Studien zur Geschichte der Medizin 3, (1933): 29–49. ———. ‘Professio Medici. Zum Vorwort des Scribonius Largus.’ Abhandlungen der Akademie der Wissenschaften in Mainz, Geistes-und sozialwissenschaftliche Klasse 9, (1950): 855–79. Edelstein, L. ‘The professional Ethics of the Greek Physician.’ Bulletin of History of Medicine 30, (1956): 391–419 = Edelstein, L. ‘The professional Ethics of the Greek Physician.’ in Ancient Medicine. Selected Papers of Ludwig Edelstein, ed. O. Temkin and L. C. Temkin, 319–48. Baltimore: Johns Hopkins University Press, 1967. Fleischer, U. Untersuchungen zu den pseudohippokratischen Schriften Παραγγελίαι, Περὶ ἰητροῦ und Περὶ εὐσχημοσύνης. Berlin: Junker und Dünnhaupt Verlag, 1939. Gourevitch, D. Le triangle hippocratique dans le monde gréco-romain. Le malade, sa maladie et son médecin. Rome: École française de Rome, 1984. Hands, A. R. Charities and Social Aid in Greece and Rome. London: Thames and Hudson, 1968. Horstmanshoff, H. F. J. ‘The Ancient Physician: Craftsman or Scientist?’ Journal of History of Medicine 45, (1990): 176–97. Jouanna, J. ‘La lecture de l’éthique hippocratique chez Galien.’ in Médecine et Morale dans l’Antiquité, 19–23 août 1996, ed. H. Flashar and J. Jouanna, 211–53. VandœuvresGenève: Fondation Hardt, 1997. Koelbing, H. M. Arzt und Patient in der antiken Welt. Zürich and München: Artemis Verlag, 1977. Kudlien, F. ‘Medicine as a ‘liberal art’ and the question of the physician’s income.’ Journal of History of Medicine 31, (1976): 448–59. ———. Der griechische Arzt im Zeitalter des Hellenismus. Seine Stellung in Staat und Gesellschaft. Wiesbaden: Franz Steiner, 1979. ———. ‘Die Unschätzbarkeit ärztlicher Leistung und das Honorarproblem.’ MedizinHistorisches Journal 14, (1979): 3–16. ———. Die Stellung des Arztes in der römischen Gesellschaft. Wiesbaden: Franz Steiner 1986. Lain Entralgo, P. Arzt und Patient. Zwischenmenschliche Beziehungen in der Geschichte der Medizin, deutsche Übersetzung von M. Degenhardt. München: Kindler, 1969. Marasco, G. ‘Les salaires des médecins en Grèce et à Rome.’ in Le normal et le pathologique dans la Collection hippocratique. Actes du Xème colloque interna-

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tional hippocratique, (Nice: 6–9, X, 1999), ed. A. Thivel and A. Zucker, 769–86. Nice: Publications de la Faculté des Lettres de Nice-Sophia Antipolis, 2002. Massar, N. ‘Un savoir-faire à l’honneur. “Médecins” et “discours civique” en Grèce hellénistique.’ Revue belge de philologie et d’histoire 79.1, (2001): 175–201. ———. Soigner et servir. Histoire sociale et culturelle de la médecine grecque à l’époque hellénistique. Paris: De Boccard, 2005. Mazzini, I. ‘Le accuse contro i medici nella letteratura latina e il loro fondamento.’ Quaderni linguistici e filologici 2, (1982–84): 75–90. Mudry, Ph. ‘Medicus amicus. Un trait romain dans la médecine antique.’ Gesnerus 37, (1980): 17–20. ———. ‘La déontologie médicale dans l’Antiquité grecque et romaine. Mythe et réalité.’ Revue médicale de la Suisse romande 106, (1986): 3–8. ———. ‘Éthique et médecine à Rome: La Préface de Scribonius Largus ou l’affirmation d’une singularité.’ in Médecine et Morale dans l’Antiquité, 19–23 août 1996, ed. H. Flashar and J. Jouanna, 297–336. Vandœuvres-Genève: Fondation Hardt, 1997. Nutton, V. ‘Healers in the Medical Market-Place: Towards a Social History of GraecoRoman Medicine.’ in Medicine in Society. Historical Essays, ed. A. Wear, 15–58. Cambridge: Cambridge University Press, 1992. Pigeaud, J. ‘Les fondements philosophiques de l’éthique médicale: Le cas de Rome.’ in Médecine et Morale dans l’Antiquité, 19–23 août 1996, ed. H. Flashar and J. Jouanna, 255–96. Vandœuvres-Genève: Fondation Hardt, 1997. Pisi, G. and Torti, G. Il medico amico in Seneca—Il suo regno non avrà mai fine. Roma: Bulzoni, 1983. Pleket, H. W. ‘The social status of physicians in the Greco-Roman world.’ in Ancient Medicine in its Socio-Cultural Context. Papers Read at the Congress held at Leiden University (13–15 april 1992), ed. Ph. J. van der Eijk, H. F. J. Horstmanshoff and P. H. Schrijvers, 27–33. Amsterdam and Atlanta: Rodopi, 1995. Roselli, A. ‘Il medico nelle città ellenistiche. Le iscrizioni onorarie per i medici e i trattati deontologici ippocratici.’ in La science médicale antique. Nouveaux regards. Études réunies en l’honneur de Jacques Jouanna, ed. V. Boudon-Millot, A. Guardasole and C. Magdelaine, 353–71. Paris: Beauchesne, 2007. Schulthess, O. s.v. Μισθός, Real-Enzyklopädie der klassischen Altertumswissenschaft 15.2, (1932): coll. 2078–95. Temkin, O. Hippocrates in a World of Pagans and Christians. Baltimore and London: Johns Hopkins University Press, 1991. Tromp de Ruiter, S. ‘De vocis quae est ΦΙΛΑΝΘΡΩΠΙΑ significatione atque usu.’ Mnemosyne 59, (1931): 271–306.

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Visky, K. ‘La qualifica della medicina e dell’architectura nelle fonti del diritto romano.’ Iura 10, (1959): 24–66. Wenkebach, E. ‘Der hippokratische Arzt als das Ideal Galens.’ Quellen und Studien zur Geschichte der Medizin 3, (1933): 363–83. Will, E. ‘Notes sur ΜΙΣΘΟΣ.’ in Le Monde Grec. Pensée, littérature, histoire, documents. Hommages à Claire Préaux, ed. J. Bingen, G. Cambier and G. Nachtergael, 426–38. Bruxelles: Editions de l’Université de Bruxelles, 1975.

CHAPTER 13

The Practical Application of Ancient Pulse-Lore and its Influence on the Patient-Doctor Interaction Orly Lewis This paper examines the effects of the emergence of pulse measurement as an essential diagnosis and prognosis method used on Graeco-Roman patients. It argues that the introduction of this diagnostic tool brought about changes to the encounter between patients and their doctors and may have also increased intimacy and patients’ forthcomingness during these encounters. The paper demonstrates that the popularity and conspicuity of the practical and theoretical engagement with the pulse afforded many opportunities for the transmission of professional knowledge from doctors to patients. It argues that this transmission of knowledge was often actively encouraged by doctors for the sake of selfpromotion and promotion of the medical profession as a whole. At the same time, doctors also attempted to restrict this transmission of knowledge in order to use their exclusive competence in the pulse as means for establishing their authority and superiority over patients. Introduction In the fifth-century BC treatise Prognostic, attributed to Hippocrates, the author lists various natural phenomena relating to the patient (e.g. respiration, urine, excrements and sleep) that should be examined by the physician when called upon to make a prognosis. In this context the author also explains what the * This research was made possible by the generous support of the Alexander von Humboldt foundation and Philip van der Eijk, to whom I am grateful for the ongoing assistance. I have benefited from comments made on earlier versions of this paper by audiences in Berlin and Tel-Aviv. I am grateful to Heinrich von Staden for his assistance with Marcellinus’ work, to Marquis Shane Berrey of the University of Iowa for making his enlightening dissertation available to me and to the editors of the volume for their patience and assistance during the revision of the paper. A special thanks also to Christine Salazar of the Humboldt-Universität zu Berlin for her helpful advice and to Ann Ellis Hanson for her useful comments. All mistakes remain, nevertheless, my own. © koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_015

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particular quality and character of these phenomena may indicate concerning the condition of the patient.1 These are indeed also the phenomena which the authors of the fifth- and early fourth-century BC collections entitled Epidemics actually examined during their encounter with the numerous patients whose cases they report.2 Comparing these and other guidelines and practices of the period to those described by later ancient3 writers, one notices a fundamental difference concerning one phenomenon, namely, the pulse of the patients and its examination during the patient-physician encounter. The early physicians generally considered throbbing observed in patients an unnatural and mostly random phenomenon, a sign of disease simply by virtue of its existence rather than its quality, as opposed to natural phenomena such as respiration, urine and sleep; these may indicate either health or disease according to their quality at a particular moment. Accordingly, they mention throbbing motions observed in the bodies4 of their patients only sporadically and they often record such motions without any reference to their quality.5 On the contrary, later physicians such as Herophilus (fl. third century BC) and Galen (second century AD) considered the throbbing of the arteries, i.e. the pulse (sphygmos), a natural and constant phenomenon occurring throughout the body and its examination a fundamental part of the encounter with patients. Galen, for instance, describes numerous incidents in which he examined the pulse of his patients and used the information he gained from the particular character of each patient’s pulse (e.g. its speed or size)6 to establish both a diagnosis and a prognosis.7 1  Progn. 5 (L. 2.122) (respiration); 10, (L. 2.134) (sleep); 11 (L. 2.134–38) (excrements); 12, (L. 2.138–42) (urine). Cf. Epid. 1.10 (L. 2.668–70 = Jones, 180) for a similar list. 2  See, for example: Epid. 1.2 (L. 2.608 = Jones 150); 1.4 (L. 2.632 = Jones 162) (excrement and urine); ibid. Epid. 1.26, case 1 (L. 2.684 = Jones 186) (sleep and respiration). 3  Throughout this paper the term ‘ancient’ refers to Graeco-Roman. 4  They did not restrict such motion only to the heart or the vessels, but attributed it also to other parts of the body, such as the head (Acut. (spur.) 18 (L. 2.480 = Potter 306)) and the abdomen (hypochondrium; Progn. 7, (L. 2.126)); on the localisation of the motions perceived by the so-called Hippocratic authors, see Duminil, M.-P. (1983). Le sang, les vaisseaux, le coeur dans la collection hippocratique, 311–12; cf. Shigehisa Kuriyama’s discussion on the conception of the location of the throbbing motion (see note 14 below). 5  Duminil, Le sang, 311–16. An exception is Carn. 6 (L. 8.592 = Joly 192), which refers to the constant throbbing of the heart and the “hollow vessels”. Another reference to a natural and constant motion of vessels is Loc. Hom. 3 (L. 6.280 = Craik, 38–40), but the author explicitly states that this is a unique phenomenon occurring only in the vessels of the temples. 6  The Greek term used by writers since Herophilus is megethos, which is commonly translated, in reference to the pulse, as “size”, rather than “magnitude”. 7  For some examples see notes 47 and 48 below.

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Interestingly, our sources indicate that this new practice had not escaped the patients’ notice. While in Archaic and Classical Greek literature throbbing motions (pēdēma, palmos) are always connected to emotional extremes,8 later sources attest a different conception. A fragment of the second century BC satirist Lucilius, for example, mentions the touching (tetigit) of the vessels and heart and a character in one of Persius’ satires (first century AD) urges the doctor to touch (tange) his heart and vessels in order to determine if he is ill.9 Some of Galen’s patients also entreated him to take their pulse and then eagerly asked for his verdict and Seneca the Younger (first century AD) notes that in order to advise about the appropriate time for eating or bathing, the physician “must touch the vessels [i.e. the pulse] (vena tangenda est)”.10 Plutarch, on the other hand, remarks that “no one should be ignorant of the particularities of his own pulse” and that it is “useful and easy” to know, without having to turn to a physician, whether one’s pulse is, for instance, frequent (pyknos) or rare (manos).11 Indeed, Marcellinus, writing shortly before Galen, wonders whether he knows of any layman, who has not tried to feel his own pulse.12 Moreover, from Quintilian we learn that taking the pulse had become a symbol of the patient’s encounter with the physician:13 There are other [gestures] which indicate things by means of mimicry. For example, you may evoke the image of a sick man by mimicking the gesture of a physician palpating the vessels [i.e. the pulse], or a cithara player by moving your hands as though they were plucking the strings. 8  In these sources the motion is described as occurring in the heart alone; see for example: Hom., Il. 22, 451–52: “my heart beats, almost reaching my mouth” (ἐν δ’ ἐμοὶ αὐτῇ στήθεσι πάλλεται ἦτορ ἀνὰ στόμα, my own translation); Eur., Bacchae 1288: “speak, as my heart is jumping [in fear at] what is to come” (λέγ’, ὡς τὸ μέλλον καρδία πήδημ’ ἔχει; translated by Richard Seaford). Cf. Hom., Il. 7, 216; 10, 94–95; 22, 460–61 and see Staden, H. von (1989). Herophilus: The Art of Medicine in Early Alexandria, 268. 9  Lucilius, fr. 680 Warmington; Persius, 3.107. 10  Gal., De praecogn. 2.5 and 3.11, (K. 14.607; 616–17 = Nutton, CMG V,8,1, 76 and 86); Sen., Ep. 22. 11  Plut., De san. tuenda 26, 136e7–f4. 12  Marcellin., Puls. 3–4 (numbers refer to lines in Schöne’s edition, available also on the Thesaurus Linguae Graecae). For the dating of his work, see Staden, Herophilus, 282 n. 150 and Schöne, H. (1907). ‘Markellinos’ Pulslehre. Ein griechisches Anekdoton’, Festschrift zur 49. Versammlung deutscher Philologen Schulmänner, 449–50. I am deeply grateful to Heinrich von Staden for assisting me with this passage and making available to me his new collation and reading of it from his forthcoming edition of Marcellinus’ work. 13  Translated by Butler, slightly modified. Quint., Inst., 11.3.88: alii [scil. gestus] sunt qui res imitatione significant, ut si aegrum temptantis venas medici similitudine aut citharoedum formatis ad modum percutientis nervos manibus ostendas. See also Baker’s article in the present volume (Chapter Fourteen, 366–389), who discusses such symbols of the profession.

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There is, therefore, substantial evidence that the patients had not only noticed that physicians were in the habit of performing a certain examination that entailed palpating their wrists, but also had some understanding concerning what it was that physicians were actually trying to feel (i.e. not simply beats but the beating of the vessels),14 how they were trying to describe what they felt (e.g. by terms such as pyknos, frequent) and how the practice would help establish the patients’ condition and the required regimen. The question thus arises: how did the pulse, once thought to be a pathological symptom like pain or tumours and which had received little attention from the physicians, become a target for the patients’ curiosity? How did it become a practice requested by the patients during the medical examination, and how did it turn into a tool for their attempts at self-diagnosis? How did they become aware that there is a pulsation to be felt in the first place and that it can aid in diagnosis and prognosis? How did they come to consider it to be so crucial as to be worth requesting immediately upon the physician’s arrival? How did they learn (or believe they had learned) where and how to measure their own pulse? How, moreover, did they learn that a pulse can be pyknos, frequent, a key term in ancient theories of the pulse (‘pulse-lore’)? This paper will attempt to answer these questions and to establish (a) to what extent and by what means was this knowledge15 transmitted (intentionally and unintentionally) to the patient and (b) in what way did the knowledge of the ancient physicians on the pulse affect the encounter between patients and physicians.16 By ‘patient’ I do not refer only to a homo patiens in the literal sense of a sick or suffering person, but rather to a ‘patient’ in the broader sense, namely, a person, who is not himself a physician and who therefore interacts with physicians in matters related to health or illness (for example, in conversation or as a member of an audience) from an inferior medical epistemological position,17 but not in the capacity of a student or apprentice of the 14  As Shigehisa Kuriyama has shown, this is not an obvious concept: Kuriyama, S. (1999). The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine, 23–60. 15  The term ‘knowledge’ with reference to the pulse is used throughout the paper to refer both to the physiological ideas concerning the pulse as well to the distinction between the types of the pulse and their classification. 16  On the causes for the change in the physicians’ conception of corporal throbbing ­following the change in anatomical knowledge, see Kuriyama, Expressiveness, 30–37 and von Staden, Herophilus, 262–72. 17  In other words, someone who is not himself a physician; so, for example, I do not read the case of Glaucon’s friend—who asks Galen, whether he may have altered his pulse by getting out of bed shortly before Galen’s arrival—as a testimony to the ancient patient’s knowledge of the ‘art of the pulse’, since this patient was himself a physician. In fact,

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medical art. Scholars have heretofore focused on the physicians’ theories and their professional debates, while the effects of the changing18 knowledge and debate about the pulse on the perspective of the ancient patients, their medical knowledge and their interaction with their physicians have hardly been addressed.19 This is particularly striking in light of the fundamentally practical and patient-oriented importance ascribed to the pulse by the ancient physicians themselves, who claimed that the aim of the ‘art of the pulse’ (hē peri tous sphygmous technē) was to enable the physician to “know what there is and to prognosticate the things which are about to happen to the sick”.20 This paper is aimed, therefore, at shifting the focus from the content of the ancient ‘art of the pulse’—that is, from the physicians’ theories and debates— to the practical application of this art during the physicians’ encounters with patients and its consequences. Beginning with the late fourth century BC, Galen seems to be ascribing this patient’s question and the professional knowledge it implies to the patient’s profession, which he mentions at the beginning of his report on this patient (ἰατρὸς ὤν, Gal., De loc. aff. 5.8 (K. 8.363)). 18  Throughout this paper I refer to ‘change’ rather than to ‘development’ or ‘advance’ in order to avoid any hint to the concept of a linear advance towards modern knowledge. Even if one would like to examine the history of ancient medicine through such a prism, (s)he will end up, in the case of ancient ideas on the pulse (as, in fact, with many other fields of medicine), not with one, but with many lines going in different directions—often even backwards: Galen’s conception and terminology of the pulse, for example, was not necessarily more ‘correct’, i.e. closer to modern knowledge, than Erasistratus’ or Herophilus’. 19  The most extensive discussions on ancient theories of the pulse are Harris, C. R. S. (1973). The Heart and the Vascular System in Ancient Greek Medicine—from Alcmaeon to Galen, especially 181–95, 244–51, 397–431 and von Staden, Herophilus, 262–88; but Wellmann, M. (1895). Die pneumatische Schule bis auf Archigenes, 70–71, 169–201 is still important for the pulse theory of the Pneumatist school. On particular tools and methods used by the physicians (e.g. Herophilus’ water-clock) see von Staden, Herophilus, 282–83 and Berrey, M. S. (2011). Science and Intertext: Methodological Change and Continuity in Hellenistic Science. Unpublished dissertation from the University of Texas, 58–91, who also discusses Herophilus’ use of pulse theory in the broader scientific and social-political contexts; Deichgräber, K. (1957). Galen als Erforscher des menschlichen Pulses: ein Beitrag zur Selbstdarstellung des Wissenschaftlers (De dignotione pulsuum I 1), 3–39. For the aims and style of Galen’s writings, see Asper, M. ‘Un personaggio in cerca di lettore: Galens Großer Puls und die “Erfindung” des Lesers’, in Fögen, T. (2005). Ancient Technical Texts, 21–39; Mattern, S. P. (2008). Galen and the Rhetoric of Healing, e.g. 78, 148, 151, 157; Barton, T. (1994). Power and Knowledge: Astrology, Physiognomics, and Medicine under the Roman Empire, 133–68; Garcia-Ballester, L. ‘Galen as a clinician: His methods in diagnosis’, in Haase, W. (1994). ANRW 2.37.2, 1656–57. 20  Gal., De diff. puls. 1.1 (K. 8.496); cf. De praesag. ex puls. 4.11. (K. 9.420) and Marcellin., Puls. 19–21.

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when the pulse was first described as a natural and constant motion of the arteries, whose variations may be interpreted as diagnostic signs, I shall trace the changes within the practice of examining the pulse until the days of Galen and the means by which the ancient patients may have learned about the pulse and its significance. I shall show that the ancient patient had numerous opportunities to witness the physicians’ interest in the pulse and their knowledge of it and that the conspicuity of both the practice and the theoretical interest afforded many opportunities for the transmission of this knowledge. I shall argue, furthermore, that while the physicians often carried out this transmission unintentionally, at times they also encouraged it to a certain extent. * * * Based on the extant sources we can begin to speak of a ‘measuring’ of patients’ ‘pulse’—i.e. of the constant motion of their arteries—and its incorporation into the physicians’ examination routine with Praxagoras of Cos, a physician active in the late fourth and early third centuries BC, whose ideas have reached us only via the testimonies of later sources. Praxagoras recognised that there is a constant and natural pulsation in the body which occurs only in a certain set of vessels, namely, the arteries (artēriai); he called this motion sphygmos, as opposed to motions such as palmos or tromos, which he considered unnatural motions of the arteries.21 This observation led Praxagoras to the conclusion that if the sphygmos is not in itself a pathological symptom, variations in it may serve as elucidating symptoms concerning the condition of the body and that the pulse could thus be used as a diagnostic tool.22 Praxagoras distinguished between types of pulse according to size and speed (using terms such as “big”, megas, and “quick”, tachus) and he held the notion of a ‘healthy’ pulse, as opposed to a pulse indicating a pathological condition.23 It is very likely, therefore, that Praxagoras used this tool as part of his diagnostic procedure and that some of his patients had their pulse palpated and compared against some natural measure. We do not know, however, how Praxagoras examined the pulse, nor to what extent his patients were aware of this addition to their encounter with their physician or of the new conception lying at its basis, namely, the pulsation of all arteries, and only arteries, as a natural and healthy phenomenon. A more detailed picture of the practice of measuring patients’ pulse, albeit still fragmentary, emerges with Praxagoras’ most acclaimed student, the Hellenistic physician Herophilus of Chalcedon, who used two methods for 21  Praxagoras, frs. 26, 28–29, Steckerl. 22  Praxagoras, frs. 84–85, Steckerl. 23  Ibid. and Marcellin., Puls. 283–84.

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timing the beats of the pulse. With the aid of Greek metre and Aristoxenus of Terantum’s musical theory, Herophilus established a ‘primary time unit’ which served him as the basic unit for measuring the duration of the arteries’ dilations and contractions and the ratio between these motions (i.e. the rhythmos of the pulse). With reference to this time unit he described the natural pulse of different age groups, to which he then compared his patients’ pulse according to their age.24 The details of this theory have been comprehensively discussed by others and need not concern us here.25 What is, however, important for our present discussion is that this theory and method indicate that Herophilus had probably measured the pulse of a substantial number of individuals of all age groups. For in order to establish that the pulse of a particular new-born or adolescent whom he was examining, was indeed the ‘natural’ pulse for that age group, he had to compare it to the pulse of other individuals of a similar age. This also implies that he was measuring the pulse also of individuals whom he had deemed healthy (by means other than pulse measurement), for he could not have based his identification of the ‘natural’ adolescent pulse only on measuring the pulse of ill people. The second method used by Herophilus for measuring the pulse was a water-clock:26 There is a story (logos) that Herophilus had such confidence in the frequency (pyknosphyxia) of the pulse, using it as a reliable [diagnostic] sign, that he constructed a water-clock capable of containing a specified measure [of water] for the natural pulse of each age and that upon entering to visit a patient, he would set up his water-clock and feel [the pulse] of the person suffering from fever. By as much as the [number of] movements of the pulse would exceed [the number] natural for filling up the water clock, by that much he declared the [patient’s] pulse too frequent—that is, that [the patient] had more or less fever.

24  Herophilus, frs. 174–88b, von Staden. 25  Von Staden, Herophilus, 276–82 and Berrey, Science, 60–73. 26  Translated by von Staden with some modifications. Herophilus, fr. 182, von Staden: οὕτω δὲ τῇ πυκνοσφυξίᾳ τὸν Ἡρόφιλον θαρρεῖν λόγος ὡς βεβαίῳ σημείῳ χρώμενον, ὥστε κλεψύδραν κατασκευάσαι χωρητικὴν ἀριθμοῦ ῥητοῦ τῶν κατὰ φύσιν σφυγμῶν ἑκάστης ἡλικίας εἰσιόντα τε πρὸς τὸν ἄρρωστον καὶ τιθέντα τὴν κλεψύδραν ἅπτεσθαι τοῦ πυρέσσοντος· ὅσῳ δ’ ἂν πλείονες παρέλθοιεν κινήσεις τῶν σφυγμῶν παρὰ τὸ κατὰ φύσιν εἰς τὴν ἐκπλήρωσιν τῆς κλεψύδρας, τοσούτῳ καὶ τὸν σφυγμὸν πυκνότερον ἀποφαίνειν, τουτέστι πυρέσσειν ἢ μᾶλλον ἢ ἧττον.

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It is difficult to see how the patients and their companions27 could have failed to notice and not be at least mildly intrigued or bemused by such a device, which must have required some fussing and fiddling on Herophilus’ part. The two vessels of the water clock had to be correctly positioned, the top vessel had to be filled and both had to be put away at the end of the examination.28 We can only speculate that some of his more educated patients had even expressed their interest and perhaps received some explanation from Herophilus. Herophilus’ theoretical and practical investigations of the pulse were the beginning of a long and heated debate on the physiology of the pulse, the types of pulse and their names and the diagnostic and prognostic significance of each type. Although many of the ancient writings devoted exclusively to the pulse are lost, the extant sources such as Galen and Marcellinus offer substantial information not only on the change in the knowledge concerning the pulse, but also on the importance and popularity of the use of this knowledge, as well as some fascinating details on the ways in which it was put into practice.29 The pulse became, so the sources attest, the key and preferred method for establishing a diagnosis and prognosis, to which the examination

27  For the presence of friends and members of the family and household during the physician’s examination, see Mattern, Galen, 84–86, 88–90. 28  Berrey, Science, 73–80, has convincingly argued, based on evidence of the use of waterclocks and the terminology used by Marcellinus, that this would have been an in-flow water-clock composed of an upper vessel, out of which the water would flow, and a lower vessel, which would receive the flow of water and would have markings indicating different amounts of water. Each mark would have corresponded to a certain number of beats expected to be perceived during the time it took the water to reach the particular mark. Marcellinus is the sole source for this method of timing the pulse and refers only to Herophilus; it is thus unclear whether others had used it as well. On the reliability of Marcellinus’ report, see Berrey, Science, 73 n. 53 and von Staden, Herophilus, 283. 29  Ten works on the pulse have survived: six by Galen (On the Differences of the Pulse, On Distinguishing the Pulse, On the Causes of the Pulse and On Prognosis from the Pulse— each consisting of four books, as well as one book on the summary of his works on the pulse and an introductory treatise for beginners); one by Marcellinus; three anonymous treatises attributed spuriously to Soranus (in Latin), Rufus and Galen. The Ps.-Galenic treatise Medical Definitions also includes a summary of the ‘pulse-lore’. Other works, written after Herophilus’ lost treatise On Pulse, have been lost: besides those of which we know (namely, Archigenes’ massive work on the pulse and Galen’s extensive commentary on it), the extant sources attest to a lively debate in which various physicians, such as the Pneumatists and followers of Herophilus, took part, most likely in writing as well (see 356–57 below).

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of phenomena such as facial appearance and excrements were only auxiliary.30 One of the main reasons for its prominence was mostly conceptual, namely, the belief that the pulse was a means to reveal the hidden physical and mental condition of patients as well as secrets they may be trying to keep from the physician.31 This was a result, on the one hand, of the perception that the pulse is an internal bodily activity, affected directly by unseen conditions inside the body (for example, the humoural condition or the mixture of hot, cold, dry and wet—both of which depend on activities such as eating and sexual intercourse)32 and on the other hand, of the fact that the pulse is a phenomenon observable from outside the body. The popularity of the pulse was further aided by the fact that it was more easily obtained, and its inspection considerably more pleasant and “decent” (euprepēs), than that of urine and other excrements and secretions.33 Another indication for the popularity of the pulse in medical practice was the need to lay down practical professional guidelines. We find such guidelines most clearly exposited in the treatises of Ps. -Soranus (in Latin) and Marcellinus, which are both entitled On Pulse; strikingly, both authors discuss the method and deontology of examining the patients’ pulse before turning to the theoretical aspects concerning the types and qualities of the pulse and their diagnostic significance. Such expositions of practical guidelines, at the beginning of treatises dedicated to the pulse, point to an audience for whom such guidelines were relevant as well as to the problem of ‘unguided’ and ‘erroneous’ pulse examination being practised; they imply, in other words, the existence of an active and dynamic practice. These guidelines explain, for instance, in which part of the body and for how long the pulse should be palpated, how many fingers should be used and how great a pressure one should apply.34 Furthermore, 30  See, for instance: Celsus, Med. 3.6.5; Marcellin., Puls. 19–33. 31  Secret information such as emotional states, eating against dietetic prescriptions, the taking of particular drugs or sexual intercourse; Galen explains in detail the effects of various conditions in his On the Causes of the Pulse and more briefly in De puls. ad tir. 10–12 (K. 8.468–74). For some examples, see Mattern, Galen, 148, 151 and the references given by Nutton in Nutton, V. (1979). Galen, On Prognosis, 197 (comment on K. 14.631.15–635.9 = Nutton, CMG V,8,1, 102,1–104,23). Marcellinus discusses the pulse’s ability to reveal the unseen (kekrummenon) in Puls. 18–21. 32  On this aspect of pulse physiology see Harris, The Heart, 337–38 and 428–29 and more generally: 181–83, 227–29, 261–65. 33  Marcellin., Puls. 23–30 and cf. Gal., De puls. ad tir. 1 (K. 8.454) on the wrist being the preferable point of examination since it does not require removing any of the patient’s clothes. 34  Marcellin., Puls. 19–30, 114–72; Ps.-Soranus, Puls. (Rose, 275–76); Gal., De puls. ad tir. 1, K. 8.453–54—on the evidence concerning the practical guidelines see Lewis, O. (2015).

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these passages indicate that the palpation technique itself must have been conspicuous and that the examination of the pulse would have been perceived by the ancient patients as noticeably different from the touching and probing to which they were accustomed in their encounter with physicians. First, it entailed more than a mere flittering brush of the fingers over the patient’s wrist; it involved, rather, the application of a static pressure for the duration of at least ten beats. Second, the wrist is not an obvious place to palpate—there is no vital organ beneath it and unless the patient had specifically complained of some pain in that area, (s)he would probably not have expected to be so attentively palpated there. The conspicuity of this new kind of palpation is, I suggest, part of the reason why pulse palpation became a common symbol for the patient-physician encounter.35 Moreover, the habit of some physicians to palpate the pulse right at the beginning of their encounter with the patient, before properly conversing with him or her (and contrary to the proposed etiquette),36 would have rendered the act more conspicuous and even crude.37 Marcellinus’ claim, that such conduct is not only “indecent” but also “somewhat clownish” (hypagroikon) may have been a reaction to the popular symbolic representation and not only an expression of professional exasperation.38 It is the proliferation of such unprofessional practices, it seems, which made the deontological guidelines necessary. For a key point stressed by these authors concerned the right time for conducting the pulse-palpation in the course of the examination: rather than immediately palpating the patient’s pulse, the physician is recommended to speak to the patient first and enquire about his or her condition. This chat, says Marcellinus, is important for learning “about the [patient’s] sickness and especially about the patient himself” and it will also, says the Ps. Soranus, allow the physician to rest from the efforts of his profession.39 There was, however, a further reason for the recommendation

‘Marcellinus’ De pulsibus: a Neglected Treatise on the Ancient “Art of the Pulse”’, SCI 34, 195–214. 35  See p. 347 above. 36  On the proposed etiquette concerning the time at which the pulse should be examined, see the following paragraph. 37  For this being a habit, see Marcellin., Puls. 128–29. 38  Marcellin., Puls. 126. 39  Ibid., 140–45; Ps.-Soranus, Puls. (Rose, 275,17–276,2). Marcellinus stresses that particular care is needed in the case of children and women, “who are unaccustomed to be seen in their private life or to be repeatedly questioned about it” (Marcellin., Puls. 137–38).

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to delay the examination of the patients’ pulse, namely, the recognition that their pulse may be affected by the arrival and presence of the physician:40 The pulse of the sick person (kamnontos) undergoes some change and alteration especially in anticipation of the physician’s entrance, either because he is rejoicing, in the hope of a swift recovery, in particular if it is a very skilled physician [who is arriving], or because he is frightened of hearing from the physician something bad concerning death. Such changes of the pulse, due not to the pathological condition of the patient but to the patient’s concerns or hopes, could have led to mistakes in the diagnosis of the pulse and hence in the diagnosis and prognosis of the patient’s condition as a whole. Chatting with the patient before examining the pulse was required, therefore, also in order to help the patient regain his or her composure and thus allow his or her pulse to return to its size, speed, rhythm and so forth, prior to the physician’s arrival. As Celsus explains:41 Experienced physicians do not seize the patient’s arm with their hand as soon as they arrive, but first sit down and with a cheerful countenance ask how the patient finds himself; and if the patient has any fear, they calm him with pleasant talk, and only after that move their hand to touch the patient. Thus, it appears that the importance awarded to the pulse as a symptom, together with the recognition of the physicians’ effect on the patients’ pulse

40  My own translation. Marcellin., Puls. 130–34, Schöne 459: ὁ τοῦ κάμνοντος σφυγμὸς τροπήν τινα καὶ ἀλλοίωσιν ὡς ἐπὶ τὸ πλεῖστον ἀναδέχεται πρὸς τὴν εἴσοδον τοῦ ἰατρεύοντος, ἤτοι γεγηθότος δι’ ἐλπίδος ταχείας ἀναρρώσεως καὶ μάλιστα εἰ πολλὴν ὁ ἰατρὸς ἕξιν ἔχει ἢ δεδοικότος δι’ ἀπώλειαν ἀκούσεσθαί τι φαῦλον παρὰ τοῦ ἰατροῦ. Cf. Celsus, Med. 3.6.6: “the bath and exercise and fear and anger and any other affection of the mind often move them [scil. the vessels]; so that when the physician first arrives, the solicitude of the patient who is wondering how the physician will assess his condition, may disturb the vessels [i.e. the pulse]” (translated by Spencer, with slight modifications); as well as Ps.-Soranus, Puls. (Rose, 275–76) and Gal., De praesag. ex puls. 1.4. (K. 9. 250.). 41  Translated by Spencer, slightly modified. Celsus, Med. 3.6.6: . . . periti medici est non protinus ut venit adprehendere manu brachium, sed primum desidere hilari vultu percontarique, quemadmodum se habeat, et si quis eius metus est, eum probabili sermone lenire, tum deinde eius corpori manum admovere. Cf. Ps.-Soranus, Puls. (Rose, 275,19–21), who explains that the delay allows the patient “to regain his composure” (se recomponere).

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and the consequence it may have, affected the interaction between the physicians and their patients. Moreover, the sickbed was not the only opportunity for laymen to encounter the physicians’ knowledge and practice of the pulse. Galen emphasises the importance of being well acquainted with the natural pulse of the patient also in various healthy states (e.g. after eating, training or sleeping), in order to obtain a standard against which the patient’s pulse may be measured when (s)he calls for the physician, thus enabling him to correctly identify the patient’s condition. This can be achieved, according to Galen, through long acquaintance with the patient, during which his or her “arteries [i.e. pulse] must be observed on a number of occasions, most particularly when the subject is in perfect health and resting from all vigorous activity; but in other [healthy] states as well”.42 An occasion for the examination of the pulse of healthy people was offered by the gymnasia, where physicians used to examine the pulse of various individuals, both before and after the physical training, in order to note the effects of the training on their pulse. At times, this process entailed also the recording of the person’s physical and mental conditions (for example: age, complexion, mood) as well as his or her habitual regimen.43 It is difficult to imagine that this habit of the physicians would have remained unnoticed by those being examined and by others who were present at the time. Another means by which knowledge on the pulse was made conspicuous and transmitted to ancient patients is the public debates, as part of the tradition of the agōn. Such debates included, for instance, discussions among the physicians and medical students on the terminology and classification of the different kinds of pulse and were attended by a lay public as well.44 It 42  Translated by Singer, with slight modifications. Gal., De puls. ad tir. 9 (K. 8.462–63): δεῖ πολλάκις ἧφθαι τῆς ἀρτηρίας, μάλιστα μὲν ὑγιαίνοντος ἀμέμπτως καὶ ἐν ἡσυχίᾳ πάσης σφοδρᾶς κινήσεως, ἤδη δὲ καὶ ἐν ταῖς ἄλλαις διαθέσεσιν. Cf. De praecogn. 2.6, 11.4 and 14.5–7 (K. 14.607, 659 and 671–72 = Nutton, CMG V,8,1, 76, 128 and 140). Galen dedicated an entire treatise (De sanitate tuenda—On Matters Concerning Health) to the importance and method of preserving one’s health and thus to the importance of consulting a physician, throughout one’s life, even in times of health (see for example: De san. tuenda 6.1 (K. 6.381–83 = Koch, CMG V,4,2, 169–70)). The examination of the healthy types of pulse was crucial also for finding the most natural and healthy pulse which could be used as a standard (kanōn) for the human pulse in general (De dign. puls. 2.2–3 (K. 8.857–62)). 43  Gal., De dign. puls. 2.2 (K. 8.847–57) and see on this passage: Deichgräber, K. (1965). Die griechische Empirikerschule. Sammlung der Fragmente und Darstellung der Lehre, 315–17. 44  Galen, for instance, complains about the terminological arguments which often take place at the Temple of Peace (Gal., De. diff. puls. 1.1 (K. 8.495)) and see also ibid. 2.6 (K. 8.590–92), where Galen explains to his students how to argue against the followers of

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is perhaps at such an occasion that Marcellinus witnessed physicians “who show off (epideiknymenoi) their skill and practice [in the ‘art of the pulse’] to laymen”.45 Moreover, as has been shown by Markus Asper and Tamsyn Barton, the treatises on the pulse were another stage on which the professional agōn took place in the form of polemical refutations of the conceptions and classifications of the pulse proposed by rival physicians. Since these treatises were written for, and read by, both physicians and laymen, they may be considered another means by which knowledge was transmitted in different periods from professional practitioners to laymen belonging to the political and social elite.46 In addition, the patient’s bedside was another occasion for medical debate, and one in which technical details and terms were often discussed.47 At times, especially with the educated elite, Galen even describes to his patients what he feels while palpating their pulse or how this observation had led him to a particular diagnosis.48 Such explanations as well as the public debate on the pulse should be understood in the broader context of the ancient physicians’ use of the pulse, namely for self-promotion and for the promotion of the medical profession as a whole. Physicians unskilled in the ‘art of the pulse’, warn the authors, will not be able to identify the patient’s pulse correctly and thus will not reach the correct diagnosis and prognosis. Galen, for one, made great use of the pulse and the skill which its measurement required in his attempts to establish his authority and superiority over other physicians in the eyes of patients.49 He achieved this by explicitly drawing his patients’ attention (falsely at times)50 to the role played by the pulse and especially to his skilled sensing and interpretation of it in his successful prognoses and uncovering of secrets

Archigenes and their distinctions of pulse types. On the tradition of the agōn and its role in the ancient debates on the pulse, see Barton, Power, 13–14, 147–49 and Mattern, Galen, 69–72. 45  My own translation. Marcellin., Puls. 163–64, Schöne 460: ὅσοι . . . ἄσκησιν καὶ συγγυμνασίαν ἐπιδεικνύμενοι τοῖς ἰδιώταις. 46  Asper, ‘Un personaggio’, 29–36; Barton, Power, 147–49; see also Berrey, Science, 89–91. For a list of ancient pulse treatises, see note 29 above. 47  For instance: Gal., De diff. puls. 1.1 (K. 8.495); De praecogn. 11.3–10 (K. 14.658–61 = Nutton, CMG V,8,1, 126–30), in which (K. 14.661.5–7 = Nutton, 130, 5–7) Galen refers also to other cases; see also Mattern, Galen, 70–71, 87–90. 48  For instance: Gal., De praecogn. 3.3–16 and 7.14–15 (K. 14.617–18 and 639–40 = Nutton, CMG V,8,1, 86 and 108); De. loc. aff. 5.8 (K. 8.362–65). 49  Asper, ‘Un personaggio’, 27–36; Mattern, Galen, 78, 148, 151; see also Nutton, Galen, 232 (note on 14.12 (K. 14.673.13 = Nutton, CMG V,8,1, 142,14)). 50  See Mattern, Galen, 78 as well as the passages she lists (ibid. n. 22).

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they were trying to hide from him.51 Also Marcellinus stresses the importance of the physician’s skill in identifying and interpreting the pulse and attests to physicians trying to impress laymen (idiōtais) and promote themselves by showing off their skills in the ‘art of the pulse’.52 The physicians, therefore, tried to turn the pulse, or more exactly the knowledge of the pulse, into a criterion for choosing the best physician. The pulse and its importance, we may say, did not remain unnoticed since the physicians did not want them to go unnoticed. Being skilled in the ‘art of the pulse’ was important for gaining superiority not only over rival physicians,53 but also over the patients. Even though patients had access to theoretical and practical knowledge by the means discussed in this paper, such knowledge would have remained useless, stress Galen and Marcellinus, without extensive practical experience and training.54 Such experience, moreover, was not easily attained—there was no tool to aid the physician but his fingers and a long training of his sense of touch, haphē (together with the study of theory).55 As Galen emphatically states:56 I therefore urge the student to train both his intellectual faculties and his sense of touch, in order that he may be able to identify [different kinds of] pulse in practice, not just to distinguish them in theory. The startingpoint for this practical experience is the learning of the theoretical precepts. Yet the relevant degree of, say, frequency is not something that can be expressed in words, even though there is a great difference [in practice, between frequencies of the pulse]. Marcellinus too refers at the onset of his treatise to the long time required for both the theoretical and practical training and stresses the interdependency 51  For instance: Gal., De praecogn. 7.6–18 (K. 14.637–41 =Nutton, CMG V,8,1, 106–10); De loc. aff. 5.8 (K. 8.363–64). 52  Marcelllin., Puls. 6–11, 115–24, 163–64. 53  The athletic trainers were also professional rivals and the promotion of skill in pulse theory and practice may have been a further tool for establishing the physicians’ role among the athletes, an aim to which Galen’s treatise Thrasybulus, or is Health part of Medicine or of Gymnastics (Thrasybulus sive utrum medicinae sit an gymnasticae hygiene) is dedicated. 54  Marcellin., Puls. 8–11, 115–24; Gal., De diff. puls. 1.3 (K. 8.500), De dign. puls. 1.1 (K. 8.767–71); Praecog. 14.3–12 (K. 14.670–73 = Nutton, CMG V,8,1, 138–42). 55  Deichgräber, Galen, 6–12. 56  Translated by Peter N. Singer, slightly modified. Gal., De puls. ad tir. 12 (K. 8.478): ἀσκεῖν οὖν παρακελεύομαι τόν τε λογισμὸν ἅμα καὶ τὴν ἁφὴν, ὡς ἐπ’ αὐτῶν τῶν ἔργων γνωρίζειν δύνασθαι τοὺς σφυγμοὺς, οὐ λόγῳ διακρίνειν μόνον. ἀρχὴ δὲ τῆς ἐπὶ τῶν ἔργων τριβῆς ἡ διὰ τοῦ λόγου διδασκαλία. καὶ γάρ τοι καὶ τῆς πυκνότητος οὐχ οἷόν τε τὸ ποσὸν λόγῳ ἑρμηνεῦσαι, καί τοι μεγάλην ἔχει διαφορὰν ( . . . ).

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between the two, that is, between the haphē on the one hand and reason (logismos) and judgement (gnōmē) on the other.57 Such claims, concerning the skill required for employing the ‘art of the pulse’ as a diagnostic and prognostic tool, were most likely addressed at colleagues and students of medicine in order to stress the need of practical experience in a time of transition from the traditional practical apprenticeship to a more literary heuristic medium.58 Nevertheless, they may have also been a response to the dissemination of the knowledge concerning the pulse among patients. In this context they would have been an attempt to ensure that the patient would still recognise the need for the physician to examine his or her pulse, thus excluding the keen and educated laymen who might have thought it enough to read the medical literature and carefully and repeatedly observe the physician at work.59 The prospect—constantly emphasised by the physicians—of gleaning some crucial and hidden information, would have made the ancient patients eager to try and examine their own pulse and the tangibility and accessibility of the pulse would have made them even more confident of succeeding. As Plutarch says, “it is easy”.60 Even Galen admits, in certain contexts, that it can be simple to distinguish certain qualities of the pulse, such as its strength or size61 and Marcellinus and Plutarch attest in fact to patients who believed that they could ‘do it themselves’.62 Indeed, this could have been another reason for the constant introduction of new terminology and minute distinctions: not only in order to outdo professional rivals,63 but also in order to limit the knowledge of the patients or more particularly, their practical application of it. Terms like “quick”, “frequent” and even “big” are not technical sophistications like later terms such as “soft” (malakos) and “hard” (sklēros) or Galen’s twenty-seven distinctions according to three dimensions of

57  Marcellin., Puls. 1–10. 58  On this see Asper, ‘Un personaggio’, 23–24, 27–28. 59  While Galen recognises the importance of the patient’s input in reaching a correct diagnosis and that in order to be able to offer useful input the patient must ‘understand the material’ (Garcia-Ballester, ‘Galen’, 1660–61), this is not the case with the pulse (and see note 67 below). 60  See p. 347 above. 61  He admits that “even someone who is inexperienced (agymnastos) knows immediately whether a pulse is strong or weak” (Gal., De diff. puls. 3.2 (K. 8.645)) and that it is not really possible to measure whether a pulse is quick or not, but one simply knows this intuitively (De dign. puls. 3.1 (K. 8.882)). 62  See p. 347 above. 63  On the deliberate complication of ancient ‘pulse-lore’ in the context of professional rivalry and master-pupil relations, see Barton, Power, 13–14, 138, 154–57, 162.

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the artery;64 rather, they are clearer and simpler (one may even say, with much caution, ‘intuitive’) descriptions of a motion and they had been used from a very early stage to describe the throbbing motions observed in the body.65 In other words, these basic and more traditional terms do not leave much room for displaying one’s skill and superiority.66 The patients, therefore, played an indirect role in shaping the ‘pulse-lore’: their interest in it and their belief that they understood the ‘art of the pulse’ provided a further reason (i.e. in addition to the competition among the physicians themselves) for the need to continuously change and professionalise the knowledge.67 Conclusion Τhe aim of this paper was to answer two main questions: (a) to what extent and by what means was the change in medical knowledge transmitted to the patient? (b) how did the change of knowledge concerning the pulse affect the patient and the physician’s interaction with him? Despite the limited sources, this brief survey allows us to begin to answer these questions. From as early as the time of Praxagoras of Cos, ancient patients had their pulse, i.e. the motion of their arteries, examined. With the increase in the importance awarded by the physicians to the pulse, it did not only become a popular topic in their professional debates but also a popular practical tool which they regularly used in their encounters with patients. This examination routine, which took on a particular and distinctive shape, served as an opportunity for both intentional and unintentional transfer of theoretical and practical technical knowledge from the physician to the patient. The distinctive method which the examination of the pulse required and the brazen habit of

64  For a comprehensive discussion of the terminology used in ancient ‘pulse-lore’ see Harris, The Heart, 181–95, 244–51, 252–66, 397–413. 65  Epid. 4.1.20b (L. 5.158); 7.83 (L. 5.438 = Jouanna, 98). For Praxagoras, see p. 350 above. Herophilus: frs. 162, 179–181 and see also von Staden, Herophilus, 273–286. 66  Not only was terminology made complicated—the field of the causes of the pulse is another example: Galen, who wrote four books on this topic and claims to be the first to have done so, argues that even though someone inexperienced may be able to recognise whether a pulse is strong or weak, (s)he would not know the cause for such a pulse and hence, would not be able to infer a diagnosis or prognosis from the pulse (De diff. puls. 3.2 (K. 8.645—and see note 61 above)). 67  As opposed to the diagnosis and classification of pain, where patients played a direct role (see Courtney Roby, Chapter Eleven in this volume, 305–22.).

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examining the pulse right at the beginning of the encounter with the patient, made the procedure itself conspicuous and hard to miss; as such, it is likely to have been one of the means by which patients could have learned about this ‘new’ phenomenon (i.e. the constant and natural pulsation of arteries) and the basic method of finding the place of palpation without any deliberate didactic intention on behalf of the physicians. Moreover, one did not have to be ill, or to be present during the physician’s visit of an ill friend or family member, in order to have had his or her pulse examined or to have witnessed the examination of the pulse of others: a visit to the gymnasia, the baths or other public places would have afforded plenty of opportunities to do so. The professional debates among the physicians, conducted in the presence of healthy and ill patients or made available to them in the form of treatises written by the physicians in the hope of promoting themselves as (practical and epistemological) medical authorities, served as a means for transmitting knowledge on the pulse and on its examination to the patient, including knowledge on technical terminology and conceptions (e.g. types of pulse, the differences among them or their clinical significance). On other occasions, this type of knowledge seems to have been transmitted by the physicians directly to the patients, following perhaps questions raised by the patients. Consequently, the physicians contributed greatly to the conspicuity of the ‘art of the pulse’, thus encouraging the patients to take notice of current debates and practices. At the same time, the physicians also tried to control the transmission of knowledge to patients and to limit their ability to put it to use: the knowledge transmitted was not intended to teach the patients how to use the pulse, but rather to make them appreciate the physicians’ use of it and encourage them to spread the word about it. To this end, the patients had to be aware of the phenomenon itself, its importance and, more particularly, its complexity; it is the latter which required them to be acquainted in addition with some technical terms, but only up to a limit. The patients should be aware and even understand such terms qua terms (i.e. theoretically), but not the corporal manifestations of these terms in practice. It is possible that the pulse became such a central topic in medical writings and debates exactly because of its practical importance and its role in winning the hearts of patients. Despite the absence of the direct voice of the patient and the difficulty in gauging the effect of the pulse-practice on the patients’ personal experience during the interaction with their physicians, it may be concluded that the change in the physicians’ knowledge of the pulse also brought about a change in the course of the examination of patients. It entailed a new kind of physical interaction with the patients, which, as we have seen, did not escape the

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patients’ attention. Moreover, the identification of the individuality of the pulse and of the effect of the emotions and of regimen on it was tightly connected with, and perhaps one of the causes for, the accentuation of the physician’s role in calming and soothing his patients (even if this was ultimately designed to aid the physician’s success in diagnosis and prognosis). It also contributed to the shaping of the intrusive practice of asking the patients, or their companions, personal questions concerning habits and moods. Furthermore, although the nature of the sources does not allow for certainty, it is not unreasonable to conclude that the idea that their pulse may reveal to the physician acts and emotions which they would prefer to keep secret, may have led patients to be more forthcoming in their interaction with their physicians and to share such information on their own accord. If the physicians attempts to use the ‘art of the pulse’ as a tool for establishing a loyal clientele that will seek their services on a regular basis, was indeed successful, then this may well have been a further contribution of the pulse to the development of greater intimacy between the ancient patients and their physicians. Texts and Translations Used Celsus. On Medicine. (Celsus, Med.). Ed. G. Serbat. Paris: Les Belles Lettres, 1995. ———. On Medicine. Trans. W. G. Spencer. Cambridge, MA and London: Harvard University Press, 1935. Euripides. Bacchae. Ed. R. Seaford. Warminster: Aris and Phillips, 1996. ———. Bacchae. Trans. R. Seaford. Warminster: Aris and Phillips, 1996. Galen. Opera omnia. Ed. C. G. Kühn. Leipzig: Cnobloch, 1821–33. ———. On Distinguishing the Pulse. (De dign. puls.). Ed. C. G. Kühn, vol. 8. Leipzig: Prostat in officina libraria Car. Cnoblochii, 1824, repr. Cambridge: Cambridge University Press, 2011. ———. On Matters Concerning Health. (De san. tuenda). Ed. K. Koch. CMG V,4,2. Leipzig u. Berlin: Teubner. ———. On Prognosis. (De praecogn). Ed. V. Nutton. CMG V,8,1. Berlin: Akademie-Verlag, 1979. ———. On Prognosis from Pulse. (De praesag. ex puls). Ed. C. G. Kühn, vol. 9. Leipzig: Prostat in officina libraria Car. Cnoblochii, 1825, repr. Cambridge: Cambridge University Press, 2011. ———. On the Affected Places. (De loc. aff.). Ed. C. G. Kühn, vol. 8. Leipzig: Prostat in officina libraria Car. Cnoblochii, 1824, repr. Cambridge: Cambridge University Press, 2011.

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———. On the Differences of the Pulse. (De diff. puls.). Ed. C. G. Kühn, vol. 8. Leipzig: Prostat in officina libraria Car. Cnoblochii, 1824, repr. Cambridge: Cambridge University Press, 2011. ———. On the Pulse for Beginners. (De puls. ad tir). Ed. C. G. Kühn, vol. 8. Leipzig: Prostat in officina libraria Car. Cnoblochii, 1824, repr. Cambridge: Cambridge University Press, 2011. ———. Pulse for Beginners. Trans. P. N. Singer in Galen, Selected Works. Oxford: Oxford University Press, 1997. Herophilus. Fragments. Ed. H. von Staden in Herophilus: the Art of Medicine in Early Alexandria. Cambridge: Cambridge University Press, 1989. Hippocrates. Œuvres completes d’Hippocrate. Ed. and trans. E. Littré, vol. 1–10. Paris: J.-B. Ballière, 1839–61. ———. Places in Man. (Loc. Hom). Ed. E. M. Craik. Oxford: Clarendon Press, 1998. ———. Epidemics 1. (Epid.). Ed. W. H. S. Jones. Vol 1. Cambridge, MA: Harvard University Press, 1923, repr. 1957. ———. Epidemics 4. (Epid.). Ed. É. Littré. Tome 5. Paris: J.B. Baillière, 1846. ———. Epidemics 5. (Epid.). Ed. J. Jouanna. Tome 4.3. Paris: Les Belles Lettres, 2003. ———. Epidemics 7. (Epid.). Ed. J. Jouanna. Tome 4.3. Paris: Les Belles Lettres, 2000. ———. On Fleshes. (Carn.). Ed. R. Joly. Tome 13. Paris: Les Belles Lettres, 2003. ———. Regimen in Acute Disease (Spurious). (Acut. (spur.)). Ed. P. Potter. Vol 8. Cambridge, MA and London: Harvard University Press, 1988. Homer. Iliad. (Il.). Ed. D. B. Monro and T. W. Allen. Oxford: Oxford University Press, 1902, repr. 1978. Lucilius. Fragments. Ed. E. H. Warmington in Remains of Old Latin, vol. 3. Cambridge, MA and London: Harvard University Press, 1938. Marcellinus. On Pulse. (Puls.). Ed. H. Schöne, “‘Markellinos’ Pulslehre’. Ein griechisches Anekdoton”, in Festschrift zur 49. Versammlung deutscher Philologen Schulmänner, 448–72. Basel: Emil Birkhäuser, 1907. Persius. Satires. Ed. G. G. Ramsy. Cambridge, MA and London: Harvard University Press, 1918, repr. 1961. Plutarch. On the Perservation of Health. (De san. tuenda). Ed. J. Defradas, J. Hani and R. Klaerr. Paris: Les Belles Lettres, 1985. Praxagoras. Fragments. Ed. F. Steckerl in The Fragments of Praxagoras of Cos and his school. Leiden: Brill, 1958. Quintilian. Institutio Oratoria. (Inst.). Ed. C. Halm. Leipzig: Teubner, 1868. ———. Institutio Oratoria. Trans. H. E. Butler. Cambridge, MA and London: Harvard University Press, 1922, repr. 1993. Seneca. Letters to Lucilius. (Ep.). Ed. F. Prechac. Paris: Les Belles Lettres, 1985.

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Ps.-Soranus. On Pulse. (Puls.). Ed. V. Rose in Anecdota Graeca et Graecolatina, vol. 2. Amsterdam: Verlag Adolf M. Hakkert, 1963.

References Asper, M. ‘Un personaggio in cerca di lettore: Galens Großer Puls und die “Erfindung” des Lesers.’ in Ancient Technical Texts, ed. T. Fögen, 21–39. Berlin: Walter de Gruyter, 2005. Barton, T. Power and Knowledge: Astrology, Physiognomics, and Medicine under the Roman Empire. Ann Arbor: University of Michigan Press, 1994. Berrey, M. S. Science and Intertext: Methodological Change and Continuity in Hellenistic Science. Unpublished dissertation from the University of Texas, Austin, 2011. Deichgräber, K. Galen als Erforscher des menschlichen Pulses: ein Beitrag zur Selbstdarstellung des Wissenschaftlers (De dignotione pulsuum 1.1), Sitzungsberichte der Deutschen Akademie der Wissenschaften zu Berlin. Klasse für Sprachen, Literatur und Kunst 1956, no. 3. Berlin: Akademie-Verlag, 1957. ———. Die griechische Empirikerschule. Sammlung der Fragmente und Darstellung der Lehre. Berlin: Weidmann, 1965. Duminil, M.-P. Le sang, les vaisseaux, le coeur dans la collection hippocratique. Paris: Les Belles Lettres, 1983. Garcia-Ballester, L. ‘Galen as a Clinician: His Methods in Diagnosis.’ in Aufstieg und Niedergang der römischen Welt 2.37.2, ed. W. Haase, 1636–71. Berlin and New York: Walter de Gruyter, 1994. Harris, C. R. S. The Heart and the Vascular System in Ancient Greek Medicine—from Alcmaeon to Galen. Oxford: Oxford University Press, 1973. Kuriyama, S. The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine. New York: Zone Books, 1999. Lewis, O. “Marcellinus’ De pulsibus: a Neglected Treatise on the Ancient ‘Art of the Pulse’”, Scripta Classica Israelica 34 (2015), 195–214. Mattern, S. P. Galen and the Rhetoric of Healing. Baltimore: The John Hopkins University Press, 2008. Nutton, V. Galen. On Prognosis. CMG V,8,1. Berlin: Akademie Verlag, 1979. Staden, H. von Herophilus: the Art of Medicine in Early Alexandria. Cambridge: Cambridge University Press, 1989. Wellmann, M. Die pneumatische Schule bis auf Archigenes. Berlin: Weidmannsche Buchhandlung, 1895.

CHAPTER 14

Images of Doctors and their Implements: A Visual Dialogue between the Patient and the Doctor Patricia A. Baker Images of physicians, patients, and medical instruments were placed on Graeco-Roman funerary monuments, altars and fresco paintings. These representations are examined here to determine whether there existed a standard convention by which physicians were depicted in order that the lay and possibly illiterate viewers could identify what the scene represented. Greek physicians were frequently shown with cupping vessels, midwives were seen with birthing stools, while Roman physicians were often shown with various surgical implements. It is argued that the correlation between the types of objects depicted with the medical practitioner was deliberately made by the artist to signify the nature of medicine the individual practiced, so that the viewer could identify the role the practitioner had in their society. A number of years ago, I tuned into the middle of a radio programme about doctors and their relationships with their patients.1 The part of the discussion I heard concerned physicians speaking about their patients’ beliefs of how they should appear when working. All of those interviewed commented on the fact that they were expected to be wearing a white coat or surgical scrubs and, most importantly, they should always have a stethoscope. Despite the fact that the implement and clothing are not always required for examinations and medical procedures, patients still maintained that they were necessary. This conception is no doubt given and reinforced by the popular representation of doctors in various forms of Western media. In the majority of instances doctors are depicted as wearing a white coat or surgical scrubs and as having a stethoscope placed around their necks. There was no discussion on the part of the programme I heard about why the stethoscope, in particular, has come to 1  Unfortunately, I do not remember which station or programme this was; however, it was definitely delivered in English, and I heard it either in the UK or the United States. In either case, this is significant given that both countries adhere to similar medical practices in terms of treatment and diagnosis.

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symbolise a medical professional in the west. Yet, it may be because the instrument is not painful when used, as a needle or scalpel can be, so it immediately gives the patient a sense of security that the doctor will not harm them. It also signifies that the wearer is professionally trained, has met the standards set in their society to be called a doctor and is, therefore, qualified to treat the ill. In essence, one could state that the stethoscope is comparable to a medical degree hanging from the physician’s neck. Significantly, it also demonstrates that in highly literate Western societies many of our commonly understood ideas and expected behaviours are relayed through visual rather than written or verbal forms of communication.2 It is possible that a large majority of people living in the Graeco-Roman world were illiterate, or, if they were capable of reading, did not record their opinions on the subject of medicine or physicians or had little need to access medical texts. Thus, the radio interview prompted me to consider two points. First, whether there was a particular manner in which doctors were represented in the ancient world that allowed potential patients to recognise them; and second, to see if there is any form of material culture that could indicate the procedures and / or the medical philosophy a doctor might have practiced and understood. For example, as mentioned, we recognise the stethoscope as a representation of modern Western medical traditions. In comparison, we may associate a different set of medical tools with another tradition, such as acupuncture needles for Chinese medicine. In order to gain access to the wider perception of doctors held in the GraecoRoman period, I examine a number of surviving images showing physicians, medical tools and forms of treatment. The advantage of studying medical imagery—funerary monuments, votive reliefs and painted remains—is that the majority of them were displayed publically, so the situations presented on them had to be easily identifiable by the viewer. It is, therefore, likely that the images corresponded to the ancient doctor’s appearance, or were at least representative of the general public’s expectation of how they should look, giving us a glimpse into the social conscience of the time. Undertaking this form of analysis necessitates a comparative examination of medical images from the past, which helps to highlight any analogous features on the representations of physicians that might indicate commonly held opinions about their appearance. It is likely that the expectations of a healer would have changed over time, between societies and in different locations (the treatment one might receive in healing sanctuaries, for example, might differ from what they would 2  See Baker, P. A. (2013). The Archaeology of Medicine in the Greco-Roman World, 2–8.

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receive in a doctor’s or patient’s home). Along with these aspects, I discuss here the objects depicted on the medical imagery to determine whether they represented a particular characteristic related to the medical traditions the doctor followed or whether they indicate how the general public perceived a qualified doctor to be trained, or both. In relation to this, it will be shown that images of Greek doctors in the Hellenic (fifth and fourth centuries BC), Hellenistic (late fourth to first centuries BC), Imperial Roman (first to fourth centuries AD) and later Roman (fourth and fifth centuries AD) periods were often depicted with cupping vessels. On the other hand, doctors with Roman names in the Imperial and Late Roman periods were represented differently from those with Greek names, often without cupping vessels. Thus, the questions to be addressed are what does the vessel represent and why is there a difference in representation? Cupping vessels were hollow bowl or bell shaped objects with a narrower neck that terminated in a round opening smaller than the bowl of the object (Fig. 14.1). Those that survive in the archaeological record are made out of copper-alloy.3 Descriptions of them in ancient literature also state that they were made of horn and glass. Some of them, particularly the remaining artefacts, were solid. To create a vacuum for suction a piece of burning lint was placed in the bowl. Celsus suggests using models with holes at the top for patients who were afraid of being burnt by the flame.4 With the open instruments, doctors would suck the air out of them and close the opening with a piece of wax to create suction. These objects were used for wet and dry cupping. The procedure for wet cupping involved the practitioner making a small incision in the part of the body being treated. The cupping vessel was placed over the incision, and the vacuum effect caused the tainted blood or infected matter to be drawn out of the body. This practice was not only used for infections, but when the body was believed to be too moist and out of balance in accordance to humoral medicine. Opposed to this was treatment through dry cupping, when no incision was made. Dry cupping was also employed to release bad or excessive humours along with other treatments such as those for headaches and painful joints.5 3  Bliquez, L. (1994). Roman Surgical Implements and Other Minor Objects, 32–33; Künzl, E. (1983). Medizinische Instrumente aus Sepulkralfunden der römischen Kaiserzeit, 21–23; id. (1984–85). ‘Der Schröpfkopf vom Limeskastell Zugmantel’, Saalburg Jahrbuch 40/41, 30–33; Milne, J. (1907). Surgical Instruments in Greek and Roman Times, 101–05. 4  Celsus, Med. 2.11. 1–2. “cf. also Bliquez, L. (2015). The Tools of Asclepius: Surgical instruments in Greek and Roman Times. Leiden.” 5  E.g. Celsus, Med. 2.2. 5–6; 3.21. 9–10; 5.27. 2.

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Methods of Interpretation

As with any study with limited resources, a word of caution must be given about the use of visual remains. There are instances (such as those discussed below), even where an inscription accompanies an image, when it is difficult to determine whether the individuals represented were either the doctor or the patient. Sometimes art historians and archaeologists make identifications of images on visual remains that, after a period of time, become commonly accepted interpretations. However, re-evaluations of previous studies can show that the initial identifications may be either incorrect or uncertain. For example, a brief study of a votive relief found in the Asclepieion in Athens has six male figures venerating the deities Asclepius, Demeter and Kore carved onto it. There is an inscription that tells us they were doctors and gives the names of five of the six individuals supposedly depicted on it.6 Yet, it should be questioned whether those who were unable to read the inscription could ascertain whether the six men depicted were physicians. In mythological scenes there were some standard methods of representing deities so the viewer could recognise them: labelling, depicting them with particular attributes, showing the adversary of the deity, placing the deity in unusual situations and showing it in a specific context.7 For the doctors on this relief, however, their identification is ambiguous. They are shown with their arms raised, which traditionally identifies them as suppliants venerating the deities, whether they were physicians or not.8 Upon closer inspection, it looks as if the suppliants might have been depicted holding something in their raised hands. Many monuments were painted, and details were added to the relief carving that helped to portray the role(s) the figures held, but unfortunately, in this particular instance the information is lacking. If something were to survive, consideration should be given to whether there were similarities in the objects held, if the clothing of the images was painted with a specific colour or textile design that might have helped in their identification, much like the purple worn by Roman emperors or the stripes by a Roman senator, for example. It was not simply the colour purple, but variations in shade of the colour that indicated the ­maturity

6  Athens, National Museum 1332; Kaltsas, N. (2002). Sculpture in the National Archaeological Museum, Athens, 224–25; Klöckner, A. ‘Getting into contact: Concepts of human-divine encounter in classical Greek art’, in Bremmer, J. and Erskine, A. (2010). The Gods of Ancient Greece, 108–09. 7  Woodford, S. (2003). Images of Myths in Classical Antiquity, 15–27. 8  Klöckner, ‘Getting’, 108.

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and character of the politician who wore it.9 Hence, this example warns us against taking previous interpretations for granted, and urges us to consider other aspects of the images that might inform us how they were viewed in the ancient world. Not only must the modern viewer of the image consider what is represented on the object, they should also try to understand how it was viewed in the context in which it was created. For the ancient world, there is a variety of evidence in the forms of sculptures, paintings, mosaics and textiles, for example, indicating the existence of a rich and varied visual culture. Numerous studies in the fields of art history, philosophy, anthropology and archaeology have illustrated that the meanings of images extend beyond representations of people, objects and events.10 Through them, they convey philosophies and cultural rules to those who made and saw them. Those looking at images from outside the culture and period in time in which they were made, including the archaeologist and historian, will have a different perspective and interpretation of them and will likely impose their own perceptions onto the objects being viewed.11 Some art historians have turned to the works of Sartre and Lacan to theorise how meanings were expressed and communicated through imagery.12 Both Sartre and Lacan argued that vision has two polarities: the glance, which comes from the self, and the gaze, which emanates from the other. In the study of imagery, this is taken to mean that the glance originates from the work itself or ultimately the artist and / or person who commissioned it; whilst the gaze emits from the viewer of the object. The experience is comparable to that of 9  Bradley, M. (2009). Colour and Meaning in Ancient Rome, 197–201. 10  E.g. Berger, J. (1972). Ways of Seeing; Bryson, N. et al. (eds.) (1994). Visual Culture Images and Interpretation; Gell, A. ‘The technology of enchantment and the enchantment of technology’, in Coote, J. and Shelton, A. (1994). Anthropology, Art and Aesthetics, 40–66; Stewart, A. (1997). Art, Desire, and the Body in Ancient Greece. 11  For example, one can see the conveyance of the fifth century Athenian balanced and ideal body in Polykleitos’ Doryphorus: Diels, H. (1914). Antike Technik; Tobin, R. (1975). ‘The canon of Polykleitos’, AJA 74.4, 307–21). See also Elsner, J. (1995). Art and the Roman Viewer: The Transformation of Art from the Pagan World to Christianity; Stewart, Art, 13; Woolf, G. ‘Seeing Apollo in Roman Gaul and Germany’, in Scott, S. and Webster, J. (2003). Roman Imperialism and Provincial Art, 139–52 and Zanker, P. (1990). The Power of Images in the Age of Augustus. 12  See Stewart, Art, 13–19 for a thorough discussion on the topic, and on which my description of Lacan’s and Sartre’s theories is based. Cf. also Lacan, J. (1978). The Four Fundamental Concepts of Psycho-Analysis, 70–119 and Sartre, J. P. (1969). Being and Nothingness. An Essay on Phenomenological Ontology.

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the writer and reader of a literary work. In brief, they argue that someone’s gaze upon us will force us to react in certain manners. The reactions we have, according to Lacan and Sartre, are a response to our social rules that we project onto the other or those who gaze at us. There is no intention to fully develop and discuss their theories in relation to visual experience. However, they have helped to inform us that there is a reciprocal dialogue between the artist and the viewer that is informed by cultural rules. Moreover, the visual representations help to convey meanings.13 The original meanings held by images can be lost over an extended period of time.14 To the modern eye, a Greek or Roman image and its value will be interpreted and understood differently than to eyes of the synchronic viewers. Yet, Goldhill argues further that the visual aspects of communication can change within a short time frame from the Hellenic to Hellenistic, and from the Hellenistic to Late Roman periods. He observed that in classical Athens public displays were viewed from a collective, democratic perspective; whilst the change in political systems away from the city-state and the development of Epicurean and Stoic philosophy led to an individual perspective on viewing. A shift is also seen in the late Roman period when Christian ideals begin to influence how the viewer observes the object.15 Therefore, to overcome this difficulty, archaeologists and art historians begin their studies by making comparative and contextual examinations to determine any similar themes in representation that can ultimately communicate the meanings held within the image. 2

The Doctor in Literature

Although images are the focus of this paper, a brief discussion of the doctor’s appearance as described in ancient literature will be given for further comparison. Surviving descriptions of how a doctor was expected to look in

13  Morphy, H. and Perkins, M. ‘The anthropology of art: A reflection on its history and contemporary practice’, in Morphy, H. and Perkins, M. (2006). The Anthropology of Art, 1–32; Oosten, J. ‘Representing the spirits: The mask of the Alaskan Inuit’, in Coote, J. and Shelton, A. (1994). Anthropology, Art, and Aesthetics, 113–36. 14  Oosten, ‘Representing’, 113–14. 15  Goldhill, S. ‘Refracting classical vision’, in Brennan, T. and Jay, M. (1996). Vision in Context: Historical and Contemporary Perspectives on Sight, 18–26.

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ancient literature are few and vague, but some of those share certain common elements with the visual representations discussed below. In essence, we learn that doctors should be of good appearance, well-mannered, clean, carry the tools of their trade, and that they are sometimes accompanied by their ­students.16 Yet, no information is given as to what was meant by “good appearance”, “clean” or “well-mannered”, which are culturally specific concepts and would have been understood by the reader at the time.17 Furthermore, people of other occupations and walks of life would also have had similar qualities. Thus, it is likely that these characteristics would not have been the distinguishing behavioural aspects of doctors, though they would have been expected of them. Interestingly, it is their accoutrements that appear to have been what set them apart from people in other vocations. Lucian, for example, indicates that some doctors might have tried to attract patients into employing their services with beautiful and expensive tools. Unaware that you are doing the same as the most ignorant physicians, who get themselves ivory pill-boxes, and silver cupping vessels and gold inlayed scalpels when the time comes to use them, however, they do not know how to handle them, but someone who has studied his profession comes upon the scene with a knife that is thoroughly sharp, though covered with rust, and frees the patient from his pain.18

16  E.g. [Hipp.], Decent. 7–8 (L. 9.226); [Hipp.], Jusj. (L. 4.628); Lucian, Ind. 29; Mart., Epigrams, 5.9. Cf. also Ecca (Chapter Twelve, 323–344 in this volume), who discusses the popular image of the physician as found in the Hippocratic Praecepta. 17  These descriptions provide us with more details on the physician’s expected behaviour, but in essence we still do not have many precise details about their cultural meanings. An anthropological comparison to illustrate this point can be found in the manner in which cleanliness is viewed in gypsy societies. In this society, the clothing worn below the waist of the body must be washed separately from the clothing worn above the waist. This form of cleansing is related to their conception of pollution (Okely, J. ‘Gypsy women: Models in conflict’, in Ardner, E. (1975). Perceiving Women, 55–86). Many of us outside this social structure would not think of this practice when using the term ‘clean’. 18  Lucian, Ind. 29. (Trans. Harmon): οὐκ εἰδὼς ὅτι καὶ οὶ ἀμαθέστατοι τῶν ἰατρῶν τὸ αὐτὸ σοὶ ποιοῦσιν, ἐλεφαντίνους νάρθηκας καὶ σικύας ἀργυρᾶς ποιούμενοι καὶ σμίλας χρυσοκολλήτους· ὁπόταν δὲ καὶ χρήσασθαι τούτοις δέῃ, οἱ μὲν οὐδὲ ὅπως χρὴ μεταχειρίσασθαι αὐτὰ ἴσασιν· παρελθὼν δέ τις εἰς τὸ μέσον τῶν μεμαθηκότων φλεβότομον εὖ μάλα ἠκονημένον ἔχων ἰοῦ τἄλλα μεστὸν ἀπήλλαξε τῆς ὀδύνης τὸν νοσοῦντα.

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More importantly, Lucian suggests that these tools of the trade and their physical condition (cleanliness, sharpness, etc.) could designate whether a physician could be trusted in their practices or not. Furthermore, it is likely that these objects were used to trick people, as Lucian suggests. Another example of a different type of medical professional who was recognised by an object was the midwife. Besides her personal qualities—wellread, long fingers, short finger-nails, strong and experienced19—Soranus also mentioned that she carried objects that helped in the birthing process. These were the birthing chair, a hard and a soft bed, oils, things to smell, pillows on which to lay the infant, and swaddling clothes.20 It is the stool, however, that he describes in detail. It had a crescent shaped seat with arms on the sides, for the parturient to hold, a back to provide her with support, and the bottom sides of the chair were fully enclosed. The midwife was expected to position herself below the seat, and her helper stood behind the parturient and placed her arms around the birthing woman for support.21 A surviving Roman funerary monument from Ostia dedicated to Scribonia Attice offers a parallel to Soranus’ description.22 This has a depiction of a birthing scene, showing a midwife kneeling below a parturient who is seated on a birthing stool, with a helper holding her around her chest, and a chair with arms and covered sides. It is assumed that Scribonia Attice was a midwife from the relief on her tomb, but her profession is not mentioned on the inscription. Both the inscription and Soranus’ work are of similar date (early second century AD), so in correlation they suggest a common practice for childbirth during the period.23 Thus, with the exception of Soranus’ description, the indefiniteness of the literary descriptions, in many respects, suggests that objects are symbolic of the role the person played and the type of treatment they offered. Since it was likely to have been widely recognised, there was no need to write about this aspect in detail. 3

Descriptions of Images

Since information provided in ancient literature about a physician’s appearance is vague, we now turn to the examination of the surviving images of 19  Sor., Gyn. 1.4. 20  Ibid., 2.2. 21  Ibid., 2.3. 22  See Porter (Chapter Ten, 285–303 in this volume and fig. no. 1). 23  Meiggs, R. (1960). Roman Ostia, pl. 30.

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individuals who have been identified as doctors. In this section twelve representations will be discussed in detail. The main attributes of these are also listed in Table One. For comparative purposes, five further images will be described: they depict distinctive healing events and support my argument that there were specific manners employed in illustrating physicians who specialised in providing different types of treatments. The image that is earliest in date is a relief sculpture housed in the archaeological museum in Basel, Switzerland (Fig. 14.2. Table One, no. 1).24 It is fragmentary, surviving in eleven pieces. No legible inscription remains, nor is its archaeological provenance known. Judging from the technical detail of the relief sculpture, it is likely that it dates to the late sixth or early fifth centuries BC. The relief must have been Greek and come from either a funerary monument or an altar. The surviving fragments display a seated, bearded man holding a staff in his right arm. Standing next to him are the incomplete remains of a young male indicated by a bare leg, by which hangs a cupping vessel. Two cupping vessels are positioned at the top of the relief, one over each of the individuals. The fragments of the younger male’s right hand and arm appear as if he is holding something up to the face of the seated male. This relief is identified as a medical scene because of the cupping vessels, which correspond to those surviving in the archaeological record, as described above. Yet, it is difficult to see what functions the individuals filled. Since the seated male has a beard and appears to be older than the standing male, it might be assumed that he is the doctor and the younger male is his student, assistant or patient. The beard was a symbol of wisdom in the ancient world, as seen on portraiture of philosophers especially from the second century AD. However, since a staff is placed next to the older male, this might suggest he was the patient, particularly in comparison to the scene painted on the Greek arryballos (Fig. 14.3) discussed next, where one of the patients is shown seated and holding a staff; whilst the physician is a young male. Although there are problems with providing an accurate account over the identification of the individuals on this sculpture, the objects depicted with them help us, and no doubt the ancient viewer, to recognise that one or both of these people were healers. A similar situation is depicted on a fifth century red figure painting, likely to have come from Greece or Magna Graecia.25 No recorded archaeological context is given for the arryballos that is now in the Louvre (Fig. 14.3. Table 24  Berger, E. (1970). Das Basler Arztrelief, 3–22. 25  Paris, Louvre, CA 2183, formally Slg. Paytel; Beazley, J. D. (1927/28) ‘An Askos by Makron’, BSA 29, 206–207; Berger, Das Basler, 77.

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One, no. 2). The scene painted on it shows a seated doctor who appears to be bleeding a patient. The patient is standing next to the doctor, and a large bowl is on the ground between them. The doctor is holding the patient’s arm in his left hand and an implement in his right hand with which he cuts the patient’s arm. Others are shown waiting in a queue to be treated, identifiable as being ill or injured by their staffs and bandages. Although these aspects indicate a medical scene, the three cupping vessels placed above the doctor and a patient further supports this interpretation. Two fragmentary images dating to the fourth / third centuries BC also share similar qualities with the two representations already discussed. The first (Table One, no. 3) is the votive relief of Telemachus from the Athenian Asclepieion.26 This relief commemorates Telemachus’ bringing the cult of Asclepius to Athens.27 Depicted on it is a bearded, seated figure. The figure might be Asclepius, because a dog (one of his attributes) is shown beneath the chair on which he sits. Also shown beneath the chair are three smaller figures, one of which holds a staff. Above the seated figure are three implements. One is a pair of forceps, one appears to be a cupping vessel and the third is indeterminate. Although fragmentary, this relief indicates that the viewers may have seen medical objects as a representation of the various types of healing that might have been offered in sanctuaries. Furthermore, this shows a link between the sacred healing practice in the Asclepieion and medical practice in other contexts.28 It might also indicate that besides incubation, visitors to the sanctuary could have had access to physicians who offered treatments for certain ailments. The second fragmentary image is thought to have come from Piraeus.29 It is also likely to have been part of either a votive or a funerary relief (Fig. 14.4. Table One, no. 4). Three steps were carved on it, each having a cupping vessel placed upon it. Next to the steps are parts of a bare leg and an arm. Rather than being depicted in profile, as is done on the other images, the leg of this image faces out towards the viewer. As with the other fragmentary remains, this one can be identified as having some form of medical association on account of the

26  Walter, O. (1930). ‘Ein neugewonnenes Athener Doppelrelief’, ÖJh 26, 75–7, figs. 46–47. 27  Edelstein, E. J. and Edelstein, L. (1998). Asclepius: Collection and Interpretation of the Testimonies, vol. 2, 120, n. 4; IG 22 no. 4960a. 28  On further correlations between secular and sacred medicine, see van Schaik (Chapter Nineteen), 471–496 in this volume. 29  Berger, Das Basler, 77, fig. 96.

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tools, but the lack of archaeological information about provenance, makes it difficult to say much more about it. The fifth image is the funerary monument of Eukarpos of Miletus (Table One, no. 5). The inscription gives us the name of the dedicator, but no information about his profession. The relief was found in Athens and probably dates to the second century BC.30 The monument has a male and female carved in relief, and both figures face out towards the viewer, much like the object described previously. A cupping vessel is placed over the head of the male figure, presumably Eukarpos.31 The similarities in representation of medical experts with cupping vessels on Greek monuments continues well into the Roman period (first to the fourth centuries AD). The doctor, Jason, for example, was commemorated on a complete Athenian funerary inscription dating to the second century AD (Fig. 14.5; Table One, no. 6). A bearded man is shown seated with a younger, naked male standing next to him. The seated figure is touching the patient on the stomach. Placed next to the patient is a large cupping vessel, which is half the size of the standing figure, making the tool out of proportion in comparison to the people carved on it.32 Surviving from the same period as the monument to Jason is an inscription from Siscia (Sisak, Croatia), which was located in the Roman province of Pannonia Superior. The inscription commemorates a military doctor with a Greek name, M. Marcus Hegetor (Table One, no. 7). The monument is fragmentary, but it was clearly decorated with images of instruments, including a cupping vessel, a bone lever and a pair of forceps.33 Cupping vessels are shown twice more on monuments from the Roman period, as far as I am aware. The first is a surviving votive relief from the Asclepion in Athens, which is thought to date to the second century AD (Table One, no. 8). It shows an open box containing scalpels with a cupping vessel placed on either side of the box.34 The second and final representation is a relief sculpture from a sarcophagus found in Ravenna that dates to the third 30  Conze, N. (1893–1922). Die attischen Grabreliefs 4, no. 2078, Tab. 455; National Museum Athens no. 1195. 31  Berger, Das Basler, fig. 97. 32  British Museum Archive 1865.0103.3; Berger, Das Basler, fig. 99. On doctors touching their patiens, please see Kosak (Chapter Eight), pp. 245–264 in this volume. 33  ILS = Dessau 2601; Gummerus, H. (1932). Der Ärztestand im römischen Reiche nach den Inschriften, 100, no. 392. 34  Athens National Museum, Svoronus no. 1378. Berger, Das Basler, 77, fig. 98.

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century AD (Fig. 14.6; Table One, no. 9). As is common to the Greek images discussed, one person was shown seated and the other standing. However, this time it is the standing figure who seems to be performing some sort of treatment on the eyes of the seated person. Above the head of the seated figure is a cupping vessel, which like the image of Eukarpos may indicate that the seated figure was the healer. The inscription is dedicated to a young girl with no ­mention of a doctor on it. Yet, also inscribed over the heads of the two figures are the words Memphi Glegori, which might be associated with the goddess Isis, given that the term relates to Memphis. Another argument put forth is that it represented a doctor, who practiced “spiritual healing” in light of the possible relationship to Isis.35 In comparison to these Greek monuments, those with Roman names show a change in representation without cupping vessels. The earliest example of this type is found on a Roman military funerary monument from Moesia Superior. It dates to the first century AD and is dedicated to Cam(ilia) Rufus Ravenna, a soldier of the 11th Claudian Legion (Table One, no. 10). No medical title is listed on the inscription, but it had an open box, like the relief from the Asclepion in Athens (Table One, no. 8), that contained two surgical hooks in one side and two scalpels in the other. A pair of forceps and scales were also carved next to the box.36 A funerary monument dedicated to the doctor P. Aelius Pius Curtianus dating to the Hadrianic period (117–38 AD) with images of medical tools was found at Praeneste in Latium (Table One, no. 11). Shown on the monument are two scrolls on either side of an open box of scalpels.37 Again the box of tools is accompanied by other objects that were associated with medical practices at the time. A rather more difficult depiction to interpret is a relief sculpture from either a funerary monument or an altar now in the Altes Museum in Berlin (Table One, no. 12).38 This dates to the late first century BC or first century AD. Depicted on it is a large seated male figure holding what appears to be a scroll in his left hand. In front of him are three smaller standing males. The first two men are placed behind an altar with a buchrania and garland depicted on it. The first man is giving something to the seated figure, which looks like a scroll, 35  Berger, Das Basler, 79–80; Gummerus, Der Ärztestand, 70–71, no. 259. 36  Gummerus, Der Ärztestand, 102–03, no. 399. 37  CIL, 14, 3030; Gummerus, Der Ärztestand, 50–51, no. 177. 38  Antikensammlung, Staatliche Museen zu Berlin, no. sk 804.

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but it is not entirely clear. Behind him is a man with a veiled head, a sign that he was either a priest or he was making a sacrifice. Following him is a man with a horse. The man may be a soldier as indicated by his cape and what might be a spear shaft placed over his shoulder. The image is damaged where the spear would end, so it is impossible to say if it had a pointed terminal. Also shown behind the priest is a tree with a snake coiled in its branches. An open box with tools that could be used in the treatment of broken bones: large forceps, levers and scalpels, is placed in the air between the seated figure and the tree. However, these tools are also similar to those used in metalworking. Many interpretations can be made of this image. It may be a dedication to Asclepius given the size of the seated figure, the snake, altar, priest and possible medical objects. It could be a seated doctor or even veterinarian, given the horse in the image. It may also be representing something non-medical, since there is nothing surviving that can help us determine if the male figures and possibly the horse were injured or ill, and the tools might have had another function. A later Roman sarcophagus with a Greek inscription, which warned that the sarcophagus was not to be reused, was found at Portus Traiani, Ostia (Table One, no. 13).39 Although the inscription is not related to anything medical, the image depicted on it is that of a bearded and seated figure. Unlike earlier representations, the man in this relief is seen reading a book roll. Next to him is a cabinet with an open box of medical instruments placed on top of it. Inside the box is a collection of knives and scalpels; while inside the cabinet are possibly other book rolls and what appears to be a bowl—though these objects are roughly carved and might be something else. It is possible that the book rolls indicate that the doctor was educated, particularly since book rolls appear on the inscription dedicated to P. Aelius Pius Curtianus. By the time these images were created, it may have been that trustworthy doctors were recognised as individuals who gained their abilities through the study of medical texts. For comparative purposes, five other images are discussed that portray different types of healing events and help to support the argument that there were specific manners of illustrating a range of situations that helped the viewer recognise the occasion. For example, the type of healing carried out in sanctuaries involved the practice of incubation, which is indicated on a relief sculpture dating to the fourth century BC found at the Asclepieion in Piraeus (Fig. 14.7). 39  IG, 14, 943; Gummerus, Der Ärztestand, 52, no. 184.

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The relief depicts a female lying on a couch, presumably a patient, with two males, another female and a child standing at her feet. Placed over the head of the patient are two standing figures larger in size than those at her feet, most likely Asclepius and his daughter Hygieia. They are identified as the divinities because of their size in comparison to the other figures shown on the relief, and because Asclepius is laying his hands over the sleeping image. It is rather more difficult to determine who the people at the foot of the bed represent. They might be other patients, relatives or perhaps priests and priestesses. Τhey are all depicted holding their right hands up to their faces, similar to the images of the six doctors on the altar to Asclepius, Demeter and Kore described above. This is a fairly common gesture believed to designate praying or veneration. It may be that the prayers of the onlookers would have helped the gods to heal the patients.40 They might also have had something painted on their hands that does not survive, and that would have helped the synchronic viewer identify their exact purpose. In any case, the archaeological context of the image and the position of the patient are all indicative of the activity of incubation that occurred in healing sanctuaries.41 Another situation in which healing might have been different from that of a doctor’s house or sick patient’s home was during battle. There are three representations from the ancient world of the wounded being healed in battle that I know of. Only one of the images has a recognisable doctor. The other two scenes are difficult to determine, because they both show a wounded soldier being bandaged by a figure wearing armour. One is from a red figure vase painting dating to the fifth century BC,42 and the other is from Trajan’s column (second century AD).43 A couple of interpretations can be made of these images. First, the person holding the bandages in both could be a doctor wearing armour to protect himself during battle; or second, it could be a

40  Klöckner, ‘Getting’, 108. 41  Further examples of imagery from healing sanctuaries can be found in the LIMC under Asclepius and Hygieia. 42  Sosias’ kylix (ARV2, 21.1, 1620; Beazley Addenda 2, 154) with Achilles tending the wounded Patroklos (Berlin F 2278). 43  For the depiction on Trajan’s column, Wilmanns argues that the image treating the wounded soldier was a capsarius or someone responsible for wrapping wounds (Wilmanns, J. C. (1995). Der Sanitätsdienst im römischen Reich, 135). Scarborough, on the other hand, provides evidence to the contrary and maintains that it is a soldier treating another soldier because both are wearing armour, and there is some evidence that soldiers knew some basic medical treatments (note 44). (Scarborough, J. (1968). ‘Roman medicine and the legions: A reconsideration’, Medical History 12, 254).

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s­ oldier bandaging his fellow soldier.44 At the time, it might have been clear to the viewer who these people were, but now viewing these images out of context makes the interpretation difficult because both the soldier and the doctor are dressed for battle in a similar fashion. In comparison, the third image has a less ambiguous representation of a doctor than the previous two. The scene in question (Fig. 14.8) is a fresco painting from the Casa di Sirico in Pompeii and it dates to the early first century AD. It is evidently based on a section of the Aeneid, where the hero Aeneas has been wounded in battle.45 In both the poem and the image the same ­scenario is depicted. Aeneas was wounded with a spear that struck his thigh. The doctor, Iapyx, came to his aid and tried to remove the spearhead by pulling it both with his hands and with forceps. Aeneas stood during the treatment and leaned on his spear and his son, Ascanius, for support. Iapyx was unable to remove the spearhead, so the goddess Venus made him think of using Cretan Dittany to help in the removal of the weapon. It is likely that this story was well-known in the Roman era; yet some people may not have been aware of it, so we must ask how was it possible for someone unfamiliar with the epic to be able to identify Iapyx as a doctor? Instead of simply being portrayed as an elderly man attempting to remove the weapon from Aeneas’ thigh, he is shown working with a pair of forceps, rather than bandages, as seen with the other two battle scenes discussed above. Thus, the forceps shown with Iapyx are likely to have been an indicator of his role as a healer. Yet, these depictions only inform us of part of the story, as it were. It needs to be addressed why certain tools were used to represent doctors and why there is a change of depiction in the Roman period. 4 Discussion From the descriptions mentioned above, the most commonly shown tool is the cupping vessel with nine out of the twelve main images depicting them (Table One, nos. 1–9). Berger pointed out this common trait in his study concerned with the identification of the relief located in the Basle museum.46 Yet, he did 44  Dionysius of Halicarnassus in Antiquitates Romanae 9.50.5 states that soldiers knew how to bandage themselves because sometimes they did it to avoid active duty: κατεδήσαντο γὰρ αὐτῶν οἱ πολλοὶ τοὺς ὑγιεῖς χρῶτας ὡς τραυματίαι. 45  Verg., Aen. 12, 383–440. 46  Berger, Das Basler, 63–85.

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not make comparisons with representations that depicted other medical tools, nor did he ask some significant questions: why was the cupping vessel used and what did it indicate about the doctor? It is clear that the tool signified a doctor, particularly a Greek doctor. Eight out of the nine are shown on monuments that are associated with Greece or had Greek names inscribed on them. The one exception is the sarcophagus from Ravenna (Table One, no. 9). Further support for this instrument being significant to Greek medicine and doctors is noted by the use of the cupping vessel on the reverse side of Greek coins that were minted at the sites of Astakos, Arcania (fourth century BC), Atrax, Thessaly (mid fourth century BC), Epidauros (late fourth century BC and the mid-second century BC), and the site of Aigiale, Amorgos (ca. 300 BC).47 Further consideration needs to be given to the function of cupping vessels in order to determine why they were used in medical imagery. As instruments, along with surgical knives and scalpels, they were used in ancient medicine to surgically balance the humours. Yet, knives had other surgical and non-­surgical functions. The cupping vessel, on the other hand, is the only implement that was designed specifically for balancing the humours. Given the variations in medical texts on the descriptions of bodily functions, it is clear that not all Greek doctors in the ancient world would have treated ailments in accordance to the humoral system. Nonetheless, the concept of balance also permeated other areas of Greek and Roman ancient life and is found in literature concerning the well-balanced soldier, for example.48 Thus, the average person may not have been fully familiar with the medical and philosophical aspects of proportionate humours, but might have had a basic understanding that the maintenance of their health required some form of balance both within their daily activities and within their body. Since this idea developed in Greek philosophical medicine,49 it is possible that the cupping vessel might have been a general expression of this concern. The common idea that a healthy body was a balanced body is found in Greek and Roman medical literature, as was an attempt to locate the origin of a disease within a specific part of the body (locus affectus).50 Locating the origin of the disease might be expected to have been the interest of doctors, specifically 47  Ibid., 70–7. Penn, R. G. (1994). Medicine on Ancient Greek and Roman Coins, 142–43. 48  E.g. Vegetius, De re militari (Veg., Mil.), 1.6. 49  E.g. [Hipp.], Nat. Hom. (L. 3.6.39); Salubr. (L. 6.72). 50  McDonald, G. C. ‘The locus affectus in ancient medical theories of disease’, in Baker, P. A. et al. (2012). Medicine and Space: Body, Surroundings and Borders in Antiquity and the Middle Ages, 63–83.

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by those trained in the Greek humoral tradition. However, this, like the concept of humoral balance, has been found to have filtered into commonly held perceptions about illness. Hughes argued this point through an examination of the archaeological remains of votive body parts from healing sanctuaries.51 She also has shown that the act of offering votive parts or statuettes of people pointing to specific areas of their bodies signified an ancient view that the ill understood their bodies to be fragmented or made incomplete by a medical condition. Once the affected area was healed, Hughes argues that it was no longer seen to be fragmented, but was returned to its balanced and complete state. Hence, an understanding that medical treatments and the doctors who performed them, i.e. to treat a body through restoring balance to an affected part, in some instances, could easily be signified by the cupping vessel, the one tool created to do just that. More specifically, this type of healing is mainly associated with the Greek Hippocratic tradition. Although it is known that Roman doctors were also aware of this form of treatment and the concept of balance is integral to many aspects of their lives, it is curious as to why they are depicted in a different manner. As shown above, during the Roman period there is a switch to depicting medical scenes and physicians with other surgical implements (Table One, nos. 10–13). The transformation might be indicative of a changing approach to healing with the possible inclusion of more surgical procedures. Although the medical literature of the Greek period provides descriptions of surgical treatments, the majority of archaeological evidence for instruments appears in the Roman period.52 The instruments also correspond with the idea expressed by Lucian that doctors used expensive tools to attract patients. So it is the tools that indicate the training of the doctor. Moreover, from the archaeological record, it would appear that surgery was performed more widely from the first century AD onwards in comparison to earlier periods. The perception of doctors might have changed as not only someone who could restore balance, but also as someone who could more readily perform surgery.

51  Hughes, J. (2008). ‘Fragmentation as metaphor in the classical healing sanctuary’, Social History of Medicine 21.2, 217–36. Hughes, J. (forthcoming). The Anatomy of Ritual Votive Body Parts from the Graeco-Roman World. 52  The majority of archaeological remains of instruments date to the Roman imperial period and is found throughout the empire. Some of the many sources that discuss them are: Bliquez, Roman and Jackson, R. ‘The surgical instruments, appliances and equipment in Celsus’, in Sabbah, G. and Mundry, J. (1994). La Médecine de Celse, 167–209.

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Yet, there is still the question as to why Greek doctors continued to be depicted in the same manner after this apparent shift in medical practice and representation. It is possible that they represent local medical traditions that were particularly associated with a region or society, much like the comparison I made between modern Western and Chinese medical practices. In the ancient world there is evidence for regional ‘specialisms’ in treatment. For example, a relief sculpture found in Gallia Belgica dating to the second century AD depicts a scene of a doctor treating a patient’s eye. Interestingly, a proportionally larger amount of evidence for the treatment of the eyes has been found in the Roman province of Gallia Belgica than any other place in the Roman Empire in the forms of collyrium stamps and cataract couching implements.53 Therefore, the image in conjunction with the other archaeological evidence indicates a regional preference and expectation of how doctors should be represented iconographically and how health care should be performed. 5 Conclusion By concentrating on the few surviving images of medical scenes from antiquity along with the medical encounters in warfare and between deities and suppliants, I have argued that certain iconographical patterns were followed in the production of images portraying physicians and that these patterns were likely informed by the public perception of what a doctor did and how he looked. These patterns not only helped the viewer of the object recognise the roles the individuals held, but also to understand the tradition of medicine the doctor followed. Moreover, this study has shown that in the Roman period, at least, there was an understanding by the wider public that there were physicians who followed different medical traditions and/or specialisms, which were culturally or regionally specific. Hence, the visual dialogue between the artist, the doctor and the patient, may have helped to reinforce a patient’s expectations of a physician. Conversely, this may also be indicative of how a doctor chose to represent him- or herself to the patient in order to present themselves as trustworthy and skilled.

53  Baker, P. A. (2011). ‘Collyrium stamps: An indicator of regional medical practices in Roman Gaul’, EJA 14.1–2, 158–89.

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Table of Images Date

Greek Location Roman

Inscription

Cupping Other Figures Vessel Instruments

1 2 3

500 BC 480 BC 400 BC

Greek Greek Greek

Illegible None Telemachus

x x x

4 5

4th/3rd BC Greek 2nd BC Greek

6 7

1st/2nd AD Greek 1st/ 2nd AD Greek

8

2nd/3rd AD Greek

9

2nd half of Roman the 3rd AD

10 Early first AD

Roman

11 Hadrianic

Roman

Basel Louvre Asclepion, Athens Piraeus? Athens

None Eukarpos from Miletus Athens Jason M. Mucius Siscia, Pannonia Hegetor medicus Superior coh(ortis) XXXII vol(untariorum) Athens None Asclepion Ravenna Memphi Glegori Museum over the seated and standing figure Cam(ilia) Rufus Moesia Superior, Ravenna miles Burnum leg(ionis) XI (Croatia) C(laudiae) Praeneste, P. Aelio Pio Latium Curtiano medico Berlin None

12 First BC or Roman AD? 13 3rd/4th AD Roman Portus Traiani

A warning not to invade or reuse the sarcophagus

x

x x x

x x

x x

x x

x

x

x

x

x

x

x

x x

x

x

x

384

FIGURE 14.1

Baker

Roman Cupping Vessel. 1st–3rd century. Copper Alloy. Courtesy of the Wellcome Library.

FIGURE 14.2

A Greek medical relief located in the Archaeology Museum in Basel. After Berger 1970, fig. 1. Drawing by L. Bosworth.

FIGURE 14.3  Drawing of a fifth century BC aryballos depicting a doctor or surgeon treating a patient. Notice the cupping vessels above the doctor. Courtesy of the Wellcome Library, London.

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Images of Doctors

FIGURE 14.4

Votive Relief from Piraeus, Greece. After Berger 1970, fig. 96. Drawing by L. Bosworth.

FIGURE 14.6

Relief from Ravenna. After Berger 1970, Fig. 79. Drawing by L. Bosworth.

FIGURE 14.5

Funerary monument of Jason the Doctor. Athenian, Second century AD. Courtesy of the Wellcome Library.

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FIGURE 14.7

Fragment of a relief from the Asclepion at Piraeus, fourth century BC. Courtesy of the Wellcome Library, London.

FIGURE 14.8

Roman fresco painting of the doctor Iapyx treating Aeneas, Casa di Sirico, Pompeii, first century AD. Courtesy of the Wellcome Library, London.

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Texts and Translations Used Celsus. On Medicine (Med.). Trans. W. G. Spencer. Cambridge MA and London: Harvard University Press and William Heinemann Ltd, 1971. CIL Corpus Inscriptorum Latinorum. Consilio et Ductoritate Academie Litterarum Regiae. Borussical Edition. Berlin: Akademie der Wissenschaften, 1862–. Dionysius of Halicarnassus. Trans. E. Carey. Cambridge, MA and London: Harvard University Press and William Heinemann Ltd, 1941. Hippocrates. Decorum (Decent.). Trans. W. H. S. Jones, 267–301. London and Cambridge, MA: Harvard University Press and William Heinemann Ltd, 1952. ———. The Oath ( Jusj.) Trans. W. H. S. Jones, 289–301. London and Cambridge, MA: Harvard University Press and William Heinemann Ltd, 1948. ———. Nature of Man (Nat. Hom). Trans. W. H. S. Jones, 1–41. London and Cambridge, MA: William Heinemann LtD and Harvard University Press, 1959. ———. Regimen in Health (Salubr.). Trans. W. H. S. Jones, 43–59. London and Cambridge, MA: William Heinemann LtD and Harvard University Press, 1959. IG Inscriptiones Graecae. Berlin-Brandenburgische Akademie der Wissenschaften. Berlin, 1825–1877. ILS Dessau, H. Inscriptiones Latinae Selectae. Berlin: Apud Weidmannos, 1892–1916. Lucian. The Ignorant Book Collector (Ind). Trans. A. M. Harmon. London and New York: William Heinemann Press Ltd and G. P. Putnam’s and Sons, 1921. Martial. Epigrams. Trans. D. R. Shackleton Bailey. Cambridge, MA and London: Harvard University Press, 1993. Soranus. Gynecology (Gyn). Trans. O. Temkin. Baltimore: The Johns Hopkins University Press, 1956. Vegetius. Epitome of Military Science. Trans. N. P. Milner. Liverpool: Liverpool University Press, 1993. Virgil. Aeneid (Aen). Trans. H. Rushton Fairclough. Revised G. P. Gould, 300–67 (for book 12). London and Cambridge, MA: Harvard University Press, 2000.

References Baker, P. A. ‘Collyrium Stamps: An Indicator of Regional Medical Practices in Roman Gaul.’ European Journal of Archaeology 14.1–2, (2011): 158–89. ———. The Archaeology of Medicine in the Greco-Roman World. Cambridge: Cambridge University Press, 2013. Beazley, J. D. ‘An Askos by Makron.’ British School of Athens 29, (1927/28): 206–07. Berger, E. Das Basler Arztrelief. Basel: Archäologischer Verlag, 1970. Berger, J. Ways of Seeing. London: Penguin, 1972.

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Bliquez, L. Roman Surgical Implements and Other Minor Objects in the National Archaeological Museum of Naples. Mainz: Verlag Philipp von Zabern, 1994. Bradley, M. Colour and Meaning in Ancient Rome. Cambridge: Cambridge University Press, 2009. Bryson, N., Holly, M. A. and Moxey, K. (eds.). Visual Culture Images and Interpretation. Hannover: Wesleyan University Press, 1994. Conze, N. Die attischen Grabreliefs. Vienna: Akademie der Wissenschaften zu Wien, 1893–1922. Diels, H. Antike Technik. Leipzig: B. G. Teubner, 1914. Edelstein, E. J. and Edelstein, L. Asclepius: Collection and Interpretation of the Testimonies, 2 vols. Baltimore: Johns Hopkins University Press, 1998. Elsner, J. Art and the Roman Viewer: The Transformation of Art from the Pagan World to Christianity. Cambridge: Cambridge University Press, 1995. Gell, A. ‘The Technology of Enchantment and the Enchantment of Technology.’ in Anthropology, Art and Aesthetics, ed. J. Coote and A. Shelton, 40–66. Oxford: Clarendon Press, 1994. Goldhill, S. ‘Refracting Classical Vision.’ in Vision in Context: Historical and Contemporary Perspectives on Sight, ed. T. Brennan and M. Jay, 17–28. London and New York: Routledge, 1996. Gummerus, H. Der Ärztestand im römischen Reiche nach den Inschriften. Helsinki: Akademische Buchhandlung. 1932. Hughes, J. ‘Fragmentation as Metaphor in the Classical Healing Sanctuary.’ Social History of Medicine 21.2, (2008): 217–36. ———. The Anatomy of Ritual Votive Body Parts from the Graeco-Roman World. Cambridge: Cambridge University Press, forthcoming. Jackson, R. ‘The Surgical Instruments, Appliances and Equipment in Celsus’ De Medicina’ in La Médecine de Celse, ed. G. Sabbah and J. Mundry, 167–209. SaintÉtienne: Publications de l’Université Saint-Étienne, 1994. Kaltsas, N. Sculpture in the National Archaeological Museum, Athens. Los Angeles: J. Paul Getty Museum, 2002. Klöckner, A. ‘Getting Into Contact: Concepts of Human-Divine Encounter in Classical Greek Art.’ in The Gods of Ancient Greece: Identities and Transformations, ed. J. Bremmer and A. Erskine, 106–25. Edinburgh: Edinburgh University Press, 2010. Künzl, E. Medizinische Instrumente aus Sepulkralfunden der römischen Kaiserzeit. Cologne: Rheinland Verlag GmbH, 1983. ———. ‘Der Schröpfkopf vom Limeskastell Zugmantel.’ Saalburg Jahrbuch 40/41, (1984/5): 30–33. Lacan, J. The Four Fundamental Concepts of Psycho-Analysis. New York: Penguin, 1978. LIMC Lexicon Iconographicum Mythologiae Classicae. Zürich: Artemis Verlag, 1981–1997.

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McDonald, G. C. ‘The Locus Affectus in Ancient Medical Theories of Disease.’ in Medicine and Space: Body, Surroundings and Borders in Antiquity and the Middle Ages, Proceedings of the Anglo-Dutch Wellcome Symposium, Nijmegen, November 2007, ed. P. A. Baker, H. Nijdam and C. van ’t Land, 63–83. Leiden: Brill, 2012. Meiggs, R. Roman Ostia. Oxford: Clarendon Press, 1960. Milne, J. Surgical Instruments in Greek and Roman Times. Oxford: Clarendon Press, 1907. Morphy, H. and Perkins, M. ‘The Anthropology of Art: A Reflection on its History and Contemporary Practice.’ in The Anthropology of Art: A Reader, ed. H. Morphy and M. Perkins, 1–32. Oxford: Blackwell, 2006. Okely, J. ‘Gypsy Women: Models in Conflict.’ in Perceiving Women, ed. E. Ardner, 55–86. London: Malaby Press, 1975. Oosten, J. ‘Representing the Spirits: The Mask of the Alaskan Inuit.’ in Anthropology, Art, and Aesthetics, ed. J. Coote and A. Shelton, 113–36. Oxford: Clarendon Press, 1994. Penn, R. G. Medicine on Ancient Greek and Roman Coins. London: B. T. Batsford, 1994. Sartre, J. P. Being and Nothingness an Essay on Phenomenological Ontology. London: Methuen, 1969. Scarborough, J. ‘Roman Medicine and the Legions: A Reconsideration.’ Medical History 12, (1968): 254–61. Stewart, A. Art, Desire, and the Body in Ancient Greece. Cambridge: Cambridge University Press, 1997. Tobin, R. ‘The Canon of Polykleitos.’ American Journal of Archaeology 74.4, (1975): 307–21. Walter, O. ‘Ein neugewonnenes Athener Doppelrelief.’ Jahreshefte des Österreichischen Archäologischen Instituts 26, (1930): 75–7. Wilmanns, J. C. Der Sanitätsdienst im römischen Reich. Medizin der Antike (2). Hildesheim, Zürich and New York: Olms Weidmann, 1995. Woodford, S. Images of Myths in Classical Antiquity. Cambridge: Cambridge University Press, 2003. Woolf, G. ‘Seeing Apollo in Roman Gaul and Germany.’ in Roman Imperialism and Provincial Art, ed. S. Scott and J. Webster, 139–52, Cambridge: Cambridge University Press, 2003. Zanker, P. The Power of Images in the Age of Augustus, trans. A. Shapiro. Ann Arbor: University of Michigan Press, 1990.

CHAPTER 15

Case Histories in Late Byzantium: Reading the Patient in John Zacharias Aktouarios’ On Urines Petros Bouras-Vallianatos This paper provides the first analysis of case histories in the Byzantine period as they feature in the On Urines of John Zacharias Aktouarios (ca. 1275–ca. 1330). This group of clinical accounts is of special importance in that they have no counterpart in the Greek-speaking world since Galen. This study aims to illustrate various factors determining the patient’s response to the physician’s advice through close examination of John’s clinical narratives. The first part deals with the terminology that John uses to indicate the patient’s gender, age, social status, and clinical condition. The second part explores the significance of John’s acquaintance with the patients, the patient’s socio-economic background, and also the patient’s experience in connection with the physician’s professional expertise. Byzantine medical literature remains largely unexplored.1 In particular, the medical literary output of the late Byzantine period (which dates roughly from the recapture of Constantinople from the Latins in 1261 up to its fall to the Turks in 1453) has been hardly studied by modern scholars, not least due to lack of modern critical editions of the texts. And yet, in this late period there is a flourishing of notable medical authors such as Nicholas Myrepsos and

* I would like to thank Georgia Petridou, Chiara Thumiger, and the anonymous reviewer for their comments on this paper. I am also grateful to Dionysios Stathakopoulos and Ludmilla Jordanova for their insightful remarks on an earlier draft of this paper. 1  I use the term ‘Byzantine medical literature’ to refer to the medical works produced in the Byzantine Empire from the transfer of the capital from Rome to Constantinople in AD 330 until the fall of the city to the Ottoman Turks in 1453. We may divide this literary output into two main phases: a) the early Byzantine phase covering the first centuries up to the Arab invasion of Alexandria in 642; and b) the subsequent centuries, including the period where the focus of scholarly activity moved to Constantinople. Cf. Temkin, O. (1962). ‘Byzantine medicine: Tradition and empiricism’, Dumbarton Oaks Papers 16, 97–115.

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John Zacharias Aktouarios, as well as a vast number of usually anonymous ­collections of recipes (the so-called iatrosophia) and a considerable number of Arabic medical texts in Greek translation.2 Out of this rich medical production, I have chosen to focus on John Zacharias Aktouarios, as I consider him an exceptional case for making a conscious effort in his writings to connect theory with practice. In his extensive work On Urines, John deems it necessary to substantiate his material with detailed reports of his medical visits, thus providing a vivid image of contemporary daily contact with his patients.3 John plays a dual role in presenting his clinical accounts; he is both a practising physician, and thus a central character in the story, and a ‘chronicler’, i.e. he constructs a narrative based on the patient’s history and the physician’s performance. In this chapter, I would like to examine how John represents his patients by considering various factors such as the terminology used and the patients’ response. My purpose is neither to offer a retrospective diagnosis of the illnesses that troubled John’s patients nor to evaluate his prognoses or the efficacy of his therapeutic methods. Rather, I would like to explore the narrative patterns that shape the patient’s portrait and his or her relationship with the physician. Since these particular accounts have never been examined before, the first part of this chapter discusses the identity of the sufferer and the place of the case histories in John’s work, while the second part focuses on examples of patients’ representation.

2  For a review of the very few recent publications on late Byzantine medicine, see Congourdeau, M.-H. ‘La médecine à Nicée et sous les Paléologues: état de la question’, in Cacouros, M. and Congourdeau, M.-H. (2006). Philosophie et sciences à Byzance de 1204 à 1453. Les textes, les doctrines et leur transmission, 185–88. See also Stathakopoulos, D. ‘The location of medical practice in 13th-century Eastern Mediterranean’, in Saint-Guillain, G. and Stathakopoulos, D. (2012). Liquid & Multiple: Individuals & Identities in the thirteenth-century Aegean, 135–54, who provides a thoughtful reconstruction of medical practice in the thirteenth-century Greek-speaking world. 3  I am aware that by focusing on the construction of the patient in the case histories, I omit not only the representation of the physician, but also a further level of discussion, which would include various rhetorical devices used by John to attract the readers’ attention and communicate his experiences to them. For these topics and their connection to the particular role of place and time in John’s narrative, see Bouras-Vallianatos, P. (2015). Medical Theory and Practice in Late Byzantium: The Case of John Zacharias Aktouarios (ca. 1275–ca. 1330), 113–59.

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John and His Case Histories

John was born around 1275 in Constantinople, where he later studied medicine and was active as a practising physician during the reign of Andronikos II Palaiologos (1282–1328).4 He composed three works. His long medical handbook, Medical Epitome, is dedicated to Alexios Apokaukos, who was a good friend and patron as well as the commander of the Byzantine fleet, and had a lively interest in medicine. It consists of six books dealing with all aspects of medicine (from diagnosis to diet and pharmacology) and although it belongs to the genre of encyclopaedic medical works written throughout the Byzantine period, it is mainly addressed to well-educated contemporaries with a strong medical awareness, philiatroi.5 John is also the author of a treatise in two books, On the activities and illnesses of the psychic pneuma and the corresponding mode of diet, in which he argues that any disturbance in the quality of a pneuma caused by lifestyle factors, above all diet, can cause problems in its circulation, affect various activities in the human body, and lead to a number of illnesses.6 Moreover, he composed an extensive treatise on uroscopy, On Urines, which will constitute the main focus of this chapter.7 4  The majority of John’s biographical details comes from the letters he exchanged with contemporary scholars, and which constitute part of a collection of epistles under the name of his friends George Lakapenos and Andronikos Zarides; cf. George Lakapenos and Andronikos Zarides, Epistles. For an overview of John’s life and works, see Kourousis, S. (1980–82). ‘Ὁ Ἀκτουάριος Ἰωάννης Ζαχαρίας παραλήπτης τῆς ἐπιστολῆς ι´ τοῦ Γεωργίου Λακαπηνοῦ’, Ἀθηνᾶ 78, 237–76 (The article was reprinted in Kourousis, S. (1984–88). Μελέτη Φιλολογική, 101–40); Hohlweg, A. (1983). ‘Johannes Aktuarios. Leben, Bildung und Ausbildung. De Methodo Medendi’, Byzantinische Zeitschrift 76, 302–21 (A slightly shorter version of the article was republished in English by Armin Hohlweg and it was entitled: id. (1984). ‘John Actuarius’ De Methodo Medendi—On the New Edition’, Dumbarton Oaks Papers 38, 121–33); Schmalzbauer, G. ‘Johannes Zacharias Aktuarios’, in Leven, K.-H. (2005). Antike Medizin: ein Lexikon, 470–71; and Bouras-Vallianatos, P. ‘Ioannes Zacharias Aktuarios’, in Grünbart M. and Riehle A. (forthcoming). Lexikon der byzantinischen Autoren. 5  The work is usually cited in Latin, i.e. De Methodo Medendi. The first two books have been published in Ideler, J. (1841–42). Physici et medici graeci minores, 2, 353–463. The last four books remain unedited and are only available through a sixteenth-century Latin translation in Mathys, C. H. (1556). Actuarii Ioannis filii Zachariae Opera, 2, 153–563. 6  Lat. De actionibus & affectibus spiritus animalis. Ideler, Physici, 1, 312–86. For John’s theory on pneuma, see Hohlweg, A. ‘Seelenlehre und Psychiatrie bei dem Aktouarios Johannes Zacharias’, in Pellegrin, P. and Wittern, R. (1996). Hippokratische Medizin und antike Philosophie, 513–30. 7  Lat. De Urinis. Ideler, Physici, 2, 3–192. The text circulated in an exceptionally large number of manuscripts. Diels, H. (1905–06). Die Handschriften der antiken Ärzte, 2, 109, provides a list of about forty codices. Georgiou, S. (2013). Edition critique, traduction et commentaire critique du livre 1 ‘De Urinis’ de Jean Zacharias Actouarios, has recently provided a critical edition of

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On Urines is John’s earliest work and shows him keen to establish himself among his contemporaries in treating a topic that had not hitherto received much close attention.8 The work is divided into seven books. The first book (Book One) serves as an introduction, where John provides a definition of the various characteristics of urine related to specific parts of a graduated urine vial. The next two books (Books Two and Three) deal with diagnosis of various diseases. Here there are more details on the urine vial in relation to its size, especially the bottom part, which shows John’s awareness of the identification of various kinds of sediments in the process of a precise diagnosis. Books Four and Five focus on aetiology. John explains there the various causes of a disease and he correlates the nature of urine to age, gender, time, place, and exercise. The last two books (Books Six and Seven) deal with prognosis by correlating certain categories of urine to particular organs, so that the physician should be able to provide a prognosis with some degree of certainty. It is notable that John provides a clear distinction between each method. On Urines includes a total of eleven case histories involving twelve patients altogether.9 The last medical author who made use of case histories in Greek before the time of John was Galen in the second century AD.10 It is no coincidence that the first book of the On Urines. On the role of experience in John’s On Urines, see Kudlien, F. (1973). ‘Empirie und Theorie in der Harnlehre des Johannes Aktuarios,’ Clio Medica 8, 19–30. See also, Bouras-Vallianatos, P. ‘Contextualizing the Art of Healing by Byzantine Physicians’, in Pitarakis, B. (2015). ‘Life is Short Art Long’: The Art of Healing in Byzantium, 111–12, in which I discuss John’s introduction of a special urine vial divided into eleven specific sections. 8  On uroscopy in Byzantium, see Dimitriadis, K. (1971). Byzantinische Uroskopie; Diamandopoulos, A. (1997). ‘Uroscopy in Byzantium’, American Journal of Nephrology 17, 222–27; and Touwaide, A. ‘On uroscopy in Byzantium’, in Diamandopoulos, A. (2000). Ιστορία της Ελληνικής Νεφρολογίας, 218–20. 9  John, On Urines 2.19 (Ideler 2, 50, 26–52, 1); 3.10 (Ideler 2, 62, 29–63, 13, two female patients); 3.9 (Ideler 2, 92, 9–93, 3); 4.12 (Ideler 2, 95, 34–96, 9); 6.7 (Ideler 2, 154, 31–156, 11); 6.12 (Ideler 2, 162, 17–163, 27); 6.12 (Ideler 2, 163, 27–164, 11); 6.13 (Ideler 2, 165, 9–166, 16); 6.13 (Ideler 2, 166, 24–167, 5); 7.13 (Ideler 2, 181, 11–183, 12); and 7.15 (Ideler 2, 186, 5–187, 4). It is interesting to note that we cannot find any examples of case histories in John’s other works. 10  See Mattern, S. P. (2008). Galen and the Rhetoric of Healing, who provides a fresh study of the entire repertoire of Galenic case histories; and Lloyd, G. E. R. ‘Galen’s un-Hippocratic case-histories’, in Gill, C. et al. (2009). Galen and the World of Knowledge, 115–31. As regards the early Byzantine period, one might mention here Alexander of Tralles, who wrote in the sixth century and included a limited number of references to his patients when he discussed therapy. However, these examples could be seen more as brief references demonstrating the validity of a suggested pharmacological recipe rather than clinical narratives. For example, see Alexander of Tralles, Therapeutics 1.15 (Puschmann 1, 551, 17–25). See also my discussion on Alexander of Tralles’ self-promotion strategy in his works,

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the rebirth of this ‘genre’ in the Greek-speaking world occurred in the early Palaiologan Byzantium. That period was marked by a rich intellectual activity and the production of works written in high style Greek.11 Scholars participated in theatra, gatherings of literati hosted by a powerful patron or even by the emperor himself, in which rhetorical set pieces were performed.12 Niels Gaul has recently coined the term “late Byzantine sophistic”, which describes scholarly activity in that period as a parallel to the intellectual movement of the Second Sophistic.13 Consequently, as a distinctive product of a glorious past, which had many parallels with John’s era, the Galenic case histories became the ideal model for John’s case histories. The majority of cases (seven) are situated in the books on prognosis, while two can be found in Books II and III on diagnosis and two more are embedded in Books IV and V on aetiology. Each of them is an integral part of each chapter’s contents, appearing in the middle of it or towards its end. The case histories are not of equal length: some are short, comprising just a few lines, while others are quite long, extending to up to three printed pages. However, all case histories share some common features, which allow us to study them as a distinct category of material: they are all narrated in the past tense and John is an eyewitness present in every single case, even when he describes the involvement of other physicians. Thus, all the case histories constitute examples of his personal experience relating to contemporary patients. John does not follow a strictly chronological approach and there is no systematic attempt to locate his cases in time and space, as in the majority of the Hippocratic clinical accounts. Furthermore, there is no mention of crises and specific critical days and his nosological data is limited.14 All patients mentioned remain anonymous. The Bouras-Vallianatos, P. (2014). ‘Clinical experience in late antiquity: Alexander of Tralles and the therapy of epilepsy’, Medical History 58, 341–42. 11  On Palaiologan intellectuals, see Ševčenko, I. ‘Society and intellectual life in the fourteenth century’, in Berza, M. and Stănescu, E. (1974). Actes du 14e Congrès International des Études Byzantine, 1, 69–92. (The article was reproduced in Ševčenko, I. (1981). Society and intellectual life in late Byzantium); and Mergiali, S. (1996). L’enseignement et les lettrés pendant l’époque des Paléologues. 12  On late Byzantine theatra, see Marciniak, P. ‘Byzantine Theatron—A Place of Performance’, in Grünbart, M. (2007). Theatron. Rhetorische Kultur in Spätantike und Mittelalter, 277–85. 13  Gaul, N. (2011). Thomas Magistros und die spätbyzantinische Sophistik: Studien zum Humanismus urbaner Eliten der frühen Palaiologenzeit. 14   For a general introduction to Hippocratic clinical accounts in the Epidemics, see Langholf, V. (1990). Medical Theories in Hippocrates: Early Texts and the ‘Epidemics’. On the role of the patient in the Epidemics, see the chapters of Chiara Thumiger and John Wee (Chapter Three and Four), 105–137 and 138–165 in this volume.

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main focus is on diagnosis and prognosis by means of uroscopy. There are, nonetheless, occasional brief references to therapeutic advice. In all cases, and in particular in agonistic accounts involving the presence of other physicians, John presents himself in true Galenic fashion, as the most capable physician in attendance and his advice as the most beneficial for the patient.15 When a patient dies, it is either due to the severity of the disease or the erroneous treatment given by other physicians. Finally, as in Galen’s treatises, the case histories do not constitute an independent work, but are part of his medical argument to provide support for a particular theoretical exposition. John is conscious of the special nature of these accounts as distinct elements of discourse in his work. Although he uses a variety of ways to introduce his case histories,16 the most common one involves the use of the term ἱστορία (“inquiry” or “written account”).17 In tracing the occurrence of the term in a medical context,18 it is quite remarkable that the term does not appear in medical sense in the Hippocratic Epidemics. The term must have had some special significance for the physicians of the Empiric sect, who considered experience the primary source of medical knowledge. However, since no work by members of the sect survives intact we only know of their writings from short fragments.19 Galen’s use of the term is extremely limited; there are only two instances in connection with a case history that might indicate its usefulness to his readers.20 It seems that John’s usage of the term echoes that of Galen. However in his work, it takes a central role and is used in a distinctive way. 15  On agonistic accounts in Galen’s works, see Mattern, Galen, 69–97. 16  For example, John makes use of a past form of the verb διηγέομαι (“to set out in details” or “narrate”) in connection with ὁράω (“to see”) in two cases, see John, On Urines 2.19 (Ideler 2, 50, 27–28); and 6.7 (Ideler 2, 154, 32). 17  There are four examples where the use of the word ἱστορία indicates the beginning of the narrative; John, On Urines 6.12 (Ideler 2, 163, 29); 6.13 (Ideler 2, 166, 26); 7.13 (Ideler 2, 181, 13); and 7.15 (Ideler 2, 186, 6). In the rest of the cases, the term appears twice at the end of the case history and once in the middle of the story; John, On Urines 3.10 (Ideler 2, 63, 11); 7.13 (Ideler 2, 183, 9); and 7.13 (Ideler 2, 182, 33). 18  The term had been used as early as the fifth century BC by the Greek historian Herodotus to signify learning or knowledge obtained by ‘inquiry’ with regard to the Persian wars; Herodotus, The Histories 1. proem (Legrand 1, 1, 1): Ἡροδότου Θουρίου ἱστορίης ἀπόδεξις ἥδε [. . .]. 19  On Empiricism and history, see Deichgräber, K. (1965). Die griechische Empirikerschule: Sammlung der Fragmente und Darstellung der Lehre, 298–301; Staden, H. von. (1975). ‘Experiment and experience in Hellenistic medicine’, Bulletin of the Institute of Classical Studies 22, 190; and Guardasole, A. ‘Empiriker’, in Leven, K.-H. (2005). Antike Medizin: ein Lexikon, 254–55. 20  Gal., De anat. admin. 7.13 (K. 2.632.5 = Garofalo, 459, 16); and De loc. aff. 4.8 (K. 8.266. 11–12).

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TABLE 1

Examples of the use of forms of ‘ἱστορία’ in Galen’s and John’s case histories

Galen

John Zacharias Aktouarios

On Anatomical Procedures 7.13 (K. 2.632.5 = Garofalo, 459, 16): διὰ γὰρ τὸ χρήσιμον τῆς ἱστορίας [. . .].

On Urines 6.12 (Ideler 2, 163, 29–30):

On the Affected Parts 4.8 (K. 8.266.11–12): βέλτιον οὖν ἔδοξέ μοι καὶ ταῦθ᾽ ὑμῖν ἱστορῆσαι.

καὶ τοιαύτην ἱστορίαν ἑτέραν, καὶ ταῦτα προσεπιθήσω τῷ λόγῳ [. . .]. On Urines 6.13 (Ideler 2, 166, 26–27): καὶ προσθήσω κἀπὶ τούτων ἱστορίαν ἑτέραν σαφηνείας τινὰ τῶν λεγομένων ἕνεκεν. On Urines 7.13 (Ideler 2, 181, 12–13): καὶ ταύτην ἐπιθήσωμεν τὴν ἱστορίαν τῷ λόγῳ λυσιτελοῦσαν [. . .]. On Urines 7.15 (Ideler 2, 186, 5–6): ἀλλὰ κἀνταῦθα θεὶς τῷ λόγῳ ἱστορίαν προσήκουσαν ἐφ’ ἕτερα τῷ λόγῳ τρέψομαι.

As we can see from the examples mentioned above, the term ἱστορία functions as an emphatic pointer for the reader:21 John uses it to prepare his audience for a more crucial piece of information that will follow later on. For example: Theory: [. . .] and the colour of the urine already seems extremely reddish and almost becomes even more red. Introduction to case history: But in order to provide my account with some kind of grace, and at the same time to make my speech trustworthy, let us introduce this case history too, which I think will benefit my account.

21  The special role of the case histories in John’s texts is also attested in various manuscripts. For example, in a fifteenth-century codex, Parisinus gr. 2304, the scribe indicates the beginning of six out of the eleven case histories by inscribing the word ἱστορία in red ink in the margin, fol. 32v; 58v; 99v; 100v; 108r; and 110v (autopsy, October 2012). For a physical description and a list of contents of the manuscript, see Omont, H. (1886–98). Inventaire sommaire des manuscrits grecs de la Bibliothèque Nationale, 2, 233.

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Case history: One woman from the soft and rich [. . .] was in danger of becoming distressed at the idea of having an only child.22 John freely admits that he is citing a specific case in order to lend support and corroborate his argument. At the same time, the common use of this word at the beginning of a case history marks its function as a transitional step between the theoretical and the clinical details. John here expands his narration by embedding a text, which deals with everyday practice. The theoretical details give way to the real entities, the characters of a case history. 2

The Patients

2.1 Terminology Before exploring how John depicts his patients, I will look briefly at the various terms he uses to describe them. The main characters in a case history are John and his patients, although occasionally other contemporary physicians feature too. At times, a patient’s relative is also present. The physician’s perspective is mostly given through a powerful first-person narration. John usually represents himself as making an observation or reporting his thoughts and medical actions. For example: When I (ἐγώ) saw these (signs) and having been persuaded [. . .].23 or even more decisively: As for me when I (ἐγώ) suddenly saw him still in a healthy condition, although his urine was giving the impression that he suffered from a most severe sickness [. . .].24 The narration usually shifts from the first-person to the third-person singular, in order to present the patient’s medical condition. The patient might be a woman or man, an adolescent or an old man. John uses a variety of terms that 22  All translations from Greek are my own. John, On Urines 7.13 (Ideler 2, 181, 9–19). 23  John, On Urines 4.12 (Ideler 2, 96, 7–8). 24  John, On Urines 6.7 (Ideler 2, 155, 17–20). Sometimes, John chooses to use the first-person plural, ‘we’, which is even more common in the theoretical parts of his work; see, John, On Urines 6.12 (Ideler 2, 164, 6). On these stylistic aspects, see the relevant chapter by Chiara Thumiger (Chapter Three), pp. 105–137 in this volume.

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can all be translated as ‘patient’ in English. He refers to his patients as ἀσθενής, ἄρρωστος, κάμνων/κάμνουσα, νοσοῦσα, and πάσχων, thus, denoting someone who is ill.25 He also frequently uses the term ἄνθρωπος (“person”), which could refer to either a male or female patient.26 It is significant that there is no case history dealing with slaves. A female patient can also be called merely a γυνή (“a woman”). Overall, female patients feature in three case histories.27 Occasionally, there are words with special connotations in the immediate context. For example, the masculine form of the present participle of the verb πυρέσσω (“to be feverish”), that is πυρέσσων, indicates a man suffering from heavy fever.28 The term is only used twice, although cases of fever are reported elsewhere too. It seems that John uses the participle to express a dramatic change in the condition of a patient, that is a deterioration that reaches its climax, when he states that he “was relieving himself of all his physical needs in bed”.29 In a similar vein, the term ἀλγοῦσα is only used when John wants to denote the chronic pain of a female patient, thus indicating certain special ongoing characteristics of a patient’s condition.30 Furthermore, θεραπευόμενος (“one who receives medical treatment”), the passive participle of the verb θεραπεύω (“to heal”), refers to a case where John’s own therapeutic recommendation plays a central role.31 This particular account begins by presenting the patient as rejecting a certain medicament. Thus, the use of the term θεραπευόμενος emphasises the treatment as a process, and indicates its particular significance for the rest of the story. 25  John uses the term ἀσθενής and ἄρρωστος once each; John, On Urines 6.7 (Ideler 2 155, 33); and 6.12 (Ideler 2, 164, 6). He employs the term κάμνων/κάμνουσα six times; John, On Urines, 6.12 (Ideler 2, 162, 26); 6.12 (Ideler 2, 163, 25); 6.13 (Ideler 2, 165, 16); 6.13 (Ideler 2, 165, 33); 6.13 (Ideler 2, 166, 6–7); 6.13 (Ideler 2, 166, 14). Finally, the terms νοσοῦσα and πάσχων appear twice and once respectively; John, On Urines, 3.10 (Ideler 2, 62, 31); 3.10 (Ideler 2, 63, 3); and 6.7 (Ideler 2, 155, 29). On the use of various terms in Galenic case histories, see Mattern, Galen, 98–119, and the introduction to this volume. 26  The term is used nine times for male patients and twice for females: John, On Urines, 2.19 (Ideler 2, 51, 3); 2.19 (Ideler 2, 51, 9); 3.9 (Ideler 2, 92, 34–35); 4.12 (Ideler 2, 96, 5); 6.7 (Ideler 2, 155, 35); 6.7 (Ideler 2, 156, 8); 6.12 (Ideler 2, 163, 26–27); 6.12 (Ideler 2, 164, 7); 6.13 (Ideler 2, 167, 2); 6.13 (Ideler 2, 165, 35); and 7.13 (Ideler 2, 183, 7–8). 27  John, On Urines 3.10 (Ideler 2, 62, 30); 3.10 (Ideler 2, 63, 8); 6.13 (Ideler 2, 165, 10); 7.13 (Ideler 2, 181, 14); 7.13 (Ideler 2, 181, 30); 7.13 (Ideler 2, 182, 2); and 7.13 (Ideler 2, 182, 22). 28  John, On Urines 6.13 (Ideler 2, 166, 28); and 7.15 (Ideler 2 186, 16). 29  John, On Urines 6.13 (Ideler 2, 166, 31–32). 30  John, On Urines 3.10 (Ideler 2, 62, 31–32). For a list of various terms denoting and characterising various qualities of pain in Galen, see Siegel, R. (1976). Galen on the affected parts: translation from the Greek text with explanatory notes, 205. 31  John, On Urines 2.19 (Ideler 2, 50, 37).

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Although John does not give us precise ages for his patients, he occasionally designates them with words that provide an approximate notion of how old they were. Thus, he uses the noun μεῖραξ (“lad” or “adolescent”) twice probably to refer to a boy in his late teens;32 while one patient is called γέρων (“old man”).33 When John uses the term γνώριμος (“acquaintance”), he emphasises his familiarity with the patients.34 In one particular instance, he gives his readers a wealth of information about a patient’s lifestyle, thus laying emphasis on his acquaintance with the patient.35 Furthermore, it is worth mentioning that no indication of a patient’s profession is given. Nevertheless, there are cases where we find information regarding their social background. This sort of information is provided either by adverbs indicative of origin, such as ἀγροίκως or ἀγρόθεν (“coming from the countryside”), or adjectives denoting socio-economic status, such as πλούσιος (“wealthy”).36 Such social distinctions among patients, as we will see later, are important for the patients’ own assessment of the physician’s medical advice. 2.2 The Patient’s Response In this section, I look closely at some characteristic examples of patientphysician encounters concentrating on the patient’s angle. Before John proceeds to the results of his examination of a patient, he usually inserts the history of the patient’s illness. In this part of his narrative, John’s interest is devoted totally to the patient and he emphasises the importance of individualised patient care. This specific part of the narrative does not have the clear structure of a scientific report. The details related to the various symptoms, are usually scattered throughout his narration. The focus is clearly on the careful examination of the urine, while other information, including the general clinical picture of the patient and sometimes his or her pulse rate, plays only a supplementary role. For example: It was wintertime and my acquaintance (γνώριμος) to whom I referred had been badly treated by someone and spent his time going from one authority to the other until the evening, in an attempt to find a solution to the injustice. He spent most of the day without food, and even when it 32  John, On Urines 4.9 (Ideler 2, 92, 10); 6.12 (Ideler 2, 162, 17–18); and 6.12 (Ideler 2, 162, 20–21). 33  John, On Urines 7.15 (Ideler 2, 186, 7); and 7.15 (Ideler 2, 186, 27). 34  John, On Urines 6.7 (Ideler 2, 154, 31); 6.7 (Ideler 2, 154, 33); and 7.15 (Ideler 2, 186, 7). 35  John, On Urines 6.7 (Ideler 2, 154, 31–156, 11). 36  John, On Urines 3.10 (Ideler 2, 63, 9); and 6.12 (Ideler 2, 163, 33). Ideler’s edition reads wrongly ἀγροικῶς instead of the correctly accented version ἀγροίκως. A female patient is characterised as wealthy: John, On Urines 7.13 (Ideler 2, 181, 15).

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was necessary to take some food, he preferred mostly salted or dried meat. [. . .] It was in his nature to set himself against people that were opposed to him, and to be in anguish for fear of suffering greatly. For this reason, he passed the night sleepless and his body became dry and short of sleep. It was in his nature that in the past too, he had consumed gifts of bad food, as he gave us to understand. [. . .] All these things gathered the yellow bile, which was removed through his urine. When he saw an unusual colour in his urine, he realised that there was some kind of irregularity and he told me about it and asked me to find out the cause.37 At this point of the narrative John has not yet become actively involved. We can see that the patient is the most highly developed character in the narrative. The patient appears as John’s acquaintance and as someone who had failed to follow a proper diet all his life. This seems to be the main reason for his sickness. The patient appears to be suffering from a kind of mental disorder, which is perhaps reflected in his expressed views of being unjustly treated. We are not informed of any other symptom, such as pain, which features in some other cases, and the first instance of physician-patient communication is concerned exclusively with the nature of the urine. An observation made by the patient suffices to present himself before the physician. Even someone without any particular medical knowledge can attest the power of urine as a mirror of the internal condition of the body. However, the physician, who has the appropriate experience and training, will be able to provide the reasons behind the disease and attempt a diagnosis: I asked him to bring the urine vial with his urine the following day [. . .] when the night came, he lay down having eaten only a small portion of food, and brought to us in the morning a urine vial with blue urine like that of a jaundiced patient. And he thought that he was without fever. Prediction: if he does not take proper care, he will suffer from jaundice. The next day [. . .] and before night the humour [yellow bile] started moving and was getting warm and there was a big change in the man and [. . .] he repented and asked for salvation. According to my judgement, I taught him with words that he should not show disbelief to the physicians that command him, and, knowing that the yellow bile was not in much excess, I told him to abstain from heavier food and wine. Following a leaner diet [. . .] he was freed from the disease.38

37  John, On Urines 6.7 (Ideler 2, 154, 32–155, 17). 38  John, On Urines 6.7 (Ideler 2, 155, 17–156, 6).

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FIGURE 15.1

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Bononiensis 3632 (mid-15th c.), fol. 20v, with permission of the Bibliotheca Universitaria di Bologna. The miniature shows John holding a urine vial with an inscribed motto derived from the opening phrase of his work ‘On Urines’, re�lecting the popularity of his uroscopy treatise. The text above the miniature reads: ὀκτάριος, which is found in various manuscripts instead of the usual ἀκτουάριος, and seems to be a vernacular version of the same term. The phrase on the right-hand side reads: πάλαι μ(ὲν) ἴσως φιλοτιμί(ας) ἔργον τιθέμενος, which coincides with the introductory phrase of John’s On Urines (Ideler 2, 3, 1).

We can see clearly John’s insistence on the patient’s poor diet as the cause of his illness. Although he refers briefly to the patient’s general clinical picture, we can attest his reliance on providing a diagnosis through an examination of the urine. A distinct colour in the urine helps the physician to make a diagnosis. The patient appears to have a fever, but does not accept the physician’s verdict. The latter, in an attempt to get the patient’s attention and communicate the severity of his condition, emphasises the reading of the urine’s colour, which leads to his prognosis. The urine becomes the physical symbol that dominates the physician-patient interaction. Despite the warning he receives, the patient continues to eat and drink inappropriately. The patient is the constant focus of the narrator’s account. He perceives the physician’s actions as a symbolic transformation of a visible sign (the urine’s

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colour) into a verbal pronouncement (prognosis) through the examination of the urine.39 The physician appears before his patient using the interpretive power of uroscopy. The patient consistently refuses to accept the physician’s prognosis, which takes the form of advice. The patient’s denial can only result in the aggravation of his problem. The reciprocal character of the physicianpatient interaction is emphatically attested by the patient being presented as begging for his ‘salvation’. This entreaty can be interpreted as an act of repentance, which indicates the patient’s reliance on the physician’s assistance despite his initial rejection. The physician’s prognosis is confirmed in the end and the medical usefulness of uroscopy is once again confirmed. The patient is now persuaded to follow a specific, healthy diet in the years to come. The developing intimacy between the patient and the physician, which follows the dramatic climax of the patient’s suffering, concludes with the physician’s exhortation to the patient not to mistrust doctors again. Consequently, we can see that the physician, in this case John, persists in providing a treatment to the patient (who also happens to be his acquaintance) by employing the interpretative power of the colour of the urine. In two further cases, the patient’s response to the suggested therapy is negative. In the first case, John visits a patient who happens to suffer from a serious urinary disease.40 He seems to prepare a lozenge, which is characterised as “bitter”. In the unedited fifth book of his Medical Epitome, John provides a recipe for the “bitter” lozenge, which seems to derive its name from the bitter almonds, which constituted its basic ingredient, and gave it its bitter taste.41 Furthermore, it seems that under certain circumstances the lozenge was mixed with ὀξύμελι, a mixture of vinegar and honey, which only made it taste even more bitter, as it can be seen in the following case: 39  On healing ‘gestures’ as part of ancient rhetoric and, in particular, in Latin medical literature, see the collection of essays by Gaide, F. and Biville, F. (2003). Manus medica. Actions et gestes de l’officiant dans les textes médicaux latins. Questions de thérapeutique et de lexique. In particular, on medieval uroscopy, see McVaugh, M. R. (1997). ‘Bedside manners in the Middle Ages’, Bull. Hist. Med. 71, 201–23; Wallis, F. (2000). ‘Signs and Senses: Diagnosis and Prognosis in Early Medieval Pulse and Urine Texts’, Social History of Medicine 13, 265–78; and Moulinier-Brogi, L. (2012). L’ uroscopie au Moyen Áge: “lire dans un verre la nature de l’homme”, 77–92. See also Kosak (Chapter Eight), pp. 245–264 in this volume. 40  John, On Urines 2.19 (Ideler 2, 50, 26–52, 1). 41  John, Medical Epitome, Laurentianus gr. 75.11 (AD 1412/13), fol., 220v, ll., 7–16 (autopsy, February 2012): Τροχίσκος ὁ πικρὸς πρὸς στομαχικούς· ἡπατικούς· σπληνικούς· ἰκτερικούς· σελινόσπερμα· ἄσαρ· ἀψίνθιον· ἄνισον· ἀμύγδαλα πικρὰ [. . .] κοιλιακοὺς δυσεντερικοὺς μετὰ οἴνου αὐστηροῦ· αἱμοπτοϊκοὺς μετὰ ὀξυκράτου [. . .]. For a physical description and a list of contents of the manuscript, see Bandini, A. (1764–70). Catalogus codicum manuscriptorum Bibliothecæ Mediceæ Laurentianæ, varia continens opera Græcorum partum, 2, 158–59.

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Taking this drug in my hands, I think it was the bitter lozenge, I mixed it with as much oxymeli as I considered enough, and added warm water to it, in order to make it more liquid and easy to swallow, and then I gave it to the patient to drink. He took the cup and pressed his lips firmly against it, when he felt that the drug was disgusting, for it was very bitter indeed; but since he was a man, in all other respects proud and profound, and with regard to the provision of drugs disobedient and not tractable and wanted to tease us he tested how easy it was to vomit it [. . .].42 Swallowing a pill is a hard task for many adults even in modern societies. We can clearly see here that John attempts to provide his patient with an easier to swallow version of the lozenge, thus giving us an insight into his active involvement with his patient’s case and his eagerness to persuade him. In the case of the patient who followed the inappropriate diet, I showed how the display of a particular colour in urine could aid a physician’s attempt to provide a prognosis for a disease and induce the patient to comply with the exigencies of a particular therapy. Similarly, the active involvement of the physician in the preparation of a medicament could enhance the level of trust the patient showed towards the physician. However, by shifting his narration from the first-person to the third-person singular, John ultimately lays emphasis on the patient’s reluctance to take the medicine and demonstrates that there was no point in further urging him in that direction. Another similar case history involves treating two patients at the same time.43 Two women were suffering from terrible pain for different reasons. John proceeds to examine their urine and observes a small quantity of branlike sediment in the urine of one patient, whereas most of the fluid is a reddish-yellow. The other patient has less dense sediment and most of the fluid is white. The narration skips the diagnostic part and proceeds directly to the therapy: For the first female patient [. . .] we recommended a diet and she was saved from the disease. The other one was not persuaded to drink the drug we gave her in order to treat the disease.44 [. . .] as she did not ­happen to know the name of the drug, she would not drink it. The woman 42  John, On Urines 2.19 (Ideler 2, 50, 30–51, 8). 43  John, On Urines 3.10 (Ideler 2, 62, 29–63, 13). 44  The original reads: ἡ δ᾽ἑτέρα φάρμακον μέντοι ὑφ᾽ἡμῶν πεπωκέναι πέπειστο λυσιτελῆσον τῷ πάθει. However, the addition of οὐ (“not”) before πέπειστο is necessitated by the context. The previous sentence refers to a female patient who followed the suggested treatment, whereas the next sentence comes as a contrast to this if one considers the presence of

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was in all other respects like a peasant [ἀγροίκως ἐσταλμένη]. I abandoned her and left and I do not know what happened to her [. . .].45 The first woman follows the recommended diet and recovers, while the second refuses to take a certain drug. Although John does not name or specify the medicine, he reports the woman’s emphatic refusal, a fact he ascribes to her ignorance. There is no attempt to reason with her in order to convince her to follow the recommended treatment. He simply explains that the woman was from the countryside, thus probably reflecting sociocultural stereotypes of the period, which connected erudition with the urban elite. If we compare the case of the female patient with the aforementioned cases of the male patients, we can see that John does not show the same degree of patience here. Furthermore, it seems that patients without experience of medical assistance, patients who were deemed ignorant or uneducated as a result of their socioeconomic background, were reluctant to seek or follow medical advice, which seemed strange to them or simply unfamiliar. In the final section of this part I examine a case of patient-physician interaction in which in addition to John other physicians are also present. These episodes serve as illustrative examples of the complex relationship John develops with his patients. There are three cases of this kind, which make up to roughly a quarter of the total number of case histories.46 The patient is usually a wealthy woman asking for medical advice at home. John appears to challenge and argue with his colleagues by focusing on various approaches regarding the patient’s diagnosis and therapy. In the most notable example,47 the woman appears to have drunk a purgative, which had been prepared by a Syrian physician, which presumably indicates a foreign doctor who happened to practise at Constantinople.48 However, the drug offers only a temporary purgation and, because of its strong action, causes severe abdominal pain. The physician tries to alleviate the pain and ultimately the woman believes that she has fully recovered. So far John is μέντοι and its close association to δέ (which contradicts the previous μέν). The second sentence therefore requires the negative οὐ(κ). 45  John, On Urines 3.10 (Ideler 2, 63, 3–13). 46  John, On Urines 6.12 (Ideler 2, 162, 18–163, 27); 6.13 (Ideler 2, 165, 9–166, 16); and 7.13 (Ideler 2, 181, 11–183, 12). 47  John, On Urines 6.13 (Ideler 2, 165, 9–166, 16). 48  The term used by John is “Σύρος”. This might be the young Syrian physician, who was introduced to the Emperor Andronikos II around 1299–1300 by the scholar Maximos Planoudes; see, Maximos Planoudes, Epistle 12 (Leone, 27, 18–20).

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not involved in the patient’s treatment and appears to be a passive observer making comments on another physician’s advice, as well as on the patient’s response. However, immediately after he actively engages with the patient, he describes her urine and stresses the patient’s reactions: Her urine was warm and thick and became thinner [. . .] and it would have been better to proceed to a purgation using a clyster, but I could not persuade her because she was scared [. . .] after a short while, when her condition became worse she called one of the most notable physicians and he arrived and pronounced the disease of the patient was ­hypochondrismos 49 [. . .] and I persuaded her to accept the purgative [. . .] and she drank the drug, which purged her mildly, and was freed from her terrible pains.50 The patient does not seem to trust John’s advice as a result of her fear. John must be in the early stages of his career and does not manage to gain the patient’s trust.51 Various other symptoms develop and the patient’s condition gradually deteriorates. The patient decides to call one of the most notable doctors. The woman while relying on the second physician’s diagnosis agrees to drink John’s purgative, which, as it seems, did not conflict with the other physician’s advice, and, thus, is finally freed from the pain. John succinctly reports that the woman had finally been persuaded to follow his expert medical advice. It is clear that patients who could afford to consult more than one doctor did not hesitate to do so. The female patient above, for instance, compared the two doctors’ views before she made her decision, and complied with John’s recommendation only after consulting another, more experienced physician. In this case, although we do not have John performing a healing ‘gesture’ himself, the presence of the ‘most notable physician’ functions as an evident symbol

49  A disease related to the ὑποχόνδρια(ον), i.e. the soft parts of the body below the cartilage and above the navel. See Leven, K.-H. ‘Hypochonder’ in Leven, K.-H. (2005). Antike Medizin: ein Lexikon, 448. 50  John, On Urines 6.13 (Ideler 2, 165, 21–166, 16). 51  John’s youth is also confirmed when he discusses a gynaecological problem related to the uterus and the menstrual cycle in an extract from the last of these three case histories. He appears eager to state his lack of specialist knowledge on the topic. John, On Urines 7.13 (Ideler 2, 182, 19–21): ἐπεὶ δὲ περὶ γυναικείων παθῶν μετὰ οὐ πολὺ βίβλους ἀναγνοὺς ἐπαιδευόμην ὅσον κακὸν ἐπέχεσθαι τὰ ἐπιμήνια πέφυκε [. . .].

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of professionalism and trustworthiness for the patient, and, thus, as a central element of the persuasion process.52 3 Conclusions John is certainly a skilful raconteur, who is interested in drawing out certain details in the portrayal of his patients. His narration reconstructs an image of reality, which is informed by John’s medical knowledge, his perceptions, and his social relationships. Persuasion is the salient feature in the contact between patient and physician. It stresses the importance of the physician’s advice and signals the cases where the expert’s recommendation is not accompanied by verbal debate or dispute on behalf of his patients. More importantly, we can identify recurrent elements of symbolic significance, such as the visual encounter of the urine vial and the lively experience of a drug preparation, which help the patients to decipher the physician’s actions and show the physician’s awareness of the need for individualised patient care. This process of individualisation is articulated through a common ‘language’ of communication that may be adjusted according to the patient’s needs and special characteristics, such as, for instance, the degree of John’s familiarity with the individual patient, the patient’s social-economic origins, their experience, and professional expertise. John makes a strong case for how an efficient and resourceful healer should ‘read’ not only the patient’s body but also the patient’s response. Texts and Translations Used Alexander of Tralles. Therapeutics. Ed. T. Puschmann, Alexander von Tralles: OriginalText und Übersetzung nebst einer einleitenden Abhandlung: ein Beitrag zur Geschichte der Medicin, vol. 1, 441-vol. 2, 585. Vienna: Wilhelm Braumüller, 1878–79. Galen. On Anatomical Procedures (De anat. admin.). Ed. C. G. Kühn, Opera Omnia, vol. 2, 205–731. Leipzig: Car. Cnoblochi, 1821. ———. On Anatomical Procedures (De anat. admin.). Ed. I. Garofalo, Anatomicarum administrationum libri qui supersunt novem, Earundem interpretatio arabica

52  On the centrality of trust in the attending physician and the efficacy of belief in the effectiveness of the recommended course of action for the success of the therapeutic process, see van Schaik (Chapter Nineteen) in this volume.

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Hunaino Isaaci filio ascripta; tomus alter libros 5–9 continens. Naples: Instituto Universitario Orientale, 2000. ———. On Affected Parts (De loc. aff.). Ed. C. G. Kühn, Opera Omnia, vol. 8, 1–452. Leipzig: Car. Cnoblochi, 1824. George Lakapenos and Andronikos Zarides. Epistles. Ed. S. Lindstam, Epistulae XXIII cum epimerismis Lacapeni. Gothenburg: Elanders Boktryckeri, 1924. Herodotus. The Histories. Ed. Ph.-E. Legrand, Histoires, 9 vols. Paris: Les Belles Lettres, 1930–60. John Zacharias Aktouarios. On the activities and illnesses of the psychic pneuma and the corresponding mode of diet (De actionibus & affectibus spiritus animalis). Ed. J. Ideler, Physici et medici graeci minores, vol. 1, 312–86. Berlin: G. Reimer, 1841–42. ———. Medical Epitome (De Methodo Medendi), Books 1–2. Ed. J. Ideler, Physici et medici graeci minores, vol. 2, 353–463. Berlin: G. Reimer, 1841–42. ———. Medical Epitome (De Methodo Medendi), Books 1–6. Tr. in Latin C. H. Mathys, Actuarii Ioannis filii Zachariae Opera, vol. 2, 1–563. Paris: Bernardus Turrisanus, 1556. ———. On Urines (De Urinis). Ed. J. Ideler, Physici et medici graeci minores, vol. 2, 3–192. Berlin: G. Reimer, 1841–42. Maximos Planoudes. Epistles. Ed. P. Leone, Epistulae. Amsterdam: M. Hakkert, 1991.

References Bandini, A. Catalogus codicum manuscriptorum Bibliothecæ Mediceæ Laurentianæ, varia continens opera Græcorum patrum, 3 vols. Florence: Typis Regiis, 1764–70. Bouras-Vallianatos, P. ‘Clinical Experience in Late Antiquity: Alexander of Tralles and the Therapy of Epilepsy.’ Medical History 58, (2014): 337–53. ———. Medical Theory and Practice in Late Byzantium: The Case of John Zacharias Aktouarios (ca. 1275–ca. 1330). PhD diss., King’s College London, 2015. ———. ‘Contextualizing the Art of Healing by Byzantine Physicians.’ in ‘Life is Short Art Long’: The Art of Healing in Byzantium, ed. B. Pitarakis, 104–22. Istanbul: Pera Museum, 2015. ———. ‘Ioannes Zacharias Aktuarios.’ in Lexikon der byzantinischen Autoren, ed. M. Grünbart and A. Riehle. Vienna: Akademie Verlag, forthcoming. Congourdeau, M.-H. ‘La médecine à Nicée et sous les Paléologues: état de la question.’ in Philosophie et sciences à Byzance de 1204 à 1453. Les textes, les doctrines et leur transmission, ed. M. Cacouros and M.-H. Congourdeau, 185–88. Leuven: Peeters, 2006. Deichgräber, K. Die griechische Empirikerschule: Sammlung der Fragmente und Darstellung der Lehre. Berlin: Weidemannsche Verlagsbuchhandlung, 1965.

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Diamandopoulos, A. ‘Uroscopy in Byzantium.’ American Journal of Nephrology 17, (1997): 222–27. Diels, H. Die Handschriften der antiken Ärzte, 2 vols. Berlin: Verlag der Königlichen Akademie der Wissenschaften, 1905–06. Dimitriadis, K. Byzantinische Uroskopie. PhD diss., Rheinische Friedrich-WilhelmsUniversität Bonn, 1971. Gaide, F. and F. Biville (eds.) Manus medica. Actions et gestes de l’officiant dans les textes médicaux latins. Questions de thérapeutique et de lexique. Paris: Publications de l’Université de Provence, 2003. Gaul, N. Thomas Magistros und die spätbyzantinische Sophistik: Studien zum Humanismus urbaner Eliten der frühen Palaiologenzeit. Wiesbaden: Harrassowitz, 2011. Georgiou, S. Edition critique, traduction et commentaire critique du livre 1 ‘De Urinis’ de Jean Zacharias Actouarios. PhD diss, École Pratique Des Hautes Études-Paris, 2013. Guardasole, A. ‘Empiriker.’ in Antike Medizin: ein Lexikon, ed. K.-H. Leven, 254–55. Munich: Beck, 2005. Hohlweg, A. ‘Johannes Aktuarios. Leben, Bildung und Ausbildung. De Methodo Medendi.’ Byzantinische Zeitschrift 76, (1983): 302–21. ———. ‘John Actuarius’ De Methodo Medendi—On the New Edition.’ Dumbarton Oaks Papers 38, (1984): 121–33. ———. ‘Seelenlehre und Psychiatrie bei dem Aktouarios Johannes Zacharias.’ in Hippokratische Medizin und antike Philosophie, ed. P. Pellegrin and R. Wittern, 513– 30. Hildesheim: Olms-Weidmann, 1996. Kourousis, S. ‘Ὁ Ἀκτουάριος Ἰωάννης Ζαχαρίας παραλήπτης τῆς ἐπιστολῆς ι´ τοῦ Γεωργίου Λακαπηνοῦ.’ Ἀθηνᾶ 78, (1980–82): 237–76 (repr. in Kourousis, S. Μελέτη Φιλολογική. Athens: Papadakēs, 1984–88, 101–40). Kudlien, F. ‘Empirie und Theorie in der Harnlehre des Johannes Aktuarios.’ Clio Medica 8, (1973): 19–30. Langholf, V. Medical Theories in Hippocrates: Early Texts and the ‘Epidemics’. Berlin: De Gruyter, 1990. Leven, K.-H. ‘Hypochonder.’ in Antike Medizin: ein Lexikon, ed. K.-H. Leven, 448. Munich: Beck, 2005. Lloyd, G. E. R. ‘Galen’s un-Hippocratic case-histories.’ in Galen and the World of Knowledge, ed. C. Gill, T. Whitmarsh and J. Wilkins, 115–31. Cambridge: Cambridge University Press, 2009. Marciniak, P. ‘Byzantine Theatron—A Place of Performance.’ in Theatron. Rhetorische Kultur in Spätantike und Mittelalter, ed. M. Grünbart, 277–85. Berlin: De Gruyter, 2007. Mattern, S. P. Galen and the Rhetoric of Healing. Baltimore: John Hopkins University Press, 2008.

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McVaugh, M. R. ‘Bedside Manners in the Middle Ages.’ Bulletin of the History of Medicine 71, (1997): 201–23. Mergiali, S. L’enseignement et les lettrés pendant l’époque des Paléologues (1261–1453). Athens: Hetaireia tōn Philōn tou Laou, 1996. Moulinier-Brogi, L. L’ uroscopie au Moyen Âge: “Lire dans un verre la nature de l’homme”. Paris: Honoré Champion, 2012. Omont, H. Inventaire sommaire des manuscrits grecs de la Bibliothèque Nationale, 3 vols. Paris: A. Picard, 1886–98. Schmalzbauer, G. ‘Johannes Zacharias Aktuarios.’ in Antike Medizin: ein Lexikon, ed. K.-H. Leven, 470–71. Munich: Beck, 2005. Ševčenko, I. ‘Society and Intellectual Life in the Fourteenth Century.’ in Actes du Actes du XIVe Congrès International des Études Byzantines, ed. M. Berza and E. Stănescu, vol. 1, 69–92. Bucharest: Editura Academiei Republicii Socialiste România, 1974. (repr. Ševčenko, I. Society and intellectual life in late Byzantium. London: Variorum Reprints, 1981). Siegel, R. Galen on the affected parts: translation from the Greek text with explanatory notes. Basel: S. Karger, 1976. Staden, H. von ‘Experiment and experience in Hellenistic medicine.’ Bulletin of the Institute of Classical Studies 22, (1975): 178–99. Stathakopoulos, D. ‘The location of medical practice in 13th-century Eastern Mediterranean.’ in Liquid & Multiple: Individuals & Identities in the thirteenthcentury Aegean, ed. G. Saint-Guillain and D. Stathakopoulos, 135–54. Paris: Association des amis du Centre d’histoire et civilisation de Byzance, 2012. Temkin, O. ‘Byzantine Medicine: Tradition and Empiricism.’ Dumbarton Oaks Papers 16, (1962): 97–115. Touwaide, A. ‘On Uroscopy in Byzantium.’ in Ιστορία της Ελληνικής Νεφρολογίας, ed. A. Diamandopoulos, 218–20. Athens: Papazēsēs, 2000. Wallis, F. ‘Signs and Senses: Diagnosis and Prognosis in Early Medieval Pulse and Urine Texts.’ Social History of Medicine 13, (2000): 265–78.

part 6 The Informed Patient: Self-Healing and the Patient as Physician

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CHAPTER 16

Treatment of the Man: Galen’s Preventive Medicine in the De Sanitate Tuenda John M. Wilkins Ideally in Galen’s model of preventive medicine, the patient does not become a patient at all but remains a healthy person able to maintain his or her health without need of either medicines or other therapies. This chapter is divided into four sections, Galen’s ideal patient; less than ideal patients; patients in old age; and patients whose nature is inclined to a bad mixture of humours, and so in need of medication. In all four categories, even those where medical recommendations such as blood-letting are recommended, Galen offers an option based on hygieine, or the art of maintaining good health. Galen’s aim in de sanitate tuenda is to ensure that a well-educated person can lead a healthy life by learning what does harm and what benefits him or her. The chapter explores the extent to which the patient can really be independent of the doctor, and the interesting balance between nature and urban life which constitutes good health in Galenic thought. Galen was a physician whose medical career and production of medical texts were designed to create great authority and outperform all rivals. When he first arrived in Rome, he claims to have diagnosed conditions that had defeated other doctors: from this moment onwards his works are filled with cases in which patients were amazed and saved from serious illness by his comprehensive knowledge.1 Such a success rate was designed to give Galen credibility as a physician greater than any of his rivals; but it also left the patient completely at the mercy of the all-wise physician.2 What could the patient know in comparison with the vastly experienced medical man? Paradoxically, however, it is Galen who helps us to understand what the patient can do for him- or herself in a remarkable treatise on maintaining 1  Many cases are conveniently collected in Mattern, S. P. (2008). Galen and the Rhetoric of Healing. 2  On Prognosis is the main text on Galen’s triumphal arrival in Rome. For Galen’s powerful self-presentation, see also Gleason, S. ‘Shock and Awe: the performance dimension of Galen’s anatomy demonstrations’, in Gill, C. et al. (2009). Galen and the World of Knowledge, 85–114. © koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_018

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good health, De sanitate tuenda.3 In this approach to preventive medicine, the doctor can step back into a monitoring role, one in which he checks the particular constitution of each individual, so that the individual, now a person (anthrōpos) rather than a patient (ho paschōn), can keep in good health by leading a healthy daily life based on the institutions of the ancient city—the baths, the gymnasia, the stoas and meeting places. Within this civic setting, the healthy life is shaped by what Galen called the six necessary or ‘non-­natural’ activities of the body, namely respiration and transpiration, eating and drinking, movement and rest, sleep, humoural balance and mental well-being. If this healthy regime could be observed, with help from non-medical professionals such as trainers, masseurs and nurses for children, then in principle the individual would expect to have considerable independence from the doctor and barely be a ‘patient’ at all. Galen declares that this preventive approach constitutes half of the art of medicine (De san. tuenda 1.1 (K. 6.1) and 3.1–5 (K. 6.7–8)). Of course, being the self-aggrandizing writer that he was, much of the treatise concerns details and complications in which the doctor appears indispensable. Nevertheless, he concludes with the objective that the individual who successfully follows the regime will “have little need of doctors” (De san. tuenda 6.14 (Koch 197.16–7 = K. 6.450)). Galen envisages that the ideal individual will be a person of means who can devote a huge amount of time to good health, as had the author of the Hippocratic De diaeta 3.68–69 (71–78 Joly = L. 6.594–606). Galen’s ideal is the canonical body based on the best constitution set out in the treatise of that name and modelled on the canon of Polyclitus, whose peerless statue of the doryphoros could be seen replicated in public areas in numerous parts of the Roman Empire. A person with the ideal constitution would need to take measures to compensate for the aging of the body and the demands of exercise and diet, but would be able to make quite small adjustments and would also be a good judge of when adjustments were needed. By definition, almost no body has the ideal constitution. However, Galen made clear in On 3  See Grimaudo, S. (2008). Difendere la Salute. Igiene e disciplina del soggetto nel De sanitate tuenda di Galeno and Wöhrle, G. (1990). Studien zur Theorie der antiken Gesundheitslehre for detailed studies of this treatise. Galen presents his programme as if it is all his own work, but Wöhrle traces the long history of such treatises from the Hippocratic Corpus onwards, and some of Galen’s material is similar to details found in Celsus and Asclepiades of Bithynia, the latter of whom Galen in this treatise dismisses as wrongheaded. In fact, it is Asclepiades’ model of the body that Galen dislikes rather than his programme for preventive medicine. Throughout this paper I refer to the edition of Koch (CMG V 4, 2 Koch). The interested reader may also wish to consult Kühn 6, 1–452.

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the Best Constitution (De opt. corp. const. 3.4 = K. 4.744–5) that an individual could fall some way short of the ideal with minimal damage to their health. In De sanitate tuenda, he goes further. It is possible (but not ideal) to work all day as a doctor, politician or administrator, or as a manual worker, and still remain healthy, if essential corrections are put in place: again, this is a regime for the citizen living in one of the cities of the empire. And provided that a prudent and healthy regime is followed throughout life—something Galen had done himself for decades—good health is still achievable in the more fragile period of old age. Galen probably wrote his treatise on preventive medicine in 180 AD in his second period of residence in Rome.4 The treatise concentrates on how the individual may maintain his health with minimal intervention from the doctor, provided the patient is not subject to serious or congenital disease. It is designed to complement or perhaps anticipate Galen’s many therapeutic treatises by keeping the individual in good health—though there is considerable overlap with therapy, particularly in the later books of the treatise that deal with serious illness and old age. Galen appears to envisage a person living in a city with a healthy climate and public infrastructure, a city of Asia Minor probably like the town of his birth, Pergamum, or Ephesus. He implies that a healthy life can be lived in a ‘standard’ Greco-Roman town, applicable in principle throughout the temperate parts of the Empire, perhaps even in his adopted home of Rome with its many challenges to health.5 Imperial slaves appear to be working in Rome (see below), while references to most homes containing a bath might be true of Priene or Olynthus in the fourth century BC, or of better-equipped homes in the Roman Empire. The climate he envisages seems to belong to Western Asia Minor (De san. tuenda 2.7 (Koch 56.1–59.23 = K. 6.124–133)), though he gives most attention to the use of baths, gymnasia, and massage, and how these in different combinations can rectify problems before they become too serious. A person may need lighter or more vigorous massage, wrestling or boxing rather than running, or different levels of humidity at the baths. Baths attached to gymnasia had become commonplace in the Hellenised East as in Italy itself by the second century AD.6

4  Bardong, K. (1942). Beiträge zur Hippokrates- und Galenforschung, 627–28, and the CMG edition p. 7. 5  See for example Scobie, A. (1987). ‘Slums, sanitation and mortality in the Roman world’, Klio 68, 399–433; Scheidel, W. (1994). ‘Libitina’s bitter gains: seasonal mortality and endemic disease in the ancient city of Rome’, Anc. Soc. 25, 151–75; and Morley, N. ‘The salubriousness of the Roman city’, in King, H. (2005). Health in Antiquity, 192–204. 6  Mitchell, S. M. (1993). Anatolia, vol. 1, 216–17.

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Ideally, then, in Galenic medicine, the patient does not become a patient at all, but remains a healthy person who after an initial diagnosis of his/her constitution is able to maintain his or her health without need of either medicines or other therapies. This will be achieved through leading a healthy life style in the ancient city, “according to nature”. The healthy person will not necessarily discover how to live healthily spontaneously, but will need the advice of those services normally available in the ancient city, such as children’s nurses, gym trainers and masseurs to keep the body and soul in balance. These professionals, part of the infrastructure of civic life, may need to take further advice from a doctor, as we shall see. This chapter is divided into four sections: Galen’s ideal patient; less than ideal patients; patients in old age; and patients whose nature is inclined to a bad mixture of humours, and so in need of diagnosis and medication. In all four categories, even those where medical recommendations such as bloodletting are recommended, Galen offers a less invasive option such as sleep or changed diet, based on hygieinē, or the art of maintaining good health. Galen’s aim in De sanitate tuenda is to ensure that a well-educated person can lead a healthy life by learning what does harm and what benefits him or her (De san. tuenda 6.14 (Koch 197.2–17 = K. 6.443–450)). Galen says that he is writing for readers who are not trained in medicine but do have experience of argument and reason (logismos). Such people do not live like “irrational animals” but judge from experience which foods, which exercises, and how much sex are harmful or beneficial. Armed with this personal knowledge, the educated person (the sort of person who reads Galen’s books can guard against what harms and embrace what is beneficial. An understanding of one’s own constitution is a key issue, and much of the treatise makes it appear difficult for a patient to acquire such knowledge. In most cases, only the doctor has that knowledge, but Galen seems in principle to approve full autonomy for the patient who has no complications. Galen enables us to follow the healthy person from birth, and to see the emerging level of independence, from the ideal young man who has been correctly brought up from infancy, to the youth who is able to calibrate his needs. There is room for error, since younger age-groups are more resilient, but experience and sound judgement will win through during a long healthy life, as long as no accidents and illnesses befall. From birth, the body faces certain constraints, in particular the need to replenish lost heat and energy with food and drink that is dissimilar from the body (De san. tuenda 1.3 (Koch 5.35–6.26 = K. 6.7–9)). Digestion of this material may be incomplete and may generate bad humours. In addition, as the body ages, it cools and dries and becomes less able to achieve full assimilation of food and drink. What is needed to ensure good digestion and therefore

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good health until an advanced age is a life lived “according to nature”, by which Galen means a way that keeps the humours and organs of the body in balance and in equilibrium with each other, good habits, and a full understanding of one’s own constitution. One is likely to be a man. Galen here, as elsewhere in his work, makes occasional references to women, but nearly always in a context linked with reproduction. So, for example, in a very important passage mentioned below, a young man with a good constitution will have a mother with a good constitution, the father not being mentioned in this respect. Apart from that, there is no consideration of women with different humoural constitutions from men (cooler and moister, for example) or of women’s lifestyles, not to mention child rearing, demanding different consideration from that of a men. Galen here clearly diverges from, for example, the Hippocratic Regimen in Health, a treatise which does discuss (Salubr. 6 = L. 6.82) different dietary needs for women. The main role of the doctor, if strong medical intervention is not needed (on this, please see the end of the chapter), is to have a knowledgeable overview. In Galen’s view, the patient may have a good idea of what is needed, for example, in response to fatigue, but this will be particular and based on what is familiar to the patient, and not applicable to different kinds of fatigue in that patient or to the needs of other patients. Similarly, professionals in gymnastics, such as the author Theon, whom Galen takes to task, have an understanding of massage and exercises suitable for gymnasts, but little understanding of how exercise and massage should be deployed in general. The same applies to wet nurses, who have particular expertise but not a full understanding of the nature of the infant: Galen even claims to advise the nurse on when the baby needs changing (De san. tuenda 5.7; CMG 148.21–149.34; K. 6,342–349). Cooks too have a good understanding of how to prepare food, but little knowledge of the body’s needs. In all these areas, the doctor should be called in because he has a comprehensive understanding of the nature of the body. Thus, the patient can largely depend on professional experts, but will need the doctor for an understanding of how his or her particular nature works. An initial diagnosis is needed. Galen has a nice example of individuals being led astray by observing good health in another, without a good understanding of their own natures (De san. tuenda 5.7 (Koch 148.21–149.34 = K. 6.342–349)). There is widespread admiration of a goatherd who drank milk with honey and thyme until an advanced age. A number of people followed his diet, and some were made ill with dental, renal and liver problems, while others remained in good health. The explanation, Galen reveals, is that the nature of the individual is the key issue, and whether or not goat’s milk is beneficial in adults will depend on the kind of

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liver a person has and its porosity to thickening liquids. He might also have added that the goatherd was well used to his milky diet, whereas newcomers to such a food may well not benefit from the change. In addition to the matter of habituation, the goatherd spent much of his life in the countryside and therefore led a life rather different from Galen’s apparent intended urban audience, for whom Galen does not in general recommend milk (especially for the elderly)—though for babies, of course, it is ideal. 1

The Ideal Patient

Much of the treatise is taken up with a young man who has the “best constitution”. He is the ‘canon’ against which all other cases may be calibrated. He has a mother of the best constitution, who feeds him herself with milk, which is the closest possible to the food he received in the womb (De san. tuenda 1.7 (Koch 17.26–29 = K. 6.31–37)), though Galen also suggests that wet nurses might be used. The mother or nurse herself must live a life of moderation (De san. tuenda 1.9 (Koch 21.34–22.11 = K. 6.45–47)), so that the infant will not be exposed to any kind of excess that may destabilise his excellent nature, and the infant at an early age is trained in moderate and rhythmical movement, first of all with swaddling and rhythmical movement of limbs, then with motion on water and with music. Uncoordinated movement of arms and legs is discouraged, in order to foster habits which encourage balance and moderation. There will be disciplining of unruly emotion as well, so that the infant’s mood remains balanced. This can best be done when they have woken in the morning and have played for a while (De san. tuenda 1.10 (Koch 23.29–24.2 = K. 6.49–50)). They are hungry. At this time, they can be trained to health and a good constitution in the body and obedience and temperance in the mind, by being told that they will not be fed until they agree to whatever is needed, whether a bath or gentle massage. Galen has much to say in other treatises on ethical and moral training.7 In his treatise of hygiene behaviour and ethical conduct is part of health and wellbeing since mental wellbeing is one of the six necessary activities of the body (more on this below). The mother or nurse will also sing and use her voice rhythmically in order to foster balance in the body (De san. tuenda 1.8 (Koch 21.13–20 = K. 6.37–38)):

7  The Soul’s Dependence on the Body (Quod animi mor. Galeni Scripta Minora 2 = K. 4.11.767–822) and The Affections and Errors of the Soul (De an. aff. dign. et cur. Boer (CMG) = K. 5.1.1–57), for example.

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whoever undertakes the bringing up of infants must be able to guess accurately what is moderate and comfortable and provide this before increasing distress throws the body and mind into an excess of activity, and if ever the increasing distress escapes his notice, to try to provide immediately the thing desired or to remove the annoyance either by rocking in the arms or by modulation of the voice, which sagacious nurses are accustomed to deploy.8 The infant is thus introduced to the six necessary activities for maintaining good health mentioned above, that is breathing and transpiring in good air; eating and drinking; exercise and rest, sleeping and waking, filling and emptying the fluids of the body, and mental well-being.9 All of these will be established in a disciplined way during infancy, and the infant will be accustomed to a healthy life. Custom, what the body is used to, is a key, Aristotelian, element of Galen’s regime, and is built on what a person normally does at the city baths and gymnasia, at the Asclepieia and civic institutions, and on what he normally eats at meal times. Once established on this firm basis, the infant may be introduced to life outside the home, to get to learn about movement on boats and on horseback, and then to be introduced to life in the city. This healthy person will go for his first massage in the temperate season of spring, in the middle of the day, in a city with a well-balanced climate, so that nothing will destabilise that natural balance which his life had experienced so far (De san. tuenda 2.7 (Koch 56.1–59.23 = K. 6.124–133)). Similarly, he will be introduced to exercise and bathing in the bath houses with great care, so as to integrate a balanced physiology with balanced habits and a balanced environment. This latter will be an urban environment, since Galen seems to consider a rural life too much under threat from food shortages and heavy labour (De san. tuenda 2.7 (Koch 56.1–59.23 = K. 6.124–133)), drawing on On Good and Bad Juices (De bonis mal. sucis 1.389–93 (K. 6.749–756)).10 All these activities, Galen envisages, will be undertaken under the supervision of professional experts rather than doctors. Thus the wetnurses and nurses of childhood will be replaced by athletic trainers, ‘hygienists’ and masseurs, who will have a proper understanding of the activity they are responsible for, but who will need to refer to the doctor for an understanding of how the whole 8  Trans. Green, R. M. (1951). Galen’s Hygiene. 9  See Grimaudo, S. Difendere la Salute, 161–63; Garcia-Ballester, L. ‘On the origin of the six non-natural things’, in Kollesch, J. and Nickel, D. (1993). Galen und das Hellenistische Erbe, 105–15. 10  CMG 5,4,2 Helmreich.

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body works. For the ideal patient, therefore, the doctor remains in the background and the patient can develop a good understanding of his health needs and objectives. He can judge accurately for himself what his body needs. There is independence from the doctor, but professionals are still envisaged. Once set up in this way, the ideal patient ought to be able to lead a long life into old age without any premature aging brought about by excesses or dissolute living (De san. tuenda 5.1 (Koch 137.15–32 = K. 6.310–311)). Galen’s focus on the patient who has sufficient time and resources to devote a great deal of time to his health resembles the Hippocratic patient noted above, who is not deflected by the unfortunate demands of work. He will be perfectly constituted, Galen says, to keep himself in good shape and he has the leisure to do so (De san. tuenda 6.1 (Koch 168.23–6 = K. 6.381)). This canonical figure is thus a composite of two principles, the ideal against which all others are calibrated, and a wealthy young man brought up with all the benefits of the ruling class. The Hippocratic author acknowledges that few have the time to devote to the health care system that he proposes; Galen, slightly differently, aims for the same leisured young man but supplies all the vital modifications which busy working people have to build in to their lifestyle. Even the ideal patient will build up residues of bad humour, but his constitution is such, and his way of life is so healthy, that disruption to his health will be minimal: Let us go back to a young man with good humours by nature who has up to now been living a healthy life in every respect but now through some pressing need has been delayed for a long time on a journey and has not done his customary exercises nor bathed, and has taken poor food and drink, and after breakfast or after lunch or for the whole day has been riding on a chariot and has not had much decent sleep. Let us suppose in addition that he suffers from no excesses in the amount of food eaten and for this reason has no incomplete digestion (for it is inconceivable that such a person should have accumulated much bad humour). So he needs no long period of corrective treatment and apotherapeutic exercise suffices. (De san. tuenda 4.4.11–13 (Koch 108.16–26 = K. 6.245–246)) Note that this young man goes about his daily mealtime routine and while working suffers unavoidable delays and insufficient sleep. He is following the normal activities of a fairly wealthy Greek or Roman citizen. Inevitably, small things inimical to health befall him, but because he eats well and has a good regime in general, only small measures are needed to rectify the irregularities of this particular day.

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As we saw above, Galen envisages ideally the ‘natural’ organism of the body maintaining itself in good health in a city, in which the climate is well-mixed (we might say temperate) and supportive of healthy life in a well-mixed constitution. Where the Hippocratic author of Airs, Waters and Places had seen Asia with its well-mixed (eukratos) climate as producing human characters that were lazy and (when ruled by the absolute King of Persia) cowardly as well, in Galen’s system of health the well-mixed human body is sustained as such by the well-mixed climate of the Ionian coastal cities, and the infrastructure of the Greco-Roman city where all the civic amenities can be used for the purposes of health. The Hippocratic author saw the perils of a luxurious lifestyle in such an equable climate, while Galen plays down this danger. He returns in various passages in the treatise to damage suffered by the body if an unwise or indulgent lifestyle has been followed (De san. tuenda 5.1 (Koch 135.1–30 = K. 6.305–7), for example). He has in mind the luxurious life that some might lead in the Greco-Roman city, the excessive eating and drinking and sexual pleasure that the man lacking self-restraint (the akratēs man) might follow, and which he describes in the context of the Roman client/patron relationship at the beginning of On The Therapeutic Method (De meth. med. ). But his canonical patient will never submit to such excesses, for he has been trained from infancy in a moderate and disciplined regime. 2

The Less than Ideal Patient

The less than ideal patient is a person born with a less than perfect constitution or with the necessity to work: he is at a disadvantage. This of course is the vast majority of the population of the Roman Empire. Galen describes in On the Powers of Foods (De alim. facult. 1.2.8–9 (Helmreich 220.9–23 = K. 6.486– 487))11 the severe demands on rural workers whose labour produces such an appetite for food that the body absorbs the nutritious bread or meat products far too quickly and the flesh snatches up nutritional fluids that are half digested or raw, leading to severe accumulations of bad or misplaced humour. If the labourer is able to sleep deeply after such a meal, then many of the harmful effects are dispersed; but if not troublesome illnesses and premature death follow. Galen describes such a diet, like that of the athlete, as one that would cause accumulations of thick humour in ordinary people “like us” (the literate elite) who are not used to it. This would constitute one of those bad mixtures which I will talk about in my fourth section. 11  CMG 5,4,2 Helmreich.

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Work is prejudicial to health, in Galen’s view, but good health can be maintained in this area nonetheless. “There are many causes that disrupt the healthy lifestyle in many ways”, Galen observes at (De san. tuenda 6.1 (Koch 168.23–6 = K. 6.382–383)), “so we have assumed that the best constituted person has leisure at his disposal, because he is free of engagements in the polis”. Nevertheless, many are not in this fortunate position and do have to work. Many people, such as soldiers, athletes and manual workers in town and country can only undertake their work because they have a strong constitution, and as such, provided they eat moderately, will stay healthy (De san. tuenda 5.12 (Koch 166.14–18; K. 6.377)). Similarly, work and exercise may overlap to a considerable extent, and nothing excessive arise from exercise of muscles, whether in the gymnasium or on the farm. At the most, a little therapeutic massage, or what Galen widely discusses as apotherapeia, before or after would smooth out any problem: The majority of these it is possible to deploy also as exercises ( gymnasia) alone. They have a triple use in total, sometimes as work (erga) taken up for this purpose alone; sometimes as training for use in future work, and sometimes as exercises. We were once trapped in the countryside in winter and were forced to split wood for exercise ( gymnazesthai) and to put barley in a mortar to grind it and husk it, which the country people were accustomed to do every day. (De san. tuenda 2.8 (Koch 59.35–60.6 = K. 6.133–134)) Others have an unhealthy working environment. Galen considers imperial slaves (De san. tuenda 6.5 (Koch 178.11 = K. 6.405)), who might have an irreproachable physical constitution but have to work all day long for particularly powerful men or emperors, and then go home at the end of the day. At some times of the year, it is not possible for such people to leave work in time to receive a massage, go to the baths, and have a good night’s sleep. In contrast, Antoninus (Marcus Aurelius probably) was an emperor who wanted to go to the palaestra in the afternoon because he was concerned with care for the body, and so his imperial slaves could keep themselves healthy as well, and sleep properly once he had left. An unhealthy environment may not be the only problem for such slaves, since Galen finds examples of some who go to the baths but omit the massage, thereby leaving themselves open to accumulations of bad humour, while others fail to rectify their excessive working hours by living sensibly on festival days. Their slave status seems to be playing a part in Galen’s assessments here: there is an implication that some lack a disciplined regime. A less than ideal patient might by nature produce a slightly unbalanced mixture of humours, in which yellow bile or another humour might be prone

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to predominate. Such a nature might be inclined to fever and in need of a diet that includes cooling or thickening foods, or a daily bath to induce the pores of the skin to shed accumulations of yellow bile that lie in the tissues skin deep. Galen (De san. tuenda 5.11 (Koch 161.4–162.5 = K. 6.364–367)) gives the example of the philosopher Primigenes of Mytilene as a man who was prone to produce this sort of bile, and in addition led a sedentary life as an intellectual and so compounded the problem. The problem was to some extent alleviated by his walking in the stoas with friends and colleagues. In one of Galen’s interesting comments upon himself, he reveals that he has a less than ideal constitution himself and suffered numerous illnesses until the age of 28, after which his healthy regime has kept him in excellent health with no abscesses, and only occasional fevers: Nor did I remain entirely free from fever but suffered from fevers caused by fatigue (kopoi), but I have now passed very many years without suffering all the other diseases. And even though I was affected in parts of the body in which others suffer from inflammations and abscesses when they are feverish, I had neither abscess nor fever; I was fortunate to this extent for no other reason than the theory of good health. I did not benefit from a healthy constitution of the body at the start of life, nor did I have an exactly free way of life, but was tied to (douleuontes) the demands of my profession and served my friends, relatives and fellow citizens a great deal, mostly staying awake at night, sometimes for the sick, but always for the love of learning. (De san. tuenda 5.1 (Koch 136.16–24 = K. 6.377)) Not only does he have a less than ideal nature, but he also has a sub optimal way of life, often working late into the night on patients or medical research, and endangering his sleep requirements. While Galen may be uncharacteristically modest about his own claims to good health, he manages at the same time to demonstrate the success of his health care programme which he has followed in person for decades. Later he describes his daily regime (De san. tuenda 6.7 (Koch 181.16–26 = K. 6.412)), and calculations to be made if the time for bathing is postponed because of medical or other duties in the city. Eating a simple meal of bread, dates, olives and honey should take place six hours before bathing, so that there are no undigested juices in the abdomen when the visit to the baths takes place. The cases of Primigenes and Galen show that good health can be maintained in less than perfect constitutions and among working people, provided correct adjustments are made (normally with medical advice). Such adjustments may be as mild as taking a brief massage before or after activities, what Galen calls

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apotherapy, which is particularly suitable for the ideal canonical young man, or involve changes to food and exercise regime. Again, all of these are measures which can be understood and undertaken by the patients themselves, once the doctor has pronounced on the mixture of their humours. Finally, Galen is clear that the least ideal circumstance for the patient is to be in prison. Here, lack of exercise leads to considerable physical and psychological harm. 3

Elderly Patients

The old are at heightened risk. Ideally they will have led a healthy life and established healthy habits so that they do not age prematurely and do not have additional vulnerability to the condition of old age which is to have a cooler and drier body that is less able to process foods fully and more likely to deposit undigested bad humour ( perittōmata) in inappropriate parts of the body. Old men, therefore, are usually advised to take an early morning massage to disperse bad humour that has accumulated under the skin during overnight digestion of food in a cooler body. They are also advised to eat smaller meals, preferably of birds and fish rather than pork and bread, to undertake gentler exercise, to bathe less frequently and only to exercise stronger parts of the body. Good health is perfectly possible in the elderly, provided they have not led an undisciplined life, which has weakened the body and aged them prematurely. The aging process, says Galen (see above), is at work in all bodies, from birth, so old age is in that sense not particular and separate, but it is more vulnerable to bad humour. Some people age well because of a good constitution and moderate way of life. Galen offers two engaging examples of healthy old men in (De san. tuenda 5.4 (Koch 143.16–144.20 = K. 6.332–334)). One, Antiochus, a doctor, is still able to walk to his surgery at the age of 80, and pursues his daily activities thanks to a modified regime with the right sort of food, exercise and massage, and a house that is airy in summer and warm in winter. The second, Telephus, is even older, and he too follows the same advice for prudent exercise and lighter foods. Others are in need of Galen’s advice, which is specific to their particular nature and not part of a general approach to gerontology. At (De san. tuenda 5.1 (Koch 135.18–30 = K. 6.306–3-7)), Galen claims to have kept many previously sick people in good health for years with his advice on maintaining good health. Some he stopped from taking any exercise, even those linked with daily activities, because they needed to concentrate on the activities necessary for life. Others

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were told to reduce the majority of their exercise. Others were encouraged to change the kind, the order or the time of their exercises, while others had to change everything. There were similar stipulations about adjustments to bathing. Galen would not have been able to do any of these things unless he understood the different natures of the bodies he was treating and the regime that best suited each. In contrast to these people who have followed Galen’s customised advice, others have neglected very good constitutions and developed painful diseases of old age, often through lack of self-control (akolasia) or ignorance or both. Galen’s solution to ignorance is to establish “a particular healthy regime for each bodily nature” (De san. tuenda 5.1 (Koch CMG 138.4–5 = K. 6.312)). In other words, when things go wrong, the doctor needs to prescribe the regime, after which perhaps the patient can switch from being a patient to being a self-sustaining healthy person again. 4

Bad Humour and Bad Mixtures

Accumulations of bad humour or unhealthy mixtures of humours are serious conditions that require more interventionist procedures than the ones considered so far. Up to this point, the patient can be largely independent of the doctor. But bad mixtures might shorten a person’s life if it is a natural condition. It might also be produced by excessive exercise that has put undue pressure on the body and produced dangerous forms of fatigue (kopos). Or it might be produced by unwise eating, such as that mentioned above among manual labourers. The essential point for patients who have generated bad mixtures through excessive exercise or unwise eating is that the imbalances are dealt with quickly and not allowed to become habitual and thereby chronic conditions. There are several categories of kopos, associated with ulcers (helkōdes), tension (tenōdes) and inflammation ( phlegmonōdes). Let us consider the bad humour (kakochymia) caused by fatigue linked with ulceration helkōdes (De san. tuenda 4.4 (Koch 107.6–116 = K. 6.243–6.263)). The doctor must establish the daily regime of the sick person; whether that person has modified it; whether normal excretions have changed; and whether normal detoxing (lifting, exercise, cathartic drugs, emetics etc.) has ceased. The problem may be food with bad humours, or changes to the type of wine drunk. The patient may naturally be subject to ulceration, through a bad mixture of his humours. He might also work too hard at the wrong time of year, and compound the problem.

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In a person who leads a less active life a humour more based on phlegm accumulates, but with much labour, the humour is sharp [i.e. yellow] or black, sharp in summer and black in winter. An eye must be kept on the length of the labour, for the more time it continues, the more it veers away into black bile. And indeed, labour which is accompanied with much sweat produces a thicker residue (perittoma), while the residue is thinner if there is no sweat, as happens in winter and in those with a cold constitution. (De san. tuenda 4.4 (Koch 110.9–16 = K. 6.249–250)) Apotherapy might work in some cases, but in more serious cases the bad humour will not only be under the skin but also deeper in the veins and organs. In this case, the patient should cease exercise; should rest and sleep and fast for a day, and then be anointed with oil and washed in well-mixed water, and given a little food and plenty of wine. Perspiration and wine-induced urine should help disperse the bad humour. If the fatigue continues, venesection or purging may be needed, the former if blood is excessive, the latter if raw humour is evident. Many procedures follow, which all belong to therapeutic measures. But it may be that the patient does not want to submit himself to blood-letting. In this case, cathartic drugs should be used. If these two are rejected, then the patient can be treated with a method based on the preventive approach of ‘hygiene’, which I have been discussing. The objective of the blood-letting and drugs was to draw off the bad humour, so the hygienic method involves stopping all vigorous activity (which spreads the bad humour through the body), being gently oiled and massaged, being given gentle baths followed by sleep, and then foods such as barley water, depending on which humour predominates. In addition to the bad humour that accumulates when the body is fatigued or has eaten food that could not be fully assimilated into blood, there are also patients who have bad mixtures in particular parts of the body that have different characteristics. Thus, the mouth of the stomach, the cardia, may have a different nature from the stomach, or more seriously a different nature from the head (De san. tuenda 6.10 (Koch 186.25–187.22 = K. 6.425–427)). Head-aches in susceptible people may impact upon the nerves at the mouth of the stomach, and cause accumulations of bile in the intestines, unless rapid action is taken. Particularly at risk are those with a naturally warm stomach. Remedies may be according to preventive methods, that is to eat more quickly, and ensure that the stomach is strengthened before bile accumulates or by drugs such as wormwood and aloe. In this and other cases, Galen finds some role for an approach based on foods and exercises rather than drugs.

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5 Conclusion Galen claims at the beginning of the treatise that the care of the body may be divided in two parts: the maintenance of health (hygieinē) that I have been exploring in this paper, and therapy. The maintenance of health would appear at first to allow the patient an enormous amount of independence since the six necessary activities are what each person experiences in daily life and can adjust according to individual needs and changes in life. But it turns out in Galen’s account that a large amount of supervision will be needed by professional trainers (familiar figures in ancient gyms and bathhouses for those who could afford them), and that the doctor will always be needed to distinguish the true causes from the apparent ones, and to understand the patient’s constitution fully. But even with the full degree of knowledge being held only by the doctor, as we would expect in Galen’s construction of the world, a large degree of autonomy is allowed to the individual, once the doctor has diagnosed what kind of nature or constitution the person has and what the regime should be. Food and drink are prepared and consumed without professional intervention, and sleep and exercise are normally taken without supervision. This autonomy rarely extends to analysis or applied knowledge, however. Only very rarely does Galen note that he sometimes asks patients to test themselves, to taste their own perspiration, for example, to establish which humour is in excess. The person most likely to lead a healthy life is a young man of independent means and leisure (the same as was found in Hippocrates), who is not distracted by political ambition or glory, and who is in full control of his desires. Good health is his constant concern, as philosophy or virtue would be if he were a young man in a philosophical treatise. He has an emerging level of independence as he grows up and is able to calibrate accurately what his body needs. The ideal need not be defined too narrowly, as we have seen, and in Galen’s view, a well-educated person, the typical product of the Greco-Roman elite training system, ought to be able to achieve the programme. Slaves and working people are at much greater risk of poor health, but not if they are well advised. If they are younger, damage will be less severe anyway. Manual workers have a strong constitution, and provided they live in moderation and do not create bad humour, they can still maintain their good health. We might divide individuals into those who do need medical interventions in adult life, such as Primigenes and those who followed the goatherd’s life unquestioningly; those who can follow the six necessary, ‘non-natural’ activities; and those who need modifications later in life, possibly with advice,

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such as Antiochus and Telephus. As Galen observes in De san. tuenda 5.4 (Koch 142.19–21 = K. 6.330), “it is difficult to take an old man in hand”. Galen’s treatise is clearly aimed at wealthy citizens who live, in his phrase, “like us”. And wealthy citizens able to afford a leisurely life are more likely to have the resources to stay healthy. Galen merges such a wealthy citizen with his canon, his scientific model for the ideal healthy person. But he does not deduce from this that the vast majority of working people and slaves cannot be healthy. Many of them have access to the same resources of baths, aqueducts and gymnasia as their wealthy counterparts, for entrance fees were very low.12 For them, Galen has integrated exercise into the healthy system, so that his familiar denunciations of athletic excess in such treatises as Thrasyboulus will not apply to this approach to medicine. They too must resist the temptations of excess, for example those imperial slaves on festival days. Galen has not constructed a universal model for healthy living—ignoring as I said, healthy living in women—but he has made some efforts to extend the model beyond the leisured elite. His system, I believe, has interesting analogies in the modern world, where the necessary activities of air and environment, food and drink, exercise, sleep, balance in the body and mental well-being remain major elements in preventive medicine. As too does bad housing and lack of resources among the poor in both richer and poorer countries. A project recently conducted in the Exeter Medical School and led by Paul Dieppe, a rheumatologist and now Professor of Health Care and Wellbeing, explored the application of Galen’s six necessary activities to preventive medicine in the UK in the twenty first century. An online questionnaire asked the public which of the activities they thought should best be funded. The groups under investigation were self-selecting but included both the healthy and those with chronic conditions such as diabetes and depression. The questionnaire, with data from over 600 respondents, has been analysed and is to be published in the Journal of Health and Wellbeing (forthcoming).13 The findings suggest that Galen’s preventive medicine can benefit the current concerns of the public in Britain over increased depression, heart disease and diabetes. The experiments may in addition to this medical benefit cause David Wootton, author of Bad Medicine: Doctors Doing Harm Since Hippocrates to reconsider his attack on Galenic medicine. Wootton, to be sure, is concerned solely with Galen’s therapeutics and its underlying humoural theory, which in the Early Modern

12  Yegül, F. K. (1992). Baths and Bathing in Classical Antiquity, 32. 13  Dieppe, P. et al. ‘Opinions on health and wellbeing in Devon: Can we translate Galen’s views into the 21st century?’, Journal of Health and Wellbeing, forthcoming.

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Period led doctors in a number of Western countries to practice blood-letting (possibly to excess) and purgation through vomiting and emetics. If Wootton is right to reject Galen’s holistic medicine (and this is by no means clear since much of the success of biomedicine lies in firefighting disease, and much less in patient wellbeing and control of health), consideration does need to be given to what Galen considered the other fifty percent of the medical art (De san. tuenda 1.1 (Koch 3.2–4 = K. 6.1)) namely preventive medicine. According to World Health Organisation figures, all five continents face increasing levels of diabetes, heart disease and depression: change will be needed.14 If Galen can assist that change, and restore health care and wellbeing to the patient, thereby allowing doctors to concentrate on fighting disease and infection, then, I would argue, use of his programme should be considered. Responses in Exeter schools and patients’ groups to Galen’s six non-naturals, presented to the public as the ‘Galen Diet’, have been encouraging.15 Younger and older citizens have recognised the need for a systematic healthy lifestyle that is not commercially driven by big business. They value the system extending across the six activities, and, in the case of the chronically ill, an opportunity to reclaim some aspects of their heath in the face of long-term dependence on medical advice. It may seem paradoxical that the great systematiser and rhetorical powerhouse of ancient medicine16 should be the catalyst for the liberation of the patient, but that does appear to be Galen’s aim, within reason, that is. Texts and Translations Used Galen. Galeni In Hippocratis de natura hominis; In Hippocratis de acutorum morborum victu; de diaeta Hippocratis in morbis acutis. Ed. J. Mewaldt, G. Helmreich and J. Westenberger. CMG V 9,1. Berlin: Akademie Verlag, 1914. ———. Galeni De Sanitate Tuenda; De Alimentorum Facultatibus; de Bonis et Malis Alimentorum Sucis; de Victu Attenuante; De Ptisana. Ed. K. Koch, G. Helmreich, K. Kalbfleisch and O. Hartlich. CMG V, 4, 2. Berlin: Akademie Verlag, 1923. 14  Wootton, D. (2006). Bad Medicine: Doctors Doing Harm Since Hippocrates, 283 observes that Galenic medicine suffered from an inability to measure accurately and to produce statistical data. While this is true, the data now faced by medical demographers are grim, as Wootton goes on to say in his conclusions. 15  The groups who have discussed the ‘Galenic lifestyle’ have been students at Queen Elizabeths Academy, Crediton; a patients’ group in the Exeter Medical School, and students and staff at Exeter University who followed the ‘Galen Diet’ with online feedback. 16  See the essays collected in Gill, C. et al. (2009). Galen and the World of Knowledge.

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———. Galeni de rebus boni malisque suci. Ed. G. Helmreich. CMG V, 4, 2. Leipzig and Berlin: Akademie Verlag, 1923. ———. Galeni De propriorum animi cuiuslibet affectuum dignotione et curatione. Ed. W. de Boer. CMG V, 4,1,1. Leipzig and Berlin: Akademie Verlag, 1937. ———. Galeni Pergameni Scripta Minora vol. II. Ed. J. Müller. Leipzig: Teubner, 1891. ———. On Prognosis. Ed. V. Nutton. CMG V 8,1. Berlin: Akademie Verlag, 1979. ———. Difendere la Salute. Igiene e disciplina del soggetto nel De sanitate tuenda di Galeno. Ed. S. Grimaudo. Palermo: Bibliopolis, 2008. ———. Method of Medicine. Ed. and trans. I. Johnston and G. H. R. Horsley, 3 vols. The Loeb Classical Library 516–18. Cambridge, MA: Harvard University Press, 2011. Hippocrates. Hippocrate: Du Régime. Ed. R. Joly. Paris: Belles Lettres, 1967. ———. Airs, Eaux, Lieux. Ed. J. Jouanna. Paris: Les Belles Lettres, 1996.

References Bardong, K. Beiträge zur Hippokrates- und Galenforschung. Göttingen: Vandenhoeck u. Ruprecht, 1942. Dieppe, P. Marsden, D., Gill, C. and Wilkins, J. ‘Opinions on Health and Wellbeing in Devon: Can We Translate Galen’s Views into the 21st century?’ Journal of Health and Wellbeing, forthcoming. Garcia-Ballester, L. ‘On the Origin of the Six Non-Natural Things.’ in Galen und das Hellenistische Erbe, ed. J. Kollesch and D. Nickel, 105–15, Sudhoffs Archiv 32. Stuttgart: Frank Steiner Verlag, 1993. Gill, C., Whitmarsh, T. and Wilkins, J. (eds.) Galen and the World of Knowledge. Cambridge: Cambridge University Press, 2009. Green, R. M. Galen’s Hygiene. Springfield Illinois: Thomas, 1951. Gleason, S. ‘Shock and Awe: The Performance Dimension of Galen’s Anatomy Demonstrations.’ in Galen and the World of Knowledge, ed. C. Gill, T. Whitmarsh and J. Wilkins, 85–114. Cambridge: Cambridge University Press, 2009. Mattern, S. P. Galen and the Rhetoric of Healing. Baltimore: Johns Hopkins, 2008. Mitchell, S. M. Anatolia, vol. 1. Oxford: Oxford University Press, 1993. Morley, N. ‘The Salubriousness of the Roman City.’ in Health in Antiquity, ed. H. King, 192–204. London: Routledge, 2005. Scheidel, W. ‘Libitina’s Bitter Gains: Seasonal Mortality and Endemic Disease in the Ancient City of Rome.’ Ancient Society 25, (1994): 151–75. Scobie, A. ‘Slums, Sanitation and Mortality in the Roman World.’ Klio 68, (1987): 399–433.

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Wöhrle, G. Studien zur Theorie der antiken Gesundheitslehre. Stuttgart: Franz Steiner Verlag, 1990. Wootton, D. Bad Medicine: Doctors Doing Harm Since Hippocrates. Oxford: Oxford University Press, 2006. Yegül, F. K. Baths and Bathing in Classical Antiquity. Cambridge Mass: MIT, 1992.

CHAPTER 17

Literary and Documentary Evidence for Lay Medical Practice in the Roman Republic and Empire Jane Draycott The majority of surviving ancient medical literature was written by medical practitioners and produced for the purpose of ensuring the effective diagnosis and treatment of their patients, suggesting an audience of medical professionals ranging from instructors to students. This has led historians to concentrate on the professional medical practitioner and their theories, methods and practices, rather than on lay medical practitioners, or even patients themselves. This chapter seeks to redress this imbalance, and examine the ancient literary and documentary evidence for lay medical theories, methods and practices in the Roman Republic and Empire in an attempt to reconstruct the experiences of lay medical practitioners and their patients. The Roman agricultural treatises of Cato, Varro and Columella, papyri and ostraca from Egypt, and tablets from Britain are investigated, and it is established that the individual’s personal acquisition of knowledge and expertise, not only from medical professionals and works of medical literature, but also from family members and friends, and through trial and error, was considered fundamental to domestic medical practice. 1 Introduction The majority of ancient medical literature that survives from antiquity seems to have been written by medical practitioners and produced for the purpose of

* All abbreviations follow those of the Oxford Classical Dictionary (third edition) and the Checklist of Greek, Latin, Demotic and Coptic Papyri, Ostraca and Tablets, http://library.duke .edu/rubenstein/scriptorium/papyrus/texts/clist.html (accessed March 2014). All Greek and Latin documentary evidence is taken either from Papyri.info, http://www.papyri.info/ (accessed March 2014), or Vindolanda Tablets Online, http://vindolanda.csad.ox.ac.uk/ (accessed March 2014). © koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_019

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ensuring the effective diagnosis and treatment of their patients, suggesting an audience of medical professionals ranging from instructors to students.1 This partiality has led scholars of ancient medicine to concentrate on the professional medical practitioner (the physician, the surgeon, the midwife etc.) and their theories, methods and practices, rather than on lay medical practitioners, or even patients themselves. This is despite the fact that the very same literary evidence attests to the co-existence of a thriving tradition of lay medical theory, method and practice, although admittedly the components of this tradition are much more difficult to reconstruct with any certainty.2 Arthur Kleinman put forward a model indicating that the health care systems in any society can be said to comprise of three distinct sectors: popular, folk, and professional.3 In this model, the practitioners of popular medicine have no particular interest or expertise in healthcare beyond the norm; the practitioners of folk medicine are specialists in their fields but lack official or professional standing; and, finally, the practitioners of professional medicine are acknowledged as specialists and often have some sort of official status or institutional affiliation. While this model is certainly useful as a starting point, such definitive distinctions are not necessarily appropriate to healthcare in antiquity, where there was such a wide range of expertise that it was not necessarily possible to draw a firm distinction between the professional and the layman. This holds true for both the upper echelons of society, where members of the social elite were actively encouraged to acquire medical knowledge sufficient to enable them to hire the most appropriate professional medical practitioner, and the lower, where individuals might have had to resort to treating themselves, their family members, friends, and even acquaintances.4 Is it possible to reconstruct any aspect of lay medical theory, method and practice with any certainty? While lay medical theories and methods can be provisionally reconstructed from works of ancient medical literature that claim to present them, such as the Hippocratic treatise Affections, it has to be 1  On medical literature, see Martínez, V. M. and Senseny, M. F. ‘The professional and his books: special libraries in the ancient world’, in König, J. et al. (2013). Ancient Libraries, 401–17, esp. 406, 407–10. There are, of course, notable exceptions to the general rule, such as Celsus’ De Medicina or Pliny the Elder’s Historia Naturalis. 2  Efforts are being made to address this. See most recently, for example, Flemming, R. (2007). ‘Women, writing and medicine in the classical world’, CQ 57.1, 257–79, and in response Parker, H. N. (2012). ‘Galen and the girls: Sources for women medical writers revisited’, CQ 62.1, 359–86. 3  Kleinman, A. (1980). Patients and Healers in the Contexts of Culture, 49–60. 4  See for example Nutton, V. (1990). ‘The patient’s choice: A new treatise by Galen’, CQ 40.1, 236–57. Cf. also Wilkins and Petridou (Chapters Sixteen and Eighteen) 411–431 and 451–70 in this volume.

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born in mind that these were written by professional medical practitioners for lay medical practitioners, and so are perhaps not entirely representative of what lay medical practitioners were actually doing.5 Lay medical practices can, however, be reconstructed much more satisfactorily—and thus, one hopes, authentically—if we move the scope of our investigation beyond ancient medical literature to other genres, and incorporate treatises devoted to horticulture, agriculture, animal husbandry, and even religion and magic, as many of these do, in fact include references to lay, even folk, medicine.6 More significantly, in addition to ancient literary evidence, something that is often overlooked is documentary evidence in the form of papyri, ostraca, and wax and wooden tablets that gives voice not only to lay medical practitioners diagnosing and treating their family members, friends and acquaintances, but also to the patients who were experiencing these cures alongside their health problems.7 This chapter will survey both the literary and the documentary evidence for a diverse range of lay medical practices in the Italy, Spain, Egypt, and Britain of the Roman Republic and Empire, and argue that when discussing lay medical practices it is necessary to move beyond medicine and incorporate healthcare and nursing, horticulture, agriculture, animal husbandry and veterinary medicine.8 2

Lay Medical Practice in the Roman Republic and Empire

By definition, a layman (or woman) is someone without professional or specialised knowledge in a particular subject, but therein lies something of 5  On Affections, see Cañizares, P. P. ‘The importance of having medical knowledge as a layman. The Hippocratic treatise Affections in the context of the Hippocratic corpus’, in Horstmanshoff, M. (2010). (ed.) Hippocrates and Medical Education, 87–99. On the problems of relying on ancient medical literature for information on non-professional points of view, see Lloyd, G. E. R. (1983). Science, Folklore and Ideology, 215. 6  See for example Hillman, D. C. (2004). Representations of Pharmacy in Roman Literature from Cato to Ovid, 2. Hillman argues that “ancient literary sources are replete with information on the use of specific medicaments, and often shed light on cultural aspects of pharmacy that are absent from the medical sources”. 7  See for example Cuvigny, H. ‘Morts et maladies’, in Bingen, J. et al. (1997). Mons Claudianus Ostraca Graeca et Latina 2, 191–223; Cuvigny, H. ‘Morts et maladies’, in Bingen, J. et al. (1991). Mons Claudianus Ostraca Graeca et Latina 1, 75–110. 8  Hillman, Pharmacy, 22–23 argues for the existence of a “medical-artisan”, a technical expert who practiced both human and veterinary medicine, assisting overseers and herdsmen with the care of all living property found on a farm during the Middle and Late Republic.

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a paradox: for lay medicine to exist at all, laymen and women have to be in possession not only of a degree of medical knowledge, but also recognised as being so by others who might want or need to utilise it. This begs the question: how exactly does a layman or woman come by the knowledge that so empowers and enables them to undertake lay medical practice? One possible source of this knowledge is medical literature.9 While Galen differentiates between works of medical literature meant for and written by specialists, and those meant for and written by non-specialists, there is also evidence for a third type, works of medical literature meant for non-specialists but written by specialists.10 Treatises such as Rufus of Ephesus’ For the Layman (also known as For those who have no doctor to hand) set out what professional medical practitioners considered it necessary or desirable for laymen and women to know, but the opinions of laymen and women may well have differed.11 In any case, the extent to which such works were utilised by those for whom they were written is unknown. The coexistence of professional and lay medical practice in the Roman Republic and Empire is hinted at throughout Latin literature. For example, when Horace asks “if your body is seized with a chill and racked with pain, or some other mishap has pinned you to your bed, have you got someone to sit by you, to get lotions ready, to call in the doctor so as to raise you up and restore you to your children and dear kinsmen?”, he is clearly differentiating between what was perceived to be the responsibility of a member of the household in this situation, and what was perceived to be the responsibility of a member of the medical profession.12 With regard to the responsibilities of the members of a Roman household in matters relating to health, the Law of the Twelve Tables states that not only does a father have the power of life and death over a son born within a lawful marriage, but also that a father should immediately put to death a son recently 9  See Hanson, A. E. ‘Doctors’ literacy and papyri of medical content’, in Horstmanshoff, M. (2010). Hippocrates and Medical Education, 187–204; Hanson, A. E. ‘Greek medical papyri from the Fayum village of Tebtunis: patient involvement in a local healthcare system?’ in Eijk, Ph. van der (2005). Hippocrates in Context, 387–402. 10  Gal., De diff. resp. 2.7 (K. 7.854). 11  For Rufus of Ephesus’ For the Layman/ For those who have no doctor to hand, see Ullmann, M. (1994). ‘Die arabische Überlieferung der Schriften des Rufus von Ephesos’, ANRW 2.37.2, 1293–1349. The title neatly illustrates Rufus’ opinion as to under which circumstances lay medical practice was appropriate. 12  Hor., Sat. 1.1.80–3: at si condoluit temptatum frigore corpus aut alius casus lecto te adfixit, habes qui adsideat, fomenta paret, medicum roget, ut te suscitet ac reddat gnatis carisque propinquis?

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born “who is a monster or has a form different from that of members of the human race”.13 These laws emblematised the power wielded by the Roman pater ­familias over the subordinate members of his family, whose lives were, quite literally, in his hands from the moment of their births. However, these laws also imply that the pater familias not only had a strong interest in the health of the members of his familia, but was also the one who was instrumental in making the decisions with regards to ensuring it. Is there any contemporary literary or documentary evidence to support this? The most potentially fruitful source of information regarding what went on in the ancient Roman household are the agricultural treatises of Cato the Elder, Varro, and Columella. Cato the Elder (234–149 BC) is often presented as the archetypal example of a pater familias taking charge of his family members’ health.14 This results in part from claims made by Pliny the Elder (23–79 AD) in his encyclopaedia Natural History: For [Cato] adds the medical treatment by which he prolonged his own life and that of his wife to an advanced age, by these very remedies in fact with which I am now dealing, and he claims to have a notebook of recipes, by the aid of which he treated his son, servants, and household.15 A second source for these claims is Plutarch (46–120 AD), as he includes the information in his Parallel Lives. In addition, he provides some details as to what exactly Cato’s theories were, and what his methods and practices consisted of: [Cato] had written a book of recipes, which he followed in the treatment and regimen of any who were sick in his family. He never required his

13  Lex duodecim tabularum 4.2; 4.1; Cic., Leg. 3.19: cito necatus tamquam ex 12 Tabulis insignis ad deformitatem puer. See also Gardner, J. (1998). Family and Familia in Roman Law and Life, 121–23 on the pater familias’ apparent power of life and death over those in his potestas. 14  See for example the discussion of Cato in Bradley, K. ‘The Roman child in sickness and in health’, in George, M. (2005). The Roman Family in the Empire: Rome, Italy and Beyond, 67–92, 71–72. 15  Plin., HN 29.8.15: subicit enim qua medicina se et coniugem usque ad longam senectam perduxerit, his ipsis scilicet, quae nunc nos tractamus, profiteturque esse commentarium sibi, quo medeatur filio, servis, familiaribus, quem nos per genera usus sui digerimus.

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patients to fast, but fed them on greens, or bits of duck, pigeon, or hare. Such a diet, he said, was light and good for sick people, except that it often causes dreams. By following such treatment and regimen he said he had good health himself, and kept his family in good health.16 Both Pliny and Plutarch offer Cato’s longevity as proof of his medical capabilities, at least in respect of himself—unfortunately, his wife and his son were not so fortunate, both predeceasing him. However, this would appear to be something of a literary trope, as Pliny later incorporates it into his discussion of the botanist Antonius Castor.17 While there is some debate over whether the prescriptions and recipes that Pliny the Elder and Plutarch mention are the same as those found in Cato’s surviving work On Agriculture, it is beyond the scope of this paper; here we shall focus on the latter.18 The prescriptions and recipes found in On Agriculture indicate that, in addition to acting as a healer for the human members of his familia, Cato also acted as a veterinarian for his livestock, and recommended that others do the same.19 Thus throughout the text the authority of the dominus—which, it is made clear, results from a combination of knowledge and experience—is emphasised, as is the importance of drawing upon the resources immediately to hand. Of Cato’s numerous prescriptions and recipes for the treatment of both humans and animals, the ingredients required are all those which he either explicitly states were cultivated within his hortus, or were likely to have been. For example, in conjunction with his recommendation that, if an estate is located near a town, the hortus should be used to cultivate flowers for garlands, he lists those he considers to be the most suitable: “white and black myrtle, Delphian, Cyprian, and wild laurel, smooth nuts, such as Abellan, Praenestine, and Greek

16  Plut., Vit. Cat. Mai. 23.4: αὑτῷ δὲ γεγραμμένον ὑπόμνημα εἶναι, καὶ πρὸς τοῦτο θεραπεύειν καὶ διαιτᾶν τοὺς νοσοῦντας οἴκοι, νῆστιν μὲν οὐδέποτε διατηρῶν οὐδένα, τρέφων δὲ λαχάνοις ἢ σαρκιδίοις νήσσης ἢ φάσσης ἢ λαγώ καὶ γὰρ τοῦτο κοῦφον εἶναι καὶ πρόσφορον ἀσθενοῦσι, πλὴν ὅτι πολλὰ συμβαίνει τοῖς φαγοῦσιν ἐνυπνιάζεσθαι τοιαύτῃ δὲ θεραπείᾳ καὶ διαίτῃ χρώμενος ὑγιαίνειν μὲν αὐτός, ὑγιαίνοντας δὲ τοὺς ἑαυτοῦ διαφυλάττειν. 17  Plin., HN 25.5. 18  Astin, A. (1978). Cato the Censor, 183–84. See also Boscherini, S. (1993). ‘La medicina in Catone e Varrone’, in ANRW 2.37.1, 729–55. 19  On veterinary medicine in the ancient world, see Adams, J. (1995). Pelagonius and Latin Veterinary Terminology in the Roman Empire. See also Vegetius, Digestorum artis mulomedicinae libri.

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filberts”.20 Elsewhere in the treatise, laurel leaves appear in a recipe for a tonic for oxen, while black myrtle is a main ingredient in a recipe for indigestion and colic.21 In a remedy for indigestion and stranguary, he includes pomegranates, instructing his reader to “gather pomegranate blossoms when they open”, thus implying that these plants were within easy reach.22 Pomegranates also appear in a recipe for “gripes, for loose bowels, for tapeworms and stomach-worms, if troublesome”.23 While Cato emphasises the importance of knowledge and experience acquired by oneself, Varro (116–27 BC) defers to the knowledge and experience of others. He not only provides references to the works that he has utilised in the research and writing of his treatise On Agriculture, he also inserts real historical figures known to be authorities on these subjects as characters and allows them to present their theories and methods.24 He does, nonetheless, use them to praise himself and his own theories, methods, and practices: Did not our friend Varro here, when the army and fleet were at Corcyra, and all the houses were crowded with the sick and the dead, by cutting new windows to admit the north wind, and shutting out the infected winds, by changing the position of doors, and other precautions of the same kind, bring back his comrades and his servants in good health?25 Unlike Cato, Varro is not necessarily averse to physicians.26 Rather, he does not believe that they need to be present on an estate at all times, as not every medical situation requires their services.27 As far as he is concerned, “there are two divisions of such knowledge, as there are in the treatment of human beings: in the one case the physician should be called in, while in the other even an

20  Cato, Agr. 8.2: murtum coniugulum et album et nigrum, loream Delphicam et Cypriam et silvaticam, nuces calvas, Abellanas, Praenestinas, Graecas. 21  Laurel leaves: Cato, Agr. 70. Black myrtle: Cato, Agr. 125. 22  Cato, Agr. 127: malum Punicum ubi florebit. 23  Cato, Agr. 126: ad tormina, et si alvus non consistet, et si taeniae et lumbrici molesti erunt. 24  White, K. (1973). ‘Roman agricultural writers 1: Varro and his predecessors’, in ANRW 1.4, 439–97. Varro, RR 2.5.18. 25  Varro, RR 1.4.5: non hic Varro noster, cum Corcyrae esset exercitus ac classis et omnes domus repletae essent aegrotis ac funeribus, immisso fenestris novis aquilone et obstructis pestilentibus ianuaque permutata ceteraque eius generis diligentia suos comites ac familiam incolumes reduxit? 26  On Cato’s aversion to physicians, see Nutton, V. (2013). Ancient Medicine, 165. 27  Varro, RR 1.16.4.

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attentive herdsman is competent to give the treatment”.28 Thus, “all directions for caring for the health of human beings and cattle, and all the sickness which can be treated without the aid of a physician, the head-herdsman should keep in writing”.29 He repeatedly emphasises the importance of having handbooks to refer to, while concurrently he promotes literacy in his staff.30 This is perhaps an offshoot of his opinion that nothing should be bought, if it can be grown or made on the farm.31 Columella (circa 4–70 AD), like Cato, emphasises the authority of the dominus, an authority acquired through knowledge and experience: But whoever is destined for this business must be very learned in it and very robust, so that he may both teach those under his orders and himself adequately carry out the instructions he gives; for indeed nothing can be taught or learned correctly without an example, and it is better that a bailiff should be the master, not the pupil, of his labourers. Cato, a model of old-time morals, speaking as head of a family, said: “Things go ill with the master when his bailiff has to teach him”.32 Although it is the bailiff and the bailiff’s wife that are responsible for healthcare, presumably they have been instructed by the dominus and the domina.33 However, like Varro he emphasises the pedigree of his resources.34

28  Varro, RR 2.1.21: cuius scientiae genera duo, ut in homine, unum ad quae adhibendi medici, alterum quae ipse etiam pastor diligens mederi possit. 29  Varro, RR 2.10.10: quae ad valitudinem pertinent hominum ac pecoris et sine medico curari possunt, magistrum scripta habere oportet. See for example 1.69.3, in which a man is stabbed and the physician called to deal with the situation. 30  Varro, RR 2.2.20; 2.3.8; 2.5.18; 2.7.16; 2.10.10. 31  Varro, RR 1.22.1. See also Rosen, R. M. ‘Spaces of sickness in Graeco-Roman medicine’, in Baker, P. A. et al. (2012). Medicine and Space: Body, Surroundings and Borders in Antiquity and the Middle Ages, 227–43 for discussion of a lost work of Varro’s in which his opinions on the presence of physicians at the bedsides of patients are much more explicit, even moralising. 32  Columella, Rust. 11.1.4: quisquis autem destinabitur huic negotio, sit oportet idem scientissimus robustissimusque, ut et doceat subiectos et ipse commode faciat, quae praecipit. siquidem nihil recte sine exemplo docetur aut discitur praestatque villicum magistrum esse operariorum, non discipulum, cum etiam de patre familiae prisci moris exemplum Cato dixerit: “Male agitur cum domino, quem villicus docet”. 33  Columella, Rust. 11.1.22; 12 pref. 10. 34  Columella, Rust. 5.1.1.

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Thus, the treatises of Cato, Varro, and Columella set out a framework for lay medical practice within the Roman household, requiring a combination of personal knowledge and expertise supplemented—perhaps even reinforced—by relevant medical literature. Both Cato and Varro were drawing on their personal experiences of owning agricultural estates in Italy, while Columella was drawing on his uncle’s experiences of owning agricultural estates in Spain. However, it is important to remember that just because Cato, Varro, and Columella recommended that lay medical practice be undertaken and provided guidance as to how individuals should go about doing it, it does not necessarily follow that anyone did as they suggested, either in Roman Italy or Spain, or anywhere else in the Roman Empire. It is important to remember that neither professional nor lay medical theories, methods and practices were standardised throughout the Roman world.35 Yet, it is entirely possible, if not probable, that entirely independent traditions of lay medical practice developed simultaneously in different territories. For the remainder of this paper, I will examine the documentary evidence for lay medical practice from the provinces of Egypt and Britain. 3

Lay Medical Practice in Roman Egypt

In the case of Roman Egypt, there is a significant amount of evidence to suggest that the physician was not necessarily the first person from whom an individual sought to obtain medicine, ingredients for medicine or other medicinal apparatus, let alone medical diagnosis and treatment.36 On the contrary, the supply and demand of such items are frequently mentioned in documentary papyri and ostraca exchanged between family members and friends, that have been recovered from sites all over the province. During the first half of the second century AD, a number of the residents of Mons Claudianus, the pre-eminent quarry settlement in the Eastern Desert, wrote letters to members of their families living elsewhere in the hope of obtaining medicine, ingredients for medicine or other medicinal apparatus 35  Baker, P. A. ‘Diagnosing some ills: The archaeology, literature and history of Roman medicine’, in Baker, P. A. and Carr, G. (2002). Practitioners, Practices and Patients: New Approaches to Medical Archaeology and Anthropology, 16–29. 36  The section that follows draws on the findings of my doctoral thesis, subsequently published as Draycott, J. (2012). Approaches to Healing in Roman Egypt, esp. 40–60. For medicine in Roman Egypt, see Hirt Raj, M. (2006). Médicins et malades de l’Égypte romaine; for medicine in Hellenistic Egypt, see Lang, P. (2013). Medicine and Society in Ptolemaic Egypt.

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from them, despite the fact that there were a number of physicians in residence there.37 Isidorus wrote to his sons requesting two sticks of eye salve and a cushion to rest his sore arm on, while Menelaus wrote to a friend, requesting a second flask of rose oil because his own had been stolen.38 Meanwhile, Bekis wrote to his son requesting that he send a bandage suitable for a head injury, and an unnamed individual wrote to his brother claiming that his life was in danger and he needed a remedy for an inflammation of the tonsils.39 With regard to Isidorus and Menelaus, they themselves specified that the reason they were asking for these things was that they had not been able to obtain them where they were, and presumably the same rationale applied to Bekis and the unnamed individual; after all, why go to all the trouble of getting something sent out into the Eastern Desert, perhaps from as far away as the Nile Valley, if it was available right there at Mons Claudianus? However, it seems strange that a physician practising at a quarry settlement out in the desert would lack remedies such as eye salve for eye infections, rose oil for headaches and sunstroke, and something as basic as a bandage. This suggests that individuals living there sought to obtain medicine, ingredients for medicine and other medicinal apparatus from members of their family, most frequently their sons and brothers, as opposed to soliciting a medical practitioner. Conversely, this apparent preference for receiving healthcare at home could be explained by the remote location of Mons Claudianus or even the restriction of medical treatment to military personnel. So let us turn our attention to areas of Roman Egypt where such explanations do not apply: the Fayum and Oxyrhynchus. Although Soranus recommended the use of midwives in his Gynaecology it seems that in Roman Egypt, pregnancy and childbirth were family affairs that involved not only the female members of the family, but the male ones

37  O. Claud. 220—for initial translation and commentary, see Cuvigny, ‘Morts 2’, 191–223; O. Claud. 708—for initial translation and commentary, see Bülow-Jacobsen, A. (2009) Mons Claudianus ostraca graeca et latina 4, 59–61; O. Claud. 713—for initial translation and commentary, see Bülow-Jacobsen, Claudianus, 64; O. Claud. 714—for initial translation and commentary, see Bülow-Jacobsen, Claudianus, 65–66; O. Claud. 722—for initial translation and commentary, see Bülow-Jacobsen, Claudianus, 72–74. 38  O. Claud. 174—for initial translation and commentary, see Rubinstein, L. ‘Seven letters’, in Bingen, J. et al. (1992) Mons Claudianus ostraca graeca et latina 1, 161–63; O. Claud. 171—for initial translation and commentary, see Bülow-Jacobsen, A. ‘Private letters’, in Bingen, J. et al. (1992). Mons Claudianus ostraca graeca et latina 1, 157. 39  O. Claud. 221—for initial translation and commentary, see Cuvigny, ‘Morts 2’, 39; O. Claud. 222—for initial translation and commentary, see Cuvigny, ‘Morts 2’, 40.

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as well.40 In the late second or early third century AD, Thaisarion wrote to her sister and brothers, requesting two jars of radish oil which she specifically stated she needed for when she gave birth, as well as a jar of salve.41 In the early third century AD, Serapias, a soon-to-be grandmother, wrote to her sonin-law requesting that he brings her daughter to her so that she could assist with the birth of her grandchild.42 In the late third or early fourth century AD, an unnamed son wrote to his parents, requesting that they take care of his wife (who was also his sister, and thus their daughter) during the late stages of her pregnancy and labour: I repeatedly pleaded with them by letters to furnish the same concern for her and to make all the customary preparations for her delivery. For god knows that I wanted to send unguents and all the other things to be used for the delivery.43 It appears that individuals frequently preferred to be taken care of by members of their own family, even if it was inconvenient for all involved. In the third century AD, Titianos wrote to his sister (who was perhaps also his wife) to explain his long absence, “My father, on whose account I have stayed on till now in spite of illness, is also ill; and it is for his sake that I am still here”.44 He goes on to say that everyone in the household was ill, and they all had to take care of each other. In the fourth century AD, Judas, while staying at Babylon, wrote to his brother and sister back home in Oxyrhynchus: Make every effort, my lady sister, send me your brother, since I have fallen into sickness as a result of a riding accident. For when I want to turn on to my other side, I cannot do it by myself, unless two other persons turn 40  The presence of the Gynaecology in Egypt is known from PSI 117, a fragment of Book 3, and possibly Mertens-Pack³ 2347, a fragment containing five columns from a treatise of ‘Soranian’ gynaecological writing. On pregnancy and childbirth in Graeco-Roman Egypt, see Hanson, A. E. (1994). ‘A division of labor: roles for men in Greek and Roman births’, Thamyris 1, 157–202. 41  P. Mich. 508. 42  P. Oxf. 19. 43  PSI 895.9–12/SB 15560.9–12: δεύτερον ἐδεήθην αὐτῶν διὰ γρ[αμ]μάτων τὴν αὐτὴν ἐπι[μέ]λιαν [παρέ]χειν αὐτῇ καὶ πάντα τὰ εἰωθότα π[ο]ιῆσαι τῶν λοχίων. οἶδεν γὰρ ὁ θεὸ[ς ὅ]τι ἐβουλόμην καὶ τὰ μύρα κ[αὶ τὰ ἄ]λλα πάντα τὰ πρὸς τὴν χρίαν τῶν λοχίων ἀποστῖλαι ἀλλ’ ἵνα [. . .] γος[. . .]. See also O. Florida 14 and P. Oxy 3642 (both second century AD). 44  PSI 299.9–11/Sel.Pap. 1.158: ὁ δὲ πατήρ μου [μέχρι] {τ[ο]ύτου}, δι’ ὃν καὶ νοσῶν παρ[έ]μεινα {μέχρι. . .τού[τ]ου}, νοσεῖ· καὶ δι’ αὐτὸν ἔτι ἐνταῦθά εἰμι.

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me over . . . Please come yourself as well and help me, since I am truly in a strange place and sick.45 The evidence suggests that these family members not only obtained medicine for each other, but they also took care of each other, without recourse to a medical practitioner, when necessary, often at great personal inconvenience. Was this because the head of the family ordered them to, in his capacity as family healer, as Cato advised? Did he personally direct and oversee their treatment? Did the mother of the family? None of the examples discussed so far indicate any such thing. In fact, it seems it was frequently the parent that requested medical aid from their offspring, as in the case of Isidorus and Bekis. When Aurelia Techosis petitioned the prefect Aurelius Ammonius in 295 AD, she explained that she had nursed and tended her mother because such a thing was “what is owed from children to parents”.46 This indicates that when it came to healthcare, pietas or perhaps the repayment of a moral debt accrued were important considerations. Brother-sister marriage seems to have been practiced by several of the individuals discussed above, such as Thaisarion, Theonilla, Titianos and Judas. Is it then any wonder that the family members were close to the point of providing each other with medical treatment? In the cases where children were taking care of their parents, it is important to remember that these parents were also the parents of the individual’s husband or wife, as well as grandparents of any offspring twice over, which brings us back to the issue of pietas and the repayment of debt. Likewise, in the cases where siblings were taking care of each other, these siblings were both blood relations and siblings-in-law. If one of the reasons families practised brother-sister marriage was to safeguard the family circle against potentially hostile outsiders, it makes sense that when members of the family were at their most vulnerable, they turned to their relations for help. The provision of healthcare for family members, no matter which individual family member was responsible for instigating or providing it, also 45  P. Oxy 3314.5–17: πᾶν οὖν ποίησον, κυρία μου ἀδελφή, πέμψον μοι τὸν ἀδελφόν σου, ἐπιδὴ εἰς νόσον περιέπεσα ἀπὸ πτώματος ἵππου. μέλλοντός μου γὰρ στραφῆναι εἰς ἄλλο μέρος,̣ οὐ δύναμαι ἀφ’ ἐμαυτοῦ, εἰ μὴ ἄλλοι δύο ἄνθρωποι ἀντιστρέψωσίν με καὶ μέχρις ποτηρίου ὕδατ[ο]ς οὐκ ἔχω τὸν ἐπιδίδουντά μοι. βοήθησον οὖν, κυρία μου ἀδελφή. σπουδαῖόν σοι γενέσθω ὅπως τὸ τάχος πέμψῃς μοι, ὡς προεῖπον, τὸν ἀδελφόν σου. εἰς τὰς τοιαύτας γὰρ ἀνάγκας εὑρίσκονται οἱ ἴδιοι τοῦ ἀνθρώπου. ἵνα οὖν καὶ σοὶ παραβοηθήσῃς μοι τῷ ὄντι ἐπὶ ξένης καὶ ἐν νόσῳ ὄντι. 46  P. Oxy 1121.8–12: ἡ προκειμένη μου μήτηρ Τεχῶσις νόσῳ κατα[β]λ[η]θεῖσα κατὰ τὴν ἐμαυτῆς μετριότητα ταύτην ἐνοσοκόμησα καὶ ὑπηρέτησα καὶ οὐκ ἐπαυσάμην τὰ πρέποντα γείνεσθαι ὑπὸ τέκνων γονεῦσι ἀναπληροῦσα.

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enabled the consolidation and preservation of family traditions and transmission of knowledge about domestic medicine. One last papyrus letter, recovered from Oxyrhynchus and dating to the fourth century AD, provides an interesting counterpoint to the recipes for oxen medicine in Cato’s On Agriculture, despite its having been written around five hundred years later. Yet another Isidorus wrote to his son and made a request: “Give your brother Ammonianus the colt to be brought to me and the salt of ammonia, both the pounded and un-pounded, and the basil-seed, in order that I may doctor him away here”.47 Unlike the other papyri we have seen, this letter provides clear evidence of a father behaving as Cato advised (although whether this was done so deliberately is, of course, unknown), exercising his paternal authority by instructing his sons and acting as family healer or veterinarian, but in addition to this, it also provides explicit proof of the transmission of knowledge about lay medical practice. 4

Lay Medical Practice in Roman Britain

So far, I have presented a significant amount of evidence for the thriving tradition of lay medical practice in the Roman Republic and Empire, and suggested that in Roman Egypt, a medical practitioner—whether physician, surgeon or midwife—was not necessarily the first person from whom an individual sought to obtain a diagnosis, medicine, ingredients for medicine, other medicinal apparatus or even medical treatment, arguing in favour of the widespread dissemination of lay medical knowledge within that province. Although I have focussed my attention on Egypt due to the vast quantities of documentary papyri that have been recovered, it does not necessarily follow that it was the only province of the Roman Empire where this occurred. Having said that, one needs to bear in mind that nowhere near as many wax, wooden or lead tablets which deal with matters relating to health and healthcare have been recovered from Roman Britain as papyri and ostraca have been from Roman Egypt.48

47  P. Oxy 1222.1–3: δὸς τῷ Ἀμωνιανῷ τὸν πῶλον εἵνα ἐνεχθῇ μοι καὶ τὸ ἅλας τὸ ἀμωνιακὸν τὸ τετριμένον καὶ τὸ ἄτριπτον καὶ τὸ σπέρμα τοῦ ὠκίμου εἵνα. This papyrus is overlooked by Adams, Pelagonius. A similar, roughly contemporary example has been recovered from Antinoopolis, see P. Harr. 109. 48  For the Vindolanda Tablets, see Bowman, A. and Thomas, J. D. (1983). Vindolanda: the Latin Writing Tablets 1; Bowman, A. and Thomas, J. D. (1994). Vindolanda: the Latin Writing Tablets 2; Bowman, A. and Thomas, J. D. (2003). Vindolanda: the Latin Writing Tablets 3.

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Several hundred wooden tablets have been recovered from the Roman fort of Vindolanda on Hadrian’s Wall. These attest that a variety of medical practitioners were present at the fort: Marcus the medical orderly (medicus); Vitalis the pharmacist (seplasiarius); Alio the veterinarian (veterinarius); Virilis the veterinarian (veterinarius).49 Additionally, one tablet mentions an infirmary or hospital (valetudinarium) and another comprises a military strength report which divides the members of the First Cohort of Tungrians in the period 92–97 AD into four categories (lines 22–23): fifteen who are sick (aegri xv); six who are wounded (uolnerati vi); ten who are suffering from inflammation of the eyes (lippientes x), giving a total of 31 who are currently unfit for duty; and finally, 265 who are fit for active service (ualentes [cc]lxv).50 However, there is also a tantalising reference to what could be lay medical practice taking place at Vindolanda. In a tablet which dates from 97–102/3 AD, Paterna writes to Sulpicia Lepidina, the wife of Flavius Cerealis, the prefect of the Ninth Cohort of Batavians, and offers to bring her two remedies, one of which is for fever.51 Had Paterna prepared these remedies herself, or had she acquired them from one of the fort’s military medical practitioners such as Vitalis the pharmacist?52 This begs a further question: were the family members of soldiers treated by the military medical practitioners, or were they left to treat themselves?53 High ranking Roman officials such as provincial governors or prefects frequently embarked upon sojourns abroad with an entire household at their disposal, and this household could (and frequently did) include a personal physician, but was this something that minor officials could For the publication of other wax and wooden tablets from Roman Britain, see Tomlin, R. (1998). ‘Roman manuscripts from Carlisle: the ink-written tablets’, Britannia 29, 31–84. 49  Marcus: T. Vindol. 156; Vitalis: T. Vindol. 586; Alio: T. Vindol. 181; Virilis: T. Vindol. 310. On Roman military medicine, see Scarborough, J. (1968). ‘Roman medicine and the legions: A reconsideration’, Medical History 12, 254–61; Nutton, V. (1969). ‘Medicine and the Roman legions: A further reconsideration’, Medical History 13.3, 260–70; Baker, P. A. (2004). Medical Care for the Roman Army on the Rhine, Danube and British Frontiers from the First through Third Centuries AD. On Roman military medicine in Britain, see Allason-Jones, L. (1999). ‘Healthcare in the Roman north’, Britannia 30, 133–46. 50  Infirmary: T. Vindol. 155; military strength report: T. Vindol. 154. For the epitaph of Anicius Ingenuus, medicus ordinarius of the First Cohort of Tungrians, found at Housesteads, see RIB 1618. 51  T. Vindol. 294. 52  A wax tablet from Carlisle attests to the activities of Albanus the pharmacist (seplasarius), while an inscription from Mainz attests to a military seplasarius, CIL 13, 3778. 53  On evidence for the family members of soldiers experiencing ill health, see Allason-Jones, ‘Healthcare’, 143.

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(or did) do?54 Certainly Flavius Cerialis presided over an extensive household containing numerous slaves, but there is no evidence that one of them was his personal physician, or even someone with a basic level of medical knowledge and experience—the fact that Paterna is offering to bring Sulpicia Lepidina two remedies suggests that there was no one in the household capable of preparing their own. This does, however, indicate that, like the inhabitants of Roman Egypt, the inhabitants of Roman Britain might have looked to family members and friends to support them through periods of illness and infirmity. 5 Conclusion The majority of the ancient medical literature that survives from antiquity was written by medical practitioners for their peers, produced for the purpose of ensuring the effective diagnosis and treatment of their patients. However, this same literary evidence attests to the co-existence of a thriving tradition of lay medical practice, an attestation which is confirmed by documentary evidence in the form of papyri, ostraca and wooden tablets. This literary and documentary evidence indicates that this alternative tradition could be accessed not only through particular works of ancient medical literature that were composed by professional medical practitioners with laymen in mind, but also through works of ancient literature that were composed by and for laymen themselves. These latter works demonstrate the process by which both knowledge and experience were accumulated via a long process of trial and error. According to the Roman agricultural writers Cato, Varro, and Columella, once composed, these treatises were kept on hand and referred to as and when necessary by not only the dominus or domina, but also the villicus or villica, or even the members of the household in charge of various different species of livestock. This paper has surveyed both literary and documentary evidence for lay medical practices in the Roman Republic and Empire using not the medical treatises of professional medical practitioners such as Galen, but rather the agricultural treatises of Cato, Varro, and Columella, and the encyclopaedia of Pliny the Elder in conjunction with documentary evidence from two very different communities, primarily the Fayum in Egypt and to a lesser extent Vindolanda in Britain, that demonstrate how lay medical practice was

54  Nutton, Medicine, 164–65. See for example Cic., Verr. 2.3.28: Verres took his physician Artimedorus with him to Sicily in 80 BC; Cic., Fam. 13.20: Cicero recommended the physician Asclapo to Servius Sulpicius Rufus when he was about to depart for Achaea.

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­ ndertaken in ancient every-day life. This allows us to witness first-hand examu ples not only of lay medical practitioners diagnosing and treating their family members, friends and acquaintances, but also the patients who were experiencing all of this alongside their health problems. Texts and Translations Used Cato. On Agriculture. Trans. W. D. Hooper and H. B. Ash. The Loeb Classical Library 283. Cambridge, MA. and London: Harvard University Press, 1967. Cicero. Letters to Friends. Trans. D. R. Shackleton Bailey, vol. 1: Letters 1–113. The Loeb Classical Library 205. Cambridge, MA. and London: Harvard University Press, 2001. ———. On the Laws. Trans. E. H. Warmington. The Loeb Classical Library 213. Cambridge, MA. and London: Harvard University Press, 1938. ———. The Verrine Orations. Trans. L. H. G. Greenwood, vol. 1: Against Caecilius. Against Verres, Part 1; Part 2, Books 1–2. The Loeb Classical Library 221. Cambridge, MA. and London: Harvard University Press, 1928. Celsus. On Medicine. Trans. W. G. Spencer, vol. 1. The Loeb Classical Library 292. Cambridge, MA. and London: Harvard University Press, 1935. ———. On Medicine. Trans. W. G. Spencer, vol. 2. The Loeb Classical Library 304. Cambridge, MA. and London: Harvard University Press, 1938. ———. On Medicine. Trans. W. G. Spencer, vol 3. The Loeb Classical Library 336. Cambridge, MA. and London: Harvard University Press, 1938. Columella. On Agriculture. Trans. E. S. Forster and E. H. Heffner, vols. 2–3. The Loeb Classical Library 407–408. Cambridge, MA and London: Harvard University Press, 1955. Galen. Difficulties in Breathing. Trans. C. G. Kühn. Leipzig: Car. Cnoblochii, 1821–1833. Hippocrates. Affections. Diseases 1. Diseases 2. Trans. P. Potter. The Loeb Classical Library 472. Cambridge, MA. and London: Harvard University Press, 1988. Horace. Satires. Trans. H. R. Fairclough. The Loeb Classical Library 194. Cambridge, MA. and London: Harvard University Press, 1947. Pliny the Elder. Natural History. Trans. W. H. S. Jones. The Loeb Classical Library 418. Cambridge, MA. and London: Harvard University Press, 1963. Plutarch. Marcus Cato. Trans. B. Perrin. The Loeb Classical Library 47. Cambridge, MA. and London: Harvard University Press, 1948. Soranus. Gynecology. Trans. O. Temkin. Baltimore, MD.: Johns Hopkins University Press, 1991. Varro. On Agriculture. Trans. W. D. Hooper and H. B. Ash. The Loeb Classical Library 283. Cambridge, MA. and London: Harvard University Press, 1967. Vegetius. On Equine Medicine. Trans. E. Lommatzch. Leipzig: Teubner, 1903.

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Bingen, J., Bülow-Jacobsen, A., Cockle, W. E. H., Cuvigny, H., Rubinstein, L., Van Rengen, W. (eds.) Mons Claudianus Ostraca Graeca et Latina 1 (O.Claud.1–190), DFIFAO 29. Cairo: Institut Français d’Archéologie Orientale, 1992. Bingen, J., Bülow-Jacobsen, A., Cockle, W. E. H., Cuvigny, H., Kayser, F., Van Rengen, W. (eds.) Mons Claudianus Ostraca Graeca et Latina 2 (O.Claud. 191–414), DFIFAO 32. Cairo: Institut Français d’Archéologie Orientale, 1997. Bowman, A. and Thomas, J. D. (eds.) Vindolanda: the Latin Writing Tablets (Tabulae Vindolandenses) 1. London: Society for the Promotion of Roman Studies, 1983. ———. (eds.) Vindolanda: the Latin Writing Tablets (Tabulae Vindolandenses) 2. London: British Museum Press, 1994. ———. (eds.) Vindolanda: the Latin Writing Tablets (Tabulae Vindolandenses) 3. London: British Museum Press, 2003.

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Bülow-Jacobsen, A. ‘The Private Letters.’ in Mons Claudianus Ostraca Graeca et Latina I (O.Claud.1–190), ed. J. Bingen, A. Bülow-Jacobsen, W. E. H. Cockle, H. Cuvigny, L. Rubinstein, W. Van Rengen, 123–57, DFIFAO 29. Cairo: Institut Français d’Archéologie Orientale, 1992. ———. Mons Claudianus Ostraca Graeca et Latina 4: the Quarry-texts (O.Claud. 632– 896), DFIFAO 47. Cairo: Institut Français d’Archéologie Orientale, 2009. Cañizares, P. P. ‘The Importance of Having Medical Knowledge as a Layman. The Hippocratic Treatise Affections in the Context of the Hippocratic Corpus.’ in Hippocrates and Medical Education, ed. M. Horstmanshoff, 87–99, Studies in Ancient Medicine 35. Leiden: Brill, 2010. Cuvigny, H. ‘Morts et maladies.’ in Mons Claudianus Ostraca Graeca et Latina 1 (O.Claud.1–190), ed. J. Bingen, A. Bülow-Jacobsen, W. E. H. Cockle, H. Cuvigny, L. Rubinstein, W. Van Rengen, 75–110, DFIFAO 29. Cairo: Institut Français d’Archéologie Orientale, 1992. ———. ‘Morts et maladies.’ in Mons Claudianus Ostraca Graeca et Latina 2 (O.Claud. 191–414), ed. J. Bingen, A. Bülow-Jacobsen, W. E. H. Cockle, H. Cuvigny, F. Kayser, W. Van Rengen, 191–223, DFIFAO 32. Cairo: Institut Français d’Archéologie Orientale, 1997. Draycott, J. Approaches to Healing in Roman Egypt, BARI 2416. Oxford: Archaeopress, 2012. Flemming, R. ‘Women, Writing and Medicine in the Classical World.’ Classical Quarterly 57.1, (2007): 257–79. Gardner, J. Family and Familia in Roman Law and Life. Oxford and New York: Oxford University Press, 1998. George, M. The Roman Family in the Empire: Rome, Italy and Beyond. Oxford and New York: Oxford University Press, 2005. Hanson, A. E. ‘A Division of Labor: Roles for Men in Greek and Roman Births.’ Thamyris 1, (1994): 157–202. ———. ‘Greek Medical Papyri from the Fayum Village of Tebtunis: Patient Involvement in a Local Healthcare System?’ in Hippocrates in Context: Papers Read at the XIth Hippocrates Colloquium, University of Newcastle upon Tyne 27–31 August 2002, ed. Ph. J. van der Eijk, 387–402, Studies in Ancient Medicine 31. Leiden: Brill, 2005. ———. ‘Doctors’ Literacy and Papyri of Medical Content.’ in Hippocrates and Medical Education: Selected Papers Presented at the XIIth International Hippocrates Colloquium, Universiteit Leiden, 24–26 August 2005, ed. M. Horstmanshoff, 187–204, Studies in Ancient Medicine 35. Leiden: Brill, 2010. Hillman, D. C. Representations of Pharmacy in Roman Literature from Cato to Ovid. Unpublished PhD thesis, University of Wisconsin-Madison, 2004. Hirt Raj, M. Médicins et malades de l’Égypte romaine, Studies in Ancient Medicine 32. Leiden: Brill, 2006.

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Horstmanshoff, M. (ed.) Hippocrates and Medical Education: Selected Papers Presented at the XIIth International Hippocrates Colloquium, Universiteit Leiden, 24–26 August 2005, Studies in Ancient Medicine 35. Leiden: Brill, 2010. Kleinman, A. Patients and Healers in the Context of Culture: an Exploration of the Borderland between Anthropology, Medicine, and Psychiatry. Berkeley and Los Angeles: University of California Press, 1980. König, J., Oikonomopoulou, K. and Woolf, G. (eds.) Ancient Libraries. Cambridge: Cambridge University Press, 2013. Lang, P. Medicine and Society in Ptolemaic Egypt, Studies in Ancient Medicine 41. Leiden: Brill, 2013. Lloyd, G. E. R. Science, Folklore and Ideology. Cambridge: Cambridge University Press, 1983. Martínez, V. M. and Senseny, M. F. ‘The Professional and his Books: Special Libraries in the Ancient World.’ in Ancient Libraries, ed. J. König, K. Oikonomopoulou and G. Woolf, 401–17. Cambridge: Cambridge University Press, 2013. Nutton, V. ‘Medicine and the Roman Legions: A Further Reconsideration.’ Medical History 13.3, (1969): 260–70. ———. ‘The Patient’s Choice: A New Treatise by Galen.’ Classical Quarterly 40.1, (1990): 236–57. ———. Ancient Medicine. 2nd ed. Abingdon and New York: Routledge, 2013. Parker, H. N. ‘Galen and the Girls: Sources for Women Medical Writers Revisited.’ Classical Quarterly 62.1, (2012): 359–86. Rosen, R. M. ‘Spaces of Sickness in Graeco-Roman Medicine.’ in Medicine and Space: Body, Surroundings and Borders in Antiquity and the Middle Ages, ed. P. A. Baker, H. Nijdam, and K. van ’t Land, 227–43, Visualising the Middle Ages 4. Leiden: Brill, 2012. Rubinstein, L. ‘Seven letters.’ in Mons Claudianus Ostraca Graeca et Latina 1 (O.Claud.1– 190), ed. J. Bingen, A. Bülow-Jacobsen, W. E. H. Cockle, H. Cuvigny, L. Rubinstein, W. Van Rengen, 172–78, DFIFAO 29. Cairo: Institut Français d’Archéologie Orientale, 1992. Scarborough, J. ‘Roman Medicine and the Legions: A Reconsideration.’ Medical History 12, (1968): 254–61. Tomlin, R. ‘Roman Manuscripts from Carlisle: the Ink-written Tablets.’ Britannia 29, (1998): 31–84. Ullmann, M. ‘Die arabische Überlieferung der Schriften des Rufus von Ephesos.’ in Aufstieg und Niedergang der römischen Welt 2.37.2, ed. W. Haase, 1293–1349. Berlin and New York: Walter de Gruyter, 1994. White, K. ‘Roman Agricultural Writers 1: Varro and his Predecessors.’ in Aufstieg und Niedergang der römischen Welt 1.4, ed. H. Temporini, 439–97. Berlin and New York: Walter de Gruyter, 1973.

CHAPTER 18

Aelius Aristides as Informed Patient and Physician Georgia Petridou Aelius Aristides, one of the most renowned orators of the so-called second sophistic, has often been thought of as the paradigmatic patient who surrendered his physical and psychological health to Asclepius, and spent a large part of his life in the temple of the god at Pergamum blindly following divine orders on diet and regimen. This study looks at the Hieroi Logoi as an illness narrative and argues against such a simplistic view and in favour of a more complex picture: Aristides is a far cry far from the submissive patient, who idly resided in the Pergamene Asclepieion relying exclusively on the therapeutic powers of the god and his human ­helpers. In fact, through a close reading of a selection of passages from the Hieroi Logoi a whole new image of Aristides emerges: the informed patient who is not only in possession of the basics of the medical discourse but who also functions as a physician of sorts, taking both his own life and the lives of others into his hands. This new type of patient, the knowledgeable patient, who is well-versed in medical matters and envisages himself as an active agent of the healing process and an equally important partner in the medical encounter, ties well with other testimonies we have about knowledgeable patients mostly to be found amongst the members of the socio-political elite of the time.

* I am indebted to Janet Downie for reading and commenting on an earlier draft of this chapter and for generously sharing with me the contents of her unpublished paper entitled ‘The Therapeutic Dynamic in Aelius Aristides’ Sacred Tales’ delivered at the 2008 American Philological Association (APA) conference. I would also like to thank Philip van der Eijk, Manfred Horstmanshoff, Orly Lewis, Oliver Overwien, Paul Scade and Chiara Thumiger for their insightful comments on an earlier draft. Finally, I would like to express my gratitude to the Alexander von Humboldt Stiftung and the ‘Medicine of the Mind—Philosophy of the Body—Discourses of Health and Disease in the Ancient World’ research programme for making this research possible. The text of this contribution has been subsequently discussed at Erfurt and within the context of the ERC-funded programme ‘Lived Ancient Religion’, at MaxWeber Kolleg, University of Erfurt. Special thanks go to Jan Bremmer, Valentino Gasparini, Richard Gordon, and Jörg Rüpke for suggesting various improvements.

© koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_020

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A volume devoted to the patient in the ancient world could not do without a chapter on Publius Aelius Aristides Theodoros, one of the most conspicuous patients of antiquity, and his Hieroi Logoi (henceforth HL), his ‘Sacred Discourses’. Within the last decade or so, Aristides and his HL—a unique firstperson narrative of aretalogical nature that relates his life-long battle with illness and his intimate relationship with the god Asclepius—have received much attention from specialists working on both history of religion and history of medicine.1 The HL are no longer thought of as the delirious account of an incurable hypochondriac; instead, they are considered to be a rare first-person illness narrative, which, while being extremely elaborate and self-­conscious, offers a unique insight into the religious, medical and cultural life of the second century AD.2 1  See, for instance, Horstmanshoff, H. F. J. ‘Did the god learn medicine? Asclepius and Temple medicine in Aelius Aristides’ Sacred Tales’, in Horstmanshoff, H. F. J. and Stol, M. (2004). Magic and Rationality in Ancient Near Eastern and Graeco-Roman Medicine, 325–41; King, H. ‘Chronic pain and the creation of narrative’, in Porter, J. I. (2005). Constructions of the Classical Body, 269–86; Harris, W. V. and Holmes, B. (2008). Aelius Aristides between Greece, Rome and the Gods; Petsalis-Diomidis, A. (2010). Truly Beyond Wonders. Aelius Aristides and the Cult of Asclepius; Israelowich, I. (2012). Society, Medicine and Religion in the Sacred Tales of Aelius Aristides; and Downie (2013). 2  See more notably Israelowich, ‘Society, Medicine and Religion’, 116: “as eccentric as it seems to us, the behaviour of Aristides lay well within Graeco-Roman medical practices”. Aristides as hypochondriac: e.g. Phillips, E. D. (1952). ‘A hypochondriac and his god’, G&R 61, 23–36; Bowersock, G. W. (1969). Greek Sophists in the Roman Empire, 72; Behr, C. A. (1968). Aelius Aristides and the Sacred Tales, 162–64; and more recently, Harris, W. V. (2009). Dreams and Experience in Classical Antiquity, 92. This anachronistic and largely unhistorical attribution of hypochondriasis to the nosos of Aristides has subsided in modern studies of the HL. Just as there is a plethora of chronic medical conditions modern doctors can neither identify nor treat, likewise there would have been many more such conditions which would have left the physicians of the ancient world perplexed and utterly unable to help. On Aristides’ chronic pain and the burning issue of how we qualify and quantify pain, see King, H. ‘Chronic Pain and the Creation of Narrative’, in Porter, J. I. (1999). Constructions of the Classical Body, 269–86. For a historical study of ancient hypochondria, as pain and discomfort “occurring in the region below the cartilage”, which should be distinguished from the modern notion of hypochondria, see Leven, K.-H. ‘Hypochonder’, in id. (2005). Antike Medizin: ein Lexikon, 448; and Eijk, Ph. J. van der. ‘Melancholia and hypochondria—Steps in the history of a problematic combination’, in Cazes, H. and Morand, A. F. (in press). Miroirs de mélancolie. On the HL as a self-conscious narrative, see Petsalis-Diomidis, A. ‘Sacred writing, sacred reading: The function of Aelius Aristides’ self-presentation as author in the Sacred Tales’, in McGing, B. and Mossman, J. (2006). The Limits of Ancient Biography, 193–211; and Holmes, B. ‘Aelius Aristides’ illegible body’, in Harris, W. V. and Holmes, B. (2008). Aelius Aristides between Greece, Rome and the Gods, 81–113.

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Aristides is often thought of the paradigmatic patient, who surrendered his physical and psychological health to Asclepius and spent a big part of his life in a healing temple, blindly following divine orders on diet and regimen.3 In that sense, Aristides fits Galen’s description of the unwilling and uncooperative patient as it appears in his commentary on the Hippocratic Epidemics: this most unhelpful patient constantly revolts against the sensible medical advice given by mortal physicians while, by contrast, complying willingly with extreme and seemingly nonsensical medical advice provided by healing deities.4

3  E.g.: Festugière, A.-J. (1954). Personal Religion among the Greeks, 86–87 and 98; Perkins, J. (1992). ‘The self as sufferer’, Harvard Theological Review, 245–72; and ead. (1995). The Suffering Self. Pain and Narrative Representation in the early Christian Era, chapter 7; and Cox Miller, P. (1994). Dreams in Late Antiquity, 192. Aristides spent a substantial amount of his life frequenting healing temples and shrines and contemplating the nature of his illness and his relationship with a number of healing deities, among whom Asclepius and Sarapis are certainly the most prominent. More importantly, he spent two years of his life (145–47 AD) abiding in the temple of Asclepius in Pergamum, a period which he referred to as the Cathedra, and a period that literally changed his life by affecting the ways Aristides conceptualised illness, therapy, and not least rhetoric. 4  Gal., In Hipp. Epid. 6 comment. 4.8 (CMG V, 10.2.2, 119 = 17b.137–138 K.) = K. 17b 137: πρὸς τὴν τοιαύτην οὖν εὐπείθειαν αὐτὸς ὁ Ἱπποκράτης ἔλεγε καὶ τὰς προρρήσεις ὠφελεῖν ἡμᾶς καὶ ὅλως τὸ θαυμάζεσθαι τὸν ἰατρὸν ὑπὸ τοῦ κάμνοντος. οὕτω γέ τοι καὶ παρ’ ἡμῖν ἐν Περγάμῳ τοὺς θεραπευομένους ὑπὸ τοῦ θεοῦ πειθομένους ὁρῶμεν αὐτῷ πεντεκαίδεκα πολλάκις ἡμέραις προστάξαντι μηδ’ ὅλως πιεῖν, οἳ τῶν ἰατρῶν μηδενὶ προστάττοντι πείθονται. μεγάλην γὰρ ἔχει ῥοπὴν εἰς τὸ πάντα ποιῆσαι τὰ προσταττόμενα τὸ πεπεῖσθαι τὸν κάμνοντα βεβαίως ἀκολουθήσειν ὠφέλειαν ἀξιόλογον αὐτῷ. “Concerning then this very concept of ready obedience Hippocrates himself used to say that public predictions and generally admiration towards the doctor on behalf of the patient benefit us. Thus, at any rate even among ourselves in Pergamum we see that those who are being treated by the god obey him, when on many occasions he orders them not to drink anything for fifteen days, while they obey none of the physicians who give this prescription. For it has great power on the patient’s will to follow everything that has been prescribed, if he has been persuaded firmly that a substantial benefit to himself will follow” (all translations, unless otherwise stated, are mine). To be sure, this image of the submissive patient, who accepts and follows unquestioningly the medical prescriptions of the divine healer, the ultimate doctor, as he calls him in 1.4, is one that Aristides advocates rather deceptively for himself at the beginning of the HL: “therefore, in view of this, I decided to submit truly to the god, as to a doctor and do in silence whatever he wishes”. But this is a deceptively simplistic image and one that does not dovetail with Aristides’ active involvement in his own treatment, his exegetical role in the interpretation of the dream-visions sent by the god, as well as the constant subordination to his own views of the medical opinions expressed by both the divine and the earthly healers.

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This study argues against such a simplistic view and in favour of a more complex picture, which emerges from close analysis of a number of passages in the HL. These extracts reveal that despite Aristides’ deceptive insistence on his exemplary ready obedience to the god, he proves to be as much of a challenge for his divine healer as he was for his earthly physicians. In fact, a whole new aspect of Aristides’ persona emerges here: that of the informed patient, who double-checks his physicians’ instructions and accepts them only after much deliberation. The emerging picture of Aristides’ relationship to Asclepius is presented as being far from one-directional and involving total dependence; instead, both mortal patient and immortal physician are portrayed as bound together in a reciprocal exchange of gratitude (χάρις): Aristides offers a case of most complex and intricate illness for Asclepius to deal with and prove his constant therapeutic abilities, while Asclepius offers a unique tailor-made therapy for Aristides’ illness. 1

The Patient Becomes the Physician

Let us take for example chapters 69–74 of the first book of the HL. Aristides and his trusty foster-father Zosimos are on a theoric voyage (θεωρία) to Pergamum, when a recurrent divine dream interrupts their journey. Soon afterwards, Zosimos is sent to attend some business at one of his master’s estates, where he falls ill. His illness coincides with Aristides’ falling ill as well. Regardless of his own medical troubles, when Asclepius manifests himself, Aristides entreats the god for Zosimos’ welfare, not his own. While there is nothing remarkable about a divine epiphany of a healing deity taking place at a moment of crisis (such as disease), what is particularly notable in chapter 71 is the intensity and the vividness of the direct communication between Aristides and his god.5 We can visualise effortlessly and vividly this scene of triple supplication, unparalleled in Greek literature, in which Aristides engages apparently not for his own sake, but for Zosimos:

5  Even Behr (Sacred Tales, 34, n. 57), who denies the HL and Aristides’ communication with Asclepius any real mystical aspect, is forced to admit that chapter 71 in Book 1 “points to something secret”. On epiphany in crisis see Petridou, G. (in press). Divine Epiphany in Greek Literature and Culture, chapters two and three. On the HL as “a narrative of epiphanic autopsy”, see Platt, V. J. (2011). Facing the Gods: Epiphany and Representation in Graeco-Roman Art, Literature and Religion, 260–66.

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φανέντος δὲ τοῦ θεοῦ λαμβάνομαι τῆς κεφαλῆς ἐπαλλὰξ τοῖν χεροῖν, καὶ λαβόμενος ἐδεόμην σῶσαί μοι τὸν Ζώσιμον· ἀνένευσεν ὁ θεός. πάλιν οὖν τὴν αὐτὴν λαβὴν λαβόμενος ἐδεόμην ἐπινεῦσαι. αὖθις ἀνένευσε. τὸ τρίτον παραλαβὼν ἐπειρώμην πεῖσαι ἐπινεῦσαι· ὁ δὲ οὔτε ἀνένευσεν οὔτε ἐπένευσεν, ἀλλ’ εἶχε δι’ ἴσου τὴν κεφαλὴν καί μοι λέγει ῥήματα ἄττα, ἃ χρὴ λέγειν ἐν τοῖς τοιούτοις, ὡς ἀνύσιμα· ἁγὼ μνημονεύων οὐκ οἶμαι δεῖν ἐκφέρειν εἰκῆ. ἔφη δ’ οὖν ὅτι ἐπαρκέσει τούτων λεχθέντων· ἓν δ’ ἦν αὐτῶν ‘φύλαξον’. τί οὖν ἀπέβη αὐτῷ μετὰ ταῦτα; (72) πρῶτον μὲν ἀνίσταται παρ’ ἐλπίδας ἐξ ἐκείνης τῆς νόσου ὁ Ζώσιμος, καθαρθείς γε διὰ πτισάνης καὶ φακῆς, προειπόντος ἐμοὶ τοῦ θεοῦ ὑπὲρ αὐτοῦ, ἔπειτα ἐπεβίω μῆνας τέτταρας· When the god appeared, I grasped his head with my two hands in turn, and having grasped him, I entreated him to save Zosimos for me. The god refused. Again having grasped him in the same way, I entreated him to assent. Again he refused. For the third time I grasped him and tried to persuade him to assent. He neither refused nor assented, but held his head steady, and told me certain phrases, which are proper to say in such circumstances since they are efficacious. And while I remember these, I do not think that I should reveal them purposelessly. But he said that when these were recited, it would suffice. One of them was: “Save(d) / Preserve(d)”! What happened to him after this? (72) First of all Zosimos recovered beyond expectation from that disease, being purged with barley gruel and lentils, as the god foretold to me on his behalf, and next he lived four extra months. The verb ananeuō, employed twice in our narrative (ἀνένευσεν . . . αὖθις ἀνένευσε) to describe the twofold negative response of the divine healer— which arguably only makes the god’s climactic consent to Aristides’ appeal all the more dramatic—takes the reader back to the heroic world of the Homeric poems, where an abundance of supplication scenes addressed both to mortals and immortals is to be found.6 This scene carries all the traditional hallmarks of a supplication scene (most notably, the ritualised request expressed in a way that creates moral obligation on behalf of the person entreated and physical contact between the entreated and the supplicant), but takes them to an

6  The famous scene of Iliad 6 comes to mind, where the priestess Theano lays a fair robe on the knees of the statue of their poliadic goddess and vows luxurious sacrificial offerings in exchange for Diomedes’ death. “Thus, she spoke, but Pallas Athena denied her prayer”, ἀνένευε δὲ Παλλὰς Ἀθήνη (311). Cf. also Il. 22.205 and Od. 21.129.

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entirely new level.7 Instead of grasping the god’s knees, hand, beard—or any other bodily part of the person entreated the supplicant could reach while positioned in a lower level (both literally and symbolically) by either crouching or kneeling—Aristides grasps the god’s head. Thus, Aristides the supplicant succeeds in attaining unique proximity to the healing deity—which ultimately amounts to a kind of parity—whilst concurrently remaining in ‘a state of utter dependence’, which in turn intensifies the urgency of the appeal, and significantly increases the chances of a favourable outcome. Even the very way in which Aristides describes his clutching the head of Asclepius, first with one hand and then with the other, has the resounding dynamic of equality of two wrestlers, or even two lovers, where the pair of lovers is depicted as wrestling, rather than an act of supplication between two unequal agents, one superior, who grants the request, and one inferior, who entreats. Aristides lays extra emphasis on this spectacularly peculiar form of supplication and on being on equal terms with the god by repeating the event in summary fashion in chapter 77 of the same book: οὕτως ὅσον τε ἐπεβίω χάρις ἦν τοῦ θεοῦ, ὡς ἀληθῶς φυλάξαντος αὐτόν μοι, καὶ ἐτελεύτα παρὰ τὰ φανθέντα κινηθείς· καὶ τὰ κατ’ ἀρχὰς ὑπὸ τοῦ θεοῦ δειχθέντα, ὅτε αὐτοῦ λαβόμενος τῆς κεφαλῆς ἱκέτευον, εἰς τοῦτο ἐτελεύτησε. So this additional life was due to the grace of the god, who truly kept him for my sake / through my intervention, and he died because he had moved about contrary to my dreams. And thus ended what in the beginning was indicated by the god, when I grasped his head and supplicated him.8

7  On supplication in general, see Gould, J. (1973). ‘Hiketeia’, Journal of Hellenic Studies 93, 74–103; Grotty, K. (1994). The Poetics of Supplication; and Naiden, F. S. ‘Hiketai and Theoroi at Epidaurus’, in Elsner, J. and Rutherford, I. (2005). Pilgrimage in Graeco-Roman and Early Christian Antiquity: Seeing the Gods, 73–96. On supplication as a ritual act involving touching and carrying a certain power dynamic, see Kosak (Chapter Eight), 247–264 in this volume. On incubation in Pergamum as supplication and incubants as suppliants, see Philostratus, Vita Apollonii 4.11. On non-verbal communication in the ancient medical discourse in general, see Fögen, Th. ‘The role of verbal and non-verbal communication in ancient medical discourse’, in Mondin, L. et al. (2005). Latin et langues romanes—Études de linguistique offertes à József Herman à l’occasion de son 80ème anniversaire, 287–300. 8  Trans. Behr with emendations. On the iconographical motive of lovers (of both the same and opposite sex) depicted as wrestlers and vice versa, see Dipla, A. and Palaothodoros, D. (2012). ‘Selected for the dead. Erotic themes on grave vases from attic cemeteries’, in Back Danielsson, I. M. et al. (2012). Encountering Imagery. Materialities, Perceptions, Relations, 209–33.

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Chapters 71 and 72 of Book 1 make one thing obvious: Aristides is reluctant to comply with both the image of the helpless suppliant and, as a matter of fact, the image of the helpless patient. He may be ill and in need of a treatment but, when he finally acquires the desired remedy from Asclepius, he is both literally and metaphorically on the same level with the god. Notice here the conspicuous position of the prepositional phrase δι’ ἴσου (1.71), which could mean that the god did not nod either negatively or positively and held his head stable, but it could also be taken to refer to Asclepius’ positioning his head on the same level with Aristides’ head, perhaps even looking at his devotee straight in the eyes. It is at this moment of intense epiphanic activity, reciprocal visual exchange, and physical immediacy that the patient receives the remedy, and simultaneously appropriates the healing powers of his divine healer. Asclepius operates indirectly on Zosimos; the god heals Zosimos, but not on his own. Asclepius heals via the intermediary of Aristides, who not only appropriates the god’s healing powers—thus becoming a physician of sorts—but also appropriates the divine power and becomes a god of sorts. To be sure, to engage in incubation for other peoples’ illness was common enough.9 However, what strikes the reader as odd is that all this intense and detailed description of how Aristides found out the way to cure Zosimos is followed by an anti-climax: Aristides withholds the precise wording of the divine diagnosis and prescription (presumably either of pharmaceutical nature, or, most likely, involving advice on regimen),10 which usually follows the divine manifestation of the healing deity, and reveals nothing but the enigmatic verbal form ‘φύλαξον’. This verb could be read as an imperative of phylattō meaning ‘look after him!’, ‘take care of him!’ or ‘preserve him!’; or it could be read as an unaugmented epic aorist—we are after all in a supplication scene with distinctly epic ambiance—meaning ‘I took care of him’, ‘I preserved him’. The first is a direct order to Aristides to treat Zosimos the same way a physician would have, while the latter is a promise that the god himself has taken matters in his own hands.

9  Cf. the case of Arata from Lacedaemon, who suffered from dropsy (IG 4.2, 1, nos. 121–22, B21). It was Arata’s mother who slept in the temple of the god and dreamt of the god chopping off her daughter’s head and successfully treating the disease. Cf. also the so-called Imouthes papyrus POxy 1381, which presents many interesting parallels with the HL. More on this topic in Hanson, J. S. (1980). ‘Dreams and visions in the Graeco-Roman world and early christianity’, ANRW 23.1, 1395–1427; and Pearcy, L. T. (1988). ‘Dream, theme, and narrative: Reading the sacred tales of Aelius Aristides’, TAPhA 118, 377–91. 10  Cox Miller, Dreams, 114; Behr, Sacred Tales, 36–40; Horstmanshoff, ‘Asclepius and temple medicine’, 282.

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In chapter 74 of the same book, Zosimos is said to be in debt to both Asclepius for his divine providence and Aristides himself for his intermediary service (τῷ τε θεῷ χάριν ἔχων τῆς προνοίας καὶ τῆς διακονίας ἐμοί). The term diakonia, as it balances precariously between the generic notion of service and that of the specific religious office, keeps Aristides protected against any possible accusations of impiety, whilst simultaneously emphasising the indispensability of his liaison with the divine healer.11 Zosimos was saved by Asclepius via Aristides, who appears here to control and channel the god’s healing powers at will. Through the god’s divine providence and via Aristides’ intermediary Zosimos has earned four extra months of life, while Aristides seems to have acquired healing powers. It is this act of appropriating Asclepius’ healing powers that apparently gives Aristides the right to order his patients around and dictate to them the recommended course of action and regimen. Notice, for example, the emphasis that our text lays on the very cause of Zosimos’ eventual death: Zosimos died because he disobeyed Aristides, disregarded his medical advice not to move: ὁ δ᾿ ἀπειθήσας ᾤχετο, ἐκ δὲ τούτου ἡ τελευτή ἐγένετο αὐτῷ.12 The first book of the HL ends with yet another instance of miraculous transformation of the patient into a potent physician. Only this time, this transformation takes place via what can be described as ‘an epistolary prescription’. Aristides is said here to have become the recipient of a ‘Himmelsbrief’, a 11  For διακονία as “service”, see Pl., R. 371c, Aeschin. 3.13. It can also denote “religious service”, “attendance on a religious duty”, “ministration” as in Dem. 18.206; Act. Ap. 6.1, etc. In Polybius (15.25.21) the same term is used to denote “a body of servants” or “attendants”. On diakonia and diakonos see Blasi, A. J. (1995). ‘Office charisma in early christian Ephesus’, Sociology of Religion 56.3, 245–55. The term diakonos is synonymous, at least in certain contexts, to the term therapeutēs, on which see Pleket, H. W. ‘Religious history as the history of mentality: The “believer” as servant of the deity in the ancient world’, in Versnel, H. S. (1981). Faith, Hope and Worship. Aspects of Religious mentality in the Ancient World, 159–61. 12  Extra emphasis is also laid by Galen in his commentary on the Epidemics (see above n. 5) on the subject of the patient’s εὐπείθεια ‘ready obedience’, or ‘compliance’ with the doctor’s orders. It is precisely this essential quality for a successful patient-physician cooperation that Zosimos is lacking. On the great significance of belief in the therapeutic capacity of a healer and the efficacy of a recommended course of therapy for a healing event to take place both in antiquity and in modern times, see the interdisciplinary study of van Schaik (Chapter Nineteen), 471–496 in this volume. Zosimos’ motives for such disobedience are clarified in chapter 75. Zosimos heard about the illness of one of Aristides’ favourite servants and against Aristides’ stern warnings acted as a medical practitioner on that patient, because as we are explicitly told, Zosimos was also “skilled in the art of medicine” (τὴν τέχνην ἀγαθὸς τὴν ἰατρικήν). We may be witnessing here a case of layman medicine of the kind that was not uncommon in the second century Roman Empire. More on the topic in Draycott, (Chapter Seventeen), 431–450 in this volume.

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g­ od-sent letter (lit. ‘sent from heavens’) found right in front of the statue of Zeus-Asclepius, which, in all likelihood, contained the recommended treatment for his beloved nurse Philoumene. Aristides is subsequently dispatched from Pergamum (notice the urgency that the participle ekpempsas conveys) to raise Philoumene from the bed of sickness. The term symbolon is also of interest here. It probably means that Aristides took this epistolary tablet to be a token, a sign from the god that prompted him to immediate action. Once again, our Mysian patient takes his cue from the divine physician and becomes himself a most effective healer. (78) τὴν τοίνυν τροφὸν τὴν ἀρχαίαν, ἧς οὐδέν μοι φίλτερον—Φιλουμένη ἦν ὄνομα αὐτῇ—μυριάκις μὲν ἔσωσε παρ’ ἐλπίδας, κειμένην δέ ποτε ἀνέστησεν ἐκπέμψας ἐμὲ ἀπὸ Περγάμου, προειπὼν ὅτι καὶ τὴν τροφὸν ἐλαφροτέραν ποιήσοιμι. καὶ ἅμα λαμβάνω τινὰ ἐπιστολὴν πρὸ ποδῶν κειμένην τοῦ Διὸς Ἀσκληπιοῦ, σύμβολον ποιούμενος· εὗρον οὖν μόνον οὐ διαρρήδην ἕκαστα ἐγγεγραμμένα. ὥστε ἐξῄειν ὑπερχαίρων καὶ καταλαμβάνω τὴν τροφὸν τοσοῦτον ἀντέχουσαν ὅσον αἰσθέσθαι προσιόντος. ὡς δ’ ᾔσθετο, ἀνέκραγε τε καὶ ἀνειστήκει οὐκ εἰς μακράν. My old nurse, named Philoumene—none was dearer to me than her— whom he saved myriad times and beyond my expectations, was once lying ill in bed, and he restored her to health after having dispensed me from Pergamum by foretelling that I would relieve my nurse. And at that point, I found a letter lying before my feet in the Temple of Zeus Asclepius, and made it a sign. For not only did I discover every single thing written in it, but everything was written explicitly too. So I departed overjoyed, and I found my nurse with only enough strength left in her to perceive my arrival. And as soon as she sensed my presence, she cried out and got up not too long afterwards. Behr and others have interpreted this epistolary prescription as a feature of Aristides’ dream, not a material object that Aristides actually picks up, but it does not have to be so.13 These ‘Himmelsbriefe’ are closely associated with both oracular and healing cults and feature prominently both in literary sources and inscriptions, especially those relating the foundation of a new healing cult.14 13  Behr, Sacred Tales, 194 and id., Aelius Aristides: The Complete Works, 428, n. 103. 14  More examples in Sokolowski, F. (1974). ‘Propagation of the cult of Sarapis and Isis in Greece’, GRBS 15, 441–48; and Busine, A. ‘The discovery of inscriptions and the legitimation of new cults’, in Dignas, B. and Smith, R. R. R. (2012). Historical and Religious Memory

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The materiality of these god-sent epistolary remedies is their most prised feature: they connect the oneiric world of the dreamer with the hard reality of the illness and the need for therapy. Out of the parallels one can think of, perhaps the closest is the story Pausanias (10.38.13) reports about Asclepius appearing in a dream to the poetess Anyte and handing to her written tablets that contained the prescribed remedy for the treatment of a blind man named Phalysios.15 Anyte woke up from her dream vision only to find the same epistolary prescription she had dreamt of in her hands. The blind man opened the tablets and read them and this is how his vision was restored. It is worth noticing that Pausanias found the story in the archive of inscribed miraculous healing narratives contained in the sanctuary of Epidaurus. Perhaps Aristides was inspired by similar inscribed ex-votos in the temple of the god in Pergamum, but my main point is that we need not suppose that the letter which contained the remedy for his beloved nurse was part of his dream rather than a physical object that Aristides brought with him to his meeting with Philoumene. The narrative that contains Philoumene’s treatment provides further elaboration on the theme of Aristides operating as Asclepius’ intercessor and acting as a physician himself. If one compares it to the ekphrastic description of Zosimos’ salvation, Philoumene’s case might seem less elaborate but it is equally explicit and certainly telling of how our distinguished patient once again appropriated the divine healer’s powers, became himself the doctor and saved his nurse. Other cases of Aristides’ appropriating the god’s healing powers and acting as a physician himself are reported in more or less summary fashion. In one of them, Aristides dreams of being a priest at the temple of Asclepius and cures his limping friend by prescribing “rest” (1.15);16 while a lengthy narrative from the third book of the HL takes the notion of in the Ancient World, 241–53. However, one must not forget that ‘Himmelsbriefe’ were also a standard feature of Hellenistic and Imperial aretalogies, and the hieroi logoi has long been recognised as a narrative with a distinct aretalogical flavour to it. On ‘Himmelsbriefe’ as a typical element of Hellenistic aretalogies see Chaniotis, A. (1988). Historie und Historiker in den griechischen Inschriften. Epigraphische Beiträge zur griechischen Historiographie, 68–69. 15  Asclepius’ oneiric epiphany to Anyte is a typical example of what E. R. Dodds calls a “rapport epiphany”: i.e. the deity appears to the perceiver, who after the revelation is left with a token, a visible mémoire of the divine visitation. See Dodds, E. R. (1951). The Greeks and the Irrational, 102–34. For a more recent discussion of Asclepius’ epiphany to Anyte, see Platt, Facing the Gods, 290–92; and Petridou, Epiphany, chapter three. 16  δεκάτῃ δ’ ὑστέρᾳ ἐδόκουν ἐσθῆτα ἔχειν ἱερέως καὶ αὐτὸν παρόντα ὁρᾶν τὸν ἱερέα· ἐδόκουν δὲ καὶ τῶν ἐπιτηδείων τινὰ ὑποχωλεύοντα ἰδὼν ἐκ τῶν περὶ τὴν ἕδραν φάναι πρὸς αὐτὸν ὅτι ταῦτα ἡσυχία θεραπεύοι.

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‘healing’ to an entirely new level, and presents Aristides as saving the entire city of Smyrna and its citizens from an earthquake (3.38–43). The terminology used in 1.74 to describe the healing event is almost a word-for-word repetition of the description of the way Zosimos was healed by the god’s providence and power and Aristides’ essential intermediary service: προνοίᾳ μὲν καὶ δυνάμει τῶν θεῶν, διακονίᾳ δ’ ἡμῶν ἀναγκαίᾳ. Finally, in another excerpt (4.10) from the fourth book of the HL, upon his return to his ancestral estates Aristides is treated like the living embodiment of a healing deity whose mere sight is capable of restoring strength and vitality to his beloved old nurse. Indeed, the entirety of the HL is interspersed with analogous instances, where Aristides presents himself as well-versed in medical matters and actively involved not only in the relief or recovery of others, but also in his own relief or recovery. As with the cases discussed above, some of these selfhealing narratives are presented in a more synoptic manner and others are more elaborate. For example, sandwiched between the two cases of Aristides’ operating as a healer on both Zosimos and Philoumene lays a parenthetic narrative (1.74), which relates yet another instance of Aristides’ appropriation of Asclepius’ healing powers: this time, our distinguished patient-turnedphysician dismisses the doctor’s hesitation to give him an enema and persuades him to proceed with it regardless. In 3.20, on the other hand, Aristides refuses to follow the doctor’s prescription to take some nourishment and instead decides to cure his high fever, convulsion and a splitting headache by self-medicating intensive meditative contemplation of the statue of Zeus. 2

Two Cases of Self-Healing

These brief references to Aristides’ abilities for self-healing can be coupled with a number of more extensive passages in which Aristides makes use of the same medical terminology as do contemporary medical authors, and more interestingly, the same techniques of performative exhibition of medical expertise. Chapters 49–50 of the fifth book of the HL provide an illustration of this. They relate an oneiric therapy that cured Aristides from being immobile in the autumn of 170 AD. Aristides dreams of a meeting with not one but two doctors, who recite a remedy attributed to Hippocrates. The prescription involves strenuous running followed by jumping in the cold sea: ὅσον δὲ κἀν τούτῳ συνέβη καμεῖν ἡμέρας τινὰς, θαυμαστῶς ὡς ὁ θεὸς καὶ ἅμα εἰωθότως ἰάσατο. βορέας μὲν γὰρ ὀπωρινὸς ἦν, εἶχον δὲ ἀδυνάτως κινεῖσθαι, ὥστε καὶ τὰς ἀναστάσεις ὤκνουν· ὁ δ’ ἐπιτάττει. βέλτιον δ’ ἴσως αὐτὸ τὸ ὄναρ διηγήσασθαι, καὶ γὰρ ἔναυλόν τέ ἐστι καὶ οὐκ ἀνάγκη παραλιπεῖν. ἡκέτην

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ἰατρὼ δύο καὶ διελεγέσθην ἐν τῷ προθύρῳ ἄλλα τέ μοι δοκεῖν καὶ περὶ ψυχροῦ λουτροῦ ἠρώτα μὲν ὁ ἕτερος, ὁ δ’ ἀπεκρίνετο, τί λέγει, ἔφη, Ἱπποκράτης; τί δ’ ἄλλο γε ἢ δραμόντα δέκα σταδίους ἐπὶ θάλατταν οὕτως ῥῖψαι; Ταῦτα μὲν δὴ ὡς ὄναρ πεφάνθαι ἐδόκουν. μετὰ δὲ τοῦτο ἐπελθεῖν ὡς ἀληθῶς αὐτοὺς τοὺς ἰατροὺς, θαυμάσαι τε δὴ τοῦ ἐνυπνίου τὴν ἀκρίβειαν καὶ πρὸς αὐτοὺς εἰπεῖν, ἄρτι γε ὑμᾶς ἐδόκουν ὁρᾶν καὶ ἄρτι ἥκετε, καὶ δῆτα ὁπότερος μὲν ὑμῶν, ἔφην, ὁ ἐρωτῶν ἦν καὶ ὁπότερος ὁ ἀποκρινόμενος οὐκ ἔχω λέγειν· ἡ δ’ ἀπόκρισις οὕτως εἶχεν, ὡς ἄρα Ἱπποκράτης κελεύοι δέκα σταδίους θεῖν τὸν μέλλοντα λοῦσθαι ψυχρῷ. ἅμα δὲ ἐμαυτῷ μετέβαλον τὸ ἐπὶ θάλατταν, ὡς δηλοῦν τὸ κατὰ φύσιν τῷ ποταμῷ, καὶ οὕτως εἶπον, δέκα σταδίους θεῖν τῷ ποταμῷ συμπαραθέοντα. ἐνεθυμήθην δ’ αὐτὸ διὰ τὸ εἶναι ἐν μεσογείᾳ, ἐδόκει σαφὲς εἶναι καὶ χρῆναι οὕτω ποιεῖν. In so far as even in this time I happened to fall ill for some days, the god cured me most wondrously and in his usual way. (49) For there was an autumnal north wind, and I was unable to move, so that I even hesitated to get up. But he ordered it. Perhaps it is better to narrate the dream itself, for it is still ringing in my ears and there is no need to omit it. “Two doctors came and at the doorway, among other things, discussed, I believe, a cold bath. One asked the question, and the other answered. “What does Hippocrates say?”, he said. “What else, but to run ten stades to the sea and then jump in?” I dreamed that these things had appeared in my dream. (50) After this, the doctors themselves in fact came in, and I marvelled at the precision of the dream, and said to them, “Just now I dreamed that I saw you and just now you have come. Indeed, which one of you”, I said, “was the one who inquired and which one who answered, I cannot say. But the answer was as follows: “That Hippocrates ordered one who intended to take a cold bath, to run ten stades”. At the same time I changed in my own interest the phrase “to the sea”, as if I were making clear the descent to the river. And so I said, “to run ten stades, by running parallel to the river”. I thought of this because of being inland. It seemed to be clear and to be necessary to do this.17 Schröder maintains that there is no mention of treating opisthotonos with cold baths in the Hippocratic corpus; hence, he thinks this Hippocratic remedy is spurious.18 He does, however, mention the effects of cold baths as described 17  Trans. Behr with emendations. 18  Opisthotonia or opisthotonos is an extremely painful type of tetanic recurvation in which the body is drawn backwards and stiffens. The word and its cognates appear about

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in the second book of the De Victu (2.57 = Joly-Byl 1, 2.4, 180.28–182.3 = L. 6.570.7–17).19 Nonetheless, in the third book of the De Morbis (3.13.2 = Potter I, 2.3, 80.25–28 = L. 7.134.4–7) it is stated clearly that one possible treatment of opisthotonos includes being doused with icy-cold water: ἤν δὲ βούλῃ, καὶ ὧδε ποιέειν· ὕδωρ ὡς πλεῖστον ψυχρὸν καταχέας, ἔπειτα ἱμάτια θερμὰ καὶ καθαρὰ καὶ πόλλα καὶ λεπτὰ ἐπιβάλλειν, πῦρ δὲ τότε μὴ προσφέρειν. ὧδε καὶ τοὺς τετανικοὺς καὶ τοὺς ὀπισθοτονικοὺς ποιέειν. If you like, you can also do the following: throw as much cold water as possible, and then put on thin, clean and warm garments, but do not offer any heat at that point. Thus you must do also when treating convulsive tetanus and drawn backwards tetanus. Once again, it is difficult to conclude with any certainty that Aristides had read the exact same text we got, but given the wider philological and philosophical interest these texts held for the literati of the second century AD and Aristides’ active engagement in the medical discourse of his time, we cannot rule it out either.20 At any rate, by quoting a Hippocratic text, Aristides presents himself as well-versed in medical matters, an image that, as seen above, was a highly prised desideratum for the author of the HL. Cold baths, even in the middle of the winter, were not an uncommon Asclepian prescription in imperial times; and they were not restricted to Aristides’ case.21 In HL 2.74–79, however, we find out that following a ­prescription involving icy-cold baths—a remedy which aimed primarily at restoring the equilibrium of dryness and moisture in the body—was not an easy task and that the same remedy could come with some rather unpleasant 20 times in the Galenic corpus. Aristides seems to have suffered at least once from this disease (3.21 HL), perhaps sometime in February of 148 AD. 19  Schröder, H. O. (1986). Heilige Berichte: Einleitung, deutsche Übersetzung und Kommentar, 136, n. 100: “Diese Antwort findet sich nicht in den Schriften des Hippokrates, verständlicherweise, da es sich um einen Traum des Aristides handelt. Doch werden wenigstens die Wirkungen der kalten Bäder bei Hipp., Vict. 2, 57, 2 erwähnt”. Cf. also Festugière, Personal Religion, 94–5. None of the aforementioned scholars mentions the passage from the De morbis, which was brought to my attention by Oliver Overwien. 20  On the popularity of these texts in the second sophistic see King, H. ‘The origins of medicine in the second century AD’, in Goldhill, S. and Osborne, R. (2006). Rethinking Revolutions Through Ancient Greece, 246–63. 21  Cf., for instance, HL 2.80 and Or. 42.8 (Keil). Another well-known example can be found in Marcus Aurelius’ Meditations (5.8) van der Hout.

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s­ ide-effects in the case of patients who did not enjoy as privileged a relationship with Asclepius as Aristides did.22 The passage has been discussed in detail by Janet Downie in an unpublished paper entitled ‘The Therapeutic Dynamic in Aelius Aristides’ Sacred Tales’. In her discussion, Downie rightly lays emphasis on Aristides’ active role in his own therapy and on his revisionist attitude towards the actual treatments and the mortal physicians who prescribe them: the patient spends a great deal of time narrating his own interpretation of the prescription and replaces parts of the original prescription with others he considered more appropriate. For instance, the sea in the original oneiric prescription is replaced in Aristides’ interpretation by the river. More importantly, the discussion between the two ordinary physicians is recast to fit his complex and unique conceptual universe as a dream Asclepius sent long before the two doctors had their actual conversation. What is really significant for our purposes, as Downie remarks, is that by prioritising his own interpretation of the medical prescription itself over the one offered by the two physicians, Aristides draws attention to the central role he plays in his own therapy.23 Rather than presenting himself as a submissive patient, Aristides portrays himself as a competent and erudite physician.24 There are many other examples like those mentioned above, precisely because Aristides assumes the role of the physician on more than one occasion. Last but not least, the reader may be reminded of a comparable case in which Aristides actively assumes the role of the physician as related in chapters 19–23 from the second book of the HL. Contrary to the physician Herakleon’s ominous prediction that he would contract opisthotonos, and while still warm in his heart from having just experienced Asclepius’ epiphany, Aristides bathes in the ice-cold water of the river Meletas, which in his own words felt like the gentle and well-tempered water of a bathing pool (ὥσπερ ἐν κολυμβήθρᾳ καὶ μάλα ἠπίου καὶ κεκραμένου ὕδατος). Bathing in the river Meletas not only did not destroy his physical health, but it seemed to have given his body a healthy

22  Janet Downie regards these therapeutic procedures, which involved intense physical exercise, as more in line with Aristides’ self-representation as an athlete. More on this topic in Downie, J. (2009). ‘A pindaric charioteer: Aelius Aristides and his divine literary editor (Oration 50.45)’, Classical Quarterly 59.1, 263–69. 23  Cf. here Downie, J. (2013a). At the Limits of Art. A Literary Study of Aelius Aristides’ Hieroi Logoi, 89–102. 24  On this episode and Hippocrates as a medical authority in the HL and the work of Aristides as a whole, see Horstmanshoff, ‘Asclepius and temple medicine’, 336–37; and King, ‘Origins of medicine’, 259–60.

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pink tone and a sense of lightness.25 Throughout the rest of the day and the night his body apparently retained this warmth and the kind of perfect balance of elemental qualities, a balance which could not be achieved by human ­contrivance.26 It is this state of perfectly balanced mixture of the four elements (wet, dry, hot and cold) in the human body that Galen calls ‘perfect mixture’, εὐκρασία, in his treatise Mixtures.27 It is anyone’s guess as to whether Aristides had read his Galen or other medical treatises of related content but, I think, few would argue against the presence of technical language in this account and the fact that this description is the product of a learned and well-informed patient. Perhaps even the product of a patient who hoped to emulate, if not surpass in erudition, the physicians of his time, and thus appropriate a fair share of their powers. Given the aforementioned evidence for Aristides’ keen interest in medicine and his active involvement in the healing process—either via constant reinterpretation of the god’s advice on regimen or via contestation of the views 25  On this episode see also Cox Miller, Dreams, 184–85; and Brown, P. (1978). The Making of Late Antiquity, 54, where Aristides is ironically called “the pink professor”. On kouphotēs (‘lightness’) as a medical term commonly attested in contemporary medical authors like Galen, see Brock, N. van (1961). Recherches sur le vocabulaire médical du grec ancien, 211–12, no. 41. 26  HL 2.22–23: καὶ οὔτε τι ξηροτέρου οὔτε ὑγροτέρου τοῦ σώματος ᾐσθόμην, οὐ τῆς θέρμης ἀνῆκεν οὐδὲν, οὐ προσεγένετο, οὐδ’ αὖ τοιοῦτον ἡ θέρμη ἦν, οἷον ἄν τῳ καὶ ἀπ’ ἀνθρωπίνης μηχανῆς ὑπάρξειεν, ἀλλά τις ἦν ἀλέα διηνεκὴς, δύναμιν φέρουσα ἴσην διὰ παντὸς τοῦ σώματός τε καὶ τοῦ χρωτός. 23 παραπλησίως δὲ καὶ τὰ τῆς γνώμης εἶχεν. οὔτε γὰρ οἷον ἡδονὴ περιφανὴς ἦν οὔτε κατ’ ἀνθρωπίνην σωφροσύνην ἔφησθα ἂν εἶναι αὐτὸ, ἀλλ’ ἦν τις ἄρρητος εὐθυμία, πάντα δεύτερα τοῦ παρόντος καιροῦ τιθεμένη, ὥστε οὐδ’ ὁρῶν τὰ ἄλλα ἐδόκουν ὁρᾶν· οὕτω πᾶς ἦν πρὸς τῷ θεῷ. “During all the rest of the day and night till bed time, I preserved the condition which I had after the bath, nor did I feel any part of my body to be drier or moister. None of the warmth left me, none was added, nor again was the warmth such as one would have from a human contrivance, but it was a certain continuous body heat, producing the same effect throughout the whole of my body and during the whole time. (23) My mental state was also nearly the same. For there was neither, as it were, conspicuous pleasure, nor would you say that it was like a human joy. But there was a certain inexplicable contentment, which regarded everything as less important than the present moment, so that when I saw other things, I seemed not to see them. Thus I was wholly with the God.” Trans. Behr with emendations. 27  Cf. for instance, De temper. 37.17–32.4 Helmreich = K. 1.558–59 with van der Eijk (in press) ‘Galen on the nature of human being’, in Adamson, P. and Wilberding, J. (in press). Galen and Philosophy. A comparison between the aforementioned passage from Galen’s treatise Mixtures and the passage from the HL quoted above is an issue I would like to revisit on a future occasion.

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of his own attending physicians—it seems that Aristides resembles less and less the typical suppliant of the numerous healing shrines Galen criticises in his commentary to the Hippocratic Epidemics. Indeed, this new emerging picture of Aristides resembles more and more the portrayal of a very different kind, the informed patient, of whom Galen speaks in his On examining the best physicians: this different kind of patient trusts in the healing deity (Asclepius or Apollo) only partly, relies exclusively on his own knowledge of medicine and dialectics, and scrutinizes any given dietary regimes and regimen as much as he does his attending physicians, both on the basis of medical theory and practice.28 3 Conclusions This study has offered a close reading of a selection of passages from the HL, which cast Aristides, the famous second-century patient, in a new light. These passages present Aristides as being far from the submissive patient, who idly resided in the Pergamene Asclepieion relying exclusively on the therapeutic powers of its divine occupants; rather, they show him appropriating Asclepius’ healing powers and thus transforming himself into an informed patient, who is not only in possession of the basics of the medical discourse but who also functions as a physician of sorts. Within the narrative context of the HL, Aristides’ attempt to appropriate Asclepius’ healing powers and to act as a physician himself can also be interpreted as an attempt to become this new kind of patient, the knowledgeable patient who is well-versed in medical matters and envisages himself as an active agent of the healing process and an equally important partner in the medical encounter. More significantly, the passages discussed above are, in fact, only fragments of a wider emerging picture, which portrays a very different kind of patient mostly to be found amongst the members of

28  Οn the audience of On examining the best physicians, see Nutton, V. (1990). ‘The patient’s choice: A new treatise by Galen’, Classical Quarterly 40.1, 243–44. Galen’s treatise On examining the best physicians survives only in Arabic and is translated by Iskandar, A. Z. Galeni De optimo medico cognoscendo libelli versio Arabica. Kitāb miḥnat aṭ-ṭabīb is a ninth century Arabic translation of an otherwise lost work of Galen. Nutton approves the attribution to Ḥunain. Iskandar bases his Arabic text on two manuscripts, one in Alexandria, the other in Bursa, and supplements it with quotations from other Arabic authors, most notably Rhazes. On Rhazes and the reception of Galenic texts in the Arabic world, see Koetschet (Chapter Seven), 224–244 in this volume.

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the socio-political elite of the second century AD. This informed patient values his body highly and has the time and the knowledge to attend to his physical and psychic needs (both proactively and reactively). This patient does not relinquish control over his body and its functions, not easily at least and certainly not before he has tested the efficacy of the practitioner of the technē iatrikē and his methods. This kind of patient/medical connoisseur and his likes are perhaps the intended readers of such contemporary medical treatises on healthcare and healthcare specialists as Plutarch’s de sanitate tuenda praecepta (ὑγιεινὰ παραγγέλματα), Galen’s de sanitate tuenda, or his On examining the best physicians.29 Texts and Translations Used Acta Apostolorum (Act. Ap.) The Acts of the Apostles: The Greek Text with Introduction and Commentary. Ed. and com. F. F. Bruce. London: Tyndale Press, 1952. Aeschines. Aeschines: Orationes. Ed. M. R. Dilts, Leipzig: Teubner, 1997. Aelius Aristides. Aelius Aristides. Quae supersunt omnia. Ed. B. Keil, vol. 2. Berlin: Weidmann, 1898. ———. Aelius Aristides and the Sacred Tales. Trans. C. A. Behr. Amsterdam: A. M. Hakkert, 1968. ———. Aelius Aristides: The Complete Works. Trans. C. A. Behr, 2 vols. Leiden: Brill, 1981–86. Demosthenes. Demosthenes. On the Crown. Ed. and com. H. Yunis. Cambridge: Cambridge University Press, 2001. Hippocrates. Hippocratis De diaeta. Ed. R. Joly and Byl. CMG I, 2.4. 2nd ed. Berlin: Akademie Verlag, 2003. ———. Hippocratis De morbis 3. Ed. P. Potter. CMG I,2,3. Berlin: Akademie Verlag, 1980. Homer. Homeri Odyssea. Ed. H. van Thiel, Zürich-New York: Hildesheim, 1991. ———. Iliad XXII. Ed. and com. I. J. E. De Jong, Cambridge: Cambridge University Press, 2012. Galen. Galeni De optimo medico cognoscendo libelli versio Arabica. Ed. A. Z. Iskandar. CMG Supplementum Orientale IV. Berlin: Akademie Verlag, 1988. ———. Galeni In Hippocratis Epidemiarum librum 6 commentaria 3–6. Ed. E. Wenkebach. CMG V. Berlin: Akademie Verlag, 1956. 29  More on Galen’s treatise On Hygiene in Wilkins (Chapter Sixteen), 411–431 in this volume; on Plutarch’s De san. tuenda, see Hoof, L. van. ‘Plutarch’s “Diet-Ethics”. Precepts of healthcare between diet and ethics’, in Roskam, G. and Stockt, L. van der (2011). Virtues for the People. Aspects of Plutarchan Ethics, 109–29.

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———. Galēnou Peri kraseōn tria: Galeni De temperamentis libri 3. Ed. G. Helmreich. Leipzig: Teubner, 1904. Inscriptiones Graecae (IG) V, 2. Inscriptiones Arcadiae. Ed. F. Hiller von Gaertringen. Berlin: Reimer, 1913. Marcus Aurelius. M. Cornelii Frontonis Epistulae, Ed. M. P. J. Van der Hout. Leipzig: Teubner, 1988. Plato. Platonis Respublica. Ed. S. R. Slings, Oxford Classical Texts, Oxford: Oxford University Press, 2003. Plutarch. Plutarque, De la vertu ethique, Ed. and trans. D. Babut. Paris: Les Belles Lettres, 1969. Polybius. Ed. F. W. Walbank and Ch. Habicht. Trans. W. R. Paton, vol. 4, Books 9–15. The Loeb Classical Library 159. Cambridge, MA: Harvard University Press, 2011. POxy. The Oxyrhynchus Papyri Part 11. Ed. B. P. Grenfell and A. S. Hunt. London: Egypt Exploration Fund, 1915.

References Blasi, A. J. ‘Office Charisma in Early Christian Ephesus.’ Sociology of Religion 56.3, (1995): 245–55. Brown, P. The Making of Late Antiquity. Cambridge, MA and London: Harvard University Press, 1978. Bowersock, G. W. Greek Sophists in the Roman Empire. Oxford: Oxford University Press, 1969. Brown, P. The Making of Late Antiquity. Cambridge MA, London: Harvard University Press, 1968. Brock, N. van. Recherches sur le vocabulaire médical du grec ancien. Paris: Klincksieck, 1961. Busine, A. ‘The Discovery of Inscriptions and the Legitimation of New Cults’. In Historical and Religious Memory in the Ancient World, ed. B. Dignas and R. R. R. Smith, 241–53. Oxford and New York: Oxford University Press, 2012. Chaniotis, A. Historie und Historiker in den griechischen Inschriften. Epigraphische Beiträge zur griechischen Historiographie. Stuttgart: Franz Steiner Verlag, 1988. Cox Miller, P. Dreams in Late Antiquity. Princeton, NJ: Princeton University Press, 1994. Dipla, A. and Palaothodoros, D. ‘Selected for the Dead. Erotic Themes on Grave Vases from Attic Cemeteries.’ in Encountering Imagery. Materialities, Perceptions, Relations, ed. I.-M. Back Danielsson, F. Fahlander and Y. Sjöstrand, Stockholm Studies in Archaeology 57, 209–33. Stockholm: Stockhold University, 2012. Dodds, E. R. The Greeks and the Irrational. Berkeley: University of California Press, 1951.

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———. ‘A Pindaric Charioteer: Aelius Aristides and his Divine Literary Editor (Oration 50.45).’ Classical Quarterly 59, (2009): 263–69. ———. At the Limits of Art. A Literary Study of Aelius Aristides’ Hieroi Logoi. Oxford and New York: Oxford University Press, 2013a. Eijk, Ph. J. van der. ‘Melancholia and Hypochondria—Steps in the History of a Problematic Combination.’ in Miroirs de mélancolie, ed. H. Cazes and A.-F. Morand, Lausanne, in press. ———. ‘Galen on the Nature of Human Beings.’ in Galen and Philosophy, ed. P. Adamson and J. Wilberding, Bulletin of the Institute of Classical Studies, Supplements. London, in press. Festugière, A.-J. Personal Religion among the Greeks. Berkeley and Los Angeles: University of California Press, 1954. Fögen, Th. ‘The Role of Verbal and Non-Verbal Communication in Ancient Medical Discourse.’ In Latin et langues romanes—Études de linguistique offertes à József Herman à l’occasion de son 80ème anniversaire, ed. L. Mondin, S. Kiss and G. Salvi, 287–300. Tübingen: Niemeyer, 2005. Gould, J. ‘Hiketeia.’ Journal of Hellenic Studies 93, (1973): 74–103. Grotty, K. The Poetics of Supplication. Ithaca: Cornell University Press, 1994. Hanson, J. S. ‘Dreams and Visions in the Graeco-Roman World and Early Christianity.’ Aufstieg und Niedergang der römischen Welt 23.1, ed. W. Haase, 1395–1427. Berlin and New York: Walter de Gruyter, 1979. Harris, W. V. and Holmes, B. (eds.) Aelius Aristides between Greece, Rome and the Gods. Leiden: Brill, 2008. Harris, W. V. Dreams and Experience in Classical Antiquity. Cambridge, MA and London: Harvard University Press, 2009. Holmes, B. ‘Aelius Aristides’ Illegible Body.’ in Aelius Aristides between Greece, Rome and the Gods, ed. W. V. Harris and B. Holmes, 81–113. Leiden: Brill, 2008. Hoof, L. van ‘Plutarch’s “Diet-Ethics”. Precepts of Healthcare Between Diet and Ethics.’ in Virtues for the People. Aspects of Plutarchan Ethics, ed. G. Roskam and L. van der Stockt, 109–29. Leuven: Leuven University Press, 2011. Horstmanshoff, H. F. J. ‘Did the God Learn Medicine? Asclepius and Temple medicine in Aelius Aristides’ Sacred Tales.’ in Magic and Rationality in Ancient Near Eastern and Graeco-Roman Medicine, ed. H. F. J. Horstmanshoff and M. Stol, 325–41. Leiden: Brill, 2004. Israelowich, I. Society, Medicine and Religion in the Sacred Tales of Aelius Aristides. Leiden: Brill, 2012. Johnson, L. T. Among the Gentiles. Greco-Roman Religion and Christianity. New Haven and London: Yale University Press, 2009. King, H. ‘Chronic Pain and the Creation of Narrative.’ in Constructions of the Classical Body, ed. J. I. Porter, 269–86. Ann Arbor: The University of Michingan Press, 1999.

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———. ‘The Origins of Medicine in the Second Century AD.’ in Rethinking Revolutions Through Ancient Greece, ed. S. Goldhill and R. Osborne, 246–63. Cambridge: Cambridge University Press, 2006. Leven, K.-H. ‘Hypochonder.’ in Antike Medizin: ein Lexikon, ed. K.-H. Leven, 448. München: Beck, 2005. Naiden F. S. ‘Hiketai and Theoroi at Epidaurus.’ in Pilgrimage in Graeco-Roman and Early Christian Antiquity: Seeing the Gods, ed. J. Elsner and I. Rutherford, 73–96. Oxford and New York: Oxford University Press, 2005. Nutton, V. ‘The Patient’s Choice: A New Treatise by Galen.’ Classical Quarterly 40.1, (1990): 236–57. Pearcy, L. T. ‘Dream, Theme, and Narrative: Reading the Sacred Tales of Aelius Aristides.’ Transactions of the American Philological Association 118, (1988): 377–91. Petridou, G. Divine Epiphany in Greek Literature and Culture. Oxford and New Υοrk: Oxford University Press, in press. Perkins, J. ‘The Self as Sufferer.’ Harvard Theological Review 85, (1992): 245–72. Petsalis-Diomides, A. ‘Sacred Writing, Sacred Reading: The Function of Aelius Aristides’ Self-Presentation As Author in the Sacred Tales.’ in The Limits of Ancient Biography, ed. B. McGing and J. Mossman, 193–211. Swansea: Classical Press of Wales, 2006. ———. Truly Beyond Wonders. Aelius Aristides and the Cult of Asclepius. Oxford and New York: Oxford University Press, 2010. Phillips, E. D. ‘A Hypochondriac and His God.’ Greece & Rome 61, (1952): 23–36. Platt, V. J. Facing the Gods: Epiphany and Representation in Graeco-Roman Art, Literature and Religion. Cambridge: Cambridge University Press, 2011. Pleket, H. W. ‘Religious History As the History of Mentality: The “Believer” As Servant of the Deity in the Ancient World.’ in Faith, Hope and Worship. Aspects of Religious mentality in the Ancient World, ed. H. S. Versnel, 152–92. Leiden: Brill, 1981. Porter, J. I. Constructions of the Classical Body. Ann Arbor: The University of Michingan Press, 1999. Schröder, H. O. Heilige Berichte: Einleitung, deutsche Übersetzung und Kommentar. Heidelberg: Winter, 1986. Sokolowski, F. ‘Propagation of the Cult of Sarapis and Isis in Greece.’ Greek, Roman and Byzantine Studies 15, (1974): 441–48.

CHAPTER 19

“It may not cure you, it may not save your life, but it will help you” Katherine D. van Schaik In the modern world, we are experiencing an epidemiological shift represented by the increasing prevalence of chronic diseases relative to that of acute diseases: more people are living longer, with more diseases, than ever before in human history. How are we to understand and to respond to this change? A study of provision of cancer treatment in Western Australia, especially among Indigenous populations, can illuminate ways in which healthcare providers and societies might better understand the treatment of chronic disease: healthcare providers should take care to appreciate patient perspectives and beliefs about disease aetiology and treatment. Consideration of treatment of disease in the ancient GraecoRoman world supports the view that effective healing and maintenance of patient wellbeing occurs when healers communicate clearly with their patients about disease and treatment progression, and when healers are open-minded about patients’ utilisation of multiple treatment modalities. The Black Death. The Great White Plague. The Plague of Athens. Cholera. The modern HIV epidemic. Acute infectious diseases, the most common cause of infant mortality worldwide in 2008.1

* The author acknowledges with sincere thanks Georgia Petridou, Chiara Thumiger, and an anonymous reader, whose suggestions greatly improved the manuscript; Sandra C. Thompson for her generosity and patient instruction; and especially Christopher P. Jones, Mark J. Schiefsky, and Emma Dench, whose guidance, encouragement, and knowledge have facilitated interdisciplinary study from the beginning. ** The title is a quote from the following paper: Shahid, S. et al. (2010). ‘ “If you don’t believe it, it won’t help you”: Use of bush medicine in treating cancer among Aboriginal people in Western Australia’, Journal of Ethnobiology and Ethnomedicine 6.18, 1–9. The article is written by a member of the Western Australian research group with which the author of this chapter is affiliated. 1  World Health Organization. (2011). The Top Ten Causes of Death Worldwide. Fact Sheet 310.

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Throughout history, until the widespread use of modern antibiotics in the mid-twentieth century, acute infectious diseases were, in all likelihood, the most common cause of death worldwide.2 They killed quickly, leaving no trace in any skeletal or soft tissue remains that we might analyse today using either scientific laboratories or medical imaging techniques. And yet, the World Health Organization’s 2008 world mortality statistics show that in lowincome countries, the top three causes of death are infectious diseases: lower respiratory infections, diarrhoeal diseases, and HIV/AIDS, which together accounted for 27.3% of deaths worldwide in 2008. Malaria, tuberculosis, and neonatal infections occupy places five, seven, and ten, respectively, on the list of the top ten causes of death in 2008. In other words, at least 39.4% of reported deaths in low-income countries in 2008 were attributable to infectious causes. For middle- and high-income countries, however, the 2008 statistics differ markedly: the top three causes of death in middle-income countries were ischaemic heart disease (13.7%), stroke and other cerebrovascular disease (12.8%), and chronic obstructive pulmonary disease (7.2%). In high-income countries, ischaemic heart disease (15.6%), stroke and other cerebrovascular disease (8.7%), and trachea, bronchus, and lung cancers (5.9%) occupy the top three positions. Worldwide, including all income groups, the top three causes of death in 2008 were ischemic heart disease (12.8%), stroke and other cerebrovascular disease (10.8%), and lower respiratory infections (6.1%). The scientific data indicate a remarkable shift in causes of death from acute infections to chronic disease. This epidemiological change has been in part discussed by Mary Tinetti, MD (Internal Medicine, Geriatrics), in a recent article in the Journal of the American Medical Association, in which she calls multimorbidity—“the coexistence of multiple chronic diseases or conditions”—the “most common chronic condition”.3 People may live longer with their diseases, but they also live and die with more than one disease at a time. Acknowledgement of this epidemiological shift from acute infectious to chronic causes of death is not to say that issues surrounding the prevention and treatment of acute infectious disease, especially in low-income countries, have been adequately addressed. Nor do the data indicate that, despite the relative prevalence of infectious causes of death in low-income countries, chronic disease is not also a problem in these areas: in fact, death rates for chronic diseases such as cancer are higher and in some cases increasing at a 2  Aufderheide, A. C. and Roderíguez-Martín, C. (1998). The Cambridge Encyclopedia of Human Paleopathology, 117–18. 3  Tinetti, M. E. et al. (2012). ‘Designing health care for the most common chronic conditionmultimorbidity’, JAMA 307, 2493–94.

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more rapid rate than those in high-income countries.4 This broad shift from death due to acute disease, to death due to chronic disease, across all socioeconomic levels, indicates that as we live longer, our bodies have more time to attain an age far greater than that which humanity was accustomed to reach for most of its existence.5 Consequently, we would do well to consider the ways we treat and manage chronic disease, especially that which—as is often the case with chronic pathology—is terminal. Increasingly, physicians worldwide are considering ways in which the divide between patient understanding of chronic disease and physician understanding of chronic disease might be bridged more securely. As a recent paper entitled Using insights from behavioral economics and social psychology to help patients manage chronic diseases notes in the first line of the abstract, “despite a revolution in therapeutics, the ability to control chronic diseases remains elusive”.6 Studying patient adherence to prescribed treatment, and physician understanding of patient illness, physician and anthropologist Arthur Kleinman developed the idea of the “explanatory model”: that is, how the patient him- or herself understands the cause and meaning of the illness.7 This model has been adapted and described further in recent research, which applies the concept of the explanatory model to the treatment of patients with chronic disease with the goal of increasing treatment adherence and improving patient satisfaction and disease outcomes.8 The central point of such research is that the physician must understand the patient’s perspective, if he or she is to convince the patient to commence and to continue treatment in the setting of chronic disease. This task becomes especially difficult in two particular cases: a) when the patient and the physician occupy two very different cultural contexts, and b) when the treatment in question is especially uncomfortable, painful, or disfiguring, such as a mastectomy or nausea-inducing chemotherapy. The tension between varying, even conflicting, cultural contexts and the treatment of chronic disease within those contexts is especially challenging among the world’s Indigenous populations. Many Indigenous peoples, despite residing in countries ranked as ‘high-income’, suffer from severe ­disparities 4  Jemal, A. et al. (2011). ‘Global cancer statistics’, CA: A Cancer Journal for Clinicians 61, 69–90. 5  Caspari, R. (2011). ‘The evolution of grandparents’, Scientific American 305, 44–49. 6  Mogler, B. K. et al. (2013). ‘Using insights from behavioral economics and social psychology to help patients manage chronic diseases’, Journal of General Internal Medicine 28, 711–18. 7  Kleinman, A. (1980). Patients and Healers in the Context of Culture. 8  Morris, D. A. et al. (2012). ‘What is your understanding of your illness? A communication tool to explore patients’ perspectives of living with advanced illness’, Journal of General Internal Medicine 27, 1460–66.

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in access to healthcare, treatment outcomes, and overall patient wellbeing. Recent research has described and attempted to explain the reasons for the higher incidence of chronic disease and barriers to access to care among Indigenous populations in the United States,9 Canada,10 and Australia.11 These studies indicate that while financial, geographical, linguistic, and educational issues are significant barriers to care for many of these patients, fundamental differences in belief structures between Indigenous patients and their nonIndigenous healthcare providers, although more difficult to measure, also greatly affect patient-physician relationships and treatment outcomes. This paper emerged from my studies in medicine, in the history of medicine, in ancient history, and in the role of belief in disease treatment and patient wellbeing. As part of my medical training, I have spent approximately four months over a two-year period living and working in rural and remote Indigenous communities in Western Australia, interviewing Indigenous cancer patients, as well as Indigenous and non-Indigenous healthcare providers, about their experiences living with and treating cancer. The purpose of my research was to investigate the role of belief in patient willingness to undertake different types of cancer treatments, seeking to address belief-related disparities in cancer treatment outcomes and patient satisfaction among Indigenous patients in rural Western Australia. The title of the present article was a comment of one Indigenous patient regarding variant views of cancer therapies and beliefs regarding their efficacy.12 Questions about the role of belief in treatment—especially when the treatment is painful and the disease is chronic—have always been present in medical practice. Observations of the role of belief in disease aetiology and treatment among Indigenous patients are provided in the first section of this paper. The second section examines the role of belief in disease aetiology and treatment in Graeco-Roman antiquity. The third section considers how trust and clear communication between the patient and physician in the setting

9  Bitton, A. et al. (2010). ‘Health risks, chronic disease, and access to care among US Pacific Islanders’, Journal of General Internal Medicine 25, 435–40. 10  Elias, B. et al. (2011). ‘The burden of cancer risk in Canada’s Indigenous population: a comparative study of known risks in a Canadian region’, International Journal of General Medicine 4, 699–709. 11  Schaik, K. van and Thompson S. C. (2012). ‘Indigenous beliefs about biomedical and bush medicine treatment efficacy for Indigenous cancer patients: a review of the literature’, Australian Internal Medicine Journal 42, 184–91. 12  See ** at the bottom of the first page of the chapter.

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of chronic disease facilitate treatment and patient wellbeing in very different times and geographical locations. 1

The Role of Belief in Treatment and Treatment Efficacy in Modern Australia

We begin with the story of Michelle Torrens of New South Wales, Australia, an Indigenous Australian cancer survivor and activist who has written a book for Indigenous patients describing her experiences with cancer.13 The purposes of her book are to urge Indigenous patients to be more forthcoming in seeking and undergoing cancer treatment, and to explain the procedures and side effects they might encounter with biomedical chemotherapeutics and radiation. Ms Torrens’ experience with cancer began when, in severe pain and with substantial abdominal swelling, she presented to several physicians who twice diagnosed her with indigestion. An additional visit to the hospital and several tests later, she was diagnosed with ovarian cancer, and an emergency surgery resulted in the removal of a watermelon-sized ovarian tumour. As her book reveals, Ms Torrens is a remarkable woman, and the publication of her story attests to the challenges faced by Indigenous cancer patients and the nonIndigenous healthcare providers who assist in their treatment. Indigenous Australians suffer from higher cancer morbidity and mortality than non-Indigenous Australians. There are many reasons for this discrepancy, including “socioeconomic and educational factors, language barriers, lack of healthcare provider familiarity with cultural practices, and transportation issues”.14 Recently, however, research has identified differences in disease explanatory models as a reason for discrepancies in cancer outcomes.15 The outcomes of many qualitative, interview-based studies reveal concerns about the toxicity, side effects, and potential disfigurement of cancer treatment. One-on-one interviews, focus groups, and community observation revealed “a prevailing belief among Indigenous women that cancer was a ‘deadly disease’ and that treatment was mostly futile”.16 Moreover, women “dreaded the 13  Torrens, M. (2006). I Looked Beyond My Boundaries and Found Life Again. Featuring: the Choice of Life, Hair is Good but Life is Better. 14  See note 11. 15  For more on the explanatory model, see Kleinman, A. (1976). ‘Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research’, Annals of Internal Medicine 88, 251–58. 16  Prior, D. (2005). ‘Don’t mention the ‘C’ word: Aboriginal women’s view of cancer’, Aboriginal and Islander Health Worker Journal 29, 7–10.

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prospect of cancer treatment especially if it involved surgery”.17 Mastectomies were deeply anxiety-provoking for Indigenous women—as is often the case for women, regardless of their ethnic backgrounds—“because the breast was a vital part of their ‘womanness’ and [the loss of it] could threaten relationships with their husbands or partners”.18 Ms Torrens suggests that fear of the loss of hair, another important symbol of womanhood, is also a treatment deterrent: When they mentioned giving me chemotherapy, for example, I seriously considered not having it and just going home. To me, like to most of my friends, the word has very scary connotations. You think you are going to get even sicker and that all of your hair will fall out and never grow back.19 Besides the loss of physical symbols of womanhood and one’s place within the community, the nausea and sickness associated with chemotherapy were also found to be causes of concern for Indigenous patients. Another study showed that among Indigenous women with breast cancer, pre-existing belief in the efficacy of chemotherapeutics can be diminished by the negative side effects of the biomedical treatment, which “does not fit with the women’s view of health as feeling well and being able to care for one’s children (or grandchildren)”.20 One can see the dilemma. How is an oncologist trained in the Western biomedical tradition (who is aware of double-blind, placebo-controlled trials which strongly support the efficacy of these chemotherapeutic treatments)21 to communicate the potential efficacy of chemotherapeutics to a patient who feels worse after treatment than before?

17  Ibid. 18  Ibid. 19  Satherly, Z. (2006). ‘Review of “Hair is good but life is better” ’, Aboriginal and Islander Health Worker Journal 30, 7. 20  McMichael, C. et al. (2000). ‘Indigenous women’s perceptions of breast cancer diagnosis and treatment in Queensland’, Australia and New Zealand Journal of Public Health 24, 515–19. 21  A double-blind, placebo-controlled trial is an experimental procedure comparing the efficacy of treatments in which neither the recipients of treatment nor the researchers know which patients belong to the control group (receiving either a placebo or currently accepted treatment) and which patients belong to the test group (receiving a new treatment). The aim is to prevent bias on the part of the researchers and those evaluating the patients receiving treatment. Researchers learn to which group the patients belonged after the data have been recorded.

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Implicit in a physician’s ability to communicate such information to a patient is the patient’s attitude toward and trust in the physician. Investigation of issues of trust was precisely the purpose of the fieldwork that I and research mentors and colleagues completed in Western Australia. Feelings of cultural alienation and disconnection from healthcare providers are not uncommon among Indigenous cancer patients, and such feelings are only augmented by experiences and memories of colonialism, the Stolen Generation, and discrimination. But there are other challenges involved, too. Some Indigenous patients, for example, have expressed the view that cancer did not exist in their communities prior to European colonisation: cancer is therefore a ‘white man’s disease’ and should be treated with ‘white man’s medicine’, namely Western doctors and their surgical, radiological, and chemotherapeutic treatments. Still others perceive chemotherapeutics as ‘unnatural’ and therefore harmful. The situation is indeed of a complex nature, and it does become evident how effective patient-physician communication and the patient’s clear understanding of what these treatments involve (side effects, duration, and recovery time) are often difficult to achieve for both linguistic and cultural reasons.22 A final component of understanding Indigenous perceptions of cancer treatment involves inter- and intracultural variability in definitions of health and wellbeing. The Western perception of illness, particularly cancer, is one of what has been termed “biomedical reductionism”: cancer is understood as an identifiable change in the genetic sequence of one specific cell, which subsequently causes that one cell to grow and to divide out of control.23 On the other hand, very broadly, in Indigenous communities in Australia, health is defined as “wellbeing”, affected by lifestyle choices and relationships with others, and it “involv[es] balanced holistic dimensions” including “physical, mental, spiritual, and in some cases social and environmental aspects”.24 Illness can be brought about by interaction with evil or unhappy spirits, and cancer can be considered a consequence of ‘being sung’, or otherwise cursed by members of the community. In these cases—as in many cases in which an ailment is a consequence of singing—complete cures are brought about with the assistance

22  See note 11. 23  McGrath, P. et al. (2006). ‘Insights on Aboriginal peoples’ views of cancer in Australia’, Contemporary Nursing 22, 247. 24  Boulton-Lewis, G. et al. (2002). ‘Conceptions of health and illness held by Australian Aboriginal, Torres Strait Islander, and Papua New Guinea health science students’, Australian Journal of Primary Health, 8, 12 and 14.

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of an ngangkari healer.25 For ‘sung’ cancer patients, chemotherapy, radiation, and surgery are considered by some to be useless without the involvement of the ngangkari. In other instances, both traditional and Western healers can treat a single individual, so cultural perceptions of disease and treatment cannot be understood as strictly dichotomous, though some compartmentalisation regarding ideas about disease aetiology and its associated treatment is observed. Troubling miscommunications between Indigenous patients and their Western healthcare providers about the process of cancer treatment, patient unwillingness or inability to adhere to treatment programs, and different beliefs about treatment efficacy are often related to these very different perceptions of health, illness, and treatment. Some Indigenous cancer patients have expressed the view that biomedical treatment is somehow inadequate. This is either because their illness has been thought of as a consequence of ‘singing’, or, more commonly, because of the terrible side effects of cancer surgeries, chemotherapy, and radiotherapy: nausea, diarrhoea, vomiting, hair loss, crippling fatigue, constipation and a metallic taste in the mouth—not to mention potentially disfiguring surgeries like mastectomies and colectomies. It is not surprising that many patients feel much worse after treatment than before.26 Traditional bush medicine, on the other hand, employed both by senior women with knowledge of herbs and by some ngangkari, is derived seasonally from plants which grow in the remote inland areas of Western Australia. These remedies are administered as a tea and not in an invasive procedure; bush medicine is widely perceived as addressing health holistically. As one respondent said about bush medicine: “There is something in it . . . that is good for your insides, just as a cleanser. Makes all your body organs healthy and strong, it gets rid of all your internal stress”.27 It is notable that not only Indigenous cancer patients opt for bush medicine; some non-Indigenous medical professionals have described in interviews completed by the research team with which I was involved that the administration of bush medicine to 25  Ngangkari are traditional healers of central Australia. Note that the term ngangkari here applies to central Australian Indigenous healers; there are hundreds of different Indigenous Australian linguistic and cultural groups, each with their own unique practices and beliefs. For more information, see Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women’s Council (2013). Traditional Healers of Central Australia: Ngangkari. See also Sleath, E. (2013). ‘Traditional healers share their stories,’ Australian Broadcasting Company Alice Springs and McGrath, ‘Insights’, 245 and 251. 26  See note 11. 27  Shahid, S. et al. (2009). ‘Understanding beliefs and perspectives of Aboriginal people in Western Australia about cancer and its impact on access to cancer services’, BHC Health Services Research 9, 132.

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t­erminally ill family members prolonged life and dramatically improved its overall quality. We return to our question of what a healthcare provider in Australia should or can do in this situation of treatment of chronic disease; and, more relevant for the purposes of this volume, what does this have to do with medicine in the ancient Graeco-Roman world? Studies completed by our team in Western Australia indicated that healthcare providers’ awareness of Indigenous beliefs about cancer, and their willingness to engage with these beliefs, led to positive outcomes. Direct discussion of treatment course and side effects, as well as potential outcomes, generally facilitated better outcomes. Successful outcomes (both in terms of treatment and in terms of patient satisfaction) occurred when patients were encouraged to subscribe to traditional Indigenous remedies—if they so desired— alongside chemotherapeutic regimens, and when physicians refrained from questioning or otherwise commenting upon the reputed efficacy of such traditional treatments. In other words, Western physicians earned the trust of their patients in part by not questioning patients’ belief in efficacy of both bush medicine, and chemotherapeutics, and by predicting—as much as was medically ­feasible—the side effects and treatment course of chemotherapy and radiation. Patients’ increased trust in their physicians was demonstrated by their more forthright discussion of symptoms and by their willingness to discuss issues involving treatment side effects. When patients trusted their physicians, they more willingly accepted the toxic side effects of chemotherapy and radiation and continued treatment to its completion. In summary, these two aspects of treatment are important to remember: that acknowledgement of belief in treatment efficacy—or at least an unwillingness to question the efficacy of non-biomedical treatments—and clear prediction of treatment outcomes enabled the development of trust, as demonstrated in patients’ willingness to proceed with difficult treatments.28 2

The Role of Belief in Treatment and Treatment Efficacy in Graeco-Roman Antiquity

While living at the Pergamene Asclepieion and troubled by severe pain and abdominal swelling, Aelius Aristides of Mysia (modern Turkey), explained his symptoms to several physicians.29 Some of them told him he should be 28  See note 11; also Shahid S. et al. (2013) ‘Improving palliative care outcomes for Aboriginal Australians: service providers’ perspectives’, Biomed Central Palliative Care 12. 29  For more on Aelius Aristides, see Petridou (Chapter Eighteen), 451–470 in this volume.

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treated with surgery, others, with cauterisation; still others told him that an infection would arise and that he would die. Living with unremitting and increasing pain, Aelius Aristides was told by Asclepius in an oneiric encounter to permit the growth (φῦμα) to develop still more, a decision which caused great concern among his physicians. After months of rigorous treatments, Asclepius instructed Aristides to apply a drug containing salt to the growth, which consequently disappeared overnight. The doctors wanted to intervene to restore to normal the loose skin which had covered the tumour. However, as Aristides tells us, Asclepius would permit no such intervention, and the skin was drawn back in over the course of a few days.30 Aelius Aristides is a survivor of numerous diseases and an orator who wrote several books for posterity (δεῖ γάρ με καὶ τοῖς ὕστερον ἀνθρώποις διαλέγεσθαι)31 “to describe the providence of [Asclepius], wherein he revealed some things openly in his own presence and others by the sending of dreams” (ἢ τὴν τοῦ θεοῦ πρόνοιαν διηγεῖσθαι, ὧν τὰ μὲν ἐκ τοῦ φανεροῦ παρὼν, τὰ δὲ τῇ πομπῇ τῶν ἐνυπνίων ἐνεδείκνυτο).32 What was Aristides’ φῦμα, or growth? Was it cancer? Although φῦμα might be translated as “tumour”, in the Latin sense of swelling, such a translation suggests neoplastic malignancy to a modern, English-speaking reader. While retrospective diagnoses are always fraught with difficulty, if one were to speculate about Aristides’ growth, the diagnosis of an omental hernia might be higher on a differential list than that of a malignant neoplasm. The onset of abdominal pain and the presence of a palpable mass could be consistent with strangulation of the hernia: when the hernia reduced on its own, the pain and swelling subsided.33 While Aristides in this particular presentation of abdominal pain likely did not have ‘cancer’, or a malignant neoplasm,34 in the way a patient or physician in today’s world might understand the word, his case nonetheless prompts exploration of the ways in which chronic pain, incurable disease, and painful treatments were viewed by patients and their physicians in GraecoRoman antiquity.

30  Aristid., Or. 47.61–68 Keil. Trans. Behr. 31  Aristid., Or. 51.52 Keil. Trans. Behr. 32  Aristid., Or. 47.3 Keil. Trans. Behr. 33  Horstmanshoff, H. F. ‘Aelius Aristides: A suitable case for treatment’, in Borg, B. (2004), Paideia: The World of the Second Sophistic, 280. 34  Malignant neoplasm is unlikely because of the time course and reversibility of symptoms, though φῦμα, ατος, τό, (φύω), growth, can suggest cancer. Usually the word means ‘that which grows’, and it is frequently used to describe diseased growths, tumour, tubercle, etc.

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Evidence both textual and palaeopathological supports the existence of cancer and chronic disease in the ancient world,35 though both forms of evidence are not without their interpretive challenges. Graumann, providing many excellent examples of textual references to καρκίνωμα and καρκίνος, presents compelling arguments regarding the pitfalls of using modern medical denotations and connotations to interpret Greek words for pathologies, such as καρκίνωμα.36 He argues that while καρκίνωμα might mean cancer as the term is understood in modern medical contexts, it should be understood in its original contexts as a term applying more generally to poorly-healing or non-healing ulcerations (“schlecht oder überhaupt nicht heilende Ulzerationen (Geschwüre)”) which are either visible, on the skin’s surface, or remain invisible under the skin. Aphorisms 6.38 (L. 4.118) hints intriguingly at the potential severity of a condition involving this term: “it is better to give no treatment in cases of hidden cancer; treatment causes speedy death, but to omit treatment is to prolong life” (ὁκόσοισι κρυπτοὶ καρκίνοι γίνονται, μὴ θεραπεύειν βέλτιον· θεραπευόμενοι γὰρ ἀπόλλυνται ταχέως, μὴ θεραπευόμενοι δὲ, πουλὺν χρόνον διατελέουσιν).37 While caution in retrospective diagnosis is warranted, and attention to philological and historical context is essential, dismissal of thoughtful explanations of the pathologies described in classical texts which are offered by trained medical professionals perhaps disregards an important means by which understanding of the ancient world might be enhanced.38 A modern physician makes a differential diagnosis, or a list of possible pathologies, when he or she sees a patient who presents with an unresolved complaint. Such a diagnosis list exists, of course, provided that the physician is conscientious and thorough. Retrospective diagnoses which follow a similarly thorough technique, reliant upon possibilities, differentials, and contexts, are also valuable.39 On the basis 35  For palaeopathological evidence, see note 3, Chapter 13. 36  Graumann, L. A. ‘Die Krankengeschichten in den ‘Epidemien’ des ‘Corpus Hippocraticum’: Retrospektive Diagnosen als ein Beispiel für Kontingenz’, in Koppitz, U. et al. (2004). in Historizität: Erfahrung und Handeln, Geschichte und Medizin, 103–19. 37  Aph. 6.38 (L. 4.572). Trans. Jones. 38  For one such approach to examining the cause of death of a child patient in the early third century AD, see Graumann and Horstmanshoff (Chapter One), 21–80 in this volume. 39  For an alternative view, see Leven, K.-H. ‘ “At times these ancient facts seem to lie before me like a patient on a hospital bed”—Retrospective diagnosis and ancient medical history’, in Horstmanshoff, H. F. and Stol, M. (2004). Magic and Rationality in Ancient Near Eastern and Graeco-Roman Medicine, 369–84. The argument given dismisses the potential of contributions to the history of medicine from palaeopathological study, while understating the possibility of interdisciplinary study by an individual with appropriate training in relevant fields.

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of this guiding principle, I argue that cancer—in the modern, neoplastic sense of the term—did exist in the ancient world; that it inconvenienced and pained people; and that physicians attempted to treat it. Cancer was and remains one of many chronic disease processes associated with pain and treatment-seeking behaviour. Pain is a subjective symptom, even today described with adjectives that are as variable as patients themselves are. Modern physicians try to quantify pain: “How would you rate your pain on a scale of 1 to 10, with 10 being the worst pain you’ve experienced in your life?” is a common attempt at quantification, though still dependent upon the relativity of what a given individual’s most painful experience might be.40 Similar difficulties arise in the interpretation of chronic pain descriptions and treatments in classical texts, and Helen King discusses in detail the words used for pain and their respective contexts.41 Such a deliberate approach, taking into account the philological dimensions of ‘pain’, permits King to show cautiously examples of chronic disease and pain in Hippocratic medical texts, including sciatica and gout.42 Chronic pain was believed to derive from poorlymanaged conditions and was (and remains) an especially difficult problem for physicians to solve. As King describes, in a world in which many physicians considered acute pain a useful guide for diagnosis, prognosis, and treatment, chronic pain “is an all but indecipherable message”.43 Patients’ complaints in the setting of chronic disease often centred upon the intractable inexplicability of chronic pain: physicians simply could not tell them what was wrong, an inability which frustrated and frightened suffering patients. Treatments for chronic disease and pain could themselves be painful. The last of the Hippocratic aphorisms offers a concise yet illustrative summary of the types of painful treatment, and of the frequency of such treatments, to which patients might be subjected: “what drugs will not cure, the knife will; what the knife will not cure, the cautery will; what the cautery will not cure must be considered incurable” (Ὁκόσα φάρμακα οὐκ ἰῆται, σίδηρος ἰῆται ὅσα σίδηρος οὐκ ἰῆται, πῦρ ἰῆται ὅσα δὲ πῦρ οὐκ ἰῆται, ταῦτα χρὴ νομίζειν

40  For modern attempts to understand pain from the patient’s perspective, see Letts (Chapter Two), 81–104 in this volume. 41  King, H. ‘Chronic pain and the creation of narrative’, in Porter, J. I. (1999). Constructions of the Classical Body, 269–86. 42  Ibid., 277. See also Aff. 18 (L. 6.226), Aff. 35 (L. 6.246), Aff. 29–30 (L. 6.240–42), and Morb. 1.3 (L. 6.144–46). 43  King, ‘Chronic pain’, 279.

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ἀνίατα).44 Additionally, the ancient medical instruments excavated around the Mediterranean remind us that, while they bear striking similarities to those used in surgical procedures today, the instruments of two thousand years ago were employed without the benefit of modern anaesthesia.45 Painful treatments, if not popular among patients, were certainly in use. Our sources reveal that despite the pain of treatment, patients were willing to subject themselves to these procedures if they offered hope of cure. Marcus Aurelius, writing in the second century AD, records how there are “­bitter” things (τραχέα) that “we welcome in hope of health” (ἀσπαζόμεθα τῇ ἐλπίδι τῆς ὑγιείας).46 Aelius Aristides describes how, as treatment for this abdominal swelling at the temple, he was ordered to do “paradoxical things”: running barefoot in winter, horseback riding, and sailing to the opposite side of the harbour in a storm and then eating honey and acorns and vomiting.47 In one remarkable example from the fourth century physician Oribasius, a cure is effected by swapping one disease for another: at Pergamum, the god asks a patient who is suffering from epilepsy if he would like to exchange his disease for a different one. The patient says no, he rather seeks “some immediate relief from the evil”. When the god reassures him that the second disease would cure him more easily than anything else, the patient consents and consequently suffers from quartan fever instead.48 It is notable that, even though in the aforementioned examples, the painful treatments are proposed by the god, Aristides still tells us that his friend Zeno said of Asclepius: “nothing is more gentle” and that he is “a refuge”.49 For Aristides, the efficacy of the god’s prescriptions seems to have counterbalanced their associated pain.50 Such examples of patients undergoing painful treatments, emerging across time throughout Graeco-Roman antiquity, demonstrate generally a consistent willingness to subject oneself to painful treatments in the hope of alleviating afflictions both acute and chronic. 44  Aph. 7.87 (L. 4.608); see also Epid. 6.6.3 (L. 5.324) for references to purging, cautery, and excision as treatment for pain. Trans. Jones. 45  Nutton, V. (2013). Ancient Medicine, 188. On ancient surgical instruments and their representation on honorary monuments, and other material evidence, see Baker (Chapter Fourteen), 365–389 in this volume. 46  M. Aur., Med. 5.8.3–4 Haines. Trans. Haines. 47  Aristid., Or. 47.65 Keil. Trans. Behr. 48  Orib., Coll. Med. 45.30.10–14 (Edelstein, Testimonies n. 425). 49  Aristid., Or. 47.17 Keil. Trans. Behr. 50  The idea of using a painful treatment to correct a painful or longstanding problem has a long history. See King, ‘Chronic pain’, 273–74, and on the tradition of paradoxical treatments, see Petsalis-Diomidis, A. (2010). Truly Beyond Wonders: Aelius Aristides and the Cult of Asclepius, 151–67.

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A health provider who could treat chronic disease demonstrated greater knowledge and skill by this very task, as Caelius Aurelianus, a fifth century Roman physician, states explicitly. Aurelianus describes chronic diseases as those which: Quae solo superpositionis tempore superioribus similis, in lentimento vero varia recorporatione formantur, et peritis medicinae claram aeternam ­gloriam quaerunt.51 . . . resemble acute [diseases] only during the time of an attack, but during the intervals between attacks they are treated with various metasyncritic measures. Their successful treatment wins outstanding and everlasting glory for skilful physicians. And he continues: Chroniae autem vel tardae passionis morbi, qui iam praeiudicio quodam corpora possederint, solius medici peritiam poscunt cum neque natura neque fortuna solvantur [. . .] hinc denique Graeci Asclepium nomen sumpsisse dixerunt, quod dura curando primus superaverit vitia [. . .] Alii vero has omnino tacuerunt tamquam impossibiles iudicantes vel incurabilium passionum . . .52 Chronic or slow diseases, which are already in possession of the body by a previous crisis, can be helped only by a skilful physician. For neither nature nor luck can effect a cure . . . the Greeks say that Asclepius derived his name from the fact that he was the first to excel in the treatment of obstinate diseases . . . some authors said nothing at all about such treatments, considering them impossible, since the diseases were incurable . . . According to Aurelianus, facility with the treatment of chronic diseases is the defining skill of an especially talented physician. Aurelianus proceeds to describe treatments of many afflictions of all body parts and systems. Carcinoma is mentioned only in his treatise on acute diseases: when writing on the curability of hydrophobia, Aurelianus references carcinoma as a canoni51  Cael. Aur., TP 1.1. Text and trans. Drabkin. 52  Ibid., 1.2–3.

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cal example of a disease that is incurabilis.53 In general, chronic diseases are treated as acute diseases are treated, with the difference that longer regimens are employed as needed in the case of chronic illness. Aurelianus does not discuss in detail the ways in which a physician might persuade a patient suffering from a chronic disease to undergo treatment, though he does describe levels of treatment: that is, if a patient is still suffering after the use of one treatment, a more radical treatment can be attempted. The physician might begin with treatments more palatable to the patient, and possibly less effective, before encouraging the patient to try a more painful and possibly more effective remedy. How was a physician to accomplish the ‘successful treatment’ of chronic disease, especially if, as discussed above, treatments were themselves often painful? Patients were indeed willing to subject themselves to painful therapies, if, as Marcus Aurelius stated, they offered hope of cure. Galen, too, in his commentary on the Epidemics, writes of patients at Pergamum who were instructed not to drink at all for fifteen days, and it is stated explicitly that if the patient is persuaded that this will produce considerable improvement for him, that gives a strong inducement for him to do everything he is told: οὕτω γέ τοι καὶ παρ’ ἡμῖν ἐν Περγάμῳ τοὺς θεραπευομένους ὑπὸ τοῦ θεοῦ πειθομένους ὁρῶμεν αὐτῷ πεντεκαίδεκα πολλάκις ἡμέραις προϲτάξαντι μηδ’ ὅλως πιεῖν [. . .] μεγάλην γὰρ ἔχει ῥοπὴν εἰς τὸ πάντα ποιῆσαι τὰ προσταττόμενα τὸ πεπεῖσθαι τὸν κάμνοντα βεβαίως ἀκολουθήσειν ὠφέλειαν ἀξιόλογον αὐτῷ.54 And so we also see those among us at Pergamum who, while being treated by the god, obey his order to drink absolutely nothing for a full fifteen days . . . For the sick man’s conviction that there will assuredly follow some remarkable benefit for him has great power [to induce him] to do everything that was ordered to him.55

53  Cael. Aur., CP 3.123. 54  Gal., In Hipp. Epid. 6. comment. 4.8 Wenkebach (= K. 17b. 137). 55  With thanks to James Zainaldin for his thoughtful comments on this text.

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Persuasion of the patient by the physician is essential;56 but how could a physician persuade a patient that a difficult treatment would be successful? Consider the well-known passage from the Prognostic: Τὸν ἰητρὸν δοκέει μοι ἄριστον εἶναι πρόνοιαν ἐπιτηδεύειν· προγιγνώσκων γὰρ καὶ προλέγων παρὰ τοῖσι νοσέουσι τά τε παρεόντα καὶ τὰ προγεγονότα καὶ τὰ μέλλοντα ἔσεσθαι, ὁκόσα τε παραλείπουσιν οἱ ἀσθενέοντες ἐκδιηγεύμενος, πιστεύοιτ’ ἂν μᾶλλον γιγνώσκειν τὰ τῶν νοσεόντων πρήγματα, ὥστε τολμᾷν ἐπιτρέπειν. τοὺς ἀνθρώπους σφέας ἑωυτοὺς τῷ ἰητρῷ. Τὴν δὲ θεραπείην ἄριστα ἂν ποιέοιτο, προειδὼς τὰ ἐσόμενα ἐκ τῶν παρεόντων παθημάτων. Ὑγιέας μὲν γὰρ ποιέειν ἅπαντας τοὺς ἀσθενέοντας ἀδύνατον·τοῦτο γὰρ τοῦ προγιγνώσκειν τὰ μέλλοντα ἀποβήσεσθαι κρέσσον ἂν ἦν ἐπειδὴ δὲ οἱ ἄνθρωποι ἀποθνήσκουσιν, οἱ μὲν πρὶν ἢ καλέσαι τὸν ἰητρὸν, ὑπὸ τῆς ἰσχύος τῆς νούσου, οἱ δὲ καὶ ἐσκαλεσάμενοι παραχρῆμα ἐτελεύτησαν, οἱ μὲν ἡμέρην μίην ζήσαντες, οἱ δὲ ὀλίγῳ πλέονα χρόνον, πρὶν ἢ τὸν ἰητρὸν τῇ τέχνῃ πρὸς ἕκαστον νούσημα ἀνταγωνίσασθαι γνῶναι οὖν χρὴ τῶν παθέων τῶν τοιουτέων τὰς φύσιας, ὁκόσον ὑπὲρ τὴν δύναμίν εἰσι τῶν σωμάτων, ἅμα δὲ καὶ εἴ τι θεῖον ἔνεστιν ἐν τῇσι νούσοισι, καὶ τουτέου τὴν πρόνοιαν ἐκμανθάνειν. Οὕτω γὰρ ἂν θαυμάζοιτό τε δικαίως, καὶ ἰητρὸς ἀγαθὸς ἂν εἴη·καὶ γὰρ οὓς οἷόν τε περιγίγνεσθαι, τούτους ἔτι μᾶλλον δύναιτ’ ἂν ὀρθῶς διαφυλάσσειν, ἐκ πλείονος χρόνου προβουλευόμενος πρὸς ἕκαστα, καὶ τοὺς ἀποθανουμένους τε καὶ σωθησομένους προγιγνώσκων καὶ προαγορεύων ἀναίτιος ἂν εἴη.57 I hold that it is an excellent thing for a physician to practise forecasting. For if he discovers and declares unaided by the side of his patients the present, the past and the future, and fills in the gaps in the account given by the sick, he will be the more believed to understand the cases, so that men will confidently entrust themselves to him for treatment. Furthermore, he will carry out the treatment best if he knows beforehand from the present symptoms what will take place later. Now to restore every patient to health is impossible. To do so indeed would have been better even than forecasting the future. But as a matter of fact men do die, some owing to the severity of the disease before they summon the physician, others expiring immediately after calling him in—living one day or a little longer—before the physician by his art can combat each disease. It is necessary, therefore, to learn the natures of such diseases, how much 56  For more on the role of persuasion in medical treatment, see Pl., Grg. 456b and Lg. 720 and 857c–d. 57  Progn. 1 (L. 2.110–12). Trans. Jones.

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they exceed the strength of men’s bodies, and to learn how to forecast them. For in this way you will justly win respect and be an able physician. For the longer time you plan to meet each emergency the greater your power to save those who have a chance of recovery, while you will be blameless if you learn and declare beforehand those who will die and those who will get better. Prognosis does not offer a cure: it offers a prediction of the disease’s course and, dependent upon that course, the appropriate therapy. Prognosis facilitates persuasion of the patients such that they turn over their bodies to the physician for treatment (πιστεύοιτ’ ἂν μᾶλλον γιγνώσκειν τὰ τῶν νοσεόντων πρήγματα, ὥστε τολμᾷν ἐπιτρέπειν) because the physician is believed more readily. Patients trust the physician more willingly. Accurate prognosis not only promoted persuasion of patients but also increased a provider’s authority over other physicians in a society of multiple treatment modalities and belief systems.58 Galen’s authority over his rivals, for example, and his patients’ willingness to subject themselves to his treatments, were related to his ability to predict disease and treatment outcomes—or so Galen himself says.59 Even if some physicians in certain circumstances might have sought to be the sole health provider for their patients,60 the patients themselves do not seem to have subscribed to the beliefs and treatments of one health provider exclusively.61 Many scholars have demonstrated convincingly how efforts to distinguish between ‘rational’ and ‘temple’ medicine lead to oversimplifications of perceptions of health and healing in a world in which people—physicians and patients—approached healing in a way which today might be called holistic or multidisciplinary.62 Consider the well-known excerpt from chapter four of The Sacred Disease, which has long been held as a ‘modern’ or ‘rational’ approach to disease:

58  Mattern, S. P. (2008). Galen and the Rhetoric of Healing, 79. 59  Ibid., 76. See also Nutton’s edition of Galen’s De praecognitione. 60  Mattern, S. P. (2013). The Prince of Medicine: Galen in the Roman Empire, 239–44. 61  Nutton, Ancient Medicine, 276–78. 62  Horstmanshoff, H. F. ‘Aelius Aristides: A suitable case for treatment’, in Borg, B. (2004). Paideia: The World of the Second Sophistic, 277–90; Gorrini, E. M. ‘The Hippocratic impact on healing cults: The archaeological evidence in Attica’, in Eijk, Ph. J. van der (2005). Hippocrates in Context, 135–56; Eijk, Ph. van der (2005). Medicine and Philosophy in Classical Antiquity, 46; King, Chronic pain, 280.

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καθαίρουσι γὰρ τοὺς ἐχομένους τῇ νούσῳ αἵματί τε καὶ ἄλλοισι τοιούτοις ὥσπερ μίασμά τι ἔχοντας, ἢ ἀλάστορας, ἢ πεφαρμακευμένους ὑπὸ ἀνθρώπων, ἤ τι ἔργον ἀνόσιον εἰργασμένους, οὓς ἐχρῆν τἀναντία τούτων ποιεῖν, θύειν τε καὶ εὔχεσθαι καὶ ἐς τὰ ἱερὰ φέροντας ἱκετεύειν τοὺς θεούς·[. . .] τὰ δ’ ἐχρῆν ἐς τὰ ἱερὰ φέροντας τῷ θεῷ ἀποδοῦναι, εἰ δὴ ὁ θεός ἐστιν αἴτιος οὐ μέντοι ἔγωγε ἀξιῶ ὑπὸ θεοῦ ἀνθρώπου σῶμα μιαίνεσθαι, τὸ ἐπικηρότατον ὑπὸ τοῦ ἁγνοτάτου·ἀλλὰ κἢν τυγχάνῃ ὑπὸ ἑτέρου μεμιασμένον ἤ τι πεπονθὸς, ὑπὸ τοῦ θεοῦ καθαίρεσθαι ἂν αὐτὸ καὶ ἁγνίζεσθαι μᾶλλον ἢ μιαίνεσθαι. τὰ γοῦν μέγιστα τῶν ἁμαρτημάτων καὶ ἀνοσιώτατα τὸ θεῖόν ἐστι τὸ καθαῖρον καὶ ἁγνίζον καὶ ῥύμμα γινόμενον ἡμῖν, αὐτοί τε ὅρους τοῖσι θεοῖσι τῶν ἱερῶν καὶ τῶν τεμενέων ἀποδείκνυμεν, ὡς ἂν μηδεὶς ὑπερβαίνῃ ἢν μὴ ἁγνεύῃ, εἰσιόντες τε ἡμεῖς περιρραινόμεθα οὐχ ὡς μιαινόμενοι, ἀλλ’ εἴ τι καὶ πρότερον ἔχομεν μύσος, τοῦτο ἀφαγνιούμενοι. καὶ περὶ μὲν τῶν καθαρμῶν οὕτω μοι δοκεῖ ἔχειν.63 For the sufferers from the disease they purify with blood and such like, as though they were polluted, blood-guilty, bewitched by men, or had committed some unholy act. All such they ought to have treated in the opposite way; they should have brought them to the sanctuaries, with sacrifices and prayers, in supplication to the gods . . . Yet if a god is indeed the cause, they ought to have taken them to the sanctuaries and offered them to him. However, I hold that a man’s body is not defiled by a god, the one being utterly corrupt and the other perfectly holy. Nay, even should it have been defiled or in any way injured though some different agency, a god is more likely to purify and sanctify it than he is to cause defilement. At least it is godhead that purifies, sanctifies and cleanses us from the greatest and most impious of our sins; and we ourselves fix boundaries to the sanctuaries and precincts of the gods, so that nobody may cross them unless he be pure; and when we enter we sprinkle ourselves, not as defiling ourselves thereby, but to wash away any pollution we may have already contracted. Such is my opinion about purifications. As Philip van der Eijk compellingly argues, the text demonstrates that “gods are ruled out as causes of disease; whether they are ruled out as healers as well is not certain, since the text is silent on this subject”.64 Disease may have a divine component, though this component is, according to the treatise On the Sacred Disease, understood as working through “natural processes”.65 Consequently, combination therapy of the kinds offered by human physicians as well as by 63  Morb. Sacr. 4 (L. 6.362–64). Trans. Jones. 64  Eijk, Medicine and Philosophy, 71. 65  Ibid., 46.

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temple priests does not involve the kind of competition between treatment modalities that leads to mutually exclusive choices by patients. Indeed, the phrase ‘combination therapy’ is perhaps inadequate to describe the treatments the author of On the Sacred Disease might have had in mind, as ‘combination’ could imply the existence of discrete treatment modalities which were less categorised than we might perceive them to be. Let us return to Aelius Aristides and examine how he might have considered and utilised various treatment methods for his afflictions. In his commentary on the passage from The Sacred Tales in which Aristides seeks treatment for his abdominal pain, Horstmanshoff points out that “Asclepius himself is the best doctor” for Aristides.66 Aristides himself says, “I decide to submit to the god, truly as to a doctor, and to do in silence whatever he wishes”.67 Asclepius is a physician for Aristides. He consults Asclepius and follows his prescriptions, but this does not prevent him from doing the same for other human p ­ hysicians.68 While an element of competition for trust between human and divine healers emerges in the works of Aristides, such competition does not encourage Aristides to consult one type of healer exclusively. The important aspect of such tension is that trust in the knowledge and capabilities of the healer persuades Aristides to follow preferentially a given course of action. Aristides did trust and turn to human physicians in the treatment of his illnesses, though when they could not name or cure a given illness—because they had never seen it before—his trust in them was compromised.69 Asclepius could and did diagnose, prognose, and treat Aristides’ illnesses, and did so even as Aristides was using ointments advised by human physicians.70 3 Conclusions Considering the relationship between Aristides and his physician Asclepius, Ido Israelowich writes: “the picture that emerges from the Sacred Tales is a world in which temple medicine and scientific medicine complement each other, share a common professional language, and acknowledge the validity of each other and their therapeutic measures”.71 Aristides’—the patient’s—choice of health 66  Horstmanshoff, Aelius Aristides, 281. 67  Aristid., Or. 47.4 Keil. 68   Israelowich, I. (2012). Society, Disease and Medicine in the Sacred Tales of Aelius Aristides, 113. 69  Ibid., 113–14. 70  Ibid., 118; see also Aristid., Or. 49.10–12 Keil. 71  Israelowich, Society, Disease and Medicine, 121–12.

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provider had less to do with the perceived ease of treatment than it did with his trust in that provider’s competence and care.72 Providers who could inspire trust in their patients through accurate prognosis and prediction of disease course and treatment assumed significant roles in their patients’ care, though not necessarily to the exclusion of other providers and treatment methods.73 Treatment remained guided by patient preference: the patient preferred the physician who focused on the “symptom that most disturb[ed] the patient” and sought to explain its cause and its cure.74 Our ancient sources highlight the significance of treatment difficulty and toxicity; of the role of trust in treatment; of a physician’s ability to predict the course and outcome of treatment; and of co-existing treatments by multiple providers75—all, it might be argued, central aspects in the treatment and management of chronic and/or ­terminal illness, regardless of time and place. Belief, prognosis, and attention to the patients’ wishes have always played, and continue to play, a role in the formation and maintenance of the patient-physician relationship. Modern approaches to the treatment of illness, and especially of cancer, emphasise the importance of physicians appreciating patients’ perspectives of disease aetiology and appropriate treatment.76 The idea that Aristides “enjoyed his bad health”77 perhaps oversimplifies Aristides’ understanding of his afflictions and his narrative of them as the means by which he could express his gratitude to the physicians who healed him; establish himself as an orator; and present his autobiography and story of redemptive healing to a broader audience.78 Israelowich summarises well how we might understand better Aristides as a patient and medical writer:79

72  Aristides might have called Asclepius ‘gentle’, but this ‘gentle’ god also prescribed ostensibly unpleasant or painful remedies, including excessive bloodletting from unusual locations, such as the elbow and forehead (Aristid., Or. 48.47 Keil; Israelowich, Society, Disease and Medicine, 116). 73  Ibid., 118. 74  King, ‘Chronic pain’, 280. 75  Aristides was unusual, though his views are not unrepresentative of the medical aspects of the society in which he lived: see Israelowich, Society, Disease and Medicine, 104–05. 76  Kleinman, Patients and Healer; Dein, S. (2004). ‘Explanatory models of and attitudes towards cancer in different cultures’, The Lancet Oncology 5, 119–24. 77  Horstmanshoff, ‘Aelius Aristides’, 287. 78  Israelowich, Society, Disease and Medicine, 19–26, 29–35. 79  Ibid., 128.

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Placing the medical history of Aelius Aristides, as portrayed in the Sacred Tales, in the context of the social, cultural, and political climate in which he lived demonstrates that rather than trying to find an eccentric or alternative remedy Aristides conceived of his illness and sought medical help in the places his world designated as the most suitable for these purposes. Aristides’ choices of treatment options from those available to him suggest an erudite and careful approach rather than one which was superstitious and sporadic. Ms Torrens says of her own book: “my people are often confused by the medical system and fearful of the complex new medical treatments and technologies on offer like chemotherapy, renal dialysis and radiation therapy . . . The very mention of these words fills them with suspicion and some would prefer to go home—where they might get sicker and even die—rather than being subjected to a therapy they think might be invasive or destroy their body in some way”.80 She wrote her book with the goal of providing “a guide and a talking point for Indigenous people to bring their ill health and medical treatment out into the open so they can connect with community and receive support, encouragement and help, rather than going it alone or rejecting treatment altogether”.81 This volume discusses in detail another sick individual who wrote down his experiences for a purpose not dissimilar, though he lived nearly two thousand years before Ms Torrens, and on a different continent. Australian Indigenous belief in the significance of the health of the whole person—and in its openness to utilisation of multiple treatment modalities—has much to teach modern Western physicians and historians of medicine about the nature of the patient-physician relationship and the importance of trust and belief in the process of disease diagnosis and treatment. While GraecoRoman antiquity, it must be acknowledged, had its share of physicians impatient with patients’ seemingly fickle treatment-seeking behaviour, medicine in the world described by Aelius Aristides, with its multiplicity of treatment modalities,82 is inspiringly tolerant. But let us not, in a discussion of physicians, forget the patients, whose beliefs and goals guide their choices and treatments. Both authors, Michelle Torrens and Aelius Aristides, are survivors. They advocate the seeking of treatment for the preservation of life, and they both still acknowledge that 80  See notes 13 and 19. 81  Ibid. 82  See note 57.

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sometimes, diseases are incurable and that inevitably, people die. Their books attest to humanity’s persistent struggle with contemporary medical establishments, perceptions of disease aetiology, divine and human healers, pain, death, and above all, the desire to be cured of suffering and the desire to help others who suffer. For them, the sharing of their stories may not cure you and may not save your life, but it will help you. Texts and Translations Used Aelius Aristides. Quae supersunt omnia. Ed. B. Keil, vol. 2. Berlin: Weidmann, 1898. ———. Sacred Tales. Ed. and trans. C. A. Behr. Amsterdam: A. M. Hakkert, 1968. Caelius Aureliaus. On Acute Diseases and On Chronic Diseases. Ed. and trans. I. E. Drabkin. Chicago: University of Chicago Press, 1950. Galen. Oeuvres complètes d’Hippocrate. Ed. É. Littré, vol. 1–10. Paris: Baillière, 1839–61. ———. Claudii Galeni opera omnia. Ed. C. G. Kühn, 22 vols. Leipzig: Cnobloch, 1821–33, repr. Hildesheim, 1964–1965. ———. De praecognitione. Ed. V. Nutton, CMG V.8,1. Berlin: Akademie-Verlag Berlin, 1979. ———. Galeni In Hippocratis Epidemiarum librum VI commentaria I–VI. Ed. E. Wenkebach. CMG V 10,2,2, Berlin: Academia Berolinensis, 1956. Hippocrates. Affections. Trans. P. Potter. The Loeb Classical Library 472. Cambridge, MA: Harvard University Press, 1988. ———. Ancient Medicine, Airs, Waters, Places, Epidemics 1 and 3, The Oath, Precepts, Nutriment. Trans. W. H. S. Jones. The Loeb Classical Library 147. Cambridge, MA: Harvard University Press, 1952. ———. Epidemics 2, 4–7. Trans. W. D. Smith. The Loeb Classical Library 477. Cambridge, MA: Harvard University Press, 1994. ———. Nature of Man, Regimen in Health, Humours, Aphorisms, Regimen 1, Regimen 2, Regimen 3, Dreams. Trans. W. H. S. Jones. The Loeb Classical Library 150. Cambridge, MA: Harvard University Press, 1953. ———. Prognostic, Regimen in Acute Diseases, The Sacred Disease, The Art, Breaths, Law, Decorum, Physician, Dentition. Trans. W. H. S. Jones. The Loeb Classical Library 148. Cambridge, MA: Harvard University Press, 1953. Marcus Aurelius. Trans. C. R. Haines. The Loeb Classical Library 58. Cambridge, MA: Harvard University Press, 1953. Oribasius. Collectionum Medicarum Reliquiae. Ed. J. Raeder. Leipzig: B. G. Teubner, 1928–33. Plato. Laws. Trans. R. G. Bury, vols. 1–2. The Loeb Classical Library 187, 192. Cambridge, MA: Harvard University Press, 1926.

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———. Lysis, Symposium, Gorgias. Trans. W. R. M. Lamb. The Loeb Classical Library 166. Cambridge, MA: Harvard University Press, 2001.

References Aufderheide, A. C. and Roderíguez-Martín, C. The Cambridge Encyclopedia of Human Paleopathology. Cambridge: Cambridge University Press, 1998. Bitton, A., Zaslavsky, A. M. and Ayanian, J. Z. ‘Health Risks, Chronic Diseases, and Access to Care Among US Pacific Islanders.’ Journal of General Internal Medicine 25, (2010): 435–40. Borg, B. (ed.) Paideia: The World of the Second Sophistic. Berlin and New York: Walter de Gruyter, 2004. Boulton-Lewis, G., Pillay, H., Wilss, L. and Lewis, D. ‘Conceptions of Health and Illness Held by Australian Aboriginal, Torres Strait Islander, and Papua New Guinea health science students.’ Australian Journal of Primary Health 8, (2002): 8–16. Caspari, R. ‘The Evolution of Grandparents.’ Scientific American 305, (2011): 44–49. Dein, S. ‘Explanatory Models of and Attitudes Towards Cancer in Different Cultures.’ The Lancet Oncology 5, (2004): 119–24. Edelstein, L. and Edelstein, E. Asclepius: a collection and interpretation of the testimonies. New York, Arno Press, 1975. Eijk, Ph. J. van der, Medicine and Philosophy in Classical Antiquity. Cambridge: Cambridge University Press, 2005. Elias, B., Kliewer, E. V., Hall, M., Demers, A. A., Turner, D., Martens, P., Hong, S. P., Hart, L., Chartrand, C. and Munro, G. ‘The Burden of Cancer Risk in Canada’s Indigenous Population: A Comparative Study of Known Risks in a Canadian Region.’ International Journal of General Medicine 4, (2011): 699–709. Gorrini, E. M. ‘The Hippocratic Impact on Healing Cults: The Archaeological Evidence in Attica.’ in Hippocrates in Context. Papers Read at the XIth International Hippocrates Colloquium, University of Newcastle upon Tyne, 27–31 August 2002, ed. Ph. J. van der Eijk, 135–56, Studies in Ancient Medicine 31. Leiden: Brill, 2005. Graumann, L. A. ‘Die Krankengeschichten in den ‘Epidemien’ des ‘Corpus Hippocraticum’: Retrospektive Diagnosen als ein Beispiel für Kontingenz.’ in Historizität: Erfahrung und Handeln, Geschichte und Medizin, ed. U. Koppitz, A. Labisch and N. Paul, 103–19. Stuttgart: Franz Steiner Verlag, 2004. Horstmanshoff, H. F. ‘Aelius Aristides: A suitable case for treatment.’ in Paideia: The World of the Second Sophistic, ed. B. Borg, 277–90. Berlin and New York: Walter de Gruyter, 2004. Horstmanshoff, H. F. and Stol, M. (eds.). Magic and Rationality in Ancient Near Eastern and Graeco-Roman Medicine. Leiden and Boston: Brill, 2004.

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Israelowich, I. Society, Disease and Medicine in the Sacred Tales of Aelius Aristides. Leiden and Boston: Brill, 2012. Jemal, A., Bray, F., Center, M. M., Ferlay, J., Ward, E. and Forman, D. ‘Global Cancer Statistics.’ CA: A Cancer Journal for Clinicians 61, (2011): 69–90. King, H. ‘Chronic Pain and the Creation of Narrative.’ in Constructions of the Classical Body, ed. J. I. Porter, 269–86. Ann Arbor: University of Michigan Press, 1999. Kleinman, A. ‘Culture, Illness and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research.’ Annals of Internal Medicine 88, (1976): 251–58. ———. Patients and Healers in the Context of Culture. Berkeley: University of California Press, 1980. Koppitz, U., Labisch, A., and Paul, N. (eds.) Historizität: Erfahrung und Handeln, Geschichte und Medizin. Stuttgart: Franz Steiner Verlag, 2004. Leven, K.-H. ‘ “At Times These Ancient Facts Seem to Lie Before Me Like a Patient on a Hospital Bed”—Retrospective Diagnosis and Ancient Medical History.’ in Magic and Rationality in Ancient Near Eastern and Graeco-Roman Medicine, ed. H. F. Horstmanhoff and M. Stol, 369–84, Studies in Ancient Medicine 27. Leiden: Brill, 2004. Mattern, S. P. Galen and the Rhetoric of Healing. Baltimore: Johns Hopkins University Press, 2008. ———. The Prince of Medicine: Galen in the Roman Empire. Oxford: Oxford Uuniversity Press, 2013. McGrath, P., Holewa, H., Ogilvie, K., Rayner, R. and Patton, M. A. ‘Insights on Aboriginal peoples’ Views of Cancer in Australia.’ Contemporary Nursing 22, (2006): 240–54. McMichael, C., Kirk, M., Manderson, L., Hoban, E. and Potts, H. ‘Indigenous Women’s Perceptions of Breast Cancer Diagnosis and Treatment in Queensland.’ Australia and New Zealand Journal of Public Health 24, (2000): 515–19. Mogler, B. K., Shu, S. B., Fox, C. R., Goldstein, N. J., Victor, R. G., Escarce, J. J. and Shapiro, M. F. ‘Using Insights From Behavioral Economics and Social Psychology to Help Patients Manage Chronic Diseases.’ Journal of General Internal Medicine 28, (2013): 711–18. Morris, D. A., Johnson, K. S., Ammarell, N., Arnold, R. M., Tulsky, J. A. and Steinhauser, K. ‘What is Your Understanding of Your Illness? A Communication Tool to Explore Patients’ Perspectives of Living with Advanced Illness.’ Journal of General Internal Medicine 27, (2012): 1460–66. Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women’s Council. Traditional Healers of Central Australia: Ngangkari. Broome, Western Australia: Magabala Books Aboriginal Corporation, 2013. Nutton, V. Ancient Medicine. 2nd ed. London and New York: Routledge, 2013. Petsalis-Diomidis, A. Truly Beyond Wonders: Aelius Aristides and the Cult of Asclepius. Oxford: Oxford University Press, 2010.

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Porter, J. I. (ed.) Constructions of the Classical Body. Ann Arbor: University of Michigan Press, 1999. Prior, D. ‘Don’t mention the ‘C’ word: Aboriginal women’s views of cancer.’ Aboriginal and Islander Health Worker Journal 29, (2005): 7–10. Satherly, Z. ‘Review of Hair is good but life is better.’ Aboriginal and Islander Health Worker Journal 30, (2006). Schaik, K. van and Thompson, S. C. ‘Indigenous Beliefs About Biomedical and Bush Medicine Treatment Efficacy for Indigenous Cancer Patients: A Review of the Literature.’ Australian Internal Medicine Journal 42, (2012): 184–91. Shahid, S., Finn, L., Bessarab, D. and Thompson, S. C. ‘Understanding Beliefs and Perspectives of Aboriginal People in Western Australia About Cancer and Its Impact on Access to Cancer Services.’ BHC Health Services Research 9, (2009): 132. Shahid, S., Bleam, R., Bessarab, D. and Thompson, S. C. ‘If You Don’t Believe It, It Won’t Help You’: Use of Bush Medicine in Treating Cancer Among Aboriginal People in Western Australia.’ Journal of Ethnobiology and Ethnomedicine 6.18, (2010). Shahid S., Besserab D., Schaik K. D. van, Aoun, S. and Thompson, S. C. ‘Improving Palliative Care Outcomes for Aboriginal Australians: Service Providers’ Perspectives.’ Biomed Central Palliative Care 12, (2013). Sleath, E. ‘Traditional Healers Share Their Stories.’ Australian Broadcasting Company Alice Springs, 2013. Tinetti, M. E., Fried T. R. and Boyd, C. M. ‘Designing Health Care for the Most Common Chronic Condition—Multi-morbidity.’ JAMA 307, (2012): 2493–94. Torrens, M. I Looked Beyond My Boundaries and Found Life Again. Featuring: the Choice of Life, Hair is Good but Life is Better. Southern Cross University, 2006. World Health Organization. The top 10 causes of death worldwide. Fact sheet 310, June 2011.

Epilogue

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CHAPTER 20

Approaches to the History of Patients: From the Ancient World to Early Modern Europe Michael Stolberg This chapter looks from an early modernist’s perspective at some of the major questions and methodological issues that writing the history of patients in the ancient world shares with similar work on Patientengeschichte in medieval and early modern Europe. It addresses, in particular, the problem of finding adequate sources that give access to the patients’ experience of illness and medicine and highlights the potential as well as the limitations of using physicians’ case histories for that purpose. It discusses the doctor-patient relationship as it emerges from these sources, and the impact of the patient’s point of view on learned medical theory and practice. In conclusion, it pleads for a cautious and nuanced approach to the controversial issue of retrospective diagnosis, recommending that historians consistently ask in which contexts and in what way the application of modern diagnostic labels to pre-modern accounts of illness can truly contribute to a better historical understanding rather than distort it. Until the 1970s, the writing of medical history focused almost exclusively on physicians, on their lives and works, on their theories and discoveries. The patients remained marginal figures in these accounts. They were largely the faceless objects of the physicians’ diagnostic considerations and therapeutic and preventative interventions, of institutions of medical care, of public health campaigns, of scientific research. Only a small minority of celebrity patients like Mozart or Nietzsche attracted considerable attention, prompting, amongst others, countless attempts at identifying, in modern diagnostic terms, the diseases from which they had suffered and died.1

1  See, e.g. Böhme, G. (1981). Medizinische Portraits berühmter Komponisten; Franken, F. H. (1986–97). Die Krankheiten großer Komponisten; Neumayr, A. (2007). Berühmte Komponisten im Spiegel der Medizin.

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Over the last decades, the situation has changed profoundly. With the rise of a critical medical sociology2 and the new social history of medicine,3 and in line with a new movement for patients’ rights and widespread complaints about the dehumanizing effects of modern biomedicine, the patient has become an accepted and indeed indispensable part of the medico-historical narrative. Historians have attempted to reconstruct the subjective experience of illness in different historical periods and different socio-cultural contexts. They have described how sufferers and families coped with illness and its effects.4 They have examined the role of self-help and domestic medicine5 and the uses people made of different types of healers. They have followed patients’ attempts to make sense of their suffering in medical, bodily terms as well as in philosophical, metaphysical and religious ones. They have tried to understand the impact of religious beliefs,6 social status, and changing cultural and social norms on the experience of illness. Some thirty years after Roy Porter’s often quoted plea for medical history from “the patient’s view”,7 we can draw now on an impressive body of work. In German-language historiography, the field has even obtained a name of its own: Patientengeschichte.8 Work on Patientengeschichte has focused primarily on the history of illness and medicine from the patient’s point of view, on the patient as a sentient, 2  See e.g. Freidson, E. (1961). Patients’ views of medical practice. A study of subscribers to a prepaid medical plan in the Bronx. 3  For a good overview of changing issues and approaches see Huisman, F. and Warner, J. H. (eds.) (2004). Locating medical history. The stories and their meanings. 4  To cite only some of the major early contributions: Herzlich, C. and Pierret, J. (1984). Malades d’hier et malades d’aujourd’hui: De la mort collective au devoir de guérison; Porter, R. (ed.) (1985). Patients and practitioners. Lay-perceptions of medicine in pre-industrial society; Porter, R. and Porter, D. (1988). In sickness and in health. The British experience 1650–1850; id. (1989). Patient’s progress. Doctors and doctoring in eighteenth-century England. 5  Rankin, A. (2008). ‘Duchess, heal thyself. Elisabeth of Rochlitz and the patient’s perspective in early modern Germany’, Bull. Hist. Med. 82, 109–44. 6  See e.g. Ernst, K. (2003). Krankheit und Heilung. Die medikale Kultur württembergischer Pietisten im 18. Jahrhundert. 7  Porter, R. (1985). ‘The patient’s view. Doing medical history from below’, Theory and Society 14, 175–98. 8  For historiographical overviews see Wolff, E. ‘Perspektiven der Patientengeschichtsschreibung’, in Paul, N. and Schlich, T. (1998). Medizingeschichte: Aufgaben, Probleme, Perspektiven, 311–30; Ernst, K. ‘Patientengeschichte. Die kulturhistorische Wende in der Medizinhistoriographie’, in Bröer, R. (1999). Eine Wissenschaft emanzipiert sich. Die Medizinhistoriographie von der Aufklärung bis zur Postmoderne, 97–108; Rieder, P. (2003). ‘L’histoire du “patient”. Aléa, moyen ou finalité de l’histoire médicale?’, Gesnerus 60, 260–71 (review essay); Condrau, F. (2007). ‘The patient’s view meets the clinical gaze’, Social History of Medicine 20, 525–40.

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experiencing and acting person. Obviously, this is only one way of approaching ‘the patient’ in history, however, as this book illustrates. Many contributions to this volume do not primarily deal with the “patient’s view” in a strict sense, leave alone with the patient’s personal experience of disease and medicine. Due not least to the lack of alternative sources, they take the physician’s perspective on the patients as their starting point. What unites all of these studies, however, is their focus on the patient as an individual sufferer rather than, say, on theories of disease, famous physicians or hospitals. For historians working on the more recent past, these studies offer, for the first time, an overview of many different aspects of patienthood in ancient societies. They invite comparison and, at the same time, highlight some of the limitations and methodological challenges that any medical history has to come to terms with that puts the individual patient and his or her perspective to the foreground. In what follows, I want to present and discuss, from an early modernist’s point of view, some of the overarching questions and methodological issues that the historical study of the patient in ancient cultures, as presented in this volume, shares with that of the later times. In doing so, I hope to place this volume in a wider historiographical context and to highlight also some of the possibilities and challenges of writing a history of the homo patiens in general. I will start with the difficulties of any attempt to recover the patients’ own voices and with what we can learn about the patients’ experience of illness and medicine from the writings of others, especially physicians’ case histories. I will then offer some remarks on how a focus on the individual patient and the doctor-patient relationship can also enrich our understanding of the development of learned medical theory and practice. In conclusion, I will discuss the vexed problem of retrospective diagnosis and ask to what degree the application of modern diagnostic labels to premodern accounts of illness can contribute to a patient-centred history of medicine. 1

Recovering the Patient’s Voice

At first glance, we might take it for granted that any attempt to write a history of the patient would rely above all on what patients themselves had to say about their illnesses. We would expect, as a result, that the output of historical works on this topic would increase the more we advance in time, due to a steadily increasing availability of sources. As a look at the extant literature quickly reveals, however, this proves to be true only in part. In spite of an abundance of relevant sources and the rise of the new genre of first-person

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“pathography”,9 the more recent past has remained a relatively understudied area of Patientengeschichte.10 This comparative lack of interest among historians of the nineteenth and twentieth centuries seems to be due to a considerable extent to a different notion of the ‘patient’. Drawing on the work of Michel Foucault and of medical sociologists, historians of the nineteenth and twentieth centuries have tended to define the ‘patient’ as someone who stands in a relationship with physicians and the healthcare system in general. Book-titles like Vom Kranken zum Patienten (“From the sick [person] to the patient”) have reflected this particular understanding of the term “patient”11 and promoted it in turn. Narrowing the historical analysis of the “patient” to that of his or her role as an object of the medical gaze disregards the obvious fact, however, that patiens in Latin simply means “sufferer” and that we find it used in this sense for many centuries. As a result, in works concerned with the nineteenth and twentieth centuries, the “patient” in this new, narrow sense tends to be described virtually by definition as an object, as subordinate to the pouvoir médical, deprived of her or his individuality. Understanding the patient primarily as an object of the professional medical gaze and the healthcare apparatus, as well as a target of public health policies has been fruitful in focusing the historians’ attention on issues of power, discipline and governmentality.12 Somewhat ironically, however, historical writing about this period has paid relatively little attention to the experience and agency of the individual patient. In a sense, historians have reproduced the very marginalisation of the patient as a subject which they denounce in nineteenth- and twentieth-century medicine.13 If Patientengeschichte has been, by contrast, a particularly fruitful field of research among early modernists, this clearly also reflects different methodological preferences. Historians of premodern eras are accustomed to looking for the unfamiliar, the historically contingent. They tend to focus on what is specific to a given society or culture rather than perceiving 9  The term usually refers to sufferers’ personal accounts of their own illnesses; cf. Hawkins, A. H. (1993). Reconstructing Illness. Studies in pathography. 10  Some studies deal with the recent past within a larger chronological framework; see e.g. Lachmund, J. and Stollberg, G. (1995). Patientenwelten. Krankheit und Medizin vom späten 18. bis zum frühen 20. Jahrhundert im Spiegel von Autobiographien; Schweig, N. (2009). Gesundheitsverhalten von Männern. Gesundheit und Krankheit in Briefen 1800–1950. 11   Loetz, F. (1993). Vom Kranken zum Patienten. “Medikalisierung” und medizinische Vergesellschaftung am Beispiel Badens 1750–1850. 12  See e.g. Stein, C. (2011). ‘The birth of biopower in eighteenth-century Germany’, Medical History 55, 331–37. 13  Sarasin, P. (2001). Reizbare Maschinen. Eine Geschichte des Körpers 1765–1914.

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historical phenomena within a history of the present. Drawing on historical anthropology, Alltagsgeschichte and, to a lesser degree, literary studies early modernists have uncovered an abundance of first-person accounts of patients (as well as families and friends) from which to reconstruct the patient’s voice. In the literally hundreds of handwritten or published autobiographies that have survived from the sixteenth to the eighteenth centuries14 just as in personal diaries from that period, episodes of serious illness frequently rank among the major events the authors deemed worth recording. Likewise, in their personal correspondences early modern men and women often exchanged news about illnesses (and deaths) and about their experiences with different physicians or recommended certain remedies they had found useful before in similar cases. The fairly common practice of consultation by letter resulted in thousands of letters written by the patients themselves or their relatives or friends, with often detailed accounts of present complaints, previous illness episodes and the treatment undertaken so far.15 The body of available sources for the early modern period is impressive. Still, work on these sources has to come to terms with some serious limitations. Two deserve particular attention. The first one concerns the degree to which the surviving sources can be taken to be representative of the whole ­population. There were great differences between areas of Europe and between town and countryside but, generally speaking, the voice of lower-class patients has only rarely been preserved in first-person accounts before the nineteenth century and even then, their accounts were usually written down by someone else. Miracle books, for example, can throw some light on the role of religious faith and occasionally offer accounts of the sufferer’s previous experiences and the medical culture in which she or he moved.16 Records of court proceedings against unlicensed medical practitioners may comprise the protocols of extensive interrogations. The accused themselves and the witnesses reported how they dealt with the disease, how they interpreted it, where they sought help etc. As valuable as they are, such records can only offer isolated glimpses, however, and the context of their production inevitably leaves its mark. Accounts of miraculous healings cannot be expected to expand on the ­successful ­previous 14  Lumme, C. (1996). Höllenfleisch und Heiligtum. Der menschliche Körper im Spiegel autobiographischer Texte des 16. Jahrhunderts. 15  Stolberg, M. (1996). ‘ “Mein äskulapisches Orakel!”: Patientenbriefe als Quelle einer Kulturgeschichte der Krankheitserfahrung im 18. Jahrhundert’, Österreichische Zeitschrift für Geschichtswissenschaft 7, 385–404. 16  See e.g. Lederer, D. ‘Constructing a wonder. The influence of popular culture on miracle books’, in Behringer, W. et al. (2013). Mediale Konstruktionen in der Frühen Neuzeit, 43–56.

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efforts of physicians. And in court proceedings against unlicensed healers, people are unlikely to volunteer information on illicit practices such as magical healing, which they know might get them into trouble. Apart from these occasional first-person accounts, we largely have to rely on what other, literate members of society reported about the beliefs and practices of the silent majority and their interaction with health care providers and public health officials. The second major limitation in working with patients’ first-person writings is of a methodological kind. Even with first-person accounts, the historian’s access to the personal, subjective experience of illness and medical care is only indirect. The verbal expression of physical sensations like pain but also of feelings like fear, anger or sadness, which are frequently an important part of the illness experience, is not identical with these sensations and emotions. What is more, even the most personal, private first-person account is inevitably shaped by linguistic and literary conventions and by cultural norms such as standards of manliness, honour and self-control, to name just a few. Historians must take such effects even more into consideration when the writer could expect or indeed wanted others to read his or her account or when the account was drafted in retrospect, after a considerable amount of time had passed, as in memoirs and autobiographies. In certain respects, historians can turn this to their advantage. They can use patients’ first-person accounts as a valuable source to study the pervasive impact of such literary conventions and cultural norms. The historians’ dream of an immediate access to the patients’ experience, however, remains unfulfilled. In a way, these limitations are good news for historians who study the patient in ancient Greece and Rome and in pre-Renaissance Europe in ­general. Their access to patients’ first-person accounts is extremely limited in the first place. As the contributions to this volume demonstrate, the scarcity of first-person accounts authored by the patients themselves, or by families and friends who took care of them, is quite possibly the most important difference from modern testimonies as we set out to write the history of patients in ancient society. There are a couple of early modern patients like Hermann von Weinsberg in sixteenth-century Cologne17 and Samuel Pepys in seventeenth-century

17  Weinsberg, H. von (2000). Das Buch Weinsberg. Kölner Denkwürdigkeiten aus dem 16. Jahrhundert; cf. Jütte, R. (1989). ‘ “ Wo kein Weib ist, da seufzet der Kranke”. Familie und Krankheit in der Frühen Neuzeit’, Jahrbuch des Instituts für Geschichte der Medizin der Robert Bosch Stiftung 7, 7–24; id. (1991). Ärzte, Heiler und Patienten. Medizinischer Alltag in der frühen Neuzeit; id. (2013). Krankheit und Gesundheit in der Frühen Neuzeit.

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London18 whom historians tend to quote quite frequently. None has reached the exceptional status, however, which Aelius Aristides and his Hieroi logoi have acquired in this respect as a virtually unique (and relatively late) firstperson account from antiquity.19 Other first-person accounts of illness experiences written by patients or families that have survived from ancient Greece and Rome are fragmentary at best. As Chiara Thumiger points out in her contribution to this volume, the lack of first-person accounts must not be taken to mean that the patient’s voice remains entirely silent in the sources. Case histories, in particular, frequently reveal at least some traces of the patient’s own narrative. At times the physician may explicitly report, in his own words, what a patient told him. More frequently, case histories describe experiences and events such as physical sensations or past disease episodes of which the physician could only know from the patient and his or her family. And as we will see in a moment, case histories are a particularly rich source if we want to understand what actually happened to patients and shaped their experience of the medical encounter and of the disease itself. 2

Interactions and Practices

Late medieval and early modern authors of deontological works with titles such as De cautelis medici or Politicus medicus frequently elaborated on the patients and families, on the ways in which they dealt with illnesses and reacted to the physicians, and on what the physician had to do in order to secure their trust in his medical expertise and skills.20 Some of the contributions to this volume 18  Pepys, S. (1953). The diary of Samuel Pepys. 19  Cf. Steger, F. (2001). ‘Medizinischer Alltag in der römischen Kaiserzeit aus Patienten­ perspektive: P. Aelius Aristides, ein Patient im Asklepieion von Pergamon’, Medizin Gesellschaft Geschichte 20, 45–71; Horstmanshoff, H. F. J. ‘Asclepius and temple medicine in Aelius Aristides’ “Sacred Tales” ’, in Horstmanshoff, H. F. J. and Stol, M. (2004). Magic and Rationality in Ancient Near Eastern and Graeco-Roman Medicine, 325–41; Steger, F. (2004). Asklepiosmedizin. Medizinischer Alltag in der römischen Kaiserzeit, esp. chapter 3.3; and the contributions by Georgia Petridou and Katherine van Schaik in this volume (Chapters Eighteen and Nineteen). 20  Zerbi, G. (1495). Opus perutile de cautelis medicorum; cf. Münster, L. (1956). ‘In tema di deontologia medica. Il “De cautelis medicorum” di Gabriele Zerbi’, Rivista di storia delle scienze mediche e naturali 47, 60–83; Villanova, A. de ‘De cautelis medicorum’, trans. H. E. Sigerist, in Grant, E. (1974). A source book of medieval science; Castro, R. da (1662). Medicus-politicus: sive de officiis medico-politicis tractatus; Hoffmann, F. (1738). Medicus

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examine similar prescriptive sources from the ancient times. The chapter by Amber Porter underlines the remarkable place which Soranus and Caelius Aurelianus attributed to compassion and the idea of a “humanitas medicinae”. Along similar lines, Giulia Ecca highlights the caution that the Hippocratic Praecepta recommended to the physician when it came to charging fees. Galen in his De sanitate tuenda, as presented by John Wilkins, advised the physicians to adapt their dietetic council to the individual patient, which implied that they had to enquire quite precisely into the patient’s individual constitution and way of life. Melinda Letts studies the debates in ancient Greek medicine about the importance of the patient narrative for medical diagnosis. Obviously, those physicians who did consider the patient narrative essential for their diagnosis would have to listen carefully to what their patients had to say, devote time to them, take them seriously as individuals. In this sense, Courtney Roby shows the place Galen attributed to the patient’s account for the diagnosis of pain. Of course, the attitudes towards the patients, which we find expressed in such normative writings, cannot be taken to reflect actual practice. As the authors of these contributions show, such texts offer some clues, however, as to what patients could ideally expect when they consulted a physician—and what the medical writers, in turn, thought the patients wanted. Case histories, in turn, offer a welcome tool to examine to what degree physicians took the deontological and ethical commitments expressed in general writing seriously in their practice. In this sense, case histories are not only an important source from which we can reconstruct the patient’s own voice, especially when we lack direct first person accounts. They also offer manifold insights into what it must have meant and felt like to be a patient through the description of their interactions with the physician. After all, to this day the encounter with the physician and his or her diagnosis and treatment is frequently a central aspect of the illness experience. The case histories of Johannes Aktouarios’ De urinis, for instance, like those of other physicians, were above all a means of self-­fashioning and aimed at highlighting his outstanding skills. Yet as we learn from Petros Bouras-Vallianatos’ paper, they also hint at patients’ nonpoliticus sive regulae prudentiae secundum quas medicus juvenis studia sua & vitae rationem dirigere debet, si famam sibi felicemque praxin & cito acquirere & conservare cupit; cf. Eckart, W. U. ‘Anmerkungen zur “Medicus politicus”- und “Machiavellus Medicus”Literatur des 17. und 18. Jahrhunderts’, in Udo, B. and Wilhelm, K. (1992). Heilkunde und Krankheitserfahrung in der frühen Neuzeit (Frühe Neuzeit 10), 114–29; Jaumann, H. ‘Iatrophilologia. “Medicus politicus” und analoge Konzepte in der frühen Neuzeit’, in Häfner, R. (2001). Philologie und Erkenntnis. Beiträge zu Begriff und Problem frühneuzeitlicher “Philologie”, 151–76.

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compliance and suggest that the patients could expect physicians to make a considerable effort to win and maintain their trust. Jane Draycott shows in her contribution that a careful reading of physicians’ writings can also reveal important insights into medical lay notions and practices. These clearly had a great influence, in turn, on whether patients experienced the physician’s diagnosis and his therapeutic recommendations as helpful and comforting or not. Medical case histories are also of great value for a patient-centred history in a completely different way. They quite simply describe what the physician actually did, how he diagnosed and treated his patients. As Patricia A. Baker demonstrates in her contribution, they can be usefully supplemented in this respect by visual representations of medical practice. The unprecedented importance of pulse-diagnosis, described in Lewis’ chapter, implied that the physician touched the patient, rather than just talked to him or her, that he took his time to feel the pulse. Feeling the pulse turned patients and bystanders into the participants of a little ritual that, according to some authors, even marked the very beginning of the consultation. Uroscopy, which from the Middle Ages took the place of feeling the pulse as the most important diagnostic practice, could be similarly staged as a ritual, as a “dramatic highlight”, as Petros Bouras-Vallianatos points out. Early modern skeptics deprecatingly compared the uroscopic diagnosis with an oracle and called the uroscopist ‘piss-prophets’. This was part of their campaign against unlicensed healers but there was some truth in this statement. While patients and bystanders saw nothing but a rather unappetizing, stinking yellow fluid, the physician held the urine glass against the light, carefully examined the colour and looked for bubbles, clouds and visible contenta. He provoked a gentle circular movement of the fluid, to loosen the sediment. He might even hold the glass in front of a mirror, or let the urine settle for an hour, until he finally pronounced his diagnostic judgement. For many centuries, this was the physicians’ most powerful means by which they could impress patients and bystanders with their ability to unveil the morbid changes hidden inside the body.21 There is also considerable evidence that ancient physicians examined their patients manually—men and women alike—, as Jennifer Kosak shows, looking for palpable swellings, pain or other changes underneath the skin. The same goes—though historians have long claimed the contrary—for the learned physicians in the early modern period.22 21  Stolberg, M. (2015). Uroscopy in Early Modern Europe. 22  Id. ‘Examining the body (c. 1500–1750)’, in Toulalan, S. and Fisher, K. (2013). The Routledge History of Sex and the Body, 1500 to the Present, Oxford, 91–105.

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Diagnostic and therapeutic practices are not only important aspects of the patients’ illness experience as such. They also serve as powerful tools for the “intentional and unintentional transfer of theoretical and practical technical knowledge”, as Orly Lewis puts it in her contribution. Beyond and even without the spoken word, they reflect and convey specific ideas about the nature of diseases and their presumed causes inside and outside the body. To cite just one, particularly illustrative early modern example: the blood-letting which physicians almost routinely prescribed to their patients might strike us a means to reduce quite simple the blood-volume. Surviving comments by patients and relatives show, however, that they frequently found the blood to be slimy, full of phlegm, or all black, or burnt. In this manner, blood-letting constantly confirmed them in their belief that parts of the blood contained morbid matter or were pathological in themselves and that it was necessary to eliminate this blood from the body. We find the same phenomenon in ancient sources. As John Wilkins’ contribution to this volume makes clear, the dietetic recommendations which the physician was to make, according to Galen’s De sanitate tuenda, likewise conveyed a fairly specific implicit understanding of man’s diseases, in which an insufficient digestion of food and the resulting accumulation of bad or misplaced humours played the principal role. 3

The Patients’ Impact on Learned Medicine

To the modern reader, the term ‘patient’ tends to suggest passivity, images of the sufferer as a victim of the disease as well as an object of medical interventions. Premodern patients frequently had a very prominent and active role in the therapeutic encounter, however, all the more so when the physicians, as was often the case, came to visit them in their homes. Physicians had to talk to them at length, and often to their families and other bystanders as well. They had to ask them about their current complaints, about previous disease episodes, about their way of life, their preferred foods, their personal experiences with the effects of different medicines on their body et cetera. What is more, patients could also have a considerable impact, in turn, on the physicians’ theories and practices. Sometimes this impact was primarily an epistemological one. Throughout history, case reports of individual patients have served as a major basis for general theories and explanatory models. Melinda Letts’ contribution shows that this kind of “inductive” reasoning from individual cases to general rules already played a considerable role in the Hippocratic writings.

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The case history and the individual patient as its protagonist could contribute also in a very different way. As John Wee demonstrates in his analysis of the case histories in the Hippocratic Epidemics 1, the extant histories of individual patients—probably a selection from a much larger number of histories—were predominantly “minority reports”: they highlighted the exception from the rule or even contradicted accepted accounts. The individual stories showed that established rules could not always be trusted—which was important for the physicians to keep in mind if they wanted to avoid embarrassing diagnostic and prognostic errors. We find the same phenomenon in thousands of case histories in early modern physicians’ notebooks and publications. Collecting case histories on patients with similar complaints that seemed due to similar reasons contributed to the growing importance of the concept of disease entities and promoted a better understanding of the differences between these entities, their characteristic signs and their most promising mode of treatment.23 Other authors privileged the stories of untypical, ‘rare’ if not unique cases. These stories did not illustrate the norm, the rule, the ordinary. Instead, in line with a more general interest in the seemingly miraculous and monstrous, they showed the great variation that was possible within the limits of the laws of nature—and ultimately helped refine human knowledge of these laws.24 Patients could even influence the development of learned medical theory and practice itself. In the 1970s, British sociologist Nicholas Jewson published a couple of papers that have attracted considerable criticism but have also had a major, fruitful impact on the writing of medical history. Drawing primarily from sources from eighteenth-century England, Jewson argued that patients had a decisive impact on the learned medicine of their time, due to their superior social standing. According to Jewson the doctor-patient relationship in the eighteenth century was characterised by “patronage”. The physician’s economic and professional prospects rested decisively on the favours of a small group of high-ranking patrons. In this situation, Jewson argued, the physicians were forced to accommodate the preferences and desires of their patients as much as they could. In particular, they had to grant ample space to the patient’s 23  Stolberg, M. (2013). ‘Empiricism in sixteenth-century medical practice. The notebooks of Georg Handsch’, Early science and medicine 18, 487–516. 24  See, e.g. the telling title of Schenckius, J. von Grafenberg (1600). Observationum medicarum, rararum, novarum, admirabilium, et monstrosarum tomus unus. On the naturalphilosophical context see Daston, L. and Park, K. (1998). Wonders and the order of nature 1150–1750.

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narrative. They had to listen carefully and take the patient seriously as an individual being—otherwise they would no longer be consulted. At a time, when medical research and innovation was still primarily the domain of private practitioners, this, according to Jewson, had important consequences for the development of medical science as such. Physicians might come up with all kinds of new ideas and treatments but new findings and ideas were only likely to find broad acceptance if they were well-received not only by colleagues but above all by the patients. This, according to Jewson, lent crucial support to those new theories and practices that were in line with the patients’ expectations and preferences while others would be unable to gain recognition.25 More recently, research on the history of the doctor-patient relationship has shown that, certainly on the European continent learned physicians treated a much wider range of patients than historians had previously thought and that the social status of the majority of patients was not higher than that of their physicians. Patronage in Jewson’s sense was the exception rather than the rule. It was typical above all for the personal physicians of kings and princes whose position was similar to that of other court employees. Nevertheless the individual physician was frequently under considerable pressure to heed his patients’ wishes and desires. This was not because the individual patient had a powerful position in society: the patients’ preferences and expectations carried great weight for the simple reason that patients, in most places, could turn to someone else if they were not satisfied—and frequently did so. Patients’ widespread expectation that a skillful medical practitioner could identify the nature of their disease just by looking at their urine is a prime example. The physicians’ polemical writings against this practice were to no avail. They lost the battle. The spectacular rise of the ‘nervous sensibility’ and ‘nervous diseases’ in eighteenth-century society is another example. Research on nervous sensibility and irritability eventually supported this trend but this work was preceded and prompted in turn by a new culture of sensibility and sentimentality among the upper classes in general.26 The patients’ relatively strong position in the premodern doctor-patient relationship and the constant danger that they might consult someone else could also promote the development of specialist knowledge and skills. In a society, in which most patients were deeply convinced that uroscopy was 25  Jewson, N. D. (1974). ‘Medical knowledge and the patronage system in 18th century England’, Sociology 8, 369–85; id. (1976). ‘The disappearance of the sick-man from medical cosmology, 1770–1870’, Sociology 10, 225–44. 26  Barker-Benfield, G. J. (1992). The culture of sensibility. Sex and society in eighteenth-century Britain.

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an indispensable diagnostic tool but in which even illiterate village healers offered their services as uroscopists, physicians had to find ways to assure that people accepted their claim to superior medical expertise. Early modern physicians found two particularly promising strategies. One was public anatomy. In front of a sizeable audience they could demonstrate their practical skills as well as their knowledge of the secrets hidden in the inside of the body. The other strategy was to refine uroscopic diagnosis ever further, to introduce even more shades of colour and contenta that the truly skilled uroscopist had to distinguish, setting himself against the mass of ‘ignorant’ village uroscopists. As the paper by Orly Lewis nicely demonstrates, the patients could have a similarly powerful impact on the physicians’ practices and writings in ancient cultures. The patients saw the importance that physicians attributed to the pulse and they were quite capable of feeling their pulse themselves. This promoted a trend in medical writing and practice to make pulse diagnosis more complex and to introduce more distinctions. In this manner the physicians could continue to lay successful claim to their superior mastery of a skill which the patients, by that time, had come to appreciate and appropriate. 4

The History of Patients from the Perspective of Modern Medicine

Some contributions in this book deal with a very different—and highly ­popular—approach to the patient in history, one which has sparked one of the most heated controversies in medical historiography: retrospective diagnosis. Numerous authors—especially but not only those with a medical training— have made considerable efforts to identify, from the surviving sources, the diseases from which certain historical actors in different historical periods ‘really’ suffered or indeed died. Others, by contrast, have considered any attempt to label historical descriptions of diseases with modern diagnostic terms a largely futile enterprise. They have argued, in particular, that 1) retrospective diagnosis is frequently based on insufficient evidence, that 2) premodern descriptions of individual illnesses are inevitably framed by profoundly different disease concepts and may therefore ignore aspects considered crucial for diagnosis today and 3) that, in particular, the clinical picture of infectious diseases can alter dramatically due to genetic and immunological changes.27 27  For a useful summary of the debate see Graumann, L. A. (2000). Die Krankengeschichten der Epidemienbücher des Corpus Hippocraticum: Medizinhistorische Bedeutung und Möglichkeiten der retrospektiven Diagnose, esp. 118–22; for a very critical view see Leven, K.-H. ‘ “At times these ancient facts seem to lie before me like a patient on a ­hospital

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While these three arguments do not appear equally relevant for all sources and diseases, two other major and crucial issues frequently have failed to be even addressed—leave alone resolved—in this debate. Firstly, it surely makes a great difference whether we are drawing on historical accounts of a single case or of numerous different patients who were, at the time, believed to suffer from the same disease. When we are dealing with a single case, the arguments against retrospective diagnosis are very weighty indeed. In this volume, the contribution by Graumann and Horstmanshoff on the epitaph on Lucius Minicius Anthimianus shows at what drastically diverging diagnostic conclusions historians have arrived about this patient in the course of time. This is not to say that retrospective diagnosis of individual cases is entirely arbitrary. Usually, some diagnoses are more probable than others. Take a woman, for example, described in premodern sources as suffering from an ulcerating tumour of the breast, rapidly losing weight and dying in the course of a few months. From today’s point of view, she surely is much more likely to have suffered from breast cancer in the modern understanding of the word than from, say, coronary arteriosclerosis, apoplexy or a peptic ulcer. The more detailed the information we find in the sources and the closer we get to modern medicine, the smaller the difference becomes to establishing a diagnosis in modern medical practice, where absolute certainty cannot be achieved either. Retrospective diagnosis on individual cases in premodern times, however, can, as a rule, only offer a range of possible explanations. Retrospective diagnosis can yield more fruitful results when we are dealing with larger numbers of patients who are said to have suffered from the same disease. Though not each individual patient who was diagnosed, at the time, as a victim of the plague, leprosy or cholera can be safely taken to have actually suffered from that disease according to modern criteria, the diagnosis is quite likely to be true for many of them, at least when the clinical picture tends to be fairly characteristic and with paleopathological evidence to support the case. The second question historians have commonly failed to ask is the most fundamental one and can be summarised in two words: so what? Katherine van Schaik argues in this volume that a “dismissal of thoughtful explanations of the pathologies described in classical texts which are offered by trained medical professionals” threatens to disregard “an important means by which understanding of the ancient world might be enhanced.” The crucial question, however, is, in which cases and in what way our understanding is enhanced— bed”. Retrospective diagnosis and ancient medical history’, in Horstmanshoff, H. F. J. and Stol, M. (2004). Magic and rationality in ancient Near Eastern and Graeco-Roman medicine, 369–86.

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and in which cases retrospective diagnosis may actually be outright misleading even though it is correct in modern terms. What do we learn, for example, when we compare, with Susan P. Mattern, the description of lypē in Galen’s works with modern notions of culture-specific anxiety disorders? In which way will it help us to understand better, what it was like to suffer from lypē in ancient times or why Galen dealt with it the way he did? Undoubtedly there are certain areas in which the answer may be important. It is perfectly legitimate to want to know whether a certain kind of disease existed or was indeed prevalent in a certain area and at a certain time in history. It might even help explain major social and economic changes and it might enrich our knowledge about the interactions between nature, environment and man on the one hand and diseases on the other.28 If we are interested, however, in finding out what it meant, in a specified historical period, to suffer from a certain disease, if we want to understand why physicians, patients and relatives dealt with it in the ways they did, the use of modern diagnostic terms is more often than not a major impediment to our historical understanding. For, as medical anthropologists have amply shown, the experience of illnesses and the ways in which they are diagnosed and treated are decisively shaped by dominant notions about the body and its diseases. In fact, the experience of illness is to a large degree the experience of the images and metaphors that are associated with the disease and the diagnostic and therapeutic practices and rituals reflect the contemporary perception. For example, cancer patients today tend to perceive themselves as attacked by some kind of a secret, sinister killer deep inside their bodies whose existence they often had not even suspected until they were diagnosed. By contrast, even if we felt fairly sure that a certain patient in the first, eleventh or sixteenth century suffered from cancer in the modern sense, we can by no means conclude that he or she has the ‘same’ disease in this experiential sense. A sixteenth-century female patient with an ulcerating tumour that has eaten away large parts of her breast may most likely have suffered from breast cancer in a modern sense. Yet her experience was a very different one. At the time, cancer was associated above all with impurity and a destruction of the skin, with foul secretions and with stench. It was a disease which affected almost exclusively the borders of the body and was due to some corrupted, putrid and particularly aggressive humour. This humour could not only eat its way into the surrounding flesh, mix with the blood and settle in other parts of the body. It could also literally infect the surrounding air. Since mere contact with the 28  For an overview of relevant studies on ancient medicine see Nutton, V. (2004). Ancient medicine, London, 19–36.

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stench that emanated from a cancer patient was deemed sufficient to infect someone else with cancer, patients were perceived as a menace to others and might even be separated from their children or confined in institutions outside the city walls.29 Virtually none of this is grasped by the modern label ‘cancer’ and whether a patient ‘really’ suffered from cancer in a modern sense or not is quite irrelevant in this respect as long as he or she was taken for a cancer patient at the time. 5 Conclusion The history of patients has come of age. No serious scholar today would dispute that the patient deserves a major part in the medico-historical narrative. After all, the patients and their well-being is what much of medicine is ultimately all about, and it is above all by dealing with individual patients that medicine has historically been a constant and ubiquitous presence in society. Work on Patientengeschichte has so far focused on the early modern period. As this volume demonstrates, a history of patients can successfully be done also for ancient cultures. Of course, sources which directly reflect the patients’ personal perception and experience of their illness and of the treatment they received are hard to come by for this period. From what others wrote, physicians in particular, related to patients’ expectations and reactions and from what we know about the actual practice of medicine, it is nevertheless possible to write a history ‘from the patient’s point of view’ for ancient Greece and Rome. The importance of the patient as an object of the physicians’ considerations and practices emerges even more clearly from the surviving sources, and occasionally we can even trace the impact of the patients’ point of view, of their ideas about the sick body and the best way to diagnose and treat it. By contrast, trying to identify the diseases from which individual patients suffered in modern terms is an exceedingly difficult and risky enterprise the further we go back in time. Fortunately, it is also the least fruitful and rewarding approach, by far, that historians can take when they want to throw light on the figure of the patient and to find out more about what it meant to be sick, in ancient times as in more recent epochs.

29  Stolberg, M. (2014). ‘Metaphors and images of cancer in early modern Europe’, Bull. Hist. Med. 88, 48–74.

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Texts Used Castro, R. da. Medicus-politicus: sive de officiis medico-politicis tractatus. Hamburg: Hertel, 1662. Hoffmann, F. Medicus politicus sive regulae prudentiae secundum quas medicus juvenis studia sua & vitae rationem dirigere debet, si famam sibi felicemque praxin & cito acquirere & conservare cupit. Leiden: Bonk, 1738. Münster, L. ‘In tema di deontologia medica. Il “De cautelis medicorum” di Gabriele Zerbi’. Rivista di storia delle scienze mediche e naturali 47, (1956): 60–83. Schenckius von Grafenberg, J. Observationum medicarum, rararum, novarum, admirabilium, et monstrosarum tomus unus. Frankfurt: Paltheniana, 1600. Villanova, A. de ‘De cautelis medicorum’. Trans. H. E. Sigerist. In A source book of medieval science, ed. E. Grant. Cambridge: Harvard University Press, 1974. Weinsberg, H. von. Das Buch Weinsberg. Kölner Denkwürdigkeiten aus dem 16. Jahrhundert, (reprint of the edn. Leipzig and Bonn 1886–1926) vol. 5. Düsseldorf: Droste, 2000. Zerbi, G. Opus perutile de cautelis medicorum. Venice: [Berthonus, 1495].

References Barker-Benfield, G. J. The culture of sensibility. Sex and society in eighteenth-century Britain. Chicago/London: University of Chicago Press, 1992. Böhme, G. Medizinische Portraits berühmter Komponisten, 2 vols. Stuttgart: Fischer, 1981. Condrau, F. ‘The Patient’s View Meets the Clinical Gaze.’ Social History of Medicine 20 (2007): 525–40. Daston, L. and Park, K. Wonders and the order of nature 1150–1750. New York: Zone Books, 1998. Eckart, W. U. ‘Anmerkungen zur “Medicus politicus”—und “Machiavellus Medicus”— Literatur des 17. und 18. Jahrhunderts.’ in Heilkunde und Krankheitserfahrung in der frühen Neuzeit (Frühe Neuzeit 10), ed. B. Udo and K. Wilhelm, 114–29. Tübingen: Max Niemeyer Verlag, 1992. Ernst, K. ‘Patientengeschichte. Die kulturhistorische Wende in der Medizin­ historiographie.’ in Eine Wissenschaft emanzipiert sich. Die Medizinhistoriographie von der Aufklärung bis zur Postmoderne, ed. R. Bröer, 97–108. Heidelberg: CentaurusVerlags-Gesellschaft, 1999. ———. Krankheit und Heilung. Die medikale Kultur württembergischer Pietisten im 18. Jahrhundert. Stuttgart: Kohlhammer Verlag, 2003.

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Franken, F. H. Die Krankheiten großer Komponisten, 4 vols. Wilhelmshaven: Noetzel, Heinrichshofen-Bücher, 1986–97. Freidson, E. Patients’ views of medical practice. A study of subscribers to a prepaid medical plan in the Bronx. New York: Russell Sage Foundation, 1961. Graumann, L. A. Die Krankengeschichten der Epidemienbücher des Corpus Hippo­ craticum: Medizinhistorische Bedeutung und Möglichkeiten der retrospektiven Diagnose. Aachen: Shaker, 2000. Hawkins, A. H. Reconstructing Illness. Studies in pathography. West Lafayette: Purdue Univ. Press, 1993. Herzlich, C. and Pierret, J. Malades d’hier et malades d’aujourd’hui: De la mort collective au devoir de guérison. Paris: Payot, 1984. Horstmanshoff, H. F. J. ‘Asclepius and Temple Medicine in Aelius Aristides’ “Sacred Tales”.’ in Magic and Rationality in Ancient Near Eastern and Graeco-Roman Medicine, ed. H. F. J. Horstmanshoff and M. Stol, 325–41. Leiden/Boston: Brill, 2004. Huisman, F. and Warner, J. H. (eds.). Locating medical history. The stories and their meanings. Baltimore and London: John Hopkins Univ. Press, 2004. Jaumann, H. ‘Iatrophilologia. “Medicus politicus” und analoge Konzepte in der frühen Neuzeit’, in Philologie und Erkenntnis. Beiträge zu Begriff und Problem frühneuzeitlicher “Philologie”, ed. R. Häfner, 151–76. Tübingen: Niemeyer Verlag, 2001. Jewson, N. D. ‘Medical Knowledge and the Patronage System in 18th Century England.’ Sociology 8, (1974): 369–85. ———. ‘The Disappearance of the Sick-Man From Medical Cosmology, 1770–1870.’ Sociology 10, (1976): 225–44. Jütte, R. ‘ “Wo kein Weib ist, da seufzet der Kranke”. Familie und Krankheit in der Frühen Neuzeit.’ Jahrbuch des Instituts für Geschichte der Medizin der Robert Bosch Stiftung 7, (1989): 7–24. ———. Ärzte, Heiler und Patienten. Medizinischer Alltag in der frühen Neuzeit. Munich/ Zürich: Artemis and Winkler, 1991. ———. Krankheit und Gesundheit in der Frühen Neuzeit. Stuttgart: Kohlhammer Verlag, 2013. Lachmund, J. and Stollberg, G. Patientenwelten. Krankheit und Medizin vom späten 18. bis zum frühen 20. Jahrhundert im Spiegel von Autobiographien. Opladen: Leske and Budrich, 1995. Lederer, D. ‘Constructing a Wonder. The Influence of Popular Culture on Miracle Books.’ in Mediale Konstruktionen in der Frühen Neuzeit, ed. W. Behringer, M. Havelka and K. Reinholdt, 43–56. Affalterbach: Didymos-Verlag, 2013. Leven, K.-H. ‘ “At Times These Ancient Facts Seem to Lie Before Me Like a Patient on a Hospital Bed”. Retrospective Diagnosis and Ancient Medical History.’ in Magic and Rationality in Ancient Near Eastern and Graeco-Roman Medicine, ed. H. F. J. Horstmanshoff and M. Stol, 369–86. Leiden/Boston: Brill, 2004.

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Loetz, F. Vom Kranken zum Patienten. “Medikalisierung” und medizinische Vergesell­ schaftung am Beispiel Badens 1750–1850. Stuttgart: Franz Steiner Verlag, 1993. Lumme, C. Höllenfleisch und Heiligtum. Der menschliche Körper im Spiegel autobiographischer Texte des 16. Jahrhunderts. Frankfurt: Peter Lang Verlagsgruppe, 1996. Neumayr, A. Berühmte Komponisten im Spiegel der Medizin, 4 vols. Vienna: Ed. Wien, 2007. Nutton, V. Ancient medicine. London: Routledge, 2004. Pepys, S. The diary of Samuel Pepys, vol. 3. London: Dent, 1953. Porter, R. ‘The Patient’s View. Doing Medical History From Below.’ Theory and Society 14, (1985): 175–98. ———. (ed.). Patients and practitioners. Lay-perceptions of medicine in pre-industrial society. London: Cambridge University Press, 1985. Porter, R. and Porter, D. In sickness and in health. The British experience 1650–1850. London: Fourth Estate, 1988. ———. Patient’s progress. Doctors and doctoring in eighteenth-century England. Cambridge/Oxford: Polity Press, 1989. Rankin, A. ‘Duchess, Heal Thyself. Elisabeth of Rochlitz and the Patient’s Perspective in Early Modern Germany.’ Bulletin of the History of Medicine 82, (2008): 109–44. Rieder, P. ‘L’histoire du “patient”. Aléa, moyen ou finalité de l’histoire médicale?’ Gesnerus 60, (2003): 260–71. Sarasin, P. Reizbare Maschinen. Eine Geschichte des Körpers 1765–1914. Frankfurt: Suhrkamp Verlag, 2001. Schweig, N. Gesundheitsverhalten von Männern. Gesundheit und Krankheit in Briefen 1800–1950. Stuttgart: Franz Steiner Verlag, 2009. Steger, F. ‘Medizinischer Alltag in der römischen Kaiserzeit aus Patientenperspektive: P. Aelius Aristides, ein Patient im Asklepieion von Pergamon.’ Medizin Gesellschaft Geschichte 20, (2001): 45–71. ———. Asklepiosmedizin. Medizinischer Alltag in der römischen Kaiserzeit. Stuttgart: Franz Steiner Verlag, 2004. Stein, C. ‘The Birth of Biopower in Eighteenth-Century Germany.’ Medical History 55, (2011): 331–37. Stolberg, M. ‘ “Mein äskulapisches Orakel!”: Patientenbriefe als Quelle einer Kulturgeschichte der Krankheitserfahrung im 18. Jahrhundert.’ Österreichische Zeitschrift für Geschichtswissenschaft 7, (1996): 385–404. ———. ‘Empiricism in Sixteenth-Century Medical Practice. The Notebooks of Georg Handsch.’ Early Science and Medicine 18, (2013): 487–516. ———. ‘Examining the Body (c. 1500–1750).’ in The Routledge history of sex and the body, 1500 to the present, ed. S. Toulalan and K. Fisher, 91–105. Oxford: Routledge, 2013. ———. ‘Metaphors and Images of Cancer in Early Modern Europe.’ Bulletin of the History of Medicine 88, (2014): 48–74.

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———. ‘Uroscopy in Early Modern Europe. Farnham: Asgate 2015. Wolff, E. ‘Perspektiven der Patientengeschichtsschreibung.’ in Medizingeschichte: Aufgaben, Probleme, Perspektiven, ed. N. Paul and T. Schlich, 311–30. Frankfurt/ New York: Campus-Verlag 1998.

Index Locorum Abū Bakr al-Rāzī The Comprehensive Book of Medicine Introduction to the Art of Medicine 13 ch.  Book of Experiences

228, 237, 233 229, 233 236

Acta Apostolorum (Act. Ap.) 6.1 458 n. 11 Aeschylus Fragmenta 362 34 Aelius Aristides Orationes (Or.) 42.8 463 n. 21 47 385, 389 47.3 480 nn. 30, 31, 32 47.4 453 n. 4, 489 n. 67 47.17 483 n. 49 47.61–68 480 nn. 30, 31, 32 47.65 483 n. 46 47.69–74 454 47.71 457 47.71–2 457 47.74 461 47.77 456 48.19–23 393 48.22–3 465 n. 26 48.47 490 n. 72 48.74–9 463 48.80 463 n. 21 49.10–12 489 n. 70 49.20 461 49.38–43 461 50.10 461 51.49–50 391 51.52 480 nn. 30, 31, 32 Aetius of Amida Libri Medicinales (Lib. Med.) 4.3 (Olivieri 360, 18) 276 n. 49



4.19 (Olivieri 367, 10) 7.37 (Olivieri 289, 14) 7.71 (Olivieri 321, 9) 8.38 (Olivieri 455, 1) 8.48 (Olivieri 471, 14)

276 n. 49 276 n. 49 276 n. 49 276 n. 49 276 n. 49

Aetius the Doxographer  Placita 2.83 4.11

306 n. 11 306 n. 11

Al-Huǧwirī Kašf al-maḥǧūb

238

Al-Kaskarī Compendium of Medicine 22

230, 241

Aktouarios, John Zacharias De Urinis De Urinis pr. (Ideler 2, 3, 1) 2.19 (Ideler 2, 50, 26–52, 1) 2.19 (Ideler 2, 50, 27–28) 2.19 (Ideler 2, 50, 30–51, 8) 2.19 (Ideler 2, 50, 37) 2.19 (Ideler 2, 51, 3) 2.19 (Ideler 2, 51, 9) 3.10 (Ideler 2, 62, 29–63, 13) 3.10 (Ideler 2, 62, 30) 3.10 (Ideler 2, 62, 31) 3.10 (Ideler 2, 62, 31–32) 3.10 (Ideler 2, 63, 3) 3.10 (Ideler 2, 63, 3–13) 3.10 (Ideler 2, 63, 8) 3.10 (Ideler 2, 63, 9) 3.10 (Ideler 2, 63, 11) 4.9 (Ideler 2, 92, 10) 4.9 (Ideler 2, 92, 34–35) 4.12 (Ideler 2, 96, 5) 4.12 (Ideler 2, 96, 7–8) 6.7 (Ideler 2, 154, 31) 6.7 (Ideler 2, 154, 31–156, 11) 6.7 (Ideler 2, 154, 32) 6.7 (Ideler 2, 154, 32–155, 17) 6.7 (Ideler 2, 154, 33) 6.7 (Ideler 2, 155, 17–20)

392 401 402 n. 40 395 n. 16 403 n. 42 398 n. 31 398 n. 26 398 n. 26 403 n. 43 398 n. 27 398 n. 25 398 n. 30 398 n. 25 404 n. 45 398 n. 27 399 n. 36 395 n. 17 399 n. 32 398 n. 26 398 n. 26 397 n. 23 399 n. 34 399 n. 35 395 n. 16 400 n. 37 399 n. 34 397 n. 24

520 Aktouarios, John Zacharias (cont.) 6.7 (Ideler 2, 155, 17–156, 6) 400 n. 38 6.7 (Ideler 2, 155, 29) 398 n. 25 6.7 (Ideler 2, 155, 33) 398 n. 25 6.7 (Ideler 2, 155, 35) 398 n. 26 6.7 (Ideler 2, 156, 8) 398 n. 26 6.12 (Ideler 2, 162, 17–18) 399 n. 32 6.12 (Ideler 2, 162, 18–163, 27) 404 n. 46 6.12 (Ideler 2, 162, 20–21) 399 n. 32 6.12 (Ideler 2, 162, 26) 398 n. 25 6.12 (Ideler 2, 163, 25) 398 n. 25 6.12 (Ideler 2, 163, 26–27) 398 n. 26 6.12 (Ideler 2, 163, 29) 395 n. 17 6.12 (Ideler 2, 163, 29–30) 396 6.12 (Ideler 2, 163, 33) 399 n. 36 6.12 (Ideler 2, 164, 6) 397 n. 24 6.12 (Ideler 2, 164, 6) 398 n. 25 6.12 (Ideler 2, 164, 7) 398 n. 26 6.13 (Ideler 2, 165, 9–166, 16) 404 n. 46 6.13 (Ideler 2, 165, 9–166, 16) 404 n. 47 6.13 (Ideler 2, 165, 10) 398 n. 27 6.13 (Ideler 2, 165, 16) 398 n. 25 6.13 (Ideler 2, 165, 21–166, 16) 405 n. 50 6.13 (Ideler 2, 165, 33) 398 n. 25 6.13 (Ideler 2, 165, 35) 398 n. 26 6.13 (Ideler 2, 166, 6–7) 398 n. 25 6.13 (Ideler 2, 166, 14) 398 n. 25 6.13 (Ideler 2, 166, 26) 395 n. 17 6.13 (Ideler 2, 166, 26–27) 396 6.13 (Ideler 2, 166, 28) 398 n. 28 6.13 (Ideler 2, 166, 31–32) 398 n. 29 6.13 (Ideler 2, 167, 2) 398 n. 26 7.13 (Ideler 2, 181, 11–183, 12) 404 n. 46 7.13 (Ideler 2, 181, 12–13) 396 7.13 (Ideler 2, 181, 13) 395 n. 17 7.13 (Ideler 2, 181, 14) 398 n. 27 7.13 (Ideler 2, 181, 15) 399 n. 36 7.13 (Ideler 2, 181, 30) 398 n. 27 7.13 (Ideler 2, 182, 2) 398 n. 27 7.13 (Ideler 2, 182, 19–21) 405 n. 51 7.13 (Ideler 2, 182, 22) 398 n. 27 7.13 (Ideler 2, 182, 33) 395 n. 17 7.13 (Ideler 2, 183, 7–8) 398 n. 26 7.13 (Ideler 2, 183, 9) 395 n. 17 7.15 (Ideler 2, 186, 5–6) 396 7.15 (Ideler 2, 186, 6) 395 n. 17 7.15 (Ideler 2, 186, 7) 399 n. 33 7.15 (Ideler 2, 186, 7) 399 n. 34

Index Locorum 7.15 (Ideler 2 186, 16) 398 n. 28 7.15 (Ideler 2, 186, 27) 399 n. 33 Medical Epitome 392, 402 On the activities and illnesses of the psychic pneuma and the corresponding mode of diet 392 Alexander of Tralles Therapeutica 1.15 (Puschmann 1, 551, 17–25)

394 n. 10

Aretaeus of Cappadocia De causis et signis acutorum morborum (lib. 1) (Caus.Ac.) 1.5 (Hude 2.15–16) 294 n. 34 1.6.7–9 (Hude 7.3–23) 301 n. 52 De causis et signis diuturnorum morborum  (lib. 2) (Caus.Ac.) 2.13 (Hude 85–90) 299 n. 47 Aristophanes Nubes (Nu.) 359 Plutus (Pl.) 518 589 Ranes (Ra.) 1497 Thesmophoriazusae (Thesm.) 880 Vespae (Vesp.) 249 300–01 Fragmenta (Fr.) 62.18 Austin Aristotle De Anima (DA) 3.4.430a De Generatione Animalium (GA) 2.2.735a29–736a23 772b6–10 Ethica Nicomachea (EN) 1.1098a18–9 11.18–9B Historia Animalium (HA) 3.1.510a12–35 3.4.514b29–515a5

188 n. 80 188 n. 80 188 n. 80 188 n. 80 188 n. 80 330 n. 15 328 n. 11 188 n. 80

280 n. 73 185 n. 67 268 n. 11 140 n. 8 140 n. 8 185 n. 67 185 n. 67

521

Index Locorum [Aristotle] Problemata (Pr.) 11.3 11.11 11.12 11.30 11.35 11.36 11.38 11.54 11.55 11.60

181 n. 49 181 n. 49 184 n. 58 184 n. 58, 185 n. 64, 187 n. 76 184 n. 58 184 n. 58 184 n. 58 184 n. 58 184 n. 58 184 n. 58

Augustine Contra Iulianum (Cont. Jul.) 51 294 n. 28 Caelius Aurelianus Celeres passiones (CP) 294 3.123 485 Tardae passiones (TP) 294 1.1–3 484 1.1.25–7 294 n. 33 1.10–1 (CML VI,  434.20–28) 294 n. 35 1.156–7 (CML VI,  522.23–33) 296 n. 37 1.172–8 (CML VI,  532.12–14) 297 n. 40 2.12.138 48 n. 108 2.12.139 48 n. 108 4.13 (CML VI, 782.1–7) 298 n. 44 4.13 (CML VI, 782.2) 298 nn. 43–44 Cato the Elder (Cato) De agricultura (Agr.) 8.2 70 125 126 127 Celsus, Aulus Cornelius De Medicina (Med.) praef. 73 (Marx 29,13–14)

438 n. 20 438 n. 21 438 n. 21 438 n. 23 438 n. 22

336 n. 43

2.1.17–19 2.2.5–6 2.7.7 2.11.1–2 3.21.9–10 3.6.5 3.6.6 3.7.1 5.26.34 5.27.2 6.11.3–5 6.18.6 7.18–19 7.20 7.20.1 7.22.5 7.33 8.2.5 Chariton Callirhoe 1.12.1 1.13.10 2.5.3 3.4.9 6.5.10

279 n. 71 367 n. 5 279 n. 71 367 n. 4 367 n. 5 297, 353 n. 30 299, 300, 355 nn. 40, 41 41 n. 68, 279 n. 71 43 n. 81 367 n. 5 279 n. 71 42 n. 74, 185 n. 67 42 n. 74 42 n. 74 279 n. 71 185 n. 67 43 n. 80 43 n. 80

300 n. 50 300 n. 50 300 n. 50 300 n. 50 300 n. 50

Cicero, Marcus Tullius De inventione (De inv.) 2.53 319 n. 49 De oratore (De or.) 3.115 319 n. 48 Epistulae ad Familiares (Fam.) 13.20 446 n. 54 In Verrem (Verr.) 2.3.28 446 n. 54 Lucullus (Luc.) 11 311 n. 33 77 456 De Legibus (Leg.) 3.19 436 n. 13 Comici Graeci Diphilos fr. 42 K.-A

328 n. 11

522

Index Locorum

Eupolis fr. 470 K.-A.

328 n. 11

Columella De re rustica (Rust.) 11.1.22 11.1.4 12 pref.10 5.1.1

439 n. 33 439 n. 32 439 n. 33 439 n. 34

Demosthenes 8.70 333 n. 26 18.206 458 n. 11 22.55 259 De cautelis medicorum 505 Dio Cassius 78 (77) 5.5

36 n. 49

Diodorus Siculus 1.98.9 13.58.3

335 n. 38 333 n. 26

Diogenes Laertius Vitae Philosophorum 7.46 10.4 10.10

311 n. 33 328 n. 12 334 n. 32

Dionysius of Halicarnassus Antiquitates Romanae (AR) 9.50.5 379 n. 44 Erotian Vocum, quae apud Hippocratem sunt, Collectio./Glossary 9.11 139 n. 4 9.18 139 n. 4 Euripides Alcestis (Alc.) 643 Bacchae (Ba.) 1288 Medea (Med.) 1183–84

34 n. 38 347 n. 8 192 n. 98

Galen Ad Glauconem de medendi methodo  (Ad Glauc. de meth. med.) 1.1 (11.4.7–5.11 K.) 93 n. 42 1.2 (11.10.13–16 K.) 93 n. 43 1.2 (11.12 K.) 210 n. 26 1.2 (11.12–13 K.) 211 n. 27 2.4 (11.98 K.) 205 n. 9 Ars Medica (Ars med.) 24 (1.371 K.) 209 n. 22 De alimentorum facultatibus  (De alim. facult.) 1.2.8–9 (6.486–487 K. = 220.9–23  Helmreich) 421 De anatomicis administrationibus  (De anat. admin.) 7.13 (2.632.5 K = 459.16  Garofalo) 395 n. 20, 396 De atra bile 6 (5.126 K.) 208 n. 20 De bonis malisque sucis (De bonis  mal. sucis) 1.389–93 Helmreich  (6.749–756 K.) 419, 419 n. 10 De causis pulsuum (De caus. puls.) 1.8 (7.144 K.) 207 2.5 (7.191–93 K.) 210 2.5 (7.193 K.) 210 n. 25 2.6 (7.197 K.) 205.9 4.2–6 (7.157–62 K.) 209 n. 22 De compositione medicamentorum  per genera (De comp. med. gen.) 6.1 (13.861 K.) 207 De crisibus (De cris.) 2.3 (9.649 K.) 208 n. 20 2.13 (9.697–700 K.) 209, 211 n. 27 2.13 (9.698 K.) 208 n. 20, 210 De difficultate respirationis (De diff. resp.) 3.10 (7.941 K.) 207 n. 15 De dignoscendis pulsibus (De dign. puls.) 1.1 (8.767–71 K.) 358 n. 54 2.2 (8.847–857 K.) 356 n. 43 2.2–3 (8.857–62 K.) 356 n. 42 3.1 (8.882 K.) 359 n. 61 De facultatibus naturalibus (De facult.  natur./De fac. nat.) 2.8 (2.113 K.) 205 n. 9 3.13 (2.192 K.) 205 n. 9 3.15 (2.211.8 K. = 254.16–17 Helmreich) 332 n. 25

Index Locorum De indolentia (Ind.) 206 42 207 48 207 De locis affectis (De loc. aff.) 213–215 1.4 (8.38 K.) 205 n. 9 2.2 (8.70 K.) 307 2.5 (8.81 K.) 313, 315 2.5 (8.82–83 K.) 315 2.6 (8.86–87 K.) 317 2.6 (8.87 K.) 307, 308 2.7 (8.88–89 K.) 313, 314, 316 2.8 (8.106–107 K.) 317 2.8 (8.107–108 K.) 311 2.9 (8.111 K.) 312 2.9 (8.112 K.) 311 2.9 (8.114 K.) 310 2.9 (8.116 K.) 312, 313 2.9 (8.117 K.) 312, 313, 315 2.9 (8.118 K.) 318 3.9 (8.178 K.) 213 n. 38, 293 n. 26 3.9–10 (8.176–93 K.) 215 3.10 (8.184–85 K.) 213, 235 n. 29 3.10 (8.185 K.) 208 n. 20 3.10 (8.190 K.) 215, 293 n. 26 3.10 (8.192 K.) 205 n. 9, 293 n. 26 3.10 (8.193 K.) 214 3.11 (8.194 K.) 305 n. 6 5.6 (8.339 K.) 306 5.8 (8.355 K.) 317 4. 2 (8.226–8 K.) 233 n. 23 4.8 (8.266. 11–12 K.) 395 n. 20, 396 5.1 (8.302 K.) 210 5.6 (8.340–41 K.) 213 n. 36 5.8 (8.363 K.) 348–349 n. 17 5.8 (8.362–65 K.) 357 n. 48 5.8 (8.363–64 K.) 358 n. 51 6.1 (8.378.9 K.) 293 n. 26 6.1 (8.380.11 K.) 293 n. 26 6.5 (8.433.1 K.) 293 n. 26 De optima corporis nostri constitutione  (De opt. corp. const.) 3.4 (4.744–5 K.) 415

523 De optimo medico cognoscendo libelli  versio Arabica (De opt. med. cogn.) 466, 466 n. 28 De ossibus ad tirones (De Ossibus) 25 (2.777.7 K.) 43 n. 86 De placitis Hippocratis et Platonis  (De plac. Hipp. et Plat.) 209 n. 22, 210 n. 24, 305 n. 4, 313 n. 36 3.7 (5.335–36 K.) 210 n. 24 4.7.24 (5.422 K.) 207 4.7.26 (5.426 K.) 207 7.7 (5.637 K.) 305 n. 5 9.1 (5.722 K.) 313 n. 36 9.1 (5.725 K.) 313 n. 37 8.6 (5.692–93 K.) 42 n. 75 9. 5. 4–6 (5.751,10–752,1 K. =  564.21–30 De Lacy) 335 n. 35 De praecognitione ad Epigenem  (De praecogn.) 487, n. 59 2.5 (14.607  K. = CMG V,8,1, 76) 347 n. 10 2.6 (14.607 K. = CMG  V,8,1, 76) 356 n. 42 3.3 (14.614 K. = CMG  V, 8.1, 82.19) 97 n. 55, 357 n. 48 3.11 (14.616–17  K. = CMG V,8,1, 86) 347 n. 10 5 (14.625–26 K.) 211 n. 31 6 (14.630–33, 634 K.) 211 n. 31 6 (14.630–33 K.) 211 6 (14.632 K.) 210 n. 24 6 (14.633–35 K.) 208 6 (14.633 K.) 212 6 (14.635 K.) 211 n. 29 6.4–16 (14.631.15–635.9  K. = CMG V,8,1,  102.1–104.23) 353 n. 31 6.15 (634 K. = CMG V, 8.1, 104) 93 n. 41 6–7 (14.630–41 K. = CMG  V, 8.1, 100–110) 93 n. 41 7 (14.640 K.) 211 n. 31 7.6–18 (14.637–41 K.  = CMG V,8,1, 106–10) 358 n. 51 7.14–15 (639–40 K.  = CMG V,8,1, 108) 357 n. 48

524 De praecognitione ad Epigenem (cont.) 11.3–10 (14.658–61 K.  = CMG V,8,1, 126–30) 357 n. 47 11.4 (14.659 K. = CMG  V,8,1, 128) 356 n. 42 11.9 (14.661.5–7 K.  = 130, 5–7) 357 n. 47 13 (14.669 K.) 211 n. 31 14.3–12 (14.670–73 K.  = CMG V,8,1, 138–42) 358 n. 54 14.5–7 (14. 671–72 K. =  CMG V,8,1, 140) 356 n. 42 14.12 (14. 673.13 K.  = CMG V,8,1, 142.14) 357 n. 49 De praesagitione ex pulsibus (De praesag.  ex puls.) 1.4 (9.250 K.) 355 n. 40 1.8 (9.268 K.) 211 n. 27 3.6 (9.2.367–68 K.) 308 n. 18 3.7 (9.375 K.) 210 3.8 (9.388 K.) 208 n. 20 4.11. (9.420 K.) 349 n. 20 De propriorum animi cuiuslibet affectuum  dignotione et curatione  (De an. aff. dign. et cur.) 206 1–10 (5.1.–57 K.) 418 n. 7 3 (5.7 K.) 209 n. 22 7 (5.37 K.) 206 n. 10 8 (5.43–44 K.) 206 n. 13 9 (5.48–51 K.) 206 n. 13 9–10 (5.48–54 K.) 207 n. 14 De pulsibus ad tirones (De puls. ad tir.) 1 (8.454 K.) 353 nn. 33–34 9 (8.462–63 K.) 356 n. 42 10–12 (8.468–74 K.) 353 n. 31 12 (8.473–74 K.) 209 n. 22 12 (8.474 K.) 201, 358 n. 56 De pulsuum differentiis (De diff. puls.) 1.1 (8.495 K.) 356 n. 44, 357 n. 47 1.1 (8.496 K.) 349 n. 20 1.3 (8.500 K.) 358 n. 54 2.6 (8.590–92 K.) 356 n. 44 3.2 (8.645 K.) 359 n. 61, 360 n. 66 3.6 (8.675 K.) 308 n. 16 3.6 (8.675 K.) 316 n. 45 3.6 (8.675 K.) 316 n. 46 3.7 (8.690–91K.) 309 n. 21

Index Locorum 3.7 (8.692 K.) 316 n. 44 4.2 (8.704 K.) 309 n. 24 4.2 (8.709 K.) 309 n. 26 De sanitate tuenda (De san. tuenda) 413–431, 467, 467 n. 29 1.1 (6.1 K.) 414 1.1 (3.2–4 Koch = 6.1 K.) 429 1.3 (5.35–6.26 Koch =  6.7–9 K.) 416 1.5 (6.28 K.) 209 n. 22 1.7 (17.26–29 Koch =  6.31–37 K.) 418 1.7.1–13 (6.32K.) 280 n. 74 1.8 (6.40K.) 207 n. 15, 209 n. 22, 209 n. 23 1.8 (21.13–20 Koch=  6.37–38 K.) 418 1.8 (21.22–33 Koch =  6.37–42 K.) 417 1.9 (21.34–22.11 Koch =  6.45–47 K.) 418 1.10 (23.29–24.2 Koch =  6.49–50 K.) 418 2.8 (59.35–60.6 Koch =  6.133–134 K.) 422 2.7 (56.1–59.23 Koch =  6.124–133 K.) 419 2.7 (56.1–59.23 Koch =  6.124–133 K.) 415 3.8 (93.19–23 Koch  = 6.211 K.) 419 4.4.11–13 (108.16–26  Koch = 6.245–246 K.) 420 4.4 (107.6–116 Koch =  6.242–264 K.) 425 4.4 (110.9–16 Koch =  6.249–250 K.) 426 5.1 (135.18–30 Koch =  6.306–3-7 K.) 424 5.1 (135.1–30 Koch =  6.305–7 K.) 421 5.1 (136.16–24 Koch =  6.377 K.) 423 5.1 (137.15–32 Koch =  6.310–311 K.) 420 5.1 (138.4–5 Koch =  6.312 K.) 425 5.4 (142.19–21 Koch =

Index Locorum  6.330 K.) 428 5.4 (143.16–144.20 Koch =  6.332–334 K.) 424 5.7 (148.21–149.34 Koch =  6.342–349 K.) 417 5.11 (161.4–162.5 Koch =  6.364–367 K.) 423 5.12 (166.14–18 Koch =  6.377 K.) 422 6.1 (168.23–6 Koch =  6.382–383 K.) 356 n. 42, 422 6.1 (168.23–6 Koch =  6.381 K.) 420 6.2 (169–70 Koch =  384–387 K.) 356 n. 42 6.5 (178.11 Koch =  6.405 K.) 422 6.7 (181.16–26 Koch =  6.412 K.) 423 6.10 (186.25–187.22  Koch = 6.425–427 K.) 426 6.14 (197.2–17 Koch =  6.443–450 K.) 416 6.14 (6.448–49 K.) 213 n. 36 6.14 (197.16–7 Koch =  6.450 K.) 414 De temperamentis (De temper.) 2.6 (1.633 K.) 209 n. 22 37.17–32.4 (1.558–59 K.) 465, 465 n. 27 De theriaca ad Pisonem liber 1 (14.212–14 K.) 46 n. 104 De tumoribus praeter naturam  (De tumor. praeter nat.) 15 (7.729 K.) 42 n. 76 De usu partium (De usu part.) 2.3 (3.96.11 K.) 86 n. 15 3.6 (3.194.18 K.) 43 n. 86 De venae sectione adversus Erasistrateos  Romae degentes (De venae sect. adv.  Erasistrateos) 9 (11.241–42 K.) 213 n. 36 In Hippocratis aphorismos commentarii  I–VII (In Hipp. Aph. comment.) 5 (17b 788.7–9 K.) 190 n. 94 23 (18a 35–36 K) 214 In Hippocratis de natura hominis librum

525  commentarii (In Hipp. Nat. Hom.  comment.) 17 (15.162 K.) 209 n. 22 In Hippocratis epidemiarum librum  primum commentarii (In Hipp. Epid. I  comment.) 1 (17.1.251–53 K. = CMG  V, 10.1, 126.11–127.17) 93 n. 42 3.1 (17a 213–14 K.) 215 3.74 (17a 758.11–16 K.) 189 n. 85 In Hippocratis epidemiarum librum  secundum commentarii (In Hipp. Epid. II  comment.) CMG V, 10, 1.1 206–07) 211 n. 31 CMG V, 10, 1.1 207–08) 215 CMG V, 10, 1.1 208) 211 n. 30, 213 In Hippocratis epidemiarum librum  sextum commentarii (In Hipp. Epid. VI  comment.) 1.10 (17.1 852 K.) 209 n. 22 2.45 (17.1.995–99 K. =  CMG V, 10.2.2, 115–117) 89 n. 27, 90 n. 28 2.45 (17.1.998.7–13 K. =  CMG V, 10.2.2, 117.5–11) 96 n. 48 2.47 (17.1.998 K.) 210 n. 26 2.47 (17.1.995–97 K. =  CMG V, 10.2.2,  115.28–116.17) 90 n. 29 2.47 (17.1.997 K. = CMG  V, 10.2.2, 116.21–26) 90 n. 31 2.47 (17.1.997–98 K. =  CMG V, 10.2.2,  116.26–117.1) 90 n. 32 2.47 (17.1.998–99 K. =  CMG V, 10.2.2, 117.4–19) 91 n. 33 2.47 (17.1.998.7–13 K. =  CMG V, 10.2.2, 117.5–11) 96 n. 48 2.47 (17.1.998–99 K. =  CMG V, 10.2.2, 117.13–19) 91 n. 34 4.8 (17.2.137–138 K. =  CMG V, 10.2.2, 119) 485, 453, 453 n. 4, 458 n. 12, 466 CMG V, 10.2.2 485–86 212, 216 CMG V, 10.2.2 486–87 207 CMG V, 10.2.2 487 214

526 In Hippocratis epidemiarum librum (cont.) CMG V, 10, 2, 2, 505–06 227 In Hippocratis librum de acutorum victu  commentarii (In Hipp. Acut. comment.) 1 (15.419 K. = CMG V,  9.1, 117.11–19) 88 n. 23 1 (15.427 K. = CMG V,  9.1, 121.22) 89 n. 24 In Hippocratis prognosticum commentarii  (In Hipp. Progn. comment.) 1.4 (18b 18–19 K.) 211 1.4 (18b 19 K.) 207 1.8 (18b 39–41 K.) 211 n. 27 1.8 (18b 40 K.) 211 nn. 30, 31 3.23 (18b 273 K.) 208 n. 20 In Hippocratis prorrheticum I  commentaria III (In Hipp. Prorrhet.  comment.) 1.2.53 (16.630.13–631.11 K.) 170 n. 12 Methodus medendi  (De meth. med.) 213, 421 4.4 (10.260.7 K.) 332 n. 25 5.12 (10.362 K.) 45 n. 96 10.9 (10.702–03 K.) 42 n. 76 6.4 (10.420.10–13 K.) 86 n. 15 6.5 (10.425.1–11 K.) 86 n. 15 8.2 (10.535 K.) 209 n. 22 8.3 (10.555 K.) 208 n. 20 8.7 (10.585 K.) 209 n. 22 10.2 (10.666 K.) 209 n. 22 10.4 (10.679 K.) 209 n. 22 10.5 (10.687 K.) 213 10.6 (10.692 K.) 209 n. 22 12.5 (10.841 K.) 210 nn. 24, 25 13.5 (10.886 K.) 43 n. 85 Protrepticus (Protrept.) 7 (1.12 K.) 206–7 Quod animi mores corporis temperamenta  sequantur (Quod animi mor.) 1–11 (4.11.767–822 K.) 418 n. 7 Quomodo morborum simulantes sint  deprehendi (De morb. simulant.) 19.7 K. 314 n. 39 Quod optimus medicus sit quoque  philosophus (Quod opt. med.)  2.5–6 (1.56,10–57,3 K. = 287,7–18  Boudon-Millot) 335 n. 35

Index Locorum Thrasybulus sive utrum  medicinae sit an gymnasticae  hygiene (Thras.) 428 40 (5.885 K.) 209 n. 22 Gellius, Aulus Noctes Atticae (NA) 18.10.8 46 Herodotus Historiae 1.1.1 3.130.10–1

395 n. 18 255 n. 26

Herophilus Fragmenta (von Staden) 162 174–88b 179–81 182

360 n. 65 351 n. 24 360 n. 65 351 n. 26

Hippocrates Aphorismi (Aph.) 2.51, 4.484.11 L. 255 6.23, 4.568 L. 214, 226, 231 6.32, 4.570.10 L.  (= Jones 186) 186 6.38, 4.572 L. 481 7.40, 4.588.8–9 L.  (= Jones 202) 190 n. 91 7.58, 4.594.10–11 L.  (= Jones 206) 190 n. 90 7.83, 5.440.5–7 L. 252 n. 23 7.87, 4.608 L. 483 n. 44 Coa Praesagia (Coac.) 39, 5.594.11–14 L.  (= Potter 114) 183 51, 5.596.11–13 L.  (= Potter 116) 179 n. 41, 181 n. 51, 188 n. 82 65, 5.598.9–10 L.  (= Potter 120) 192 98, 5.604.3–6 L.  (= Potter 126) 181 n. 50 183 157, 5.618.4–7 L.  (= Potter 140) 185 n. 66 159, 5.618.9–11 L.  (= Potter 140) 170 n. 12

Index Locorum 160, 5.618.11–15 L.  (= Potter 140–42) 184 n. 63 194, 5.626.6–10 L.  (= Potter 150) 190 n. 89 208, 5.628 L. 181 228, 5.634.14–17 L.  (= Potter 158) 183 252, 5.638.10–12 L.  (= Potter 162) 181 n. 50 253, 5.638.12–13 L.  (= Potter 164) 183 n. 56 254, 5.638.13–14 L.  (= Potter 164) 191 312, 5.652.9–11 L.  (= Potter 178) 183 n. 56 355, 5.658.23–660.3 L.  (= Potter 186) 187 n. 74 484, 5.694.2–3 L.  (= Potter 224) 170 n. 18 485, 5.694.3–7 L.  (= Potter 224) 170 n. 12, 171 n. 20 489, 5.696.2–5 L.  (= Potter 226) 190 n. 90 625, 5.728.19–23 L.  (= Potter 264) 183 n. 56 636, 5.732.4–5 L.  (= Potter 268) 183 n. 56 Cnidian Sentences/  Cnidian Maxims 88–89, 92, 162, 171–172 De Aere, Aquis, Locis (Aer.) 1, 2.12.7 L.  (= Jouanna 187.1) 140 n. 7 1, 2.12.9–10 L.  (= Jouanna 187.4–5) 147 1.12–13, 2.12.9–10 L. 84 n. 12 2, 2.14.1–10 L.  (= Jouanna 188.6–  189.3) 141 2, 2.14.3 L. (= Jouanna  188.8–9) 147 2, 2.14.4 L. (= Jouanna  188.9) 140 n. 7 3, 2.18.1–2 L. (= Jouanna  190.13–14) 139 n. 5 3, 2.18.1–2 L. (= Jouanna  190.14) 140 n. 7

527 3, 2.18.15 L. (= Jouanna;  192.6) 140 n. 7 4, 2.18.20 L. (= Jouanna  192.12) 140 n. 7 4, 2.20.4 L. (= Jouanna  193.6–7) 139 n. 5 4, 2.22.1 L. (= Jouanna  194.11) 140 n. 7 4, 2.22.1–2 L. (= Jouanna  194.10–12) 140 5, 2.24.2 L. (= Jouanna  197.4) 181 n. 48 7, 2.28.3–4 L. (= Jouanna  200.9–10) 141 n. 9 9, 4–6, 2.38.13–42.6 L.  (= Jouanna  209.11–211.11) 171 n. 19 11, 2.52.1–6 L. (= Jouanna  218.13– 219.5) 146 15, 2.62.8 L. (= Jouanna  227.5) 140 n. 7 22, 2.76.14–15 L.  (= Jouanna 238.9) 140 n. 7 De Affectionibus (Aff.) 18, 6.226 L. 434 n. 5 29–30, 6.240–42 L. 434 n. 5 35, 6.246 L. 434 n. 5 37, 6.246.16–18 L. 97 n. 58 De Affectionibus Interioribus (Int.) 1, 7.166.23 L. 251, 251 n. 16 10, 7.188.26 L.  (= Potter 102) 162 n. 52 14, 7.202.1 L.  (= Potter 118) 162 n. 52 27, 7.236.15–16 L. 251, 251 n. 16 35, 7.252.17 L.  (= Potter 188) 162 n. 52 36, 7.256.21–22 L. 252 n. 23 47, 7.282.7 L. 251, 251 n. 16 48, 7.284.8–19 L.  (= Potter 230–232) 170 n. 13 52, 7.298.11 L.  (= Potter 250) 162 n. 52 De Arte (de Arte) 7, 6.10–12 L. 90 n. 30 7, 6.10.15–12.13 L.  (= Jouanna  231.1–232.11) 174 n. 27

528 De Arte (de Arte) (cont.) 11, 6.18.14–22.14 L.  (= Jouanna  237.4–239.14) 174 n. 27 12, 6.24.2–7 L.  (= Jouanna 240.5–6) 180–181 De Articulis (Art.) 1, 4.78.9–80.1 L. 260 n. 40 35–37, 4.158–66 L. 253 37, 4.164.14–15 L. 253 37, 4.166.2 L. 253 37, 4.166.12–15 L. 253 43, 4.186.5–8 L. 260 n. 40 47, 4.206.6–7 L. 260 n. 40 47, 4.213 L. 92 n. 37 62, 4.266.13–17 L. 254 72, 4.296–300 L. 260 n. 40 78, 4.312,3–5 L.  (= Kühlewein  236.18–237.2) 335 n. 41 De Capitis Vulneribus (VC) 10, 3.214.11–16 L. 251 De Carnibus (Carn.) Carn. 6, 8.592 L.  (= Joly 192) 346 n. 5 Carn. 19, 8.612 L. 268 n. 11 De Decenti Habitu (Decent.) Decent. 1, 9.226.11–12 L.  (= Heiberg 25.10–11) 337 n. 45 Decent. 3, 9.228, 8–10 L.  (= Heiberg 25.21–23) 337 n. 45 Decent. 7–8, 9.226 L. 371 n. 16 Decent. 14, 9.240.15–16 L. 90 n. 30 Decent. 18, 9.244.1–2 L.  (= Heiberg 29.29–30) 337 n. 45 De Diebus Iudicatoriis (Dieb. Judic.) Dieb. Judic. 2, 9.298.17–19  L. (= Potter 302) 181 n. 47 Dieb. Judic. 3, 9.300.11–22  L. (= Potter 302–304) 170 n. 13 De Diaeta Acutorum/De Diaeta in Morbis Acutis (Acut.) 1, 2.224.1–8 L.  (= Joly 36, 1–10) 171 1, 2.224.2–9 L.  (= Jones II.62.1–10) 88 n. 21 3, 2.228.2–6 L.  (= Joly 37.7–10) 138 n. 1, 162 n. 51

Index Locorum 46, 2.320.5–324.4 L.  (= Joly 56.3–18) 138 n. 1, 152 De Diaeta Acutorum (Acut. (spur.)) 9, 2.436.8–438.1 L. 97 n. 57 18, 2.480 L. (= Potter 306) 346 n. 4 De Diaeta Salubri (Salubr.) 6.72 L. 380 n. 49 De Flatibus (Flat.) Flat. 1, 6.90.5 L. 251 Flat. 1, 6.90.3 L. (= Jouanna  102.3–4) 119 n. 39 Flat. 6, 6.96.23–98.2 L.  (= Jouanna 109.5–8) 141 n. 9 Flat. 6–7, 6.96–98.16 L.   (= Jouanna 109.5–111.1) 151 n. 33 De Fracturis (Fract.) 1, 3.412.1–2 L. 254 2, 3.422.5–6 L. 255 5, 3.432.9 L. 97 n. 57 7, 3.442.1–4 L. 254 8, 3.444.16–17 L. 260 n. 40 13, 3.460–66 L. 260 n. 40 13, 3.462.4–5 L. 260 n. 40 15, 3.470.10–11 L. 260 n. 40 16, 3.476.8–10 L. 260 n. 40 19, 3.482.9–10 L. 252 n. 23 43, 3.554.9–12 L. 255 De Haemorrhoidibus (Haem.) 252 De Humoribus (Hum.) 2, 5.478.6–13 L.  (= Jones 64–66) 178 n. 36 10, 5.490.9–16 L. (= Jones  80–82) 185 n. 67 De Iudicationibus ( Judic.) Judic. 43, 9.290.9–11 L.  (= Potter 292–93) 184 n. 61 De Locis in homine (Loc.Hom.) 3, 6.280 L. (= Craik 38–40) 346 n. 5 De Medico (Medic.) 1, 9.206.4–9 L. 256 1, 9.204.11–12 L.  (= Heiberg 20.11–12) 334 n. 34 8, 9.214.18–20 L. 255 n. 27 De Morbis I (Morb. I) 1.3, 6.144–46 L. 482, n. 42 1.20, 6.178.5–180.7 L.  (= Wittern 54.15–58.6) 174 n. 27 1.29, 6.198.14–17 L. 250 n. 14

Index Locorum De Morbis II (Morb. II) 2.6, 7.14.8–22 L.  (= Jouanna 137.9–138.5) 190 n. 91 2.12, 7.20.7–8 L. 250 n. 14 2.15, 7.28.7 L. 251 2.21, 7.36.1–13 L. (= Jouanna  155.10–156.9) 190 n. 91 2.22, 7.36.14–38.5 L. (= Jouanna  156.10–157.10) 187 n. 72 2.36, 7.52.16–17 L. 250 n. 14 2.47, L. 7.70.20–22 250 n. 14 2.48, 7.72.6–13 L.  (= Jouanna 183.5–13) 181 n. 49 2.50, 7.76.10 L. (= Jouanna  186.13) 181 n. 45 2.51, 7.78.16–17 L.  (= Jouanna 188.10–12) 113, 119 n. 38 2.60, 7.94.6–8 L. 250 n. 14 2.65, 7.100.1–7 L.  (= Jouanna 204.3–10) 187 n. 74 2.67, 7.102.4–25 L.  (= Jouanna  205.17–206.18) 187 n. 73 2.72, 7.110.1–4 L. 251 De Morbis III (Morb. III) 3.13.2, 7.134.4–7 L.  (= Potter 80.25–28) 463 3.11, 7.130.21 L. 252 n. 23 3.13, 7.132.18–134.7 L.  (= Potter 26) 187 n. 74 3.16, 7.150.21–23 L.  (= Potter 50) 181 n. 49 3.9, 7.128.6–7 L. 251 3.15, 7.136.11–15 L.  (= Potter 82.22–25) 169 n. 9 De Morbis Popularibus I = Epidemiarum  Libri (Epid. 1) 1.1, 2.598.11 L.  (= Kühlewein  1.180.11–12) 145 n. 25 1.2, 2.608 L. 346 n. 2 1.4, 2.616.4–5 L.  (= Kühlewein  1.184.15–16) 145 n. 25 1.4, 2.632 L. 346 n. 2 1.5, 2.634.6–636.4 L.  (= Kühlewein  189.24–190.3–6) 131 n. 65

529 1.5, 2.634.6–636.4 L.  (= Kühlewein  189.24–190.6) 174 n. 28 1.5, 2.634.6–636.4 L.  (= Kühlewein  189, 24–190, 6) 166, 174 n. 28, 176 1.5, 2.634.8–636.1 L. 249 1.7, 2.638.8–9 L.  (= Kühlewein  1.190.22–23) 145 n. 25 1.8, 2.642.4–5, 8 L.  (= Kühlewein  1.191.19, 22) 157 n. 46 1.8, 2.642.4–10 L.  (= Kühlewein  1.191.19–24) 159 (chart) 1.8, 2.642.5–10 L.  (= Kühlewein  1.191.19–24) 147 1.8, 2.642.9 L.  (= Kühlewein  1.191.24) 154 n. 36, 154 n. 37 1.8, 2.644.7–11 L.  (= Kühlewein  1.192.10–14) 150, 158 1.8, 2.646.1 L.  (= Kühlewein  1.192.20) 161 n. 49 1.8, 2.646.2–3 L.  (= Kühlewein  1.192.21–22) 148 1.8, L. 2.646.9–648.6  (= Kühlewein  1.193.6–18) 155 1 8,1–15, 2.646.9–648.6  L. (= Kühlewein  1.193.6–18) 159 (chart) 1.8, 2.646.11–13 L.  (= Kühlewein  1.193.7–10) 151 n. 32 1.8, 2.646.13–648.4 L.  (= Kühlewein  1.193.10–16) 149 1.8, 2.648.6–650.3 L.  (= Kühlewein  1.193.19–194.5) 150 1 8,1–12, 2.648.6–650.4 L.  (= Kühlewein  1.193.19–194.7) 160 (chart)

530 De Morbis Popularibus I (cont.) 1.9, 2.650.9–654.5 L.  (= Kühlewein  1.194.13–195.10) 157 1.9,1–28, 2.650.9–656.1 L.  (= Kühlewein  1.194.13–195.14) 160 (chart) 1.9, 2.654.3 L.  (= Kühlewein  1.195.8–9) 158 n. 47 1.9, 2.654.1 L.  (= Kühlewein  1.195.6) 148 n. 30, 154 n. 37 1.9, 2.656.7–658.2 L.  (= Kühlewein  1.195.21–196.2) 143, 148, 150 1.9, 2.656.4–6 L.  (= Kühlewein  195, 18–19) 186 n. 69 1.9, 2.658.6–12 L.  (= Kühlewein  1.196.6–13) 149 1.9, 2.660.1–3 L.  (= Kühlewein  1.196.19–21) 154 n. 36 1.9, 2.660.1–5 L.  (= Kühlewein  1.196.19–23) 148 1 9, 1–6, 2.660.1–5 L.  (= Kühlewein  1.196.19–23) 160 (chart) 1.9, 2.662.3–664.4 L.  (= Kühlewein  1.197.7–16) 150 1.9, 2.664.10–12 L.  (= Kühlewein  1.198.1–3) 151 n. 32 1.9, 2.664.12–666.3 L.  (= Kühlewein  1.198.3–5) 148, 161 n. 49 1.10, 2.668–70 L. 346 n. 1 1.10, 2.668.14–670.2 L.  (= Kühlewein  1.199.10–11) 142 1.10, 2.668.14–670.15 L.  (= Kühlewein  199.8–200.2) 176–177

Index Locorum 1.13, case 1, 2.682.8–9 L.  (= Kühlewein  202.15–16) 126 1.13, case 1, 2.682.14 L.  (= Kühlewein  1.202.21) 154 n. 37 1.13, case 1, 2.682.14–15 L.  (= Kühlewein  1.202.21–22) 154 n. 36 1.13, 2.684 L. 346 n. 2 1.13, case 1, 2.684.3 L.  (= Kühlewein  203.3) 188 1.13, case 2, 2.686.1–7 L.  (= Kühlewein  203.23–204.1) 187 1.13, case 2, 2.688.1–2 L.  (= Kühlewein  204.12–13) 190 1.13, case 3, 2.688.15–16 L.  (= Kühlewein  205.2–3) 188 1.13, case 3, 2.688.10–16 L.  (= Kühlewein  204.20–205.2) 188 n. 82 1.13, case 4, 2.692.16–17 L.  (= Kühlewein  206.13–14) 187–188 1.13, case 4, 2.692.15–694.2 L.  (= Kühlewein  206.12–16) 189 1.13, case 5, 2.694.4–6 L.  (= Kühlewein  206.17–19) 131 1.13, case 10, 2.706.15–708.1 L.  (= Kühlewein  1.211.9–10) 154 n. 36 1.13, case 11, 2.708.6–710.11 L.  (= Kühlewein  1.211.15–212.14) 156 1.13, case 11, 2.710.3 L.  (= Kühlewein  1.212.6) 154 n. 37 1.13, case 11, 2.710.3 L.  (= Kühlewein  1.212.6) 148 n. 30

Index Locorum De Morbis Popularibus II = Epidemiarum Libri (Epid. 2) 2.1.6, 5.76.15–16 L.  (= Smith 22) 185 2.1.8, 5.80.1–4 L.  (= Smith 24–26) 181 n. 45 2.1.8, 5.80.3–4 L.  (= Smith 26) 181 n. 48 2.1.8, 5.80.1–14 L.  (= Smith 24–26) 181 n. 46 2.2.3, 5.84.8–9 L. 125 2.9, 5.88.11–12 L. 133 2.2.10, 5.88.13–14 L. 133 2.2.10, 5.88.13–14 L.  (= Smith 33) 171 n. 21 2.2.17, 5. 90.7–12 L. 115 2.2.18, 90.13–92.2 L. 115 2.2.18, 5.92.2 L. 126 2.2.24, 5.96.1–2 L. 251 n. 16 2.3.2, 5.104.9 L. 128 2.3.4, 5.106.3–108.6 L.  (= Smith 50) 169, n. 9 2.3.13, 5.114.17 L. 126 2.3.11, 5.116.8–9 L. 133 2.5.2, 5.128.7–11 L.  (= Smith 70) 184 n. 61 2.6.1, 5.132.15–21 L.  (= Smith 76) 185 2.6.2, 5.132.21–22 L.  (= Smith 76) 185 n. 67 2.6.4, 5.134.2–5 L.  (= Smith 76) 178 2.6.14, 5.136.2–5 L.  (= Smith 80) 184 2.6.22, 5.136.14–18 L.  (= Smith 82) 184 n. 62 De Morbis Popularibus III = Epidemiarum Libri (Epid. 3) 3.1, case 2, 3.34.8 L.  (= Kühlewein  216.6) 126 3.1, case 2, 3.36.6 L.  (= Kühlewein  216.13–14) 128 n. 59 3.1, case 6, 3.50.11 L.  (= 220, 15–16  Kühlewein) 131 3.1, case 10, 3.60.1–8 L.

531  (= Kühlewein  1.222.6–13) 156 3.1, case 10, 3.60.2 L.  (= Kühlewein  1.222.6) 155 n. 43 3.1, case 11, 3.62.10 L.  (= Kühlewein  1.223.2) 155 n. 43 3.1, case 12, 3.62.11–66.11 L.  (= Kühlewein  1.223.3–224.5) 156 3.16, 3.102.2–5 L.  (= Kühlewein  1.232.10–14) 142 3.16, 3.102.3 L.  (= Kühlewein  1.232.11) 142 n. 11 3.16, 3.102.3–5 L.  (= Kühlewein  1.232.12–13) 142 n. 11 3.16, 3.102.3–5 L. 142 n. 12 3.17, case 1, 3.104.5 L.  (= Kühlewein  1.233.3) 154 n. 37 3.17, case 2, 3.108.5–112.12 L.  (= Kühlewein  1.234.3–235.6) 156 3.17, case 2, 3.112.2–9 L.  (= Kühlewein  234.22–235.3) 191 3.17, case 3, 3.114.3 L.  (= Kühlewein  235, 13) 189 n. 85 3.17, case 7, 3.122.14 L.  (= Kühlewein 1.238.3) 154 n. 37 3.17, case 11, 3.134.2 L.  (= Kühlewein 241.4–5) 124 3.17, case 13, 3.138.13 L.  (= Kühlewein 242.24) 127 3.17, case 14, 3.140.14–142.4 L.  (= Kühlewein  1.243.13–25) 156 3.17, case 13, 3.140.10 L.  (= Kühlewein 243.9) 132 De Morbis Popularibus IV = Epidemiarum  Libri (Epid. 4) 4.3, 5.146.3–4 L. 127 4.6, 5.146.11–12 L. 117

532 De Morbis Popularibus IV (cont.) 4.13, 5.150.22 L. 126 4.12, 5.150.14–15 L.  (= Smith 94) 190 n. 91 4.1.15, 5.152.20 L.  (= Smith 96) 179 n. 41 4.1.20b, 5.158 L. 360 n. 65 4.20, 5.160.6–7 L. 118 4.25, 5.168.3–5 L.  (= Smith 110) 162 n. 50 4.26, 5.170.9 L. 126 4.27, 5.172.1–5 L.  (= Smith 114) 162 n. 50 4.30, 5.174.6–7 L. 127 n. 56 4.41, 5.182.15 L. 126 4.43, 5.184.9 L. 248 n. 3 4.61, 5.196.19–21 L.  (= Smith 140) 185 n. 67 De Morbis Popularibus V =Epidemiarum  Libri (Epid. 5) 5.2, 5.204 L.  (= Jouanna 3.2–5) 129 n. 62, 132 5.14, 5.212.20–21 L.  (= Jouanna 8.19–20) 127, 129 5.15, 5.214.18–19 L.  (= Jouanna 10.7–8) 130 5.17, 5.216.11–19 L.  (= Jouanna 11.4–14) 171 n. 19 5.25, 5.224.11–13 L. 252 n. 19 5.21, 5.220.14–19 L.  (= Jouanna 13.18–25) 169 n. 10 5.22, 5.220.20–222.11 L.  (= Jouanna 14.1–18) 169 n. 10 5.25, 5.224.6–13 L.  (= Jouanna 15.16–26) 122 5.27, 5.226.10–11 L.  (= Jouanna 17.1–3) 126 5.28, 5.226.20 L.  (=Jouanna 17.14) 130 5.31, 5.228.20–21 L.  (= Jouanna 18.18–19) 127 5.41, 5.232.6 L. 42 n. 78 5.43, 5.232.17–22 L.  (= Jouanna 21.11–18) 169 n. 10 5.46, 234.10 L.  (= Jouanna 22.8) 129 5.50, 5.236.11 L.  (= Jouanna 23.15) 115

Index Locorum 5.50, 5.236.11–20 L.  (= Jouanna 23.15–24.2) 190 n. 90 5.50, 5.236.16 L.  (= Jouanna 23.22) 126 5.55, 5.238.11–16 L.  (= Jouanna 25.6–13) 190 n. 90 5.63, 5.242.10–11 L.  (= Jouanna 28.14–29.1) 121 5.74, 5.246.25–48.1 L.  (= Jouanna 34.6–7) 118 5.81, 5.250.12 L.  (= Jouanna 37.10) 118 5.82, 5.250.14–15 L.  (= Jouanna 37.13–14) 118 5.83, 5.250 L.  (= Jouanna 38.5–6) 118 5.83, 5.250.18–252.4 L.  (= Jouanna 38.5–15) 169 n. 8 5.84, 5.252.5–6 L.  (= Jouanna 39.1–2) 122 5.87, 5.252.16–17 L.  (= Jouanna 40.2) 127 5.95, 5.254 L.  (= Jouanna 42.5–7) 130 5.95, 5.256.2 L.  (= Jouanna 42.9–10) 132 5.80, 5.248.23– 250.9 L.  (= Jouanna 36.7–37.6) 188 n. 80 De Morbis Popularibus VI = Epidemiarum  Libri (Epid. 6) 6.2.24, 5.290 L. 130, 97 n. 55 6.5.7, 5.318.1–4 L.  (= Manetti-Roselli  110.1–4) 120 6.6.3, 5.324 L. 483 n. 44 6.7.6, 5.340.8–12 L.  (= Manetti-Roselli  156.1–158.6) 170 n. 12, 181 n. 50 6.8.7, 5.344.17–346.7 L.  (= Manetti-Roselli  166.1–172.12) 177–178 6.8.31, 5.354.19–365.3 L.  (= Manetti-Roselli  192.1–194.5) 181 n. 52 6.8.31, 5. 354–56 L. 227 6.8.32, 5.356.8 L.  (= Manetti-Roselli  194.6) 181 n. 45

533

Index Locorum 6.8.32, 5.356.12–15 L.  (= Manetti-Roselli  194.10–14) 130 De Morbis Popularibus VII = Epidemiarum  Libri (Epid. 7) 7.1, 5.366.1–6 L.  (= Jouanna 48.15–49.2) 190 n. 93 7.2, 5.366.10–11 L.  (= Jouanna 49.7) 169 n. 10 7.2, 5.368.3 L.  (= Jouanna 50.1–2) 185 n. 65 7.5, 5.372.23–74.1 L.  (= Jouanna 53.11–12) 119 7.5, 5.374.7 L.  (= Jouanna 53.20–21) 124 7.5, 5.374.22–23 L.  (= Jouanna 54.13–15) 124 7.7, 5.378.9 L.  (= Jouanna 56.8) 181 n. 45 7.8, 5.378. 22–23 L.  (= Jouanna 56.23–25) 184 n. 59 7.10, 5.382.10–11 L.  (= Jouanna 58.18–19) 124 7.11, 5.382.19–21 L.  (= Jouanna 59.5–7) 187 n. 75 7.11, 5.382.15 L.  (= Jouanna 58.23) 120 7.11, 5.382.22–23 L. 252 n. 23 7.11, 5.386.21–22 L.  (= Jouanna 61.23–24) 185 n. 65 7.11, 5.384.17–19 L.  (= Jouanna 60.11–13) 124 7.22, 5.393.13–14 L.  (= Jouanna 65.7–9) 185 n. 65 7.24, 5.394.3–7 L.  (= Jouanna 65.24–66.4) 190 n. 95 7.24, 5.394.5 L.  (= Jouanna 66.2) 125 7.25, 5.394.15–16 L.  (= Jouanna 66.13–14) 126 7.25, 5.394.15–18 L.  (= Jouanna 66.13–17) 169 n. 10 7.25, 5.396.21 L. 252 n. 23 7.26, 5.398.5–6 L.  (= Jouanna 68.13) 127 n. 56 7.28, 5.400.4–5 L.  (= Jouanna 69.14–15) 121

7.29, 5.400.12–13 L.  (= Jouanna 70.6–7) 7.32, 5.400.22–402.5 L.  (= Jouanna 71.3–10) 7.36, 5.404.18–19 L.  (= Jouanna 74.11–12) 7.42, 5.408.22 L.  (= Jouanna 77.12) 7.43, 5.410.11–13 L.  (= Jouanna 78.2–5) 7.45, 5.412.19–414.5 L.  (= Jouanna 79.7–80.5) 7.45, 5.414.2–5 L.  (= Jouanna 80.1–5) 7.52, 5.420.20–21 L.  (=Jouanna 84.14–16) 7.57, 5.424.5–6 L.  (= Jouanna 86.4–6) 7.59, 5.424.14 L. 7.77, 5.434.9–15 L.  (= Jouanna  93.13–94.4) 7.83, 5.438 L.  (= Jouanna 98) 7.83, 5.440.5–7 L. 7.84, 440.5–7 L. 7.85, 5.444.1–12 L.  (= Jouanna  100.16–101.9) 7.85, 5.444.8–9 L. 7.86, 5.444.13–16 L.  (= Jouanna  101.10–102.2) 7.87, 5.444.18 L.  (= Jouanna 102.4–5) 7.88, 5.444.22–446.6 L.  (= Jouanna  102.9–103.5) 7.89, 5.446.7–17 L.  (= Jouanna 103.6–18) 7.100, 5.452.25–454.3 L.  (= Jouanna 108.4–8) 7.105, 5.456.7–8 L.  (= Jouanna 109.14–15) 7.108, 5.458.13–16 L.  (= Jouanna 111.10–15) 7.114, 5.462.8–9 L.  (= Jouanna 113.11–12)

119 190 n. 90 118 126 185 n. 65 169 121 132 133 n. 66 252 n. 23 190 n. 90 360 n. 65 252 n. 23 252 n. 23 188 n. 80 252 n. 23 169 n. 9 118 169 n. 8 122 190 184 n. 60 190 n. 93 119 n. 38

534 De Morbis Popularibus VII (cont.) 7.117, 5.462.21–23 L.  (= Jouanna 114.7–10) 132 7.118, 5.464.3–11 L.  (= Jouanna  114.14–115.5) 190 n. 95 7.123, 5.468.5–6 L.  (= Jouanna 118.4) 129 De Morbo Sacro (Morb.Sacr.) 1, 6.362–64 L. 488 7.2–5, 6.372.4–374.22 L.  (= Jouanna 15.5–22) 190 n. 92 10.3, 6.380.4–7 L.  (= Jouanna 20.5–9) 190 n. 92 12, 6.382.19–24 L. 252 De Mulierum Affectibus (Mul.) 1.2, 8.16.21 L. 251, 251 n. 15 1.21, 8.60.16–17 L. 252 n. 19 1.36, 8.86.4–5 L. 251, 251 n. 15 1.40, 8.98.1–2 L. 252 n. 19 1.41, 8.98.15 L. 254 n. 24 1.61, 8.124.3 L. 254 n. 24 1.61, 8.124.21 L. 251, 251 n. 15 1.60, 8.120.11 L. 251, 251 n. 15 1.64, 8.130.24–132.1 L. 251, 251 n. 15 1.78, 8.184 L. 266 n. 4 2.112, 8.240.7–8 L. 251, 251 n. 15 2.113, 8.242.12 L. 251, 251 n. 15 2.120, 8.262.1–2 L. 251, 251 n. 15 2.122, 8.266.1 L. 251, 251 n. 15 2.146, 8.322.5–6 L. 251, 251 n. 15 2.146, 8.322.12–13 248 n. 3 2.154, 8.330.2 L. 251, 251 n. 15 2.157, 8.332.16–18L. 252 n. 19 2.174 bis, 8.356.2–5 L. 119 2.175, 8.356.22 L. 251, 251 n. 15 2.177, 8.360.7–8 L. 215 3.217, 8.418.10–11 L. 255 n. 25 3.219, 8.422.23–424.13 L. 248 n. 3 De Natura Hominis (Nat. Hom.) Nat. Hom. 3, 6.39 L. 380 n. 49 Nat. Hom. 5, 6.42.3–6 L. 250 n. 14 De Natura Muliebri (Nat.Mul.) Nat. Mul. 96, 7.412.20–  414.1–3 L. 248 n. 3 Nat. Mul. 35, 7.378.4 L. 251 n. 15 De Natura Ossium (Oss.)

Index Locorum Oss. 14–15,  9.186.17–190.9 L. 185 n. 67 Oss. 17, 9.192.3–16 L. 185 n. 67 De Natura Pueri (Nat. Puer.) Nat. Puer. 13, 7.490 L. 266 n. 4 Hebd. 46, 8.663.18–19 L.  (= Roscher 69) 181 n. 47 De Superfetatione (Superf.) 29, 8.494.13 L. 255 n. 25 29, 8.496.5–11 L. 252 n. 19 De Vetere Medicina (Vet.Med.) 2, 572.9–574.7 L. (= Jouanna  119.12–120.15) 175 10, 1.592.17 L. (= Jouanna  131.2–3) 123 De Victu (Vict.) 1.26, 6.498 L. 268 n. 11 2.57, 6.570.7–17 L.  (= Joly-Byl  180.28–182.3) 463 3.70, 6.606,16 L.  (= Joly-Byl 202.6) 330 n. 16 Epistulae (Ep.) 11, 9.326.18–20 L.  (= Smith 60.2–5) 329 n. 14 27.8, 9.422.15–16 L.  (= Smith 120.19–20) 332 n. 22 Iusiurandum (Jusj.) 4.628 L. 371 n. 16 Praeceptiones (Praec.) 2.2–11, 9.254.4–5 L.  (= Jones 314) 172 n. 24 3, 9.254.14–256.7 L.  (= Heiberg 31.16–25) 327 4, 6, 9.258,6–15 L.  (= Heiberg 32.5–13) 330 5, 9.262.1–47 L.  (= Heiberg 32.28–33.3) 337 5, 9.258.16–260.3 L.  (= Heiberg 32.14–19) 337 9, 9.264.8–266.8 L.  (= Jones 324–326) 175 n. 30 11, 9.266.14–15 L.  (= Jones 326) 174–175 Prognosticon (Progn.) 1, 2.110.1–112.6 L.  (= Alexanderson  193.1–194.5) 175 n. 33

535

Index Locorum 1, 2.110.2–3 L.  (= Alexanderson  193.2–3) 174 1, 2.110.3–5 L.  (= Alexanderson  193.3–5) 174 n. 28 1, 2.110.12 L. 486–487 1, 2.110.1–112.11 L.  (= Alexanderson  193.1–194.9) 155 n. 42 1, 2.112.1–3 L.  (= Alexanderson  194.1–3) 167 n. 4 2, 2.112–18 L. 96 n. 49 3, 2.118.7–122.4 L.  (= Alexanderson  197.3–198.11) 170 n. 15, 170 n. 11, 170 n. 12 5, 2.122 L. 346 n. 1 5, 2.122.11–17 L.  (= Alexanderson  199.6–11) 170 n. 12, 170 n. 16 7, 2.126.3–8 L.  (= Alexanderson  201.2–9) 170 n. 12 7, 2.126.12–128.2 L. 96 n. 49, 98 n. 58, 346 n. 1 9, 2.134.5–11 L.  (= Alexanderson  205.9–206.2) 170 n. 12, 170 n. 17, 170 n. 18 10, 2.134 L. 11, 2.134.13–138.14 L.  (= Alexanderson  206.3–208.3) 170 n. 12 11, 2.134–138 L. 346 n. 1 11, 2.138.6–10. L.  (= Alexanderson  207.7–10) 171 n. 20 12, 2.138–142 L. 346 n. 1 16, 2.152.10–11 L. 96 n. 49, 97 n. 57 Prorrheticon (Prorrh.) 1.17, 5.514.10–12 L.  (= Polack 77.1–3) 181 n. 50, 183 n. 54 1.19, 5.514.14–516.1 L.

 (= Polack 77.6–8) 1.32, 5.518.3–8 L.  (= Polack 78.9–13) 1.42, 5.522.2–4 L.  (= Polack 80.4–7) 1.44, 5.522.6 L. 1.47, L. 5.522.8–9  (= Polack 80) 1.83, 5.530.13–532.1 L.  (= Polack 85) 2.1, 9.6.13–14 L.  (= Potter 216) 2.1–4, 9.6.1–20.15 L.  (= Potter 216–232) 2.2, 9.8–10 L. 2.2, 9.10.13–15 L. 2.3, 9.10.16–14.6 L.  (= Potter 220–224) 2.3, 9.12.11–12 L. 2.3, 9.12.14–15 L. 2.6, 9.22.7 L. 2.10, 9.28.26–30.9 L.  (= Potter 242) 2.2.10, 9.30.7–8 L. 2.23, 9.52.24–54.2 L. 2.24, 9.54.22 L. 2.35, 9.66.11–15 L.  (= Potter 278–280) 2.41, 9.70.20–72.4 L.  (= Potter 284) 2.42, 9.72.11 L. 2.42, 9.72.16 L. 2.42, 9.72.21–22 L.

181 n. 50, 183 n. 56 190 n. 89 183 n. 56 90 n. 31 181 n. 50 190 n. 93 174 175 n. 32 91 n. 33 129 n. 60 178 n. 36 129 250 250 n. 14 185 n. 66 97 n. 56 250 n. 14 121 n. 44 181 n. 49 173 121 n. 44 128 121 n. 44

Hoffmann, Friedrich Medicus politicus sive regulae prudentiae secundum quas medicus juvenis studia sua & vitae rationem dirigere debet, si famam sibi felicemque praxin & cito acquirere & conservare cupit 505 n. 20 Homer Ilias (Il.) 2.39 4.218 5.696 6

34 n. 34 255 n. 26 34 n. 36 455 n. 6

536

Index Locorum

Homer Ilias (Il.) (cont.) 7.216 347 n. 8 9.408 34 n. 36 10.94–5 347 n. 8 11.515 255 n. 26 16.333–34 33 n. 29 22.205 455 n. 6 22.451–452 347 n. 8 22.460–1 347 n. 8 22.481 34 n. 35 Odyssea (Od.) 6.208 333 n. 27 9.53 34 n. 35 14.39 34 n. 34 15.448 257 17.382–6 258 21.129 455 n. 6 Horace Satirae (Sat.) 1.1.80–3

435 n. 12

Ibn al-Nadīm Catalogue 240 Ibn Ḫallikān Biographies of Illustrious Men  (De Slane, 1842–71) I 238 III 239–240 Ibn Iyās The Most Beautiful Flowers on the Most Glorious Events 240–241 Ibn Šākir al-Kutubī The passing of the  deceases 240 Isḥāq ibn ʿImrān On Melancholy 1st part (Omrani)

231, 232, 235

Lakapenos, George and Zarides, Andronikos Epistles 392 n. 4 Lucian Bis Accusatus (Bis. Acc.) 1.35

251 n. 18

Adversus indoctum (Ind.) 29 Lucilius Fragmenta 680 W

371 nn. 16, 18

347 n. 9

Marcellinus De Pulsibus (Puls.) 353 1–10 359 n. 57 3–4 347 n. 12 6–11 358 n. 52 8–11 358 n. 54 18–21 353 n. 31 19–30 353 n. 34 19–33 353 n. 30 23–30 353 n. 33 114–71 353 n. 34 115–24 358 nn. 52, 54 126 354 n. 38 128 354 n. 37 130–4 355 n. 40 137–8 354 n. 39 140–5 354 n. 39 163–4 357 n. 45 283–4 350 n. 23 Marcus Aurelius Meditationes (Med.) 5.8.3–4

483 n. 46

Martial Epigrams 5.9

371 n. 16

Maximos Planoudes Epistle 12 (Leone, 27, 18–20) 404n. 48 Medicus-politicus sive de officiis medico politicis tractatus 505 n. 20 Mustio Gynaecia (Gyn.) 28.15–8R 77

269 n. 11 269 n. 11

Oribasius of Pergamum Collectiones Medicae (Med. Coll.) 25.22.6.2 43 n. 86

537

Index Locorum 44.7.17 (Raeder 122, 10) 45.30.10–14 (Edelstein,  Testimonies n. 425) 46.11.3 (Raeder 219, 32) 122.10R 139.32R

276 n. 49 276 n. 49 276 n. 49 276 n. 49

Paul of Aegina Epitomae Medicae (Med. Epit.) 6.8.1 (Heiberg 51, 21) 6.8.1 (Heiberg 51, 22) 6.8.2 (Heiberg 52, 20) 6.25.2 (Heiberg 64, 11) 6.31.2 (Heiberg 68, 19) 6.59.1 (Heiberg 98, 10) 6.90.4 (Heiberg 139, 10) 6.96.2 (Heiberg 150, 10) 6.99.2 (Heiberg 152, 14)

276 n. 49 276 n. 49 276 n. 49 276 n. 49 276 n. 49 276 n. 49, 294 n. 28 276 n. 49 276 n. 49 276 n. 49

Paulus Nicaeus De re medica 85

42 n. 77

Pausanias Descriptio Graeciae 10.38.13 460 Persius Satires (Sat.) 3.107 Philostratus Vita Apollonii (VA) 4.11 456 Plato Critias (Cri.) 109c Gorgias (Grg.)  456b Hippias Major (Hp. Ma.) 298b8–c1 304b5 Leges (Lg.) 720 857c–d (486 n. 56)

347 n. 9

249 n. 9, n. 7 335 n. 38 486 n. 56 188 n. 80 188 n. 80 486 n. 56

Respublica (R.) 371c Symposium (Sym.) 189c–d Theaetetus (Tht.) 176d4 Timaeus (Ti.) 86b1–2 Pliny the Elder Historia naturalis (HN) 7.68–9 20.17 20.123 20.126 20.129 20.148 20.161 20.191 20.211 20.253 21.140 22.121 22.158 22.31 22.59 22.65 22.82 23.148 23.74 24.50 24.83 24.106 24.128 24.140 25.5 26.79 26.141 28.39 28.66 28.71–2 28.123 28.257–9 29.8.15 29.39 29.41 30.135–9

458 n. 11 334 n. 33 188 n. 80 181 n. 52 433 n. 1 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 437 n. 17 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70 279 n. 70, 436 n. 15 279 n. 70 279 n. 70 279 n. 70

538

Index Locorum

Pliny the Elder Historia naturalis (HN) (cont.) 32.137–8 279 n. 70 32.24 279 n. 70 33.84 279 n. 70 34.151 279 n. 70 37.162 279 n. 70 Plutarch De san. tuenda 26, 136e7–f4 De stoic. repugn. 1044a Mor. De lib. ed. 3c–d Quest. Conv. 798a–b Vitae Cat. Mai. 20.4–5 23.4

467 347 n. 11 328 n. 12 288 n. 7 330 n. 15 41 n. 72 437 n. 16

[Plutarch] Vitae decem Oratorum 833 C–D

206

Polybius Historiae 15.25.21

458 n. 11

Praxagoras Fragmenta (Steckerl) 26 28–9 84 85

350 n. 21 350 n. 21 350 n. 22–23 350 nn. 22–23

Quintilian Institutio Oratoria (Inst.) 11.3.88

347 n. 13

Rufus of Ephesus For the Layman/For those who have no  doctor to hand 435 On names (Onom.) 125 43 n. 86 De fragmentis Herae Cappadocis  atque Rufi Ephesii hactenus  ignotis 215 De melancholia 213, 215–216 De ossibus 39 43 n. 86

Quaestiones Medicinales (QM) 1, 1.3 G 99 n. 63 2 90 n. 31 2, 1.5–6 G 99 n. 64 3 97 n. 55 9, 3.6–8 G 99 n. 64 9–10 97 n. 55 15–16, 4.16–24 G 96 n. 52 22, 6.8–10 G 83 n. 9 21 83 n. 9, 97 n. 55 21, 5.24–6.8 G 84 n. 11 23 83 n. 9 26 83 n. 9 33 83 n. 9 34 83 n. 9 37 83 n. 9 38 83 n. 9 40 83 n. 9, 86 n. 15 41 98 n. 59 63 97 n. 55 64 83, n. 9 71, 15.18–22 G 97 n. 53 72–73, 15.23–16.18 G 85 n. 13 73 83 n. 9 Schenckius, Johannes von Grafenberg Observationum medicarum, rararum, novarum, admirabilium, et monstrosarum tomus unus 509 n. 24 Scribonius Largus Compositiones (Comp.) ep(3).2-ep(4).1 and  ep(5).1–6 praef. 3–4 (Sconocchia  2,11–13) praef. 4 (Sconocchia  2,16–18) Professio Medici Seneca De beneficiis 6.15.1 De ira 1.15.2 Epistulae 22

299, 300 n. 51 336 n. 44 331 n. 20 300 n. 51, 336 n. 44

328, 332 269 n. 13 347 n. 10

539

Index Locorum Solon Fragmenta 13.59–62 W 13.60 W

258 255 n. 26

Sophocles Oedipus Tyrannus (OT) 1530

34 n. 38

Soranus Gynaecia (Gyn.) 1 1.2 (Ilberg 4.18–23) 1.3.3 1.4 1.4.4 1.19 (Ilberg 68.10) 1.32.3 1.39.2–3 1.42.5 1.46.2 1.47.1 1.48 (Ilberg 35.14–16) 1.53.2 1.56.3 1.60.1 1.60.2 1.60.3 1.61.1 1.64.1 2 63 2.2 2.3 (Ilberg 52–55) 2.4.3–2.6.2  (Ilberg 53.6–54.24) 2.5.1 2.5.3 2.6.2 2.6.4 2.6.5 2.9.1 2.10.1–5

265 268 n. 9, 279 n. 63 287 n. 5 278 n. 58 372 n. 19 278 n. 58 288 n. 9 265 n. 2 278 n. 55 265 n. 1 267 n. 6, 278 n. 55 268 n. 7 292 n. 21 278 n. 54, 292 n. 24 278 n. 59 266 n. 4, 279 n. 64 266 n. 4 278 n. 55 266 n. 3 267 n. 6 268 n. 9, 279 n. 372 n. 20 290 n. 17, 372 n. 21 289 n. 12 278 n. 54 278 n. 60, 279 n. 62 278 n. 54 280 n. 72 275 n. 30 268 n. 8 268 n. 10

2.10.3 268 n. 11 2.10.5 269 n. 12 2.11.1 278 n. 58 2.11.1–5 271 n. 17 2.11.3 275 n. 31 2.12.1 280 n. 72 2.12.2 269 n. 15, 274 n. 25 2.13.1 275 nn. 32–33 2.13.4 275 n. 34, 276 n. 45, 280 n. 77 2.14.1 279 n. 62 2.14.2 271 n. 18 2.14.3 276 n. 35 2.14.4 276 n. 36 2.15.2 281 n. 78 2.15.5 276 n. 42 2.15.14 276 n. 41 2.16.1 280 n. 72 2.16.2 276 n. 42 2.16.4 272 n. 20 2.18.1 278 n. 60, 279 n. 62 2.18.2 278 n. 60, 279 n. 62 2.19.1–20.3 278 n. 57, 288 n. 10 2.19.2 278 n. 55 2.19.11–15 278 n. 57 2.19.12 281 n. 82 2.19.14 274 n. 27, 281 n. 83 2.20.3 274 nn. 25, 26, 278 n. 57 2.26.1 276 n. 37 2.28.5 278 n. 60, 279 n. 62 2.29.1 278 n. 60, 279 n. 62 2.31.2 275 n. 28, 276 n. 38 2.33.1–34.5 281 n. 78 2.33.4 276 n. 42 2.33.5 276 n. 42 2.34.3 281 n. 81 2.35.2 276 n. 39 2.37.1–38.4 273 n. 21 2.37.5 276 n. 46, 281 n. 80 2.39.1–40.4 270 n. 16

540

Index Locorum

Soranus Gynaecia (Gyn.) (cont.) 2.39.10 276 n. 40 2.41.1 276 n. 44 2.39.10 276 n. 40 2.42.2 274 n. 25 2.42.4 272 n. 19, 276 n. 47 2.43.1 276 n. 43, 281 n. 79 2.44.2 278 n. 55 2.48.1 274 n. 24 2.48.2 274 n. 25, 278 n. 60, 279 n. 62 2.48.5 275 n. 29, 276 n. 48 2.48.7 276 n. 43 2.50.2 276 n. 42 2.51.4 278 n. 57, 280 n. 72 2.55.1 279 n. 62 3 268 n. 9, 279 n. 63 3.2.1 279 n. 66 3.3.4 279 n. 65 3.42.3 (Ilberg  121.26–31) 293 n. 27 3.43.1 279 n. 68 3.46.4 278 nn. 56, 58 3.48.2 267 n. 5 4 268 n. 9, 279 n. 63 4.1.3 279 nn. 65, 67 4.11.3 277 nn. 50, 52 4.11.4 277 n. 50 4.11.6 277 n. 50 4.12.1 277 nn. 50, 52 4.12.5 277 n. 50 4.12.6 277 n. 50 [Soranus] De pulsibus (Puls.) 353 275–276 354 n. 34, 355 n. 40 275.17–276.2 354 n. 39 275.19–21 355 n. 41 Statius Silvae (Silv.) 2.1.78–81 2.1.54 5.5.69–72

41 n. 72 66 n. 196 41 n. 72

Themistius Orationes quae supersunt (Or.) 32 38 n. 59 Taddeo Alderotti Whether any of the things that are known  to laymen ought to be added to the art of  medicine 87 Whether the doctor ought to question the  patient about all his symptoms and write  a book about them 87 Tertullian De testimonio animae (De anim.) 6 294 n. 28 25.5 282 n. 84 Theophilus Protospatharius De corp. hum. fabr. 1.20.6 43 n. 86 Theophrastus de Sensibus (Sens.) 43

178 n. 38

Thucydides 1.22.4 67 n. 198 1.48.3 67 n. 198 1.133 388 Varro Res Rusticae (RR) 1.16.4 438 n. 27 1.4.5 438 n. 25 1.69.3 439 n. 29 2.1.21 439 n. 28 2.10.10 439 nn. 29–30 2.20.20 439 n. 30 2.22.1 439 n. 28 2.3.8 439 n. 30 2.5.18 438 n. 24, 439 n. 30 2.7.16 439 n. 30 Vegetius Digestorum artis mulomedicinae  libri 437 n. 19

541

Index Locorum Epitoma Rei Militaris (Mil.) 1.6 380 n. 48 Villanova, Arnaldus de De cautelis medicorum

505 n. 20

Virgil Aeneid (Aen.) 12.383–440

379 n. 45

Xenophon Memorabilia (Mem.) 1.3.5

338 n. 50

Zerbi, Giuseppe Opus perutile de cautelis  medicorum

505 n. 20

Inscriptiones, Ostraca, Papyri Anonymi Londiniensis (Anon. Lond.) 1.36 181 n. 52

855.4 958 1166 1244 1612 1732 1924 IG (Inscriptiones Graecae) 5. 2, 491 7. 3434 12. 3,870 14.943 14. 1572 14. 1795

34 n. 34 32 n. 24 23, 28 n. 18, 29 36 n. 36 32 n. 23 39 n. 63 31 n. 21 32 n. 24 32 n. 24 38 n. 60 377 n. 39 33 n. 31 33 n. 31

IGUR (Inscriptiones Graecae Urbis Romae) 3.1336 31 n. 21 4.1702 28 n. 18, 31 n. 2

AP (Epigrammatum Anthologia Palatina) 3. 2. 637 28 n. 18 7.467.5 32 n. 24 7.467.8 40 n. 67 7.662 40 n. 67

ILS (Inscriptiones Latinae Selectae) 2601 375 n. 33

CIG (Corpus Inscriptionum Graecarum) 14, 2037 37 n. 52 13, 7415 45 n. 93 3272 23, 28 n. 18, 29, 59 n. 150

Leges Duodecim Tabularum/Law of the Twelve Tables 4.1 436 n. 13 4.2 436 n. 13

CIL (Corpus Inscriptionum Latinarum) 13.3778 445 n. 52 14.3030 376 n. 37 EG (Epigrammata Graeca ex lapidibus conlecta) 314 28 n. 18 314, 27 37 n. 53 314, 120 45 n. 94 618 31 n. 21 711 32 n. 23 GV (Griechische Vers-Inschriften) 395 32 n. 24

Laurentianus gr. 75.11 (1412/3 AD) fol. 220v, 7–16 402 n. 41

O.Claud. (Mons Claudianus. Ostraca Graeca et Latina) 171 441 n. 38 174 441 n. 38 220 441 n. 37 221 441 n. 39 222 441 n. 39 708 441 n. 37 713 441 n. 37 714 441 n. 37 722 441 n. 37 O.Mich. (Greek Ostraka in the University of Michigan Collection) 508 442 n. 41

542

Index Locorum

PIR2 (Prosopographia Imperii Romani saeculi 1, 2, 3) 5. 95 36 n. 49

SEG (Supplementum Epigraphicum Graecum) 29.1003 28 n. 18 33.1475 32 n. 24

P.Oxf. (Some Oxford Papyri) 19

SGO (Steinepigramme aus dem griechischen Osten) (1) no. 01/12/15 39 n. 63 (3) no. 14/13/05 39 n. 63

442 n. 42

P.Oxy (The Oxyrhynchus Papyri) 1121.8–12 443 n. 46 1381 457 n. 9 (vel Imouthes Papyrus) 1222.1–3 444 n. 47 3314.5–17 443 n. 45 PSI (Papiri greci e latini) 117 299.9–11 895.9–12

442 n. 40 442 n. 44 442 n. 43

RIB (PPalau Rib. Papiri documentari greci del Fondo Palau-Ribes) 1618 445 n. 50 Samama (Les médecins dans le monde grec.) 7,18–19 331 n. 21 35,30 331 n. 21 62,2 337 n. 46 67,13–14 335 n. 39 69,12 337 n. 46 163,9–10 337 n. 46 166,11–12 331 n. 21 224,13–14 335 n. 35 245,8 335 n. 35 245,10 331 n. 21 290,17 331 n. 21 S.B. (Sammelbuch griechischer Urkunden aus Aegypten) 15560.9–12 442 n. 43 Sel.Pap. (Select Papyri I–II) 1.158

442 n. 44

T. Vindol. (Tabulae Vindolandenses) 154 445 n. 50 155 445 n. 50 156 445 n. 49 181 445 n. 49 294 445 n. 51 310 445 n. 49 586 445 n. 49 Vérilhac vel ΠΑΙΔΕΣ ΑΩΡΟΙ 1, no. 78 31 n. 21 1, 27, p. 49 37 n. 53 1, 113 no. 76,1 38 n. 59 1, 114–15 no. 77 34 n. 38 1, 126 no. 79 34 n. 35 1, 126–27 no. 80 66 n. 196 1, 129–30 no. 82 34 n. 38 1, 134 no. 85 33 n. 29 1, 145 no. 94 33 n. 29 1, 165–68 no. 106 28 n. 18 1, 167 30 n. 19 1, 167 33 n. 32 1, 190 no. 123 34 n. 35 1, 190 no. 73 34 n. 38 1, 196 no. 126 66 n. 196 1, 217 no. 145,2 38 n. 59 1, 218 no. 146 66 n. 196 1, 232 no. 159 66 n. 196 1, 233 no. 160 38 n. 60 2, 152–54 32 n. 27 2, 37, no. 110 38 n. 58 2, 90 38 n. 60 2, 96 45 n. 97

Index Rerum Abortion 266–268 Abū Bakr al-Rāzī 225 n. 1, 227–230, 228 n. 9, 228 n. 10, 228 n. 11, 229 n. 12, 229 n. 13, 233, 233 n. 24, 233 n. 25, 233 n. 26, 235–237, 236 n. 32, 237 n. 33, 241–244, 241 n. 46 Aelius Aristides 451–470 Aging 416, 420, 424–425 Altars [see also votive relief] 365, 373, 376–377, 378 Ambiguity 139, 158, 161 n. 49, 306–308, 311, 318 Analepsis Anamnesis 63, 122–123, 175 Anger  209, 210 n. 34, 212, 218, 274–275 Anonymity 147–153, 161 Anthropology 46 n. 101, 369, 473 Anxiety 92, 171, 203–220, 228, 261, 273–274, 278 n. 54, 287, 289, 355, 355 n. 40 Aphonia 189–193 Appropriation 25, 457–458, 466 Asclepieion 368, 374, 375, 376, 377, 383, 386 fig. 14.7, 419, 451, 466, 479 Asclepius 249 n. 9, 368, 374, 377, 378, 451, 453–457, 464, 480, 483, 484, 489 Atlas, patient worried about (story in Galen) 214–215, 217, 219, 235 Australia 471, 474–479, 489–492 Authoritativeness 108, 112, 113, 128, 174–176 Authority / Authorities 89, 100, 174–176, 278–281, 348–349, 353–362, 477–480, 483, 485–489, 505, 506 Autopsy 170–171 Babies 33, 41–42, 54, 151 n. 32, 155–157, 159, 265–277, 280–281, 288, 289, 416–417, 418–419 Bad-mannered patients 337, 338, 339, 340 Bandaging 42, 56 Bathing 31, 41, 275, 419, 423 Bedside manners 169–175, 333, 334, 336, 337, 352 n. 27, 353–356, 357 Belief 120, 219 Biographical dictionaries 224–225, 237, 242

Breastfeeding 31, 41–42, 44, 49, 53, 270–274, 288, 418 Burial monuments fig. 14.5, 27–31, 66, 290, 291, 365, 366, 372, 373, 374, 375, 376, 385 Bush medicine 478–479 Byzantine medicine 390–391 Caelius Aurelianus 285–303 Callimachus, Alexandrian physician (reference in Rufus) 82 n. 3, 83–84, 85 n. 14 Callistus, grammarian (story in Galen)  207, 212 Cancer [see also tumor] 472–479, 480–484, 512–514  Case histories 23–68, 92, 138–162, 211–216, 224–225, 228, 231–236, 235, 232 n. 22, 241–243, 346, 357 n. 50, 358 n. 51, 392–397, 413, 505–507, 509 Case-study, casuistry  60 n. 155, 109–114, 232–233 Celebrities 499, 504 Character language 31–34, 120–121 Charge of greed 329 n. 14, 330, 338, 339 Charlatans 338, 339, 340 Childcare  23–68, 268–280, 418–419 Children patients 132, 171 n. 19, 354 n. 39, 436 n. 14 Classification of disease 162, 204, 217–218, 219, 226, 476, 480–482 Clinical encounter 81, 82, 98 n. 60, 99, 99 n. 62, 100, 114–116, 169–175, 228, 232, 241, 248–249, 290, 345–348, 350, 351–352, 353–356, 357–358, 360–362 Clyster 405 Cnidian Maxims 88, 88 n. 21, 89, 89 n. 24, 92 Communication 116–120, 128–129, 169, 248–249, 354–356, 357–358, 362, 366, 370, 473–474, 476–479, 485–488, 491 Co-morbidity (see multimorbidity) Compassion 119 n. 39, 270–278, 285 Consolation 27 n. 16, 40, 66 Constantinople 390, 392, 404 Constitution (of body) 85, 380, 381

544 Contraception 266–267 Conversation/Questioning 81–101, 112 n. 19, 113, 128, 133, 169–175, 354–355, 357–358, 362 Culture 24–25, 35–37, 41, 46, 66, 67 n. 200, 369 Cupping vessels 365, 367, 371, 373–374, 375–376, 379–381, 383, 384 figs. 14.1, 14.3 Death 9–50, 23–24, 32, 33 n. 33, 34–37, 39 n. 63, 41, 42 n. 78, 44, 54, 58 n. 148, 59, 61, 66, 95, 205, 206–207, 212, 216 Delirium 128, 181–183, 186–189, 226–227, 229–231 Deontological texts 325, 326, 336, 353–354 Deontology/Conduct 256–261, 325, 326, 327, 328, 330, 332, 333, 335, 336, 353–356, 505, 506 Diagnosis 47–52, 82, 85, 89 n. 27, 96, 98, 251, 312, 313, 314, 317, 320, 345–346, 348, 350–361, 365 n. 1,432, 433, 440, 444, 446, 457 Diagnosis, retrospective 23–24, 42 n. 78, 47–67, 98 n. 61, 147, 153, 480–482, 511–514 Dialogue 26, 68, 81, 86, 91, 98, 98 n. 60, 100, 112 n. 20, 169–175, 354–355, 357–358, 362 Diet 94, 267 n. 6, 278 n. 54, 347, 353 nn. 31–32, 362, 400–404, 417–418, 420, 423–424, 426, 453, 508 Diminutives 276–277, 328, 329, 338, 339 Diodorus, grammarian (story in Galen) 213 Disobedience 90, 90 n. 30, 129, 174–175, 353 n. 31, 358 n. 51 Divine healer 453, 454, 459, 461 Doctor-Patient Relationship [see also patient-physician relationship] 25, 45, 99 n. 62, 100 n. 66, 166–179, 189–193, 313, 314, 354–356, 357–358, 359, 365–367, 371, 382 Doctor’s Image(s) [see also Images of doctor(s)] 89, 89 n. 26, 91–92, 333, 347,   354 Doctor–function [see also physicianfunction]  358 n. 53, 359, 451 dokei 169 n. 10

Index Rerum Dominus/domina 439, 443 Dream(s) (see also incubation) 453 n. 4, 455–456, 457 n. 9, 459, 460, 461, 464 Early modern medicine 502–514 Effluvia 166–169, 179–194 Ego-documents 502–505 Elephantiasis 287, 298, 299, 300 Elite patient 35, 37 n. 55, 357, 413 Emotion(s)/pathē 38–40, 205–220, 285, 286, 286 n. 2, 347, 353 n. 31, 355, 362 Emotional aspects 38–40, 267 n. 6, 273–275, 316, 354–356 Empiric Sect 395 Emplotment 110, 110 n. 13 Endemic/Native Conditions 48, 54, 139–40 Exemplary case(s) 45 n. 96, 46 n. 104, 50 n. 123, 138–139, 152–153 Epistemology 86, 87, 93 n. 45, 306–307, 311, 313, 318–319, 508 Epitaph 23–68, 372, 375, 376, 377 Erasistratus  349 n. 18, 211, 217 Examination medical 52, 54, 58, 95, 96, 97 n. 57, 166–179, 189–193, 247–248, 250–251, 345–348, 350–356, 357, 360–362 Exercise 35 n. 40, 45 n. 96, 151 n. 33, 356, 417, 421–422, 425–426 Experience 25, 45 n. 96, 47 n. 107, 49 n. 117, 52 n. 126, 56–58, 62, 81, 88, 98, 100, 228, 235–236, 241, 311, 312, 314, 315, 317–319, 353, 354–355, 357–360, 438, 439, 446 Experts 23, 47, 62, 65, 87, 88, 100, 101, 278 n. 57, 281, 314, 317,355 Eye contact 278 n. 54, 290, 291, 457 Family history 23–68 Fear 90, 96, 205–206, 208–211, 214, 215–216, 226, 228, 230–231, 235–236, 251, 252, 267 n. 6, 274–275, 278 n. 54, 287, 289, 290, 347 n. 8, 355, 355 n. 40, 475–477, 491 Fever 44, 50–51, 55, 141 n. 9, 148–149, 151 n. 33, 156, 157–158, 160, 207–209, 211–214, 216, 219, 220, 398, 400–401, 445 Focalisation 116, 116–117 n. 32, 117, 117 n. 34, 123–124, 125–127, 128, 129 Folk medicine 433, 434

Index Rerum Foucault, Michel 1 n. 2, 2 n. 6, 8, 109 n. 6, 502 Freedmen 35–37, 44–45, 67 Fresco painting 365, 379, 386 fig. 14.8 Gadamer, Hans-Georg 26, 56 n. 143 Galen  203–223, 304–322, 413–431, 453, 458 n. 12, 465–466 Gangrene 42–43 Gaze 250–252, 256–257, 261, 278 n. 54, 289, 290 n. 15, 291, 353 n. 34, 369–370 Gender  27, 141 n. 10, 269, 292 n. 22, 417 Grief 31–34, 35, 39, 67, 205–208, 211, 212, 216, 219, 237, 267 n. 6, 287, 293 Habit  84, 94 Habituation (to health) 152, 417–418, 419 Hallucinations 213, 214, 227, 231, 296 (delusions) Healer’s role 366, 379, 476–478, 480, 482–491 Healing power(s) 451 Health (variations in definition of) 367, 380, 471, 475–478 Health  437, 438 Healthcare 433, 439, 443 Hippocrates 461–462 Hippocratic medicine 107–137, 138–165, 166–199, 247–264, 471–495 Hippocratic triangle 166–179 Historiography 25–26 ‘History from below’ 2, 5, 11, 253 Hope 38–39, 355 Humanitas 286, 298, 299, 300, 333, 334, 335, 336 Humours 100 n. 67, 161, 208 n. 20, 212–214, 230, 236, 353, 380, 416–417 Hypochondria/Hypochondriac 452 Hypochondrismos 405 Illness narrative 25, 82, 87 n. 20, 92, 98 n. 61, 100, 151–153, 161, 452, 473 Images  of doctor(s) [see also Doctor’s Image(s)] 290, 366, 368, 373–380, 381, 382, 384 fig. 14.2, 14.3, 385 fig. 14.5, 14.6, 386 fig. 14.8 of patient(s) 373–375, 384 figs. 14.2, 14.3,  385 figs. 14.5, 14.6, 386, figs. 14.7, 14.8

545 Incubation 457 Independence from doctor 176 n. 34, 347, 359, 361 Indigenous 140–141, 146, 471–479, 491–492 Individuality 25–26, 51, 54 n. 138, 67, 93, 96, 100 n. 67, 176 n. 34, 178–179, 414–417 Inductive Reasoning 143 Ineffability 305–306, 313, 316–317, 455 Infanticide 268–269 Infectious disease 47–67, 472 Insomnia 92, 95, 208–214, 216, 217, 219, 220 Instruction/Training/Apprenticeship  44–46, 353, 356, 358–359 Instruments, medical 366, 371, 374, 375, 376, 377, 379, 380, 386 fig. 14.8 Intimacy 248, 256–257, 290, 355–356, 362 Invitations/summons 258 Islamic hospital 224–225, 238–242 Jaundice 50, 150, 158, 162, 400 John Zacharias Aktouarios 390–409 Justice 253–256, 261 Justus, wife of (story in Galen) 210 n. 24, 211–212, 213, 219 Kleinman, Arthur 1 n. 1, 3–4, 4 n. 9, 114 n. 4 Knowledge 25, 35, 438, 439, 440, 446 Knowledge, transmission/Diffusion of  129–133, 278–28, 347–62 Expert vs. Common  44–46, 86–89, 100, 314–315 Empirical vs. Theoretical 93, 348–350, 348 nn. 16–17, 349 n. 18, 352, 356–362 Knowledgeable patient (see also patient, informed)  451–470 Law 259–261, 435, 436, 436 n. 13 Lay medicine 269 Layman / layperson 44–46, 86–89, 228, 347, 356–357, 358, 359 Liberal arts 327 n. 9, 328, 331, 332, 332 n. 23, 332 n. 24, 334, 339 Literacy, medical 168, 365, 366, 463, 465 Love 205, 211–212, 216 Lozenge 402–403 Lypē 205–220, 513

546 Madmen 224–243, 298 n. 42 Maeander the augur (story in Galen)  212–213, 214, 216, 219, 220 Mania 170 n. 12, 181–189, 225–226, 229, 274–275, 295, 296, 296, n. 39, 297, 298 Medical ethics 56 n. 143, 254–255, 300, 301 n. 51, 333, 334, 336 n. 42, 353, n. 34, 353–356 Medical fee 326, 327, 328, 329, 337, 338, 339 Medical profession 35, 44–47, 155, 335, 336, 337, 476, 491 Medicament(s) 42, 56 Melancholia 185, 208–209, 213–215, 225–232, 234–236, 293 n. 26 Melancholics 213–215, 225–231, 234–238 Mental disorder[see also mental illness] 170 n. 12, 181–189, 203–220, 225–226, 232, 305, 316, 400 Mental illness [see also mental disorders] 170 n. 12, 181–189, 224, 232, 238–239, 241 Mental patients 170 n. 12, 181–189, 224–243 Metaphor 33, 43, 308–310, 312, 316–317, 332 Midwife 41, 269, 278, 287, 288, 289, 290, 291, 372, 433, 441, 444 Migraine 294 Misericordia 286, 334, 336 Mixtures (of humours) 226, 465, 465 n. 26 Multimorbidity 472 Narratology/narratological reading  108, 108 n. 1, 116–128 Narrative medicine 2, 2 n. 6, 3–4, 4 n. 10, 8, 9 n. 16, 12, 25, 166–179 Nasutus, mother of (story in Galen) 207, 212, 214, 216, 219 Non-compliance 90, 90 n. 30, 175, 176 n. 43, 506–507 Non-natural activities 419, 427–429 Nonsense 186–189, 236 Nursery language 275–277 Obedience 92, 175, 176 n. 43, 453 n. 4; 454; 458 n. 12 Observations 83 n. 9, 92, 94, 96, 99, 224–225, 241, 351 Oral tradition 216–217, 278–280, 356–357, 359 Ostraca 432, 434, 440, 446 Oxymeli 403

Index Rerum Paediatrics/medicine for children 23–68, 270 Pain 50, 57, 94, 98, 98 n. 59, 169–173, 251, 252–253, 255, 259, 271, 286, 287, 289, 294, 295, 298, 301 n. 52, 304–307, 310–316, 318–319, 348, 354, 360 n. 67, 398, 400, 403–405, 482–483, 485 Papyri 25, 432, 434, 440, 444, 446, 452 n. 2 Parturient 30, 33, 40–41, 272, 278, 289, 290 Pater familias 436, 444 Pathomorphosis 53, 63, 65 Patient Patients, age of 27, 33, 39 nn. 63–64, 41, 48, 49, 57, 61, 149–150, 351, 353 n. 34, 356, 393, 399 Patient, bad-mannered 337, 338, 339, 340 Patient-function 360 Patients, gender of 141 n. 10, 252, 257, 315, 353 n. 34, 393, 398 Patient, informed [see also Knowledgeable patient] 175–176, 347–348, 355–357, 359, 451, 451–470, 477–479, 486–487 Patients’ knowledge 93, 168, 173–174, 312–313, 347–350, 352, 354, 356–362, 413–414, 416–417, 419–420, 451–45, 486–89 Patient names/Identities 25, 31, 36 n. 46, 66, 115, 147–153, 161 Patient perspective 25–26, 82, 93, 100, 166–179, 330, 339, 340, 349, 355–356, 365, 366, 382, 473–477, 480, 489–492 Patients, pregnant 155–157, 266–268, 278 n. 54, 287, 292 Patient’s psychology 38–40, 326, 329, 336 n. 42, 339, 340, 355–356 Patients, social status of 23–25, 35–37, 249, 250, 257, 259 n. 36, 399, 451, 460, 463, 467 Patient, submissive 247, 451, 453 n. 4, 464, 466 Patient-doctor relationship [see also Patient-physician relationship] 1–2, 4–5, 99 n. 62, 100 n. 66, 166–179, 354–356, 357–358, 359 Patient-physician relationship [see also Patient-doctor relationship] 57–58, 99 n. 62, 100 n. 66, 166–179, 326, 328, 335 n.

Index Rerum 40, 337, 354–356, 359, 457, 458, 460, 466, 476–480, 485–487, 489–492 Pediatric treatises 41, 278–280 Pergamum 415, 451, 456 n. 7, 459, 460, 485 Philanthropy 333, 334, 335, 336, 337 Philiatroi 45, 359 Phobos [see also Fear] 226, 347 n. 8, 355, 355 n. 40 phrontis/worry 204 n. 3, 205, 208–213, 215, 216, 217, 219, 220, 355, 355 n. 40 Physician Physician, amateur 45, 347, 357, 359, 451, 454, 457–458, 459 Physician, figure of 23, 25, 37, 41, 43–47, 50 n. 122, 52, 59, 60, 67, 339, 340, 347, 353 Physician-function 125–127 Physician, professional 47, 155, 345–363, 432, 433, 438, 438 n. 26, 439, 439 n. 29, 439 n. 31, 440, 441, 444, 445, 446 Physician’s reputation 91, 155, 175–176, 353, 356–359, 326, 327, 328, 329, 330, 332, 333, 334, 336, 337, 339, 340 Physician-patient relationship [see also Patient-physician/Patient-doctor relationship]  99 n. 62, 100 n. 66, 166–179, 354–356, 357–358, 359, 509, 510 Pica 278 n. 54, 291, 292 Pity 30, 285 Placebo 120 Population Narratives 140, 141 n. 10, 151 n. 33, 161 Porter, R. 1 n. 2, 2, 2 n. 4, 3, 5, 8, 9, 109, 248, 500 Power 37, 99 n. 62, 100, 101, 249, 257 of patient(s) 100, 101, 257, 451, 509, 510 of physician(s) 100, 101, 249, 257, 261, 359–360 Practice 25, 26 n. 10, 32, 42, 43, 46, 64, 345–362 Pregnancy 155–157, 265–268, 278, 287, 291, 292, 293, 441, 442, 442 n. 40 Preventive medicine 62 n. 167, 356 n. 42, 413–429, 466–467 Professional aspects 129–133 Prognosis 44, 84, 92, 96, 143, 148, 149, 153–158, 166–179, 345–346, 352–353, 355, 357, 360 n. 66, 485–487

547 Prolepsis 17 n. 55, 122, 122 n. 47, 126, 129 Psychology 203–220 Public–debate (ἀγών) 356–357 Pulse 44, 209 n. 22, 210, 211–212, 216, 219, 220, 345–362, 308–309, 314, 507 Pulse rate 346, 350–352, 355, 356, 357, 358, 359 n. 60, 359–360, 399 Purgative 56, 405, 454 Questions/Questioning 81–101, 112 n. 19, 113, 128, 133, 166–179, 354 n. 39, 355–356, 362 Rambling 187–189 Ready obedience 480, 486 Regimen 84, 98 n. 59, 138 n. 1, 151 n. 33, 152, 348, 356, 362, 413–429, 437, 451, 453, 465 Relief sculpture 291, 366, 368, 372, 373, 374, 375, 376, 377, 378, 379, 382, 384 fig 14.2, 385 figs. 14.4–14.6, 386 fig. 14.7 Religious aspects 23, 24, 37, 38 Representation(s) of doctor(s) 326, 347, 354, 365, 366, 367, 370, 371, 372, 373, 374, 375, 376 Representation(s) of patient(s) 372, 373, 374, 375, 376 Rhythm 128, 351, 355, 418–419 Ritual 40 n. 66, 67, 452–470 Rufus of Ephesus 43, 81–101, 112, 172 n. 23, 213, 215–216, 217, 224, 226–229, 226 n. 4, 227 n. 6, 231–235, 232 n. 19, 235 n. 28, 236 n. 32, 244, 279 Seasonal Changes 38, 54, 140–146, 151, 158, 161 Self-Diagnosis 464–465 Self-healing 461–462 Situatedness 141, 147 Secretions 51, 55 Secrets 46, 353, 357–358, 362 Self–Diagnosis 45 n. 96, 46, 348, 359, 361 Self-image 326 Sensation 113 Shame 206, 252, 278 n. 54, 289, 290, 291, 353 n. 34 Sickness, communal vs. personal 140–143, 146, 147, 151–153, 160–161, 476 Signs 44, 48 n. 108, 51, 54, 55 n. 140, 63, 65 n. 193, 83, 84, 92, 92 n. 36, 94, 95, 96, 99, 100, 143, 147–153, 154 n. 39, 155–158, 160, 161–162, 166–179, 345–346, 351, 352–353

548 Silence 117 n. 33, 123, 128, 189–193, 269 Silencing [the patient] 113 Skill 63, 90 Slave 35–37, 42, 45 Social aspects 248, 325, 326, 330 n. 18, 331, 332, 333, 334, 335, 336, 337, 339, 414–416, 421–423, 476–479 Social status 248, 326 n. 3, 331 Socio-political elite 414, 433 Soranus of Ephesus 265–284, 285–303 Stoics 206, 328, 334 Stuttering 184–186 Subjectivity 98–99, 100, 148, 154, 482 Suffering [see also Pain] 30, 31, 47, 49, 50, 53 n. 134, 54, 60, 285, 286, 300, 301 n. 52, 329, 336 n. 42 Supplication 249 n. 9, 455–457, 466 Surgery/operation 42–43, 50 n. 121–122, 57 n. 146, 63, 64 n. 183, 381, 482–483 Surgical tools 365, 376, 380, 381, 483; see also medical tools Sympathy 119 n. 39, 285, 287, 288, 334 n. 32 Symptoms 47–52, 57, 58 n. 148, 60, 63, 65, 169 n. 7, 232, 292, 293, 298, 452 Tabula rasa 280–281 Technical Terminology  43, 44, 110, 120, 126, 127, 132, 328, 359–360, 361 Temple healing/medicine 451–470, 466, 485, 487 Terminology 25, 26, 42 n. 76, 43, 44, 62, 65 n. 190, 328, 329, 332, 333, 334, 335, 336, 339, 346 n. 7, 350–352, 359–360, 361 Testicular inflammation 42, 185 Textuality 110–111, 110 n. 8, 144, 153–154 Theōria 454 Theory 66, 93, 96 n. 52, 348–349, 351, 352, 358–360 Touch 83, 290, 347–348, 350, 353–355, 357, 358, 375, 384 fig. 14.3, 385 figs. 14.5, 14.6, 386 figs. 14.7, 14.8, 455–456

Index Rerum Trauma 255, 260, 267–268 Treatment 31, 40, 42, 46 n. 104, 49–52, 56, 60, 61 n. 160, 63, 64 n. 183, 67, 84, 94, 96, 251–255, 286, 287, 295, 296, 297, 298, 299, 300, 301, 347, 348, 402–405, 432, 433, 440, 444, 446, 475–480, 482–485 Tuberculosis 23, 24, 47–54, 57 n. 146, 58–67 Tumor [see also cancer] 55–58, 65 Universality 86, 93, 317–319 Univocality 309–310 Urine, colour of 150, 157, 158, 160, 400–403 Urine, sediment of 143, 148, 150, 154 n. 39, 155, 157, 158, 160, 393, 403 Uroscopy 44, 345–346, 352–353, 399–406, 507 Verbalization 305–306, 313, 316–317, 366 Veterinary medicine 434, 437, 437 n. 19, 439, 444, 445 Villicus/villica 439 Visual communication 366, 369–371, 382, 455–457 Visual culture 369 Vocal Pitch 181–183 Voice Pathologies 90, 92, 94, 166–194 Voice, literal 168 Voice, subjective 98–99, 100, 168 Votive 366, 368, 374, 375, figs 14.2, 14.4; see also altar Wax tablet 432, 434, 444, 445 n. 48, 445 n. 52, 446 Wet-nurse 42, 270–275, 287, 288, 289 Women patients 139, 141 n. 10, 149, 155–157, 236, 251, 252, 256, 258, 267, 278 n. 54, 315, 353 n. 34, 417 Wooden tablet 432, 434, 444, 445, 445 n. 48, 446 Workers 258, 421–422 Worry see phrontis