“THE FIRST DISPENSATION OF CHRIST IS MEDICINAL:” AUGUSTINE AND ROMAN MEDICAL CULTURE by SHELLEY ANNETTE REID B. A., The University of Victoria, 1985 M. A., The University of British Columbia, 2001 A THESIS SUBMITTED iN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Classics) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) September 2008 © Shelley Aimette Reid, 2008 Abstract This study examines the knowledge and use of medicine in the writings of Augustine. An initial overview of Roman medical culture highlights that ancient medicine was both a practical and intellectual activity, that it was culturally linked with rhetoric, philosophy, and faith, and that many aspects of medicine were performed in a public setting. Knowledge of medicine formed part of the intellectual background of the well-educated Roman citizen, through autodidactic studies. Roman medicine underwent a minor renaissance in North Africa during Augustine’s lifetime; he would have obtained his knowledge of medicine through access to a range of textual and non-textual forms of information. Augustine’s interest in and knowledge of medical topics was more comprehensive than has been previously credited: he employed a sophisticated medical terminology; he was fascinated by aspects of human physiology, particularly the function of the senses; and he understood the philosophical divisions which separated the various medical sects. His greatest use of medicine was in the area of figurative language. His employment of medical metaphors, particularly that of Christus medicus (Christ the physician), was extensive, far exceeding that of other Latin patristics writers, both contemporaries and those who followed him. Various reasons can be adduced for the attraction which medical metaphors held for Augustine, including the popularity of the figure of Christus medicus in North Africa, the use of medicine and medical metaphor in Manichaean texts, and Augustine’s relationship with the physician Vindicianus. Augustine’s own experience with ill health was also a significant contributing factor. A painful illness in 397 likely provided 11 an impetus to his writing of the Confessions, a work filled with medical metaphor, in which he confesses as a patient to a physician. Augustine expanded this medicalization of the self to the body of Christian sufferers through reference to the pain which ancient therapeutics inflicted. He used the metaphor of the sick bed to oppose the Donatist schism, by creating opportunities for ordinary Christians to turn their illnesses into martyrdoms. This allowed them simultaneously to reject unacceptable forms of healing and obtain full participation in the church. 111 Table of Contents Abstract.ii Table of Contents iv List of Abbreviations vi Acknowledgements viii Dedication ix Chapter 1 Introduction 1 Chapter 2 Roman Medical Culture 8 Chapter Introduction 8 The Scholarship on Graeco-Roman Medicine 9 Textual Sources 17 Medicine and Literary Culture 29 Medicine and Philosophy 55 Medicine and Faith 67 Roman Health 78 Chapter 3 Medical Culture of North Africa 90 Chapter Introduction 90 Medicine in the Second Century 91 Medicine in the Fourth Century 99 Medicine and Manichaeism 113 Chapter 4 Medicine in Augustine’s Intellectual World 118 Chapter Introduction 118 Textual Sources for Medical Knowledge 120 Non-textual Sources for Medical Knowledge 147 Medicine as a Discipline 153 Chapter 5 Medical Language and Metaphor in Augustine’s Writing 163 Chapter Introduction 163 Augustine’s Knowledge of Medicine 164 Medical Metaphor: Christus Medicus 197 iv Chapter 6 Augustine’s Christian Pathology 222 Chapter Introduction 222 Culture and Geography 223 Augustine’s Suffering Body 231 The Medicalized Christian Community 256 Conclusion 287 Bibliography 290 Primary Sources, Not Including the Works of Augustine 290 Primary Sources, Works of Augustine 297 Secondary Sources 299 V Abbreviations Abbreviations used in the text for works of Augustine are taken from Augustine Through the Ages: An Encyclopedia, edited by Allan D. Fitzgerald (Grand Rapids, Mich.: William B. Eerdmans, 1999), with the exception of the substitution of Serm. for S. as an abbreviation for Sermo. Abbreviations used in the text for classical authors and their works, with the exception of Galen, are taken from the list of abbreviations found in the Oxford Classical Dictionary, edited by Simon Hornblower and Antony Spawforth (Oxford: Oxford University Press, 1996). Abbreviations used in the text for Galen’s works are taken from the list of abbreviations found in the Greek-English Lexicon, edited by Liddell and Scott (Oxford: Clarendon Press, 1968). Abbreviations which do not appear in the dictionary are given below. ANF Ante-Nicene Fathers ANRW Aufstieg undNiedergang der rOmischen Welt ATA Augustine Through the Ages CCL Corpus Christianorum, Series Latina Chron. Tardae sive chronicae passiones, Caelius Aurelianus CMC Codex Manichaicus Coloniensis CMG Corpus Medicorum Graecorum C. Th. Codex Theodosianus Comp. Compositiones, Scribonius Largus Ep. ad Val. Epistula ad Valentinianum, Vindicianus Ep. Pent. Epistula ad Pentadium, Vindicianus FC Fathers ofthe Church translation series G VI Grieschische Vers-Inschrflen Gyn. Gynaecia, Soranus or Vindicianus IG Inscriptiones Graecae IGR Inscriptiones Graecae ad res Romanas pertinentes LS A Latin Dictionary, Lewis and Short, eds. Med. De medicina, Celsus NPNF Nicene and Post-Nicene Fathers Phaen. Phaenomena, Theodorus Priscianus vi Phys. Physica, Theodorus Priscianus PL Patrologia Latina PLRE Prosopography ofthe Later Roman Empire PLS Pafrologia Latina Supplementa TAM Tituli Asiae Minoris TLL Thesaurus Linguae Latinae WSA Works ofSaint Augustine: A Translation for the 21st Century Abbreviations for works of Galen which do not appear in the Greek-English Lexicon are as follows: Anat. De anatomicis administribus Opt. corp. De optima corporis nostri Constitutione Cognosc. De cognoscendis curandisque animi morbis Usu puls. De usu pulsuum Hipp. et Plat. De placitis Hippocratis et Platonis Sanit. tuend. De sanitate tuenda Aiim. fac. De alimentorumfacultatibus Ptisana De ptisana Dign. insomn. De dignotione ex insomniis Morb. dff De morborum dfferentis Caus. morb. De causis morbis Meth. med. De methodo medendi Ven. sect. De venae sectione adversus Erasistrateos Romae degentes Cur. ratione De curandi ratione per venae sectionem Puer epil. Pro puero epileptico consilium Simp. med. De simplicium medicamentorum temperamentis acfacultatibus Comp. med. De compositione medicamentorum secundum locos Antid. De antidotis Ther. Pis. De theriaca ad Pisonem Praecog. De praecognitione Nat. man. comm. In Hippocratem de natura hominis commentarius Ep. comm. In Hippocratis epidemias commentarius Hipp. artic. comm. Hippocratis de articulis liber et Galeni in eum commentarii quatuor Med. exp. De experientia medica Opt. med. De optimo medico cognoscendo Subt. diaeta De subtiliante diaeta vii Acknowledgements The process of research and writing is never completely a solitary one. I would like to thank the most important of those who provided me the support which I needed to complete this study. My first and greatest thanks, as always, are given to my husband, Lance Husoy, who has exhibited the most extraordinary patience and fortitude during this entire process. And he would not let me quit when I most wanted to, for which I am most grateful. Thank you as well to my mother, Ella Reid, for her support, particularly for her help on the home front over the years, and to my children, Miles and Joanna, for not minding too much about having to share their mother with her books. A great deal of gratitude is owed to the members of my committee, for their generosity of time, continual encouragement, astute advice, and thought-provoking discussion. A special thank you to Paul Burns, who unwittingly changed my life when he introduced me to the study of late antiquity in my first year of graduate school. The Interlibrary Loan department of the University of British Columbia Library always responded swiftly to my many requests, and thus too deserves thanks. And, finally, my thanks as well to Tracy Deline, a friend, colleague, and travelling companion, whose good cheer and reliable optimism in the face of all catastrophe has made this academic journey so much more enjoyable than it otherwise would have been. viii For my father, Donald Eric Reid (1924— 1989), whose unfulfilled dream of making a journey down the Mississippi inspired me to my studies. ix Chapter 1 Introduction Venit Christus, sedprimo salvare, postea iudicare. The first dispensation of Christ is medicinal, not judicial. Jo. ev. tr. 36. 41 The initial impetus for this study arose from reading a very brief passage in Augustine’s Confessions: Diligebat autem ilium virum sicut angelum del, quodper ilium cognoverat me interim ad 111am ancipitemfiuctuationem jam esse perductum per quam transiturum me ab aegritudine ad sanitatem, intercurrente artiore periculo quasi per accessionem quam criticam medici vocant, certa praesumebat. She revered that man as an angel of God, for she realized that it was thanks to him that I had meanwhile been brought to my present point of wavering; and she foresaw with certainty that I would have to pass through a still more dangerous condition—a crisis, as the physicians call it—on my way from sickness to health.2 The place and time is Milan in 385 AD, and the “she” of this passage was Monica, the mother of Augustine, a woman of great Christian faith who was had accompanied the future Bishop of Hippo in his move from their native North Africa to Italy; the man whom she ‘Translation by Browne, NPNF 7. 2 Conf 6. 1. 1. See the bibliography on editions and translations used in this study; all translations are from the list of those provided. On the occasions in which I provide my own translation, for reasons of clarity or for lack of an English translation, this will be indicated. The Latin or Greek titles of works will be used in the text, with an English title provided in brackets upon the firstappearance of a given work. The exceptions to this are two treatises from the Augustinian corpus: both Confessiones (the Confessions) and Civitas Dei (City ofGod) will be referred to with their English titles as these are so well known outside the field of patristic studies. For abbreviations used in the footnotes, please refer to the List of Abbreviations on p. vi — vii. 1 esteemed at the time was Ambrose, the Bishop of Milan, one of those responsible for contributing to Augustine’s eventual conversion to Catholic Christianity. This passage appears at the beginning of Book 6 of Augustine’s Confessions, his account of his early life, from his birth to his full commitment to his new faith, which was written a decade or so after these events. Although born and reared a Christian by Monica, he had forsaken it for Manichaeism, a form of Christianity which Catholic Christians, such as Monica and Ambrose, considered heretical. He had remained a follower of Manichaeism for over nine years, but had finally renounced it while living in Milan. At this moment in his life Augustine found himself in a spiritual quandary, unsure about where he would place his religious alignments. He is still two full books away, so to speak, from the moment of conversion, but he is nevertheless at a decisive turning-point in his own story. He knows, in retrospect, that his next decisions will mean salvation or damnation. To describe his state of wavering vacillation, Augustine could perhaps have likened himself to a traveller who is faced with choices at a crossroads (“Do I choose this path, or this one, or this?”); he could have chosen the metaphor of a soldier, a general perhaps, who must decide how and in which direction to deploy forces, or even that of a potter at a wheel, contemplating the shape he will impose upon clay. The range of possible metaphorical expressions for a decisive moment in one’s life is wide. Augustine elects, however, to employ a medical metaphor, that of a sick man who must come through a worsening of his illness before he arrives again at health. This admittedly minor passage in the Confessions interested me for several reasons. To begin with, I was struck by the metaphor employed. To many a modern reader, myself included, the medical analogy which Augustine employs at first glance seems to be an odd 2 one: how could a moment of decision compare to the experience of illness? Subsequent reading in the medical literature of the classical world, however, has confirmed that this metaphor was indeed apt and fully consonant with the Roman understanding of medicine: Augustine describes this crucial moment in his life as an accessio, the Latin term for the critical moment of illness. It is the time of an illness in which the symptoms, such as fever, vomiting, or sweating, actually increase and grow acutely worse. It is a moment when life is held in the balance: the patient with worsening symptoms may grow better or may further sicken and die. The accessio critica, as Augustine describes it, is a time both of potential change and potential danger. The reader, such as I was, who lacks a full understanding of the ancient medical concept of a crisis contained in the phrase accessio critica would fail, however, to grasp the complete meaning of Augustine’s metaphor. Physicians who practise modern orthodox western biomedicine may refer to “a medical crisis,” but both they and their patients understand the term differently than did Augustine and his audience. To the former, it signifies a crucial failure in treatment, an emergency which must be responded to with swift clinical intervention, a moment in the process of a disease which must be rigorously guarded against and prevented.3 To Augustine and his audience, however, a crisis was in fact a natural and even necessary event in the course of an illness; the ancient physician actually expected illness to have a crisis.4 Thus, Augustine’s use of this medical metaphor reveals that his understanding of his spiritual crisis in Milan in 385 included the expectation that a stage of doubt and intellectual suffering before he would reach spiritual health and safety was Personal communication with E. M. Pen-i, M.D., January 2007. “See En. in Ps. 72. 20 for Augustine’s own explanation to his audience on crisis in healing. The belief in a medical crisis in this sense was part of western medical thought into the nineteenth century, and some modem alternative medical systems, such as homeopathy, subscribe to the concept. 3 not only predictable but actually essential. The language of Augustine’s chosen metaphor deftly establishes for his audience that, in his own mind, he saw order, purpose, and meaning behind his spiritual and intellectual grapplings at the time.5 Augustine’s imagery is apposite, therefore, but my own struggle to understand his use of this imagery demonstrated for me that modern ideas about medicine cannot be applied to the ancient world. I began to see that medical knowledge, as well as more general ideas about health and illness, are as dependent upon cultural and social interpretation as other forms of knowledge and belief, and that their application, literal or metaphoric, must be viewed from within that culture. The second issue which arose from this passage came indirectly from the pen of James O’Donnell, who, in his erudite and immensely useful Commentary on the Confessions, notes that the term critica, a Latinized form of the Greek medical term, is highly technical, and muses very briefly on how familiar the word would be to Augustine’s audience.6 O’Donnell does not answer his own question, but it prompted me to wonder not only what Augustine and his audience may have known about medicine, but also where he himself would have picked up a knowledge of medicine sufficient to allow him to use such technical vocabulary. Medicine was not part of the educational curriculum of the ancient classroom, and there was nothing in Augustine’s biography which would on the surface indicate an opportunity for, or even an interest in, obtaining knowledge about medical issues. Initial research in the limited scholarship done on this point found little more than the suggestion Even the non-technical term for the medical crisis, accessio, has semantic overtones to which at least some part of Augustine’s audience would respond, for it is the rhetorical term employed by Cicero (Acad. 2. 35. 112; Fin. 2. 13) to indicate an additional term which would complete a definition. Thus Augustine’s personal accessio is seen to form part of his search for the wholeness of health (salus). 6 O’Donnell 1992: supra 6. 1. 1. Neither Courcelle nor Pellegrino discuss the medical language of this work in their commentaries on the Confessions. 4 that he had obtained his medical knowledge from Vindicianus, a physician with whom he had contact while living in Carthage prior to his conversion. This proposal seemed to rest on thin evidence at best; it also placed a considerable weight on a single source for Augustine’s knowledge. The third aspect which arose from this otherwise insignificant passage was a heightened awareness of the degree to which Augustine employs medicine and the language of healing in his work. The vocabulary and imagery of medicine permeates the Confessions, for example, and, in a work which is so highly selective about the events and people which are included by the author, illness and medicine figure prominently. Health, illness, and medicine are also pressed into service with consistency throughout the Augustinian corpus, and Augustine frequently uses very specific, and often technical, medical terms. That there is extensive use of medical imagery throughout his works is not an original observation; the use of the metaphor of Christus medicus (Christ the Physician) in Augustine’s works has long been noted. The scholarship has tended to dwell, however, only on this single metaphor, to the exclusion of all other uses of the language of medicine and health, be they literal or metaphoric. I could find no scholarly comment, for example, on his frequent portrayal of the sick bed as an arena of Christian martyrdom, nor on his use of the theories of medical sects. This study will attempt to address the three issues raised by my reading of this brief passage from the Confessions. To begin with it, it will try to provide a framework for understanding Roman medicine as Augustine understood it. This seemed at first to be a relatively straightforward exercise, but as I researched further it became increasingly obvious that my understanding of what the phrase “Roman medicine” encompassed was too narrow: 5 readings in the literature of medical anthropology opened avenues of thought and discussion which considerably expanded the idea of Roman medicine into that of Roman medical culture, that is, of medicine as one aspect of the larger social and intellectual activities of a society. Medicine became a circle in a Venn diagram for the ancient world, intersecting with its literary and rhetorical culture, with its various philosophies, with many aspects of religious thought and practice, as well as the daily routines of life. The questions which medical anthropologists have asked, such as how a society defines health and how it explains illness, brought new light to my conception of ancient medicine, which had hitherto been limited to the Hippocratic and Galenic traditions. I hope to show that medical knowledge in the classical world was not as elite and esoteric as has often been portrayed. Secondly, and leading naturally from the previous point, the study seeks to assess what Augustine knew about medicine and how he garnered that knowledge. I will challenge the notion, so frequently expressed in the scholarship, that he relied solely upon what he could glean from Vindicianus. I will demonstrate that Augustine, who was living in a time of a minor medical renaissance in North Africa, had several avenues open to him for obtaining medical knowledge. Lastly, I will argue that medicine played a significant role in Augustine’s writing: he knew and used its language; he drew upon its authority as a body of knowledge; and he employed it consistently throughout his Christian career in potent metaphors. His use of medical metaphor was not limited, however, to Christus medicus, as will be explored in the final chapter. The reasons why Augustine may have been so attracted to medicine and its metaphors will be considered there as well, including a discussion of Augustine’s own 6 experience with illness, particularly as it relates to the content and composition of the Confessions. As a final note, while this study is based on a reading of the entire Augustinian corpus available to date (several newly-discovered sermons have yet to be published and so were not included), it does not pretend to be comprehensive on the subject of medicine in Augustine’s writing. 7 Chapter 2 Roman Medical Culture “Medicine was religion. Religion was society. Society was medicine.” Anne Fadiman, The Spirit Catches You and You Fall Down The quotation from Fadiman above may seem an odd epigram for a chapter which will explore the medical culture of Rome, for it stems from her account of the cultural clash experienced by a group of American physicians and the Hmong immigrants to whom they provided medical care.6 But Fadiman’s words, though removed in time and space from the topic at hand, do evoke a shared underlying theme. Unlike the modern, western experience of medicine as a “thing apart” from everyday society, the Roman concept of medicine was similar to that of the Hmong, in that medicine was tightly intertwined with many aspects of the general culture, in ways which may seem incongruous to us. This chapter will consider certain aspects of medicine within the framework of the larger Roman culture. Such a vast topic cannot be encompassed in any single chapter, and thus the focus will be restricted to four areas of inquiry: medicine as an element of Roman literary and rhetorical culture; 6 Fadiman 1997 examines the settlement of Hmong refugees from Laos in I 980s California, particularly the challenges faced by a family with a daughter who suffers from multiple seizures. The author explores the assumptions which both the Hmong and the American medical personnel who interact with them bring to their meetings with each other: the American physicians work upon a diagnosis of epilepsy caused by neural misfirings, while the Hmong believe that their daughter’s seizures are caused by the flight of her soul from her body (in Hmong, “the spirit catches you and you fall down”). 8 biomedicine’s relationship with ancient philosophy; medicine as an aspect of religious faith; and medicine as the regimen of health.7 The chapter will begin, however, with a brief consideration of the methodologies which have been employed thus far in the scholarship of ancient medicine, as well as a survey of the sources upon which the chapter will largely draw. The Scholarship on Graeco-Roman Medicine All cultures and societies must come to terms with sickness: how to avoid it, how to cope with it when it happens, and how to explain it. Analyzing the means by which a culflire addresses the critical questions of health and illness can provide an avenue for understanding its social and cultural values. Until relatively recently the standard theoretical model employed by historians of Graeco-Roman medicine, many of whom are not classicists but rather physician-historians, had been that of the Great Man, a model which focusses on the theories and methods of various ancient physicians to the exclusion of much else. This body of scholarship, while admittedly worthwhile in some ways, has some significant limitations. It has tended, first of all, to portray medical knowledge as teleological, as a natural evolution from “superstition,” as it is usually termed, to scientific “rationality.” One need not go as far back as 1924, for example, to Fielding H. Garrison, who scorned the “primitive” beliefs of Settling on neutral terms with which to discuss medicine in the ancient world is problematic. Many scholars have opted for “rational medicine” as the term for healing as it is exemplified in the Hippocratic and Galenic corpora, a term which unfortunately generates its pejorative opposite—”irrational medicine”—for all other forms of healing. See van der Eijk 2004: 5 —7 for a critique of the application of the term “rational” to Graeco Roman medicine. Gordon 1995 employs the extremely useful term “school medicine,” which draws attention both to the more formalized nature of this style of healing as well as to the various medical sects which developed in the Graeco-Roman world. For purposes of simplicity I will generally use the unqualified term “medicine” in this chapter to refer to this “school medicine,” but when it is necessary to differentiate between healing which has a biological orientation and that which does not, I will use “biomedicine” to identify’ the former. 9 pre-historic “savages,” or even to Arturo Castiglioni’s 1958 laudatory description of medicine’s “struggles against superstition and charlatanism;”8 a prominent and recent example can be found in the introduction to medical historian James Longrigg’s 1993 monograph, Greek Rational Medicine. Philosophy and Medicine from Alcmaeon to the Alexandrians, in which he extols what he terms the “emancipation of medicine from superstition:” One of the most impressive contributions of the ancient Greeks to Western culture was their invention of rational medicine. It was the Greeks who first evolved rational systems of medicine for the most part free from magical and religious elements and based upon natural causes. The importance of this revolutionary innovation for the subsequent history of medicine can hardly be overstressed.9 The most obvious danger of this historical-determinist approach is that it can mislead one into examining ancient medical ideas with an eye which assigns an inevitable superiority to modern Western medical theories and ideas. The superior tone adopted by medical historian liza Veith in her 1965 study of the history of hysteria, for example, is not unusual. After outlining the Hippocratic notion of the “wandering womb” as the source of some female illnesses, she notes: The anatomical difficulties in the way of such free and extensive migrations [of the uterus] were apparently of no concern to these writers. This may in part be due to an overwhelming ignorance of bodily structure and particularly that of the female generative 8 Garrison 1924: 21f, Castiglioni 1958: 11. Neither of these men were classical scholars, but the Cambridge classicist W. H. S. Jones, translator of Hippocrates for the Loeb series, attributed many of the medical beliefs of the Romans, for example, to the persistence of primitive beliefs and superstition. He chides some of the folk remedies of Scribonius Largus in particular: “a physician, one would think, would know better.” Jones 1957: 468. Often the titles of earlier histories of medicine speak for themselves, such as Howard W. Haggard’s 1933 monograph Mystery, Magic and Medicine: The Rise ofMedicine from Superstition to Science. Longrigg 1993: 1. See Brieger 1993: 24f for a brief review of histories of medicine designed to show this “march of the intellect,” many of them written by medical doctors themselves. See also van der Eijk 2005: 1 — 4 for a critical assessment of this approach. ‘°Veith 1965: 11. 10 Although Veith goes on to acknowledge that Hippocratic medical theory was perceived as rational by the scientists and philosophers of the time “because it was thoroughly compatible with their all-inclusive concept of nature,” it is obvious that she is in agreement with the tradition which definitively polarizes the concepts of “superstition” (and/or “magic”) against “rationality.” The tone and vocabulary of this scholarly approach is difficult to abandon. Even Audrey Cruse’s recent survey of Roman medicine, which acknowledges, for instance, the psychological context and power of incantations in the process of healing, describes early Roman medicine as a mixture of “religion, folk medicine, magic and superstition,” while medical historian Richard Durling sniffs at Plutarch’s “somewhat naive remarks” on human physiology.’2 A rather different approach to understanding health and illness in antiquity which some scholars have taken has been to concentrate on retrospective nosology, the identification and classification of diseases, in an attempt to shed light on the everyday life of the inhabitants of the ancient world. Les maladies a l’aube de la civilisation occidentale, the 1983 work of Croatian-French medical historian Mirko D. Grmek, is the classic work of Veith 1965: 15. 12 Cruse 2004: 51 —4, 59. Durling 1995: 313. See as well Cilliers 2003: 283 on what she terms the “irrational taboo” against human dissection in Greek medicine, van der Eijk 2004 summarized the collective observations of the classicists, Assyriologists and medical historians who considered the concepts of “rationality” and “magic” in ancient medicine at a conference in 2001. Their comments on the application of the term “rational” to Graeco-Roman medicine are worth noting here: the aetiological principles of Graeco-Roman medicine—humours, qualities, corpuscles—are not inherently “rational,” as they lack empirical evidence and result in therapies which are not necessarily more effective than any other forms of healing; logos is possibly more accurately translated in a medical context as “the account” or the “coherent story” rather than as “reason;” it is inappropriate to distinguish the natural from the supernatural in the Graeco-Roman world; “rational” is a term associated with a modern, positivist line of thinking, and it ignores the medical experience of the non-lite as well as the presence of the “irrational” in the writings of Hippocrates, Galen and other biomedical writers. These scholars argued that instead of looking for the “rational” in ancient medicine, historians should be concerned with the “rationale” inherent in the system. See also the remarks of Barton 1994b: 8 — 17 on the historiography of science and the use of the term “pseudo-science.” 11 nosology for the ancient world.’3 His research and that of other nosologists largely bypasses the theoretical ideas of ancient physicians to concentrate instead on the case histories which physicians and other ancient writers provided of various diseases. They seek to obtain a medical picture of the past through a combination of these case histories with archaeological evidence. It is important work, although it has at least two obstacles. To begin with, ancient diseases often resist modern interpretation. It can be very problematic to correlate ancient descriptions of diseases with modern classifications.14 Thus, attempting to understand the medical world of antiquity by determining the diseases with which ancient peoples coped may be generally useful but may be misleading in particular instances. More pertinent, however, is the objection that using nosological investigation as the means of understanding health and illness in the ancient world implies that it is even possible to make a direct link between the modern experience of illness and the experience of illness in the past. Anthropologists have shown that as the locus of disease the body is not a universal entity, but is rather a social construct, “a physical and cultural artifact.”5 The conceptualization of the body is not easily transferable from one society to another. The 13 Translated into English in 1989 as Diseases in the Ancient World. See also Jackson 1988 which places emphasis on ancient disease. Grmek has coined the term pathocoenosis to represent “the ensemble of pathological states present in a specific population at a given moment in time,” and he analyzed these states by the frequency and distribution of each disease in relation to all other diseases. See Grmek 1991:2—3. 14 Witness, for example, the continuing speculative scholarship concerning the identity of the Athenian plague of 429 BC, based upon both Thucydides’ information and archaeological investigation. The various suggestions put forth by scholars for the identity of the plague include up to 27 different diseases, including ergotism, Lassa fever, Ebola virus, and toxic shock syndrome. See Longrigg 1989 for a survey of the various diagnoses. A recent microbial DNA study from a mass grave in the Kerameikos section of Athens now suggests that it was typhoid fever, or a typhoid outbreak concomitant with another as yet unidentified agent; see Papagrigorakis et al. 2006. Another example of the difficulty of nosological identification is the translation of the Biblical term Zarã’at as “leprosy,” since the disease which bears that name in modern nosology (Hansen’s Disease) did not appear in the mid-East until after the completion of the Hebrew Bible. The general opinion is that Biblical “leprosy” was in fact one or more of any number of other disfiguring skin diseases. See Grmek 1991: 152— 176. See Leven 2004 for a critique of retrospective nosological diagnosis. 15 Scheper-Hughes and Lock 1987: 19. 12 German sociologist Barbara Duden has written eloquently about the frustration she encountered, for example, when she attempted to gain a physical understanding of the illnesses faced by female patients of a 18th century German physician, Doktor Storch, by reading the case histories in his diary: I wanted to learn from the [doctor’s] diary how and what women [in his care] felt. However, each time I tried to map the complaints of Storch’s patients onto the grid of my own body, I was frustrated. I had to give up. I either missed the point or did violence to the context. Because the suffering body about which Storch’s women complain has no point to point correspondance with the body I was taught to have.’6 The Graeco-Roman body unquestionably was composed of the same physical elements—flesh and blood, organs and glands, bones and joints, hormones and other bio chemical compounds—as the modem, Western body. But while the structures of the human body are indubitably the same, the experience of those structures as the body differs from culture to culture. In the modern, Western imagination and experience, for example, the body is essentially a Cartesian one: it is a machine which must have its “furnace stoked” with food; it is a mechanical system complete with a “pump” (the heart), “plumbing” (uro-genital system) and “wiring” (nervous system), a functioning system with parts which can readily be removed, repaired or replaced (with artificial parts, if necessary) if they malfunction or simply wear This mechanical metaphor, a potent and pervasive one for our culture, is one which the inhabitants of the Graeco-Roman world likely could not have understood (nor indeed would most Europeans until the scientific and philosophical changes of the eighteenth and nineteenth centuries); for them, the body was almost exclusively understood in terms of 16 Duden 1990: ix. The analogy of body as machine even extends to psychology; it was the nineteenth-century’s experience with steam engines which produced the Freudian concept of psychological “pressure” which must be allowed to vent properly to avoid destructive explosion. The current century models both the human body and brain on the computer; we talk naturally about mental “input” and “output” and of the body being “hardwired” for certain functions. 13 fluidity and change, and not of solid structure and stasis. The theory of humours, for example, which was only one medical theory in the classical world, was predicated upon the philosophical paradigms of some of the Pre-Socratic philosophers.’8 It produced a body which was composed of solid bones and fluid-filled vessels, the muscles and organs; the quantity, movement and discharge of the fluids formed the basis of health and illness. The physical and psychological experience of illness in a body constituted from various fluids could be expected to differ from that of a body structured as a mechanical device. This kind of cultural difference in physical perception partly explains Duden’ s failure to comprehend the physicality of the symptoms of those long-deceased patients of Doktor Storch. The women in his case histories simply inhabited a different construction of bodily experience than Duden presently does. Using nosological research may allow one to reach conclusions about the diseases with which ancient people coped, therefore, but it has limited value in understanding the illnesses which they experienced as they themselves understood them.’9 In sum, both the teleological approach of many earlier medical historians and the nosological methods of scholars such as Grmek have produced some fruitful work but have failed to provide a culturally-appropriate picture of ancient medicine. Within the last several decades, however, scholars such as G. E. R. Lloyd, Lee Pearcy, Helen King, Gillian Clark, Philip van der Eijk, Nancy Demand, and, in particular, Vivian Nutton have largely abandoned these approaches and have striven instead to illuminate the social and intellectual ‘8Nufton 1992: 22—23. 19 Medical anthropologists and sociologists draw a clear and useful distinction between the two terms which has relevance for inquiries into issues of health and illness in the ancient world. A disease is an abstract, biomedical conception of pathological abnormalities, consisting of symptoms which are both measurable and analyzable. An illness, on the other hand, is wholly experiential; it is a culturally-mediated response to a negative state of body or mind, which may or may not involve a pathological process. Paradoxically, therefore, one can be ill without having a disease, and one can have a disease without being ill. Illness, in other words, is usually but is not necessarily a biological event; illness is always, however, a social, cultural, psychological and, depending upon those involved, even a spiritual event. See Eisenberg 1977; Brown, Barrett and Padilla 1998: 11; and Kleinman 1980: 72. 14 environments of ancient medicine. They have attempted to do what Werner Jaeger had advised, which is to view medicine as a force which was not isolated from the greater Graeco-Roman culture.2°Many of them have also consciously endeavoured to “acknowledge the strangeness of ancient medical thought and the difficulty of fitting it to our [modern medical] categories.”2’ A good number of scholars have chosen to “acknowledge the strangeness” by using the insights of medical anthropology to produce a more nuanced understanding of ancient medicine.22 As one example of the value of anthropological perception, consider the traditional classification of ancient medical ideas under the antithetical rubrics of superstition and rationality. Medical anthropologists have demonstrated that it is dangerous to analyze medical beliefs as inherently right or wrong; it is far more useful to undertand them as expressions of the way in which a society attempts to order and conceptualize the cosmos. As an illustration of this ordering and conceptualization, consider cross-cultural beliefs about disease aetiology. The range of causal agents for disease is extensive; it includes agents as diverse as weather and climate, physiological imbalances, the Evil Eye, Karma, fate, and germs. In essence, however, disease aetiologies can be sorted into two distinct groups: personalistic or naturalistic forces.23 In the personalistic sphere lie those causal agents which draw a direct link between the sick person’s character, behaviour or personal circumstances and the illness; this aetiological realm involves human, supernatural or divine intervention (a witch, ghost or 20 Jaeger 1944: (vol. 3): 293 n. 2. 21 Pearcy 1998. 22 Both King 1997 and Nutton 2002 provide concise and extremely useful accounts of the transformation of academic studies in the history of ancient medicine in the twentieth century, noting in particular the insight provided by the methodologies of social historians, anthropologists and feminists on the subject. See, for example, the work of King 1998, 2005; Demand 1999; and Flemming 2000. 23 Foster 1976. 15 divinity). The sufferer suffers precisely for who he is or what he has done. When illness is perceived to be caused by these personalistic forces, focus is placed squarely upon the sufferer and meaning for the illness is sought in the sufferer’s actions or in those who may have wished him harm: “Why did this illness happen to me in particular?” the sufferer asks, or “Who did this to me?” In contrast, naturalistic aetiologies do not situate the sufferer in the explanatory model of the illness, except as the physical locus for the illness. Naturalistic causal agents are deemed to be purely impersonal, natural and impartial. The sole question asked by those who ascribe illness to naturalistic agents is “How did this happen to me?” The meaning for the illness is sought in a systemic failure, whether it be external (climate, for example) or internal (genetic mutation, for example) to the sufferer. No society subscribes exclusively to either personalistic or naturalistic aetiological explanations for disease, but societies, and the individuals which make up those societies, do tend to lean strongly to one or the other model, and their leanings reflect the way in which they comprehend and articulate the cosmos. Those who opt for personalistic aetiologies, for example, assume that the forces which shape and guide the world are themselves malleable and subject to change depending upon the will of an agent; in order to avoid illness, one must avoid disturbing the balance between oneself and the agent. By contrast, those who consider illness to be the result of naturalistic forces understand the rules which guide the cosmos as fixed, the vectors of disease lacking either the will or ability to change the rules.24 24 Plutarch seems to have anticipated the anthropologists: at Mor. 1 68B — C he divides humanity into two groups, those who seek a biomedical explanation—overindulgence in food or drink, changes in routine, air or locality, or over-exertion—for illness, and those who look to external causes such as spirits and divinities as causal agents. 16 Medical anthropologists have demonstrated that ideas about health, illness and healing are not evidence of “rationality” or “irrationality,” but that such ideas are based within a culturally-coherent framework. Contemporary Western medical ideas, lay and professional, are as culture-bound as the ideas of any other society; roles, definitions, and metaphors for health and illness are specific to us and our age. It is ill-advised to assign them arbitrarily to other societies and other times. The term “medical culture” will be employed throughout this chapter’s examination of Roman medicine in order to emphasize that the purpose is not to consider Roman medicine in a vacuum but to set it within the social, intellectual and cultural architecture of Roman antiquity. Textual Sources Diachronic approaches to ancient medicine incline to the teleological, triumphalist models of history, and thus this examination of Roman medical culture will not approach the topic chronologically but instead will maintain its focus on the latter part of the second century, the time in which the physician Galen was actively working and writing in the imperial capital.25 The period is a convenient juncture at which to stop and survey the medical landscape, not least because of Galen himself: his literary output was enormous; his subsequent influence on medical thought pervasive; and it is through Galen’s eyes that modern scholars are forced to view much of the medical experience of the Roman world. Equally useful is the availability of other informants who were either roughly contemporaneous with or who immediately preceded Galen. Additionally, the life of Galen 25 All dates are AD unless otherwise indicated. 17 roughly defines an era of medical literature, for after his death authors who throw light upon medical culture largely disappear, not to reappear for another hundred years or so. Literary sources provide the majority of the evidence, and the sources fall into two general categories: those writers whose extant works are exclusively or largely about medical issues, and those for whom discussions about medicine and health are more incidental and are incorporated into their discourse on other issues.26 A useful catalogue of the extant corpus of Latin medical texts has been produced recently by David Langslow, a Latin philologist whose work, Medical Latin in the Roman Empire, undertakes a linguistic analysis of the medical terminology of the empire.27 There remain approximately forty works covering the first six centuries of the Roman empire, in which number are included Latin translations of Greek texts, including those of Hippocrates and Galen, and collections of pharmaceutical texts. It is a surprisingly small body of literature, often fragmentary in nature, and the preponderance of it was produced in the late empire, in the fourth to sixth centuries. The relative scarcity of extant medical works is not unique to Latin: a great percentage of the medical works which were written in Greek, the language in which the majority of the medical texts were written, has also vanished.28 The fragmentary and comparatively limited nature of the extant medical writings forces one to appeal to all available resources, including a number of non-medical texts which have only incidental references to medicine. This should not obscure the genuine utility of examining non- 26 See the bibliography of primary sources for details concerning the editions and translations employed. As this study is concerned with Roman medical culture, Latin literary sources will naturally predominate, but there are Greek writers who provide significant information and insight into Roman life and thought, specifically those Greeks who spent a substantial portion of their lives in Rome. 27 Langslow 2000: 60 — 75. Note that there are no Latin medical texts surviving from the Republican period. The historical Hippocrates appears on several occasions in Plato (see Phdr. 270C, for example) and while it is recognized that the works assigned to him were the product of a number of writers writing at various times, it is convenient to refer to Hippocrates as the figurehead writer. Nutton 2004: 60 — 62 outlines the history of the corpus of texts which circulated under Hippocrates’ name in the ancient world. 28Nutton 2004: 1—7. 18 medical sources and authors, of course. These writers are often as important to our knowledge of medical culture as are the medical writers. While the non-specialist writers not only frequently demonstrate a thoroughly competent understanding of medical and health topics, they also provide social and cultural contexts which might otherwise be lacking by complete reliance upon ancient medical writers alone. A brief sketch of the biographies and bibliographies of the sources for this chapter will be given, both because these details will elicit material for discussion further on in the chapter and because some of these writers will be unfamiliar even to many classical scholars and so require proper introduction. We begin with Galen for two reasons: his prolix writings provide more biographical detail than almost any other medical author in the ancient world, and his subsequent influence on medical thought justifies giving extended space to him. Galen was a native of Pergamum in the Greek-speaking East, born there probably in the fall of 129, the son of a wealthy architect who was ambitious for his son and so provided him with the very best education.29 After receiving his medical training, Galen worked for several years as a physician in a gladiatorial school at Pergamum, but in 162 he decided to leave his provincial life and career for the sake of advancement in the imperial capital.3° He made the journey to Rome, where he lived and worked for the remainder of his life, with the exception of a three-year hiatus in Pergamum. He died circa 210.31 Galen’s career in imperial Rome was impressive: although only one of many provincial doctors thronging the capital, he eventually became part of the corps of imperial 29 See Nutton 1973 on Galen’s chronology. There are two useful biographical acounts of Galen in English: Nutton provides a generous treatment in Chapter 15 ofAncient Medicine (2004), and Singer’s introduction to the Selected Works of Galen (1997), though considerably briefer than Nutton, is still of great assistance. An older monograph on Galen which merits study is Temkin’s Galenism: Rise and Fall ofa Medical Philosophy (1973). See also Garcia Ballester 2005 and Bowersock 1969: 59—75. 30Galen, Opt. med. CMG SO IV 9.4—7. 31 See Nutton 1984a: 323 and 2004: 226 —227 on the dating of the year of Galen’s death. 19 physicians tending to the health of several emperors—Marcus Aurelius, Commodus, and Septimius Severus—and their families, as well as to that of other leading members of the city.32 The extant Galenic corpus comprises twenty-two volumes in the standard nineteenth- century German edition by Karl Gottlob KUhn, and Nutton estimates that Kuhn’s edition could be expanded by as much as thirty percent in light of works of Galen which subsequently have come to light in Arabic and Syriac texts.33 The majority of his compositions were medical treatises: anatomical and physiological works; commentaries on Greek medical writers, particularly Hippocrates, whom he held in high esteem; and books on therapeutics and prognosis. He also composed treatises which discussed medicine and health in broader, more philosophical terms, some of which were polemical diatribes on the theories and practices of the various contemporary physicians and medical sects. There are, as well, a handful of philological studies and a substantial number of philosophical works. Galen wrote treatises which expounded both logic and moral philosophy and discussed Platonic, Aristotelian, Stoic and Epicurean ideas. Of specific interest for this chapter are three of Galen’s later works with strong biographical elements: Depraecognitione (On Prognosis), which was written around 178 and which, despite its apparently clinical title, was Galen’s account of his first years in Rome; and De libris propriis (My Own Books) and De ordine librorum (The Order ofMy Own Books), which respectively summarized Galen’s writings 32 See Bowersock 1969: 62 —66 on Galen’s career at Rome and on court doctors i13 the Roman empire in general. See also Mattern 1999 on imperial patronage. Korpela 1987 examines the literary and epigraphic evidence for doctors at Rome. Opera omnia Claudli Galeni 1821 — 1833. Nutton 2004: 390 n. 22. He further notes that almost ten percent of all extant Greek literature written before 350 AD belongs to the Galenic corpus. 20 and the order of reading recommended by the author.34 These three works in particular provide illuminating glimpses into the social and intellectual life of Rome in his day. The immense size of the Galenic corpus, both in real and relative terms, contributes to an understandable tendency to overvalue his prominence in the field of Graeco-Roman medicine, a situation which is exaggerated by the scarcity of other medical texts in general.35 His has often become the voice of medical thought and opinion from the Roman empire. Scholars frequently must rely upon his compositions to hear even the echoes of the voices of others. Much of his work is polemical in nature, and therefore relying upon them exclusively to establish the medical culture of second-century Rome can distort the historical reality. One must consequently approach Galen’s works with some measure of caution.36 The significance of Galen’s influence on medicine in Byzantium, in the Arab world and eventually in the Latin West is indisputable.37 Medical thinking for the next millennium and a half would largely be Galenism, particularly the theory of humours which he vigorously championed. His impact on the Greek (later Islamic) East was immediate and on going, and although in the Latin West Galenism left its permanent mark only after AD 1000 N Galen wrote exclusively in Greek, but the titles of his works are given customarily in Latin. Nutton 1998: 242 feels compelled to caution his fellow medical historians that “medicine in antiquity cannot and should not be equated solely with that of Hippocrates and Galen.” 36 Conversely, however, it is risky to assume from either his prolificacy or his notorious prolixity that there is only seif-aggrandisement at play and thus that his contemporary influence was much less than even he himself portrays. There is scant mention of Galen by his social contemporaries, but comparatively few works have survived from that period so that silence is not particularly significant. Both Bowersock 1969 and Nutton I 984a, moreover, have dexterously shown that at the time of his death Galen had secured a weighty reputation as both physician and philosopher at Rome itself and in the Greek world at large. Interestingly, Nutton cites Christian sources, one of them Eusebius (Hist. EccI. 5. 28), as well as secular sources in support of his argument. Eusebius recounts that a small group of heretics at Rome had abandoned the scriptures for study of Euclid, Aristotle and Theophrastus. He further writes: r.voç ydp crnç bitO ttvwv iced 1tOGKDVEtCfl (Perhaps Galen is also worshipped by some of them.) Although there is no reference to him at all in Latin medical texts until Cassius Felix in the fifth century, he is mentioned with great admiration by fourth-century Greek medical writers, such as Julian’s personal physician, Oribasius; Galen also surfaces in the role of one of the dinner guests in Athenaeus’ Deipnosophists (lE, 26C — 27D, 115C — 116A). Temkin 1953: 225; Temkin 1973: 95. Nutton 1998: 242, while in agreement on the undeniable historical importance of Galenism, warns scholars “not to take the triumph of Galenism for granted.” 21 by way of Arabic influence, it was not without earlier impact. Galenism can be found in fourth and fifth-century Latin medical compilations or in Latin translations of Greek medical writers such as Oribasius.38 The bulk of Galen’s works survive in their native Greek, though a considerable number are known only from Latin, Arabic and Syriac translations.39 His works were not translated into Latin to any wide extent within his own lifetime or in the two centuries immediately following his death, but this had only a limited effect upon the reception of his thought among those of the educated class of Latin-speakers who were interested in consulting medical texts. Pierre Courcelle, for example, notes the inclusion of Galen’s Therapeutica in Cassiodorus’ list of medical texts in the library in the monastery at Vivarium in the sixth century.4° The most comprehensive extant Latin medical text was the work of a certain Aulus Cornelius Celsus, whose work De medicina (On Medicine) comprised eight books covering dietetics, pharmacology and surgery. In contrast to the detailed picture which can be painted of Galen, biographical elements for Celsus are sparse. He gave few hints about himself in his work, and it is only with reference to a few outside sources that Celsus’ origins can be determined and De medicina dated, but even then only with caution. Celsus was probably writing during the reign of Tiberius (De medicina may date to the year 21), and there are indications that he resided in either Italy or Gallia Narbonensis.4’All other biographical details are missing, although Bruno Meineke deduces from his name that he was of patrician 38 Temkin asserted that even in the late twentieth century Galen’s influence could still be felt in parts of Europe and the Middle East where traditional medicine continued to hold some sway. See Temkin 1973: 1. Translations of the Galenic corpus into modern languages has been relatively slow as the works have suffered from “respectful neglect” by classicists, but his most important works, such as those on the humours, on prognosis, and on Hippocrates’ De natura hominis (Nature ofMan), are readily available. Nutton 1972: 50. ° Courcelle 1969: 403 —409, citing Cassiodorus, Inst. 31. 2. 41 Langslow 2000: 43 —44 outlines the evidence and tentatively suggests the specific date, as well as conjecturing his place of residence. See also Nutton 2004: 373 n. 63. The evidence upon which the dating is based is admittedly conjectural, but Celsus was certainly known to both Pliny the Elder and Quintilian, both of whom lived in the latter half of the first century. 22 birth and likely related in some fashion to the Comelian gens.42 That he was well-educated can be deduced from the fact that he read widely and with apparent ease in Greek literature, both medical and otherwise. Celsus’ work was well-known in the ancient world: it was mentioned by a number of Latin writers, and through them it is known that De medicina was only one part of a considerably larger encyclopaedic work entitled Artes. In addition to the eight books on medicine, Celsus composed five books on agriculture, seven on rhetoric, probably six on philosophy, and at least one book on military affairs. All of these other works have been lost, however, owing to the selective nature of textual transmission.43 Celsus’ actual relationship to medicine remains a question of scholarly debate: it is argued by some that he was a practising physician and by others that he was a physician who had only limited clinical practice within his ownfamilia, while some reduce him to the status of a compiler or translator of Greek medical treatises or to that of a layman who produced a practical medical reference text for other non-professionals.44 There is evidence in favour of each of these scenarios: Celsus wrote obviously personal accounts of patient care, frequently emphasized by the use of the pronoun ego, for example, and he had extensive knowledge of the important contemporary as well as ancient medical writers.45 On the other hand, however, he mentioned neither any formal medical training nor a particular teacher, he avoided the —to imperative generally employed by other Latin medical writers, and, most significantly, Pliny the Elder included him under the rubric of auctores (authors) rather than 42Meineke 1941: 290—291. Knowledge of these lost books is gleaned from Quintilian (Inst. 3. 1. 21, 10. 1. 124, 12. 11. 24); Pliny (NH 10. 150, 14. 33); Juvenal (6. 244—5); Columella(1. 1. 14, 2.2. 15); and Augustine (Haer. pr. 5), amongst others. ‘ Meineke 1941: 288 —298 sums up the various arguments put forward by scholars. See also Jocelyn 1985: 303 —304 and Pardon 2005: 403 —412. See Spencer 1948: xi — xii for a detailed summary of the arguments in favour of Celsus as medical practitioner. 23 that of medici (physicians) in his list of sources for the Naturalis historia (Natural History).46 The sometimes vociferous argument over Celsus’ precise medical background depends upon two issues which will be discussed later in this chapter: the degree to which medicine formed part of the Roman liberal education, and the status and identification of a medicus in the Roman world. The Roman physician Scribonius Largus (fi. 14 — 54) lived in the generation after Celsus; he produced a medical treatise entitled Compositiones (Recipes) which was written probably between the years 44 and Scribonius apparently was, as Galen was to be in the following century, a member of the corps of physicians to the imperial family. He stated in the preface to his work that he accompanied Claudius on his conquest of Britain, which has sparked speculation that he was a military doctor, although this conjecture is doubtful.48 Although it is also unlikely that he was Claudius’ personal physician, Scribonius clearly had strong connections with the imperial court in Rome: Compositiones is dedicated to Gaius Julius Callistus, a powerful freedman of Claudius who had once assisted Scribonius by submitting on his behalf some of his earlier medical treatises for the emperor’s notice.49 There is insufficient evidence to determine Scribonius’ background and origins. Both his nomen and cognomen are rare.50 He may have hailed originally from Sicily or from one 46 Langslow 2000: 46. NH 1 contains Pliny’s index and source list; he placed Celsus among the auctores on twenty-four occasions. Pliny’s medical authorities are virtually all Greek. ‘ Sconocchia 1983: vi. See the Praefatio v — ix to his Teubner edition of Compositiones for a concise summary of the biographic information for Scribonius, including the dating of the text; refer to Langslow 2000: 49 — 53 for essentially the same information, but in English. Baldwin 1992 provides a somewhat lengthier discussion of his biography. 48 Mentioned in Compositiones are Augustus, his sister Octavia, Livia (“Augusta”), Tiberius, Antonia the Elder, Claudius and his wife Messalina. Scribonius briefly mentions his trip to Britain (“cum Britanniam peteremus cum deo nostro Caesare”) in his discussion of remedies for snakes bites; see Comp. 163. ‘ Scribonius, Comp. pref. 1, 13. Claudius’ physician is known from Tacitus Ann. 12. 61 to have been Xenophon of Cos. Hamilton 1986: 216 n. 19 infers that Callistus was a libellus (secretary) to Claudius. 50 Baldwin 1992: 74. 24 of the provinces of North Africa.5’ Despite the evident popularity of his treatise amongst ancient, medieval and early modem scholars alike, little additional biographical information survives about Scribonius, although a few scholars have speculated that he was a freedman and that he perhaps initially wrote the Compositiones in Greek.52 The treatise itself consists of 271 pharmacological prescriptions, apparently gathered together during Scribonius’ frequent travels about the Roman empire. It includes remedies for everything from eye infections to dry coughs, from blood in the urine to gout. In addition to recipes for imperial toothpaste, Scribonius also provided antidotes against snake and insect bites, as well as a recipe for the famed theriac of Mithridates, a daily dose of which was held to protect vulnerable princes from poisons of all descriptions.53 The actual pharmacology, however, though worthy of attention not only for medical historiography but for social history as well, is largely only of passing interest in this study. Of greater import is the preface to the work, a dedicatory epistle to Callistus. In this dedication Scribonius discussed the state of medicine in his day, particularly the social and ethical roles of physicians, as well as the contemporary medical debate concerning the relative therapeutic merits of drugs, surgery and diet.54 51 Baldwin 1992: 77 suggests North Africa, although not strenuously. In his preface, Scribonius speaks of being abroad, that is, away from Callistus who is presumably at the imperial court in Rome, which suggests that even if Scribonius was not a native Roman, the city was more or less his permanent home.52 Scribonius is mentioned by Galen and is one of the major sources for the fifth-century medical compendium of Marcellus of Bordeaux. Sconocchia 1983: vii — viii argues in favour of Scribonius writing his work initially in Greek, but Langslow 2000: 51 —53 offers valid counter-arguments. Scribonius, Comp. 19—32 (eye infections), 88 (dry cough), 149 (blood in urine), 158— 162 (gout), 163— 173(antidotes and Mithridates’ theriac), 59 —60 (dentifrices). The most admired extant pharmacological work from antiquity is not Scribonius’ work but that of Dioscorides of Anazarbus (c. 40 — c. 90), who wrote the five-volume Materia medica, a treatise which had an influence on both pharmacy and botanical nomenclature which lasted until the time of Linnaeus. Although Dioscorides wrote in his native Greek, he did practise in Rome during the reign of Nero, but his work, while of consequence for the history of pharmacy, is not a significant source of information for medical culture, although occasional reference will be made to his preface in this study. See Scarborough and Nutton 1982 for an introduction to the work and a translation of the preface. 25 Another provincial physician who is an important source for medical culture in the Roman world of the second century is Soranus (fi. 98 — 138), a citizen of Ephesus who, like Galen, spent his professional career in the capital of the empire.55 That he practised in Rome and that he wrote numerous works on medicine and medical history as well as several works of philology and philosophy is the sum of the solid biographical detail available on him. Although Soranus is credited with numerous and diverse medical compositions, only his famed Gynaecia, a well-regarded treatise on gynecology, obstetrics and paediatrics, survives in the original Greek. Galen referred to Soranus frequently and with great respect, despite their theoretical differences. A substantial number of Latin translations and reworkings of Soranus, particularly from late antiquity, equally attest to the approbation in which he was generally held by others as well. Caelius Aurelianus’ Celeres sive acutae passiones (On Acute Diseases) and Tardae sive chronicae passiones (On Chronic Diseases) are the only two of his translations of Soranus to have survived, although Caelius may have translated (or adapted) as many as eight others, nor was he the only writer to translate or adapt Soranus’ work.56 Soranus, whether read directly in the Gynaecia or indirectly through his Latin translators, is the only direct witness to the Methodist sect of Roman medicine. The medical writers named thus far have required a more detailed introduction as they are relatively obscure even to most classicists, but there is a medical writer who requires specific mention, though little introduction, that is, Pliny the Elder (23 — 79), the writer of the compendious Naturalis historia.57 Pliny wrote a number of works now lost—history, biography, works of paedagogy and grammar, even a treatise on how to shoot a javelin from See Hanson and Green 1994: 981 —987 for a comprehensive summary of the sparse biographical data on Soranus, most of which comes from limited internal evidence and the Byzantine Suda. 6 See Langslow 2000: 65—66 and 73 —74 on Latin translations of Soranus and pseudo-Soranus, as well as Hanson and Green 1994: 1042 — 1061 on Soranus’ Nachieben in the Latin West. ‘ See Beagon 2005: 1 —38 for a useful introduction to the background and scope of the work. 26 horseback—in addition to the prodigious Naturalis historia.58 Despite the fact that the work is not a medical text in the strictest sense, Pliny takes his place among Latin medical writers in light both of the significant space which he devoted to medical issues in his sprawling encyclopaedic work and of the subsequent influence on western medicine which his writings held. Although the stated purpose of Pliny’s work was an examination of the natural world, from the astrology and meteorology of the heavens to the anthropology and geography of the known world, as well as all that the latter contained in flora, fauna and minerals, Pliny also recorded and commented upon the topic of medicine, both in chapters dedicated specifically to this purpose, as well as incidentally throughout the Naturalis historia.59 While it is admittedly impossible to reduce such a complex work to a single theme, one could reasonably argue that the dominating motif of his work was medicine, for he highlighted the medical aspect of nature whenever possible, even in seemingly peripheral areas such as mining and metals, for example.6°Although the work may not immediately be identified today by most classicists as a medical text, nor Pliny as a medical writer, the Naturalis historia was as much a Roman medical text as was the Compositiones of Scribonius, a fact which other ancient writers confirm. Pliny’s medical chapters were the source for many of the surviving Latin medical treatises which Langslow catalogues: it formed part of several late medical compendia, two of which are still extant, the fourth-century Medicina Plinii and 58 Pliny the Younger discusses his uncle’s bibliography in Ep. 3. 5. 59NH 7 covers anthropology and human physiology, while 20—32 have specific medical topics and issues. See Langs low 2000: 62 — 63 on Pliny as a medical writer. 60 In his introduction to his book on mining and minerals, Pliny deplored the fact that miners had little interest in the possible medicinal uses of their work: Et inter haec minimum remediorum gratia scrutamur, quoto enim cuiquefodiendi causa medicina est? (And amid all this the smallest object of our searching is for the sake for remedies for illness, for with what fraction of mankind is medicine the object of this delving?) NH 33. 1. 2. Pliny then proceeded to report any and all medicinal applications for minerals. 27 the later Physica Plinii (from the fifth or sixth century),6’and his work was also a significant source for medical compilers such as Gargilius Martialis (fi. 220 — 260), of whose work, Medicinae ex oleribus etpomis (Medicinesfrom vegetables andfruit), only fragments remain.62 The remaining sources were not engaged primarily in discussing medicine and medical ideas but displayed a marked interest in the subject and provide incidental remarks which give a more rounded understanding of Roman medical culture in the second century. Two writers in particular will be drawn on: Aulus Gellius (c. 127 — 180), a minor Roman official and the author of the miscellany Noctes Atticae (Attic Nights)—which covers a diversity of topics such as grammar, history, natural history, philosophy, and medicine—and Plutarch of Chaeronea (c. 40—c. 120). Plutarch, a wealthy aristocrat and a member of the Academy, spent most of his life in the small Greek town in which he was born, but was far from living a narrow provincial life: his circle of friends included Roman consular officials and philhellenic senators, and Plutarch himself travelled to Rome and even lived there for extended periods of time on at least three occasions.63 His Moralia is a work which encompasses almost ninety separate treatises on the widest variety of topics, including an essay specifically on the topic of health, De tuenda sanitate praecepta (Rules for the Maintenance ofHealth), although as his Loeb translator points out in his introduction to this 61 See Langslow 2000: 64, 68 — 69 on these compilations. 62 See Riddle 1984: 411 —412 on the manuscript tradition for Gargilius. Maire 2002 is the most recent edition and translation (in French). Pliny was also the principal source the Liber medicinalis of Quintus Serenus, which was written sometime in the second to fourth centuries, and for Marcellus of Bordeaux. See Mazzini 1986 on Pliny’s influence on ancient and medieval herbalists. 63 Barrow 1967: xv asserts that Plutarch is “imperfectly understood if he is not seen in the environment of the Roman Empire.” See C. P. Jones 1971 and Boulogne 1994 on Plutarch’s life and his relationship with Rome and the Roman aristocracy. Plutarch lived in Rome between 70 and 79, in the winter of 8 8/89 and again in 92 or 93, and possibly on other occasions as well. See Lamberton 2001: 19 —21 on Plutarch’s familiarity with the Latin language and its literature, a familiarity which marked him out from many of his contemporaries. 28 treatise, “Plutarch had more than a casual interest in medicine,” and references to medicine and health appear in abundance throughout his works.64 Medicine and Literary Culture These writers—Galen, Celsus, Scribonius, Soranus, Pliny, as well as Gellius and Plutarch—are the main sources for Roman medical culture in the second century, and they have in common at least two things. Firstly, whether Greek or Roman, these men were from, or were strongly connected by their professional careers to, the highest echelons of Roman society. This is hardly surprising: it is the educated who write and read books, and in the ancient world the leisure to read and write was one of the consequences of class. It is more significant, however, that these were, with one possible exception, all free men.65 Greek medical theories and practices had come to Rome during the late Republic, mostly through Greek slaves, and even in the age of Galen the majority of physicians in Rome were Greeks, a great number of whom were slaves or freedmen who had been specifically trained for the profession by their masters through apprenticeships in the slave or military valetudinaria (literally, “places for gaining strength,” more like convalescent wards than in any sense equivalent to modem hospitals).66 The pursuit of medicine as a career by free and educated men such as Galen and Soranus was not particularly remarkable in the 64 Babbitt 1928: 214. Corvisier 2001: 138, noting that Plutarch’s medical knowledge was “étendues etjuste,” contends that his De tuenda sanitate praecepta was an original and thoughtful synthesis of philosophic and medical texts. See also Boulogne 1996. Durling 1995 offers a detailed list of Plutarch’s medical references, albeit with no accompanying analysis. 65 As noted above, it has been suggested by some scholars that Scribonius may have been a freedman, but that suggestion is rather tenuous and difficult to substantiate. Although little is known concerning the biographical details of Celsus, it is certain that he was neither a slave nor a freedman. 66 Forbes 1955: 343—353. Rawson 1985: 85. Nutton 1986: 37—38. See Korpela 1987 for an examination of the medical personnel in Rome over the centuries. Hospitals in any sense approaching the modem conception of the word do not appear in the Graeco-Roman world until late antiquity; see Gask and Todd 1975. 29 Greek world, where medicine had long been and remained an honourable profession, one which could attract members of the elite as well as those who were of lower social status.67 The generally disparaging attitude which the Roman aristocracy traditionally displayed towards the profession of medicus, however, is attested early on by Cicero, for example, who asserted that professions which were socially useful or which involved a higher degree of learning, such as medicine and architecture, could be undertaken honourably by Roman citizens—but only by those suited to it by their lower social class.68 Pliny, who repeated an infamous diatribe against physicians by Cato the Elder, in which he labelled them murderers sworn to kill all foreigners with their arts, was himself suspicious of physicians, whom he characterized as being in the profession for reasons of greed rather than philanthropy.69 These are more extreme and oft-cited examples of the contempt which the profession could arouse in Roman culture; they must be tempered with Cicero’s gratitude to physicians who treated him and his familia, as well as Pliny’s frequent use of the works of many of the same Greek physicians whom he attacked.7°That there was an apparent distaste or at least an 67 This held true in the Greek world despite Galen’s rhetorical protestations in Opt. med. = CGM (SO 4)1. 3 —.4 that the status of the physician had declined to the point of making it worthy only of slaves and despicable men. Pleket 1995: 27 —34 points out that the majority of Greek physicians were not from the elite classes but still enjoyed social esteem. See also Nutton 1995: 10— 13 on social status of physicians, and Nutton 2004: 248 — 271 on the range of Greek and Roman men and women who became iatroi and medici. 68 Cicero, Off 1. 42. 151. Quibus autem artibus autprudentia major inest aut non mediocris utilitas quaeritur Ut medicina, ut architectura, ut doctrina rerum honestarum, eae sunt us, quorum ordjni conveniunt, honestae. (But the professions in which either a higher degree of intelligence is required or from which no small benefit to society is derived — medicine and architecture, for example, and teaching — these are proper for those whose social position they become.) Forbes 1955: 343 —345 points to the contrast between the reverence in which the Greeks held physicians and the disdain and mistrust which the Romans generally gave to the profession. Nutton 2004: 166 surmises that Celsus’ apparent unwillingness to self-identify as a medicus owed much to the incompatibility with his status as a Roman gentleman. 69 Pliny, NH 29. 1. 1.— 8. 28. Cato’s attack is reproduced at NH29. 7. 14. 70Cicero,Att. 15.1.1.; 15. 2. 4.; Pliny, NHpassim. 30 ambiguity of feeling on the part of the Roman elite for the profession of medicus, particularly a Greek-speaking medicus, is unquestionable, however.7’ This disapproval did not necessarily extend to the subject of medicine itself, however, as Pliny made clear.72 Elizabeth Rawson points to the intellectual excitement which one of the earliest Greek physicians to spend time in Rome, Asciepiades of Bithynia, brought to the city upon his arrival there sometime in the late second century BC, but medicine had already been found to be a fit topic for Cato, who included it in his handbook on agriculture and farm management, De agricultura (On Agriculture).73 He interspersed a list of remedies for common illnesses amongst other aspects of farm life; some employed incantations, but most of these remedies were simple herb and wine mixtures. Cato also enthusiastically and notoriously prescribed cabbage (or in its place, the warmed urine of a habitual cabbage-eater) as both a wholesome and salubrious food and a panacea for a wide range of illnesses.74 In the following century Marcus Terentius Varro produced a similar work on agriculture, Rerum rusticarum (Agricultural Topics), which offered rather fewer medical remedies for the reader and markedly favoured an analytical approach toward the treatment of illness in both humans and livestock, taking pains to stress the importance of observation and recording of causes, symptoms and treatments.75 Varro was noticeably more influenced by Greek medical theories than Cato was; he must have read Hippocratic works such as De aere aquis locis (On 71 Nijhuis 1995: 49—67 employs the explanatory models of medical anthropology to argue that the Roman distrust for the Greek medical profession owed as much to a cultural difference in beliefs concerning the functioning of the human body and the clash of conflicting medical systems as it did to Roman ideals and politics. 72 Pliny, NH 29. 8. 16: Non rem antiqui damnabant, sed artem . . . (It was not medicine that our forefathers condemned, but the medical profession...) Rawson 1991: 427—443 discusses the problem of Asclepiades’ chronology and argues that he must have died by at least 91 BC. The impact of Asciepiades on Roman cultural and intellectual life is assessed in Rawson 1985: 170—178. 74Cato,Agr. 70—73,102—103,122—123,125—127,141,156—160. Jones l957offersanoverviewof Roman folk medicine as found in Cato, Varro and Pliny, albeit one which is riddled with modern cultural bias. 75Varro,Rust.2. 1.22—23,2.10.10. 31 Airs, Waters, and Places) or texts similar in content, which stressed the importance of geographic conditions such as climate, soil, winds, and local topography in matters of health.76 Moreover, despite Cato’ s attack on physicians, he too displayed a considerable knowledge of contemporary Greek medical theory, but he was as cautious and conservative in matters of health as he was in other facets of life.77 He merely preferred to opt for an orthodox, homegrown and inexpensive response to disease and illness, and in this Varro was not necessarily at odds with the elder writer. He duly followed Cato in placing the traditional virtues, including the maintenance of health, which were associated with Roman country life on a higher plane than the increasingly-Hellenized urban culture: Quod dum servaverunt institutum, utrumque sum’ consecuti, Ut et cultura agros fecundissimos haberent et ipsi valetudinefirmiores essent, ac ne Graecorum urbana desiderarent gymnasia. So long as [the Romans] kept up this practice [of living in the countryside seven days of the eight-day week] they attained both objects—keeping their lands most productive by cultivation, and themselves enjoying better health and not requiring the citified gymnasia of the Greeks.78 Varro, however, displayed much greater interest in the topic of medicine than the few snippets found in Rerum rusticarum would indicate: one section of Disciplinae, his lost work on the artes liberales, was entirely devoted to the subject.79 The interest in medicine on the part of Latin writers in the early empire, therefore, is not particularly remarkable, but the question arises as to how those Greek and Latin writers 76 Varro, Rust. 1. 4. 4—5, 1. 12. 1 —3, 2. 1. 22— 23. See Lehmann 1982 on Varro’s aetiological theories. Cato, Agr. 70—73, 101 — 104, cf. Pliny, NH29. 8. 16. Capitani 1972: 120 makes the interesting point that for the Greeks and Romans the ideas about what was “popular” medicine and what was “scientific” medicine is the reverse of today. For us, herbs and natural products would fall under the designation of “popular,” while pharmaceuticals would be “scientific;” for them, herbs and natural products would have been considered “scientific,” and the recourse to pharmaceuticals frequently considered with the sort of suspicion which most modem physicians reserve for herbs and other folk medicines. 78 Varro, Rust. 2. 1.2. Gellius, for example, cites Varro as a source in his discussion on the normal period of human gestation and on breech births at NA 3. 16, 16. 16. See Shanzer 2005: 75 — 103 for an attempt at reconstruction of Varro’s disciplinae. 32 who were not educated as physicians assumed such authority to discuss medical matters. Half of the medical sources cited above—Pliny, Gellius, Plutarch and perhaps even Celsus—were neither formally trained nor practising physicians.8°In which case, how did men who neither trained nor worked as physicians gain such an extensive knowledge of medicine? It is necessary to preface the answer to that question with a brief look at how those writers who were undoubtedly medici gained their professional training.8’ The evidence on medical training from our sources is rather sketchy; the most detailed information comes from Galen, who began his general education in Pergamum under the guidance of his father, who had first set him to the study of philosophy.82 After two years of philosophical inquiry the study of medicine was added to his education, and this move was precipitated by dreams in which the Greek god of healing, Asciepius, advised Galen’ s father that his son should receive training in the healing arts83 Galen studied medicine at a school at Pergamum, and he later travelled to Smyrna and Alexandria for further medical training.84 Soranus likewise almost certainly studied medicine in Alexandria as well as at his native Ephesus.85 Pergamum, Alexandria, Ephesus and Smyrna were only four of the long-established schools of medicine to be found in the Greek part of the Roman empire.86 These “schools” were not formal institutions but rather centres of learning—Nutton refers to them as “loose groups of practitioners associated with particular 80 Medical writers who were not physicians were not limited to Rome; the third-century North African medical writer Gargilius Martialis, mentioned above, was not a physician by profession but a soldier and farmer. See Riddle 1984: 410—411. 81 Drabkin 1944 and Kudlien 1970 together provide a comprehensive discussion of medical education in the Graeco-Roman world. 82 Galen, Cognosc. = K. 5. 41 —42. Galen, Libr. ord. = K. 19. 59, Praecog. = K. 14. 608. In addition to having divine sanction for his career, Galen was also apparently endowed with the required tottov &y’tvouv to j.ux icth j.tvitovn icai (ptoirovov (sharp intellect, good memory and desire for hard work) for the combination of philosophic and medical studies.84 Galen, Nat. fac. = K. 2. 128, Simp. med. K. 12. 177, Nat. man. comm. K. 15. 136. 85Nutton2004: 195. 86 Others were located at Cos, Cnidos, Corinth, Elea and Tarsus (the latter being in particular a centre for pharmacological studies). See Drabkin 1944: 342 and Nutton 1995: 17 n. 80. 33 theories, teachers, and places”— which had achieved an unofficial yet nonetheless powerful status in the ancient world.87 Witness, for example, the fourth-century historian Ammianus Marcellinus on the ascendancy in particular of the school at Alexandria, one which was maintained from the time of its establishment in the Hellenistic era to late antiquity: Medicinae autem, cuius in hac vita nostra nec parca nec sobria desiderantur adminicula crebra, ita studia augentur in dies ut, licet opus ipsum redoleat, pro omni tamen experimento sufficiat medico ad commendandam artis auctoritatem, si Alexandriae se dixerit eruditum. Moreover, studies in the art of healing, whose help is often required in this life of ours, which is neither frugal nor sober, are so enriched from day to day, that although a physician’s work itself indicates it, yet in place of every testimony it is enough to commend his knowledge of the art, if he has said that he was trained at Alexandria.88 Nutton posits that most of the training of iatroi in the Greek East occurred in small locally-known schools set up by individual doctors rather than in the larger centres.89 There were no comparably large or renowned schools of medicine in the Latin west; there were instead less prestigious schools which were more modest in size. Our Latin sources are vague, at best, about medical training. Celsus, as mentioned above, neither named teachers nor referred to any formal education. Scribonius, however, referred to several praeceptores—a certain Valens, a Trypho, and an Apuleius Celsus, the latter of whom, if he is correctly identified, may have run a small school in Sicily—but there is no way to establish definitively where or the circumstances under which Scribonius studied.9° In reality, however, most physicians, Greek or Roman, probably did not attend any medical institution (if it is even proper to apply this name). The majority of training would have occurred on an apprenticeship basis, in which students learned the necessary skills through practical 87Nutton 1995: 19. 88 Ammianus, 22. 18. Alexandria was noted for training in anatomy and surgery. 89Nutton 1995: 20—22 ° Scribonius, Comp., XCI (Index), 94, 171, 175. There was a physician in Centuripae in Sicily by the name of Apuleius Celsus, which has led to speculation that Scribonius studied there. See also Langslow 2000: 50 — 51. 34 experience gained by following a physician on his rounds, with supplementary education from lectures and textbooks.9’The poet Martial has left an amusing illustration of this practice: he jested about the frigid hands of the hundred students who had accompanied his own doctor on a housecall and had, to his discomfort, taken turns at examining the patient under care.92 There was no prescribed education for physicians in the Graeco-Roman world: no licensing, no regulation and very limited government control.93 There was some attempt at establishing professional standards in the early Empire; guild-like associations of physicians began to spring up around the Roman world as early as the first century, including in Rome itself, and most Greek iatroi and Roman medici actively sought to distinguish themselves from other healers, such as magicians, iatrosophists (who employed astrology for medical diagnosis and prognosis), folk healers, root cutters and herbalists.94 But success in regulating the profession, including formalizing educational requirements for physicians, could only ever be limited. Physicians did not hold exclusive status in the sphere of medicine but rather were part of a multi-faceted system of healing which Nutton has so aptly coined “the medical market place.”95 They had to compete for patients not only with one another but with the other varieties of healers as well, although Nutton contends that there was much more Drabkin 1944: 336. The propaedeutic requirements for medical students in the Roman empire will be addressed below. 92 Martial, 5. 9: Languebam: sed tu comitatus protinus ad me / venisti centum, Symmache, discipulis. / Centum me tetigere manus aquilone gelatae: / non habuifebrem, Symmache, nunc habeo. (I was feeling unwell, but you, when you promptly came to see me, were accompanied by a hundred students. A hundred hands chilled by the north wind touched me: I had no fever then, Symmachus, but I do now.) Trans. mine. Compare Hippocrates, De lege 1: itpóGttl.tov ydp ‘uitpucfic iovric v tfja itOernv ol6v thpatcti, it2v ào11c... ([Medicine] is the only science for which states have laid no penalties for malpractice. Ill-repute is the only punishment. . .). There is evidence of some governmental oversight under the empire, however, in reference to the qualifications of public physicians for tax immunities. Nutton 1971: 52 — 63 discusses some of the evidence for these immunities. Nutton 1985: 29 — 30 makes the point that the legal definition of a physician found in these immunities was for tax purposes only and was in no way concerned with verifying a physician’s expertise. 94Nutton 1995: 4 — 5 and 2004: 250. Kudlien 1970: 9. 95Nutton 1992: 15—58. 35 interaction among physicians and between various types of healers than previously believed.96 Even if one excludes the latter from the picture, however, the diversity of therapeutic approaches which a physician could employ defeated the possibility of creating a single standard of medical care or medical education.97 Scribonius effectively, if somewhat gloomily, summed up the situation: Ubi enim delectus non estpersonarum, sed eodem numero malus bonusque habetur, disciplinae ac sectae observatio pent, quodque sine labore potest contingere idemque dignitatis utilitatisque praestare videtur posse, unus quisque id magis sequitur. sic Ut quisque volet, faciet medicinam. quosdam enim a perverso proposito nemo potest movere et sane omnibus permisit liberum arbitrium magnitudoprofessionis. multos itaque animadvertimus uniuspartis sanandi scientia medici plenum nomen consecutos. For where there is no discrimination regarding people, but good and bad are held in equal esteem—regard for the discipline and the school perishes—one and all pursue whatever it is possible to attain without labor and which seems to be able to furnish the same amount of dignity and benefit to them. Thus each will practice medicine as he sees fit. No one is able to dissuade certain people from a perverse way of life, and indeed, the freedom to decide has been granted to all by the vastness of the medical profession. Therefore we recognize many followers of one aspect of the healing sciences by the full name of Physician.98 Although Scribonius clung to the notion of a profession as he saw it envisioned in the Hippocratic texts, particularily the Oath, his own words attest to the fluidity of the designation, one which is quite alien to modern perceptions of the medical “profession.”99 Essentially anyone in the Roman empire, man or woman, who wished to be considered a healer of any sort—herbalist, iatrosophist, or even physician—was able to assume the title; 96NUUOn 1995: 3 —25. Compare for example Galen, Anat. K. 2. 632 —633, in which he related that the condition of a youth struck in the chest in the gym was discussed by n2E’tovzç &Opo’toxç ‘tatpoiç, v o’tç liv ic4’yd (a great number of physicians, among whom I was also included). Trans. mine. The various medical sects of the Roman empire will be discussed below. 98 Scribonius, Comp. pref. 10. Scribonius, Comp. pref. 5: Animadvertimus. .. quosdam humiles quidem et alioquin ignotos, usu vero peritiores, vet (quodfateri pudet) longe summotos a disciplina medicinae ac ne adfines quidem eius professioni (I have noticed certain humble, and indeed otherwise unknown men. These men are clearly greatly skilled in terms of experience [in healing with drugs], although—which causes shame to admit—far removed from the discipline of medicine and not associated with that profession.) 36 the sole requirement for doing so was simply the establishment of a reputation sufficient to draw clients. In the case of physicians, one was a medicus if one behaved like and had success in the role of a medicus, regardless of the presence or absence of formal qualifications.’00 (Therein lies part of the difficulty of establishing to modern satisfaction whether or not Celsus merits the designation “physician,” as he appears to meet some standards—a range and depth of medical knowledge, attendance at the bedside of patients—but not others, such as identification of professional training or even self- identification as a medicus).’°’ While Galen devoted a treatise, De optimo medico cognoscendo (On Examinations by which the Best Physicians are Recognized), to establishing principles by which one might recognize a truly qualified medicus, his audience would have been restricted to the wealthy elite who had the time and ability to interview potential healers. While it is impossible to prove or disprove that Celsus was given formal training as a physician, either through attendance at a centre of medical learning or by means of an apprenticeship, neither model of medical education can be applied to the situation of men such as Pliny, Gellius or Plutarch. We are sufficiently secure in the biographies of these men ‘°° Pliny lamented that “the medical profession is the only one in which anybody professing to be a physician is at once trusted, although nowhere else is an untruth more dangerous” (in hac artium sola evenit Ut cuicumque medium se professo statim credatur, cum sit periculum in nullo mendacio maius). NH 29. 8. 17. See also NH 29. 5. 9. See Nutton 1985: 26 —31. Kudlien 1970: 8 —9, 17 - 18 makes the point that in classical Greece the requirements were somewhat more rigid than they were in Rome and under the Roman empire. The Greeks did not permit their slaves to be physicians, and women were limited to midwifery duties. The Romans, who largely considered medicine to be more a craft than a science or an art, were content to allow virtually anyone to practice it. jOl Scholarly preoccupation with his exact standing seems moot, however, not only because the line between a “professional” and a “non-professional” healer was vague in antiquity but also because it would have been inconsequential to society as a whole. The majority of the inhabitants of the Roman empire were poor or rural or both; medical knowledge and expertise were sought after and valued no matter the source. Reference to the reliance on intinerant physicians in the countryside can be found in both Dio Chrysostom, Or. 9. 4 and Galen, Cognosc. = K. 5. 18, Puer. epil. = K. 11. 357. See also Nutton 1986: 44—45. Compare the experience of Freya Stark on her travels in the remote parts of Iran in the 1 930s; she was frequently called upon for medical advice and assistance by the tribal inhabitants she encountered. See Stark 2001: 74 — 75. 37 to know that they did not attend a medical school nor did they undertake an apprenticeship of following a doctor about on his rounds. Their knowledge of medicine was essentially a literary one; it arose from their own diverse, even polymathic, interests and pursuits, and these men were not unique in this regard in the Roman world. A wide-range of intellectual interests among the educated class was a hallmark of the age, what one scholar describes as an “enormous contemporary curiosity, an appetite for knowledge, not very discriminatory, but very real,” combined with a strong sense of entitlement both to read about and to write on any subject which absorbed them, including medical texts and commentaries.102 It is not coincidence that, aside from Scribonius, who appears to have written only medical or pharmaceutical works, none of the extant medical writers for this period restricted himself to medical topics. The bibliographies provided above for these writers, both medical and non- medical, attest to the wide range of their interests in addition to medicine, from philology and jurisprudence to philosophy and agriculture.’03 The figurehead of polymathic learning in the Roman world was Varro, who lived in a time when the concept of an “amateur” in an intellectual or a practical field of knowledge did not necessarily carry the connotations of either dilettantism or bungling ineptitude which modern thought tends to apply to it. The ancient sources agree that Varro wrote knowledgeably about virtually the entire gamut of contemporary Roman scholarship, from linguistics and agriculture (the subjects of his two surviving works) to religion, literary history, geography, rhetoric and beyond. He was a “towering figure,” according to Gellius, “in encyclopaedic learning and in the varied sciences by which humanity is ennobled” 102 Reynolds 1986:7. See also Drabkin 1944: 342—345 and BaIler 1991. 103 This range of interests on the part of educated men in the Graeco-Roman world is yet another aspect of the difficulty of determining whether or not Celsus was a physician. That De medicina was part of a larger encyclopaedic work is insufficient grounds alone for refusing him the designation. 38 (doctrinarum autem multiformium variarumque artium quibus humanitas erudita est columina )• 104 Of particular interest is the lost Disciplinae, which was divided into nine books, each devoted to a different branch of the liberales artes: grammar, rhetoric, dialectic, arithmetic, geometry, astronomy, music, architecture and medicine. Disciplinae was well- known in the ancient world, and modem scholars consider it to be the primary model for Celsus’ Artes, although that single attribution in fact fails to give full due to the wealth of similar publications in the Graeco-Roman 05 The Disciplinae serves as a useful paradigm for this particular genre of ancient literature as well as for the polymathic style of learning which lay behind it. The Greek educational system of enkuklios paideia, which is often translated into English as “the common education,” had been borrowed by the Romans during the Hellenistic period.’06 Historians of ancient education have noted the difficulty in translating the term with any exactitude.’°7 While many Roman writers, such as Seneca and Gellius, found a fairly easy equation between the Greek term and the Latin liberales (or bonae) artes (or studia), others obviously struggled to find a translation which would do justice to both words of the Greek: Cicero chose the somewhat awkward omnis doctrina harum ingenuarum et humanarum artium, Quintilian rendered it as orbis ille doctrinae, while in late antiquity 104 Gellius, NA 19. 14. 1. Modem estimates of Varro’s corpus attribute over six hundred works to him, of which only fifty-five titles have survived and only two works are extant. Cassiodorus at Institutiones 2. 6. 1 praised Varro as peritissimus Latinorum (the most skilled of Latin writers in practical wisdom). Pliny cited him as an authority in all but five of his 37 books. 105 Langslow 2000: 45. See Stahl 1962: 11 — 12 on the origin of the genre in the Greek technical and philosophical handbooks which first appeared in the fourth century BC and came to full maturity in the Hellenistic age. When Roman intellectuals of the late Republic came into contact with their Greek counterparts they readily translated Greek handbooks, miscellanies and compendia into Latin but also borrowed the genre to produce their own Latin versions. The first century, as it happened, saw the peak of production of didactic handbooks as well as of miscellanies and compendia in both languages; the popularity and production of the genre continued right into late antiquity, and it covered an immense variety of disciplines: history, rhetoric and grammar, natural history, legal and political matters, science, technology, medicine, and philosophy. ‘° See Marrou 1964: 242 - 254 on the modelling of the Roman educational system on that of Greece. 107 Rijk 1965 attempts to define the original meaning of the phrase in Greek culture. 39 Martianus Capella employed disciplinae cyclicae.’°8 Henri Marrou observes that the term seemed to have been both general in nature, indicating the standard steps in a gentleman’s education, as well as specific, standing for the propaedeutic set of studies which prepared “secondary” students for higher levels of learning, in particular in the seven liberal arts which eventually made up the mediaeval trivium and quadrivium—grammar, dialectic, rhetoric, geometry, arithmetic, astronomy, music—all of which appear in Varro’ s list of 09 Restricting the sense of enkuklios paideia to the curriculum of the Graeco-Roman classroom, however, is arguably to apply too narrow a definition.”0 As Jaeger remarks in a prefatory statement to his three-volume study of Greek paideia, the term was more encompassing than that: It is impossible to avoid bringing in modern expressions like civilization, culture, tradition, literature, or education. But none of them really covers what the Greeks meant by paideia. Each of them is confined to one aspect of it... While Marrou does admit that enkukilos paideia could be “taken in the perfective aspect of the word ‘culture,” so as to embrace other disciplines, such as philosophy, military arts, law, drawing, as well as architecture and medicine (the two disciplines which complete Varro’s list), it is Jaeger who notes the profoundly literary aspect of enkuklios paideia: 108 Seneca, Ep. 62. 1, 88.2; Gellius, NA 13. 17; Cicero, De or. 3. 6.21; Quintilian Inst. 1. 10. 1; Martianus, 9. 998. Gellius emphasized what Robert Kaster interprets as the peculiarly Roman equation of humanitas with paideia: men such as Cicero and Varro, Gellius stated, defmed humanitas not as something akin to the Greek pt)avOpwn’tct (philanthropy) but rather to paideia, or what nos eruditionem institutionemque in bonas artes dicimus (we call education and instruction in good skills). Kaster 1986: 5 — 10. See Morgan 1998: 35 —36 for other examples of Latin translations of the term. 109 Marrou 1964: 177. The degree to which these steps, particularly the oft-mentioned division of study into three definite stages, was formalized in the Roman world is frequently debated. The field of studies for students appears to have been surprisingly narrow: grammar, literature, a bit of history, basic arithmetic and geometry, and rhetoric comprised the standard curriculum. See Marrou 1964: 265—291; Russell 1989. Cribiore 2001: 247, however, notes the paedagogical value in the restricted and canonical curriculum of the educational system of Hellenistic and Roman Egypt. 110 In the Roman world, Seneca particularly resisted this restriction. For him, the end purpose of all liberalia studia was a virtue which was to be found beyond the classroom walls. See Ep. 88. Jaeger 1943: (vol. 1) v. 40 The ancients were persuaded that education and culture are not a formal art or an abstract theory, distinct from the objective historical structure of a nation’s spiritual life. They held them to be embodied in literature, which is the real expression of all higher culture.”2 Jaeger’s emphasis upon the specifically literary aspect of enklukios paideia extends to the field of medicine: in the Greek world, the culture of medicine was not limited to clinical practice, and the fact that it spawned a substantial literature which found a widespread audience beyond physicians brings it into the fold.”3 Jaeger indeed devotes an entire chapter of his study to Greek medical literature as paideia.”4 The acquisition of medical knowledge, on both a superficial and a more thorough level, through literature and literary life (which included public readings, lectures and debates) was common practice.”5 In the perpetual Graeco-Roman debate as to whether medicine ought to be considered a craft, which had to be learned by practical experience, or a science, which required the study of natural history and biology, Aristotle had noted early on that there were in fact three types of physicians: the craftsman (b rnoopyOç), the scientist (b pxtt8KtovlKóc), and the educated man who had studied the art (6 7tatö6uiIvoc itpt tiv txviiv), and while he elsewhere argued that one could not become a practising physician solely through books, he also was of the firm conviction that the educated man’s opinion on medicine had to be given weight in any debate on the subject.”6 The final lines of the Hippocratic Law, in which the writer characterized medicine as a holy art which is revealed 112 Jaeger 1943: (vol. 1) v. Cf. Anderson 1993: 8: “[Paideia] presupposes someone who has read the approved canon of texts and absorbed from them the values of Hellenism and urban-dwelling man alike. . 113 Jaeger 1944: (vol. 3) 4 notes that medicine’s partner in health maintenance, Greek gymnastics, did not produce a literature. “ Jaeger 1944: (vol.3)3—45. 115 Jocelyn 1985: 304 argues in fact that Celsus’ De medicina is entirely an intellectual exercise and not meant to function as a practical handbook. 116 Aristotle, Pal. 1282a3. Compare Eth. Nic. 118 lb. 2: ob 7dp qxt’tvovtat ob’ ‘tntpuco’t K t3V ouflpnJ4Látwv y’tveoOn (We do not see men becoming expert physicians from a study of medical textbooks). See Temkin 1953 on the debate. 41 only to the initiated, were in fact belied, Jaeger points out, by the daily reality of Greek intellectual life: medical knowledge was as much a part of the culture of the educated man as other bodies of knowledge.”7 The modern, western tendency to isolate medicine from the general culture would have been out of place in the ancient world; medicine in Greece was not, as it is for even the well-educated of today, a body of esoteric knowledge, largely opaque, inaccessible and privileged. Athenaeus of Attaleia, a noted Greek physician of the mid-first century, advocated the inclusion of medicine “together with other subjects of learning” (öj.tz to’iç áiotç Otctrn) as useful and necessary for both intellectual stimulation and physical health.”8 Medicine formed an integral part of the Greek enkukilos paideia, one half of the education of both body and soul. In the ancient world, as Rawson rightly notes, “the place of medicine among the liberal arts was not unquestioned,” but for many writers of the first and second centuries of the Roman empire its inclusion among Varro’s Discipiinae and Celsus’ Artes would have felt natural.”9 In giving such a prominent place to medicine in the Naturalis historia Pliny revealed his own bias: “Deserving of treatment before all things are the subjects included by the Greeks under the name of ‘Encyclic Culture’ (Ante omnia attingenda quae Graeci tfjç y1cuKXiOD tcLl6icLç vocant),” he wrote in his preface to the work.’2° Plutarch attested to a ‘ Jaeger 1944: (vol. 3)11 — 12. Hippocrates, De lege 5: Td E ‘tepd Ovta pywt epotow &vOpthitotGt 6cticvutav f3f3fXotat ob Ojitç, ltp’tv f t EcJ0óatv bp’yotatv 1ttat1’.u1c (Holy things are revealed only to holy men. Such things must not be made known to the profane until they are initiated into the mysteries of science.) 118 xp4Yti.iov , <f’> 1.ta2ov &vwyicthov, irEunv ivOpthitotç &itO tw5trç I1?11c’tac â.ta tdIç áotç I.LO1Lacst ooap2cL.tf3dv6tV KCL’t t1’V ‘tatp1ic1V icth KtGKO)EIV toy tw3tiic ó’yov, ivx icci)o’t iced rya0o’t ai5.tf3o&ot ‘yvftvtcfl 7co2dKtç cutc tv ‘tç trplav plat.Lov. (It is advantageous, or rather necessary, for all men from the time of youth to study medicine alongside their other studies and to give ear to its principle, so that they might frequently become good counsellors for themselves about things useful for keeping well.) Athenaeus, On the Regimefor Health, cited in Oribasius, CMG VI 4. 139. 19 —22. Trans. mine. 119 Rawson 1985: 170. 120 Pliny, NHpref. 14. 42 similar sentiment; a knowledge of medicine, he asserted, was an essential facet of a gentleman’s education: tciv EoOEpkov 6è tsXvcov ‘tcLtpua tO tv y)cupupOv KcIA ltEptttOv iccd irttpirç Oi6Eflaç vöatEpov O&opucOv ±yc toIç qn?otctOoat tiv ocotIlpicLv lCcLt t1V by’tEUXV iirt6’t&ootv. And of the liberal arts medicine is inferior to none in elegance, distinction, and the satisfaction which it yields, and it gives to its students admission to something of very great importance—the preservation of their life and health.’2’ Galen urged the youth of his day to pursue higher studies in any of the socially-beneficial arts, and while he did not privilege medicine above all other arts, not surprisingly he included it among the arts which are closest to the divine: geometers, mathematicians, philosophers, grammarians, astronomers and physicians held the first tier, followed in ranking by painters, sculptors, grammar school teachers, carpenters, and architects, while the remaining unspecified arts made up the third order.’22 That medicine was an art which could be approached as either a vocation or simply as an area of intellectual interest for the literate and cultivated man is evident in another passage, this time in De praecognitione. Galen related that one of his first patients at Rome, Eudemus, the Peripatetic philosopher, had initially believed that Galen was primarily a philosopher by profession and that he only “dabbled in medicine as a sideline” (tóv 6è iccttd tiv ‘wtptiav v irctppyq tappovtticvcn). Galen advised him that the dreams which had instructed Galen’s father to educate him in medicine 121 Plutarch, Mor. 122E. Plutarch states further that philosophers “ci j.u iuvtáiuotv &ve)ovtcç oovtcn &.iv toç Opooç thoitcp iv tt xthp icotvç c 13.oica v, 64.tcr tO & t 2.óycp Kth tO &vx’yicaiov &thKovtaç ([ought to] be blamed if they do not consider it their duty to abolish all boundary-lines altogether, and to make a single field, as it were, of all honourable studies, and therein to cultivate them in common, thus aiming in their discussion at both the pleasant and the essential).” 122 Galen, Protr. = K. 1. 7, where his definition of the socially-beneficial arts were those which made one worthy of one’s family or made one’s family worthy. His ranking of physicians must not be taken as being indicative of the social status of all physicians in the Roman empire; many Romans considered them to be on the same level as craftsmen such as weavers and cobblers. See Nutton 1995: 11. 43 had made it clear that the pursuit of medicine was to be his profession and not a mere hobby. 123 If Celsus was indeed one of the educated “dabblers” in medicine in the Roman world (as most scholars now believe) rather than a trained physician, he clearly had in mind and in fact an audience of educated men for whom he could confidently assume both a certain magnitude of medical knowledge and an interest in medicine as one of the liberales artes. A minimal level of medical literacy on the part of men who had received an education in the liberales artes, failing a more profound knowledge of human physiology and medicine, was advocated by Gellius, and Soranus clearly demanded a degree of medical literacy even from ordinary midwives: a potential midwife had to be literate, he insisted, in order to understand medical theory as well as practice.’24 According to Suetonius, both medicine and mathematics were included in Vergil’s studies as a youth.’25 That a reasonably high standard of medical literacy did in fact form part of Graeco-Roman literary culture is evident, moreover, in the ease with which men of Plutarch’s or Gellius’ class and education could and did discuss medical issues, including human anatomy and physiology: the dinner guests at Plutarch’s Symposium, physician and non-physician alike, deliberated confidently and knowledgeably over a range of medical questions, such as the likelihood and possible aetiology of new diseases, the humoural components of female physiology, or the processes of digestion, while Gellius used his compilation to muse over issues such as the exact difference between disease and defect, the normal range of human gestation (in which he 123 Galen, Praecog. = K. 14. 608. 124 Gellius, NA 18. 10. 8: existimavi non medico soli, sed omnibus quoque hominibus liberis liberaliterque institutis, turpe esse ne ea quidem cognovisse ad notitiam corporis nostri pertinentia, quae non altius occultiusque rem ota sunt et quae natura nobis tuendae valitudinis causa et in promptu esse et in propatulo voluerit. . . (1 thought it was shameful, not only for a physician, but for all cultivated and liberally educated men, not to know even such facts pertaining to the knowledge of our bodies as are not deep and recondite, but which nature, for the purpose of maintaining our health, has allowed to be evident and obvious.) 125 Suetonius, Vita Vergil 15. 44 cited authorities ranging from Hippocrates and his Latin commentator Sabinus to the playwrights Plautus and Menander), or the opinion of the philosopher Favorinus on breastfeeding.’26 Plutarch, Gellius, Pliny, and Galen in particular leave testimony as well to the highly social atmosphere of the ancient sickroom, in which doctors debated various diagnoses and therapies with each other, while friends came to comfort the patient as well as to engage both him and the attending physicians in learned discussions on the proper course of treatment to be followed.’27 Medical knowledge as part of enkuklios paideia was not restricted to intellectual interest and pleasure. There was a practical purpose to being able to maintain your health and to treat your own minor ailments, as well as to being able to converse knowledgeably about the human body and the healing arts with trained physicians or other healers. Athenaeus of Attaleia contended that the necessity for medical knowledge was continuous and that “referring to doctors always for advice about everything is wearying and impossible” (to 6’&et KCL1 ltEpl távtov ‘wtpo9.ç 7rpoactvctqptv icot Eç KILL &8vatov).’28 Plutarch was quite specific about the need to have an intimate knowledge of one’s own body: 126 Plutarch, Mor. 73 1A — 734C; 650F —651 E; 660D — 664A. Gellius, NA 4.2; 3. 16; 12. 1. 127 Plutarch, Mor. 129D — E. Gellius, NA 12. 5, 16. 3, 18. 10, 19. 10. Pliny, NH 29. 5. 11. Galen, Praecog. = K. 14. 601 —673 passim; Hipp. artic. comm. = K. 18A. 348; Meth. med. = K. 10. 909—911; Ven. sect. = K. 11. 187— 190; Opt. med. = CMG SO IV 3. 14— 17, 4. 2. These same scenarios were likely played out in the sickrooms of the less wealthy members of society as well: family members, friends, local healers of all varieties would have clustered around the ill in an attempt to provide comfort and suggestions for healing. 128 ‘yap ob&ç KutpOc ttv otr vuictôç ot)te f.tpaç, v pskzv obSq.LkLv xoi.wv tfic tvrlc, &id KcLI iv it6ptitãtq) Klil ‘LV icaOp KXt E’tl.tlMXtt KcCI .Ootpq) ico.i. I3pthcYEi. vat itócjsi. KCL’t tvq) vol ‘Ls’yport KcLt itáar tpá8t, &‘ O2ou to? l3too vat &‘ &itáallc ti’ic Ccañc, xPc’tctv o1ev a4tI3oukAac itpOç tiv &l3a3fi vat oo.uppouaav xpnv abtiç to S’Oct vol itept itávtov ‘atpdiç irpooavwpptv KOltWöEç vat ?ivatov. (For there is almost no occasion, either at night or in the day, in which we have no need of the science, but even in walking and sitting and in anointing ourselves and in the bath and in eating and drinking and in sleeping and getting up and in all actions, though the whole of life and every part of living, we have a need of the good counsel of medicine for a harmless and beneficial life, and referring to physicians always for advice about everything is wearying and impossible.) Athenaeus, On the Regimefor Health, cited in Oribasius, CMG VI 4. 139. 23 -29. Trans. mine. 45 KEtVO ‘ L11OE tvat, tO &‘Iv icxotov cLbtoo fltE pwyiióv ‘totótritoc ivctt áittpov (iuo2cti yap th icct9’ icctotov twpopth) ip&cnv &yvoEiv f1v Xet tO cójia OEpliótntoc iccLi pót1toç, n9’ o’iç dxpE?EtGOcLt pthjievov i f3?átsaOcn npuicv. But this does seem to be true, that each person ought neither to be unacquainted with the pecularities of his own pulse (for there are many individual diversities), nor ignorant of any idiosyncracy which his body has in regard to temperature and dryness, and what things in actual practice have proved to be beneficial or detrimental to it.’29 The need to choose wisely in selecting medical advice was urged by both Scribonius and Galen. The plethora of medical options combined with the lack of regulation in the “medical marketplace” required one to make informed decisions about to whom to entrust oneself and one’s family. Scribonius bemoaned the fact that so many men of his day gave more thought and consideration to the hiring of a workman than they did to that of a physician: raro enim aliquis, priusquam se suosque tradat medico, diligenter de eo iudicat, cum interim nemo ne imaginem quidem suam committat pingendam nisi probato prius artUici per quaedam experimenta atque ita electo, habeantque omnes pondera atque mensuras exactas, ne quid errorum in rebus non necessariis accidat... Alas, rarely does anyone diligently examine a physician before placing himself and his family under his care, and yet no one would ever actually commission his own portrait unless the artist had first been carefully tested through experience. Therefore, these so-called doctors should all have weights and measures so that an error does not occur in unnecessary matters. That wealthy men in Rome did not spend the time to examine physicians closely but relied instead upon the reputations which the latter had managed to garner was the impetus for Galen’s treatise De optimo medico cognoscendo (On Examinations by which the Best Physicians Are Recognized), in which he argued that one ought to examine the skill of a physician or surgeon while healthy, and that even the man who was too lazy to study 129 Plutarch, Mor. 136E. Compare Celsus, Med. 1. 3. 13 — 14: Ante omnia autem font quisque naturam sui corporis... (But above all things everyone should be acquainted with the nature of his own body). 130 Scribonius, Comp. pref. 9. 46 medicine in depth was able to acquire sufficient knowledge to distinguish between the medical expert and the fraud.13’ One cannot take either author’s statements about a general decline in medical knowledge in Roman society completely at face value, for they both invoked the familiar trope of wealth and luxury as the downfall of civilization; their words are indicative rather that medicine was considered to be part of an intelligent and educated man’s sphere of knowledge. It was attainable, expected and even necessary. 132 Medical knowledge or literacy on the part of the upper-class was not gained, however, through the standard educational syllabus, which, oddly enough, generally eschewed the sciences upon which most of Varro ‘ s representative disciplines clearly depended. Galen reported that until the age of fourteen he was taught the elements of mathematics, arithmetic and geometry by his father, who himself had a thorough grounding in geometry, mathematics, architecture and astronomy.’33 Galen’ s educational experience was apparently anomalous, however, for although the historian Teresa Morgan reports that there is some evidence for arithmetic, geometry and mathematical exercises on papyri school texts from Hellenistic and Roman Egypt, the sciences were not generally promoted in the school curriculum, particularly not in the Latin-speaking part of the empire.134 There was some theoretical support for the study of mathematics, particularly for arithmetic and geometry, among the Romans by both Cicero and Quintilian, for example, but it was not a wholehearted endorsement.’35 The knowledge of medicine on the part of the literate classes who did not pursue it as a profession was gained not through the educational system, ‘31Galen,Opt. med. CMGSO IV 8. 10,9.14—16. 132 Galen in particular castigates the wealthy: Opt. med. = CMG SO IV 1. 3 — 7, 1. 12, 13. 1 —3.133 Galen, Libr. ord. K. 19. 59, Cognosc. K. 5. 42. 134 Morgan 1998: 6—7. 135 Marrou 1964: 281 —282; Bonner 1977: 78— 79. One possible obstacle was that higher studies in any of the sciences required a facility in Greek, as Latin scientific texts were generally lacking, although at Rome at least bilingualism among the educated class was the norm rather than the exception. See Marrou 1964: 434—435, n. 33. 47 professional training or apprenticeship, but rather it was essentially autodidactic, and it was gained through the cultural and literary life of the day which supported a polymathic approach to knowledge: it was obtained through books, debates, demonstrations and lectures.’36 Despite Galen’ s complaint that some practising physicians were in fact barely literate, the educated class in the Roman empire supported a book trade which was brisk and in the large cities at least there was a comparative abundance of accessible medical texts: treatises on anatomy, physiology, surgery and therapeutics; commentaries on Hippocrates and other early Greek medical writers; critical analyses of the various therapeutic strategies; and books of pharmacology.’37 Strabo’s warning that the book vendors might sell texts of dubious quality was echoed by Galen, who recounted instances in which books were being sold under his name in the bookstalls of Rome, some of which were genuine, others entirely counterfeit, while others were bonafide but improperly credited, a situation which prompted him to create a catalogue of his genuine works for the reading public, De libris propriis.’38 Putting aside concerns about the quality of the available books, it is clear that there was a healthy public demand for medical texts and knowledge. An anecdote related by Galen in the 136 Galen specifically stated in one treatise, Anat. = K. 2. 450, that he was writing it as an aid for autodidactic readers. Nutton’s reading of a passage from De optimo medico cognoscendo suggests that for Galen at least the medical knowledge gained through medical texts was essentially comparable to that gained by attendance at the bedside. Nutton 1990: 248, n. 53. 137 Galen, Libr. prop. = K. 19. 9. Galen’s reference to illiteracy must be understood within the context of the often vitriolic debates on the various medical sects, on which more below. Galen commented on the importance of books to contemporary medical knowledge in Anat. = K. 2. 281 —282. On the rapid expansion of the book trade in the Roman empire and the social and cultural importance of books in the age, see Reichmann 1938: 42 — 44, Boyd 1915: 62 — 63, and Reynolds and Wilson 1991: 18 - 25. Dioscorides mentioned the “many authors old and new... who have put together books on the preparation, properties, and testing of drugs. . .“. De materia medica pref 1. Fantham 1996: 14 — 15 believes that trade in technical manuals, including medical texts, likely made up the bulk of the book trade. See Nutton 1990: 247 on the possible content of medical handbooks at the time of Galen. 138 Strabo, 13.1.54. Galen, Libr. propr. = K. 19. 8— 11, 17. (This catalogue of his own works was in fact incomplete.) Other instances of Galen’s complaints about his books circulating unauthorized may be found in Anat. K.2.217,659. 48 opening sentences of De libris propriis implied that the buyer of a counterfeit book on at least one occasion was a literate though not well-educated man, which suggests that interest in medicine and medical books in Rome at least may not have been limited solely to the educated elite.’39 Pliny’s list of authors upon whom he drew in writing the Naturalis historia was remarkably extensive: he himself stated in his preface that he had read one hundred authors)4°He specified his medical sources, and his catalogue of authors included over fifty medical writers, most of whom were Greek and many of whom continued to be read by the educated: Hippocrates, Erasistratus, Asciepiades of Bithynia, for example.’4’ It is unlikely that Pliny was able to undertake such compendious research through the resources of a single private library, no matter how well-stocked. His situation, and that of other compilers or polymathic writers, must have been similar to that of Gellius. In the process of collecting his entries for the Noctes Atticae, Gellius relied heavily upon the resources of the numerous public and private libraries of Rome (and of other cities in the empire, such as Tibur and Patrae, while on visits there) for reading in all manner of topics, including medicine.’42 By one scholar’s estimation, there were twenty-six public libraries in Rome alone by the mid- first century, although T. Keith Dix argues that access to the scholarly collections in the so- called “public” imperial libraries would have been limited to those with ties to the imperial courts.143 That medical texts were to be found in at least one of the imperial libraries of Galen, Libr. prop. = K. 19. 8—9. 140 Pliny, NHpref. 17; Beagon 2005: 30 states that this number is a serious underestimation. Lloyd 1983: 148 notes the paradox between the “wealth of popular beliefs and tradition that Pliny records” and his evident use of literary sources rather than direct informants. 141 Pliny, NH 2 passim. 142 See Boyd 1915: 74 for Gellius’ many references to library use in Rome and elsewhere in the empire. Boyd has collected many of the primary sources on libraries and literary culture in ancient Rome. 143 Marshall 1983: 62 on the number of public libraries. See also Reynolds and Wilson 1991: 23 —25. Dix 1994: 284 — 287. Casson 2001: 81 — 82 argues that the architectural design of libraries at Rome, which had 49 Rome was attested by Galen. The destruction of three imperial libraries in a fire in 192 meant the loss of their valuable collections, including a number of Galen’ s early medical and philosophical works which had been stored in the Library of the Temple of Peace.” Medicine flourished in works not only of prose but of poetry as well. The physician Marcellus of Side, who lived during the reign of the Antonines, wrote a didactic medical poem in forty-two books, the Chironides, which was presented to the imperial libraries at Rome by the emperors; the work was written in Greek heroic verse, according to his funeral epigram.145 Another physician-poet of the approximately the same time period, Herakleitos of Rhodes, was honoured in an inscription as “the Homer of medical poetry” Cuitpticóv icotrjiátow “Opipoç), a designation which suggests that the genre was not entirely inconsequential)46 The extant portions of the hexameters of the Liber medicinalis (Book of Medicine) of Quintus Serenus, which date from sometime in the second to fourth centuries, provided remedies for almost a hundred diseases; its existence demonstrates that the genre was known in Latin as well as Greek.’47 twinned storage and reading areas, reflected the necessarily bilingual nature of the collections, a point which at least assures that medical texts, most of which were in Greek, would potentially have had space delegated to them. Pliny complained that most medical texts were in Greek since, if they were written in any other language, they lacked all authority and were ignored. Pliny, NH 29. 8. 17. 144 Galen, Libr. prop. = K. 19. 19, 21. The fire (which some scholars date to late 191) destroyed the Libraries of the Palatine, Domus Tiberiana and Temple of Peace, the latter located in the Forum Vespasiani and the location for literary pursuits of all sorts, according to Galen. On the fire, see also Dio Cass. 72. 24. 1 —3; 1-lerodian 1. 14.2—6. 145Anthologia Palatina 7. 158. He was also the author of other non-didactic poetry, including two extant funeral epigrams for the wife of Herodes Atticus, poems which E. L. Bowie considers to be of very high quality (he is less kind to the remains of the Chironides). See Bowie 1989: 201 —202. Side was located in Pamphylia. 146 TAM 2. 3; IGR III. 733. The inscription is undated but stylistic considerations suggest that it should be dated to the imperial period, probably the middle of the second century, according to Greek epigraphist Cohn Bailey (personal communication). That we lack extant examples or references to medical Latin in poetry does not exclude the possibility of its having been written. See Fantham 1996: 137 — 140 on the tradition of didactic poetry in Latin literature. See Peek 1955: s.v. GVI 445 and 2020 for mention of physician-poets in the Greek world. 147 Serenus in Poetae Latini minores. See also Langslow 2000: 64. 50 Just as important as medical texts for the dissemination of medical knowledge, however, was the public medical discourse. At the one end, this consisted of the social aspect of therapeutics: the observations and conversations of the cluster of healers, family members and friends around those who were ill, as mentioned above, or medical consultations or even operations which took place in the streets and open-air venues.148 At the other end, the discourse was more formalized and was tied to the culture of rhetoric. Galen believed that many of the books which were circulating without proper attribution to him had their origin in notes given by him to friends who had attended his lectures and demonstrations and wished to have a written record of the proceedings.149 He himself was an avid participant in the vigorous public medical debates—part of what Armelle Debru terms the “caractère public et agonistique de la vie médicale”—which contributed to the cultural life of the cities of the Roman empire)5° Epideictic displays were a crucial aspect of the literary culture of the Graeco-Roman world, particularly in the second century’s cultural revival which has been termed the Second Sophistic: lectures, recitations and demonstrations attracted sizeable audiences whose members came to hear poets, historians, philosophers, orators and rhetoricians; these audiences came as well to hear physicians.’5’Lectures and demonstrations such as Galen’ s held a central and critical place in the dissemination of medical knowledge to those pursuing medical studies, whether as a vocation or as an intellectual interest. Scribonius specifically 148 See Plutarch, Mor. 71 A on the public nature of operations, perfotmed to attract potential patients. Galen, Libr. propr. = K 19. 10, 14— 15; Praecog. = K. 14. 630; Ven. sect. = K. 11. 194. Anat. = K. 2. 217. See Starr 1987 on the circulation of literary texts in Rome; although he does not include medical texts in his analysis, his general description on the distribution of texts in the context of social circles would be applicable. 150 Debru 1995: 69. See Galen, Anat. = K. 2. 217, 2. 224. 151 See Fantham 1996: 211 —221 on the importance of public performance in the literary life of the Romans. Bowersock 1969: 59 — 75 discusses Galen in the specific context of the Second Sophistic, while von Staden 1995: 53 —55 emphasizes the epideictic character of Galen’s public rhetorical discourses. See also Galen, Praecog. = K. 14. 623, where he is warned by a friend that his claims of family and wealth might be considered as rhetoric designed simply to please an audience. 51 named “the deliberations and debates of highly respected physicians” (deliberationes contentionesque medicorum auctoritate praecellentium) as a source of medical information for himself.’52 Physicians readily took part in these rhetorical performances not only for the purpose of instructing their students and the public at large, but also to demonstrate their own competence and thereby to solidify the reputations upon which their practices so crucially depended. These public displays could be vigorous and even heated affairs: on at least one occasion Galen stalked out in medias res when challenged by a physician from a rival medical sect, and Celsus also alluded to medical feuds which were carried out “in many volumes and in large and contentious disputations” (per multa voluminaperque magnas contentionis [disputationes]))53 Galen was indeed so actively involved in the rhetorical aspects of medical culture that he claimed that he was attacked by other physicians in his early days at Rome as a mere oykttpoç (logiatros), that is, a “physician in word only,” and felt compelled to abandon at least temporarily these public appearances for the sake of devoting himself to his clinical medical practice and his writing.’54 Prior to that decision, however, he had given both public and private lectures on various aspects of anatomy and physiology, as well as on the texts of various ancient Greek physicians, and he had even performed public dissections to illustrate his own anatomical experiments and conclusions.’55 152 Scribonius, Comp. pref. 1. 153 Galen, Praecog. K. 14. 628. Celsus, Med. pref. 45. Celsus, at 6. 18, also employs the phrase in omnifere medicorum volumine atque sermone (in almost every book and discourse of physicians), but the context could be referring either to bedside conversations or medical lectures or even perhaps both. Nutton 1979: i describes Galen’s debating style as being in tone less philosophical but rather “akin to a bar-room brawl.” Medical debates and demonstrations could contain public challenges and ridicule from the audience if the challenge was not met; see Galen, Anat. K. 2. 642 — 643. Galen, Libr. propr. = K. 19. 15. 155 Galen, Libr. propr. = K. 19. 13— 14,20—22; Praecog. = K. 14. 612 —613,626—630; Opt. med. = CMGSO IV 9. 6, 9. 9; Anat. K. 2. 216. A number of his books were in fact verbatim or reworked notes from his lectures and debates, such as Anat. and Sect. intr. See Debru 1995: 69—81 on the role of medical demonstrations in the medical culture of the ancient world. Human dissection, which had been performed at Alexandria in the second and third centuries BC, was rare by the time of Galen but not unknown. Opportunity to see the interior human anatomy or to perform any dissection was chiefly restricted to condemned criminals, 52 Maud Gleason’s study of rhetoric in the Second Sophistic reminds us of the importance of the audience to all epideictic performances of the time: “[there] was in some sense a collaboration between speaker and audience, and the educated audience relished being the ultimate arbiter of success.”156 In the case of the public lectures and demonstrations of physicians, the audience would have been composed of a mixture of students and fellow physicians of the various medical sects, as well as those men of the educated classes who were not wholly ignorant of medical theory and practice. These latter would often have been the most important part of the assemblage for the physician holding forth, for it was their judgement upon which a physician’s profession ultimately relied since it lay in their power to hire. Their ability to judge him on his ability in both rhetoric and medicine depended upon apaideia in which both were firmly linked.’57 Celsus, for example, carefully noted that Hippocrates was equally famous for medical skill and eloquence (vir et arte etfacundia insignis), and the desire to be remembered for his eloquence as much as his medical knowledge was a motivating factor in Marcellus of Side’s composition of the Chironides.’58 Pliny in particular stressed the association of rhetoric with medicine. He wrote of the “flood of verbiage” (ingenti garrulitate) of one physician, and of the rabid perorations of another, and stated of physicians that “it is obvious that anyone among them who acquires the power of speaking at once assumes supreme command over our life and wounded or dead soldiers, and, so sadly, exposed children who had died before rescue. Galen performed dissections, including vivisection on occasion, on apes, pigs, cats, dogs and other small animals, and was also a participant in the public dissection of an elephant which had died in Rome. Anat. = K. 2. 385 —386, 619—620.156 Gleason 1995: 159. Von Staden 1995: 53 draws attention to the fact that Galen frequently, although not invariably, styled a public anatomical presentation as epideixis (exhibition or display) rather than apodeixis(demonstration). His article analyzes Galen’s place in the epideictic culture of the second century. Jaeger 1944: (vol. 3)12. 158 Celsus, Med. pref. 8. Anthologia Palatina 7. 158. 53 slaughter. . .“ (palamque est, Ut quisque inter istos loquendo polleat, imperatorem illico vitae nostrae necisquefieri )159 It is worth noting in closing this section that the pursuit of medicine as either a vocation or as an intellectual interest lacked clearly-defined propaedeutics, although Galen proposed a set of preliminary studies: attention should be paid, he posited, to the Hippocratic dictum that the study of both geometry and astronomy were germane to the study of medicine, and studies in the scientific disciplines, much like those in which his own father had enrolled him—logic, geometry, mathematics, arithmetic, architecture and astronomy—were equally essential.’6°These subjects would of course benefit any man, no matter what his ultimate path in life, for they would “sharpen the soul” in preparation for further studies, but they were demanded in particular by medicine.’6’The nature of the Graeco-Roman school curriculum, moreover, along with the absence of professional regulations and the propensity for intellectual generalism resulted in what could be regarded as interdisciplinary propaedeutics. One finds, for example, in the work of the Augustan architect Vitruvius, the following recommended programme of pre-professional studies for anyone intending to enter the field of architecture: Et Ut litteratus sit, peritus graphidos, eruditus geometria, historias complures noverit, philosophos diligenter audierit, musicam scierit, medicinae non sit ignarus, responsa iurisconsultorum noverit, astrologiam caelique rationes cognitas habeat. He ought to be a man of letters, an experienced draughtsman, learned in geometry, knowledgeable of the histories of various ages, a diligent student of philosophy, have Pliny, NH29. 3, 5. 9, 5. 11. See also Galen, Anat. = K. 2.217 on his fellow student: t&tEnoOat [epideixasthail dv itv r.toa’u, Sovaitvp abt4 aovtWivat O’yooç ittSetictuco6ç [epideiktikous] (he wished to display his [medical] talents in public, but lacked lecturing ability). 160 Galen, Med. phil. = K. 1. 54. Cf. Pseudo-Soranus, who wrote that a student of medicine ought to have initial training in natural sciences, grammar, rhetoric, geometry, arithmetic, and astronomy (‘ ed. Rose 1864: 244, lines 23ff.). 161 Galen, Cognosc. = K. 5. 64. 54 a grasp of music, not be ignorant of medicine, well-versed in the responses of lawyers, have a knowledge of astronomy and astronomical calculations.162 Vitruvius gave explanations for all of his suggested preparatory fields, some of which might seem out of place to modem perceptions of the requirements of the profession: natural philosophy, for example, provided training in important principles of nature, while ethics formed a man without greed or avarice; a knowledge of history allowed one to explain architectural motifs properly, while music assisted in the literal fine-tuning of military engines and in the acoustics of theatres; and a knowledge of both medicine and law allowed the architect to build structures which violated neither rules of health nor municipal by laws.’63 The depth of required expertise expected in a prospective student of architecture in the non-mathematical areas was apparently relatively thin: architects needed letters not for a deep knowledge of poetry but for the ability to keep proper written records, for example. What is intriguing, however, is that the proper intellectual preparation for medicine according to Galen included architecture, while the proper preparation for architecture according to Vitruvius included medicine, positions which are demonstrative of the degree to which the various disciplines within the paideia of the Graeco-Roman world were often tightly interwoven. Medicine and Philosophy I. E. Drabkin notes that the study of philosophy was either propaedeutic or concomitant with the study of biomedicine in the classical world, and indeed Galen argued that every good physician needed a thorough training in philosophy: 162 Vitr., De arch. 1. 1. 3. Trans. mine. 163 Vitr., De arch. 1. 1.4—10. 55 tt 8i otv ti )t1rEtat ltpOç tO €ivxt (ptXOGo(pov tOy ‘cxtpóv, öç âv Iititoicpátouç &koç &aic1a t’iv tvrv; Et yap yct ji?v (p5rnv GUStcLtoç icth voarj.tátcov &aqopdç icth ‘tcqiátcov veitç, v tfi ?oyucf O&opic yyoiváoOat itpoa1’pct, 1vx (p13o7tOvU)ç tfi tot5twv &o1a’1c 1tapcqivfl, xp1.tát0V tE 1(fLt0VEtV Kth onxppoai5vv ixaKev, távtct f11 tiç (poooçlictç xot td JIEpT, to t oyucOv iccti tO cpuaucOv icctI. tO tiOucóv. What grounds are then left for any doctor who wishes to be trained in the art [of medicinel in a way worthy of Hippocrates not to be a philosopher? He must be practised in logical theory in order to discover the nature of the body, the differences between diseases, and the indications as to treatment; he must despise money and cultivate temperance in order to stay the course. He must, therefore, know all the parts of philosophy: the logical, the physical, and the ethical.’64 Galen in fact did not consider himself to be a physician, but a “physician-philosopher.”65 He took pride in the fact that Marcus Aurelius had singled him out with a compliment which acknowledged both of these aspects: this man, Marcus said, “is first among doctors and the sole philosopher among philosophers” (“tthv tv ‘wtpóv irptov ‘Ivcn, tóv ö p2ooOqxov j.tOvov”).’66 It is of course extremely risky to follow Drabkin’s example in extrapolating from Galen’s case that all those who practised medicine also studied philosophy, but certainly for men of his education and class the deep-seated association between philosophy and medicine which stretched back at least as far as Plato’s Timaeus continued to be perpetuated.’67 164 Drabkin 1944: 337. Galen, Med. phil. = K. 1. 60. Galen believed that the study of logic was particularly important for the making of the best physician. Compare the Stoic philosopher Epictetus, who contended that the study of logic was instrumental in the moulding of a true philosopher. Epictetus, Discourses 1. 7. 165 Edelstein 1967: 353 observes that Galen placed his analysis of the whole human organism into his philosophical works and not his medical works. 166 Galen, Praecog. = K. 14. 660. Despite this accolade, however, the emperor failed to mention him in his Meditations. 167 The link between the two is well exemplified in Galen’s work Deplacitis Hippocratis et Platonis (On the Doctines ofPlato and Hippocrates), but he was not the only one of his age who linked the two disciplines. Celsus, Med. pref. 6—7 argued that medicine was initially one part of philosophy, since both considered the rerum naturae with the same eyes, and that in fact it was the sapping of physicial strength which the mental exertions and late nights of philosophic speculation engendered that caused philosophers to speculate on medicine in the first place. Plutarch, a practising Academic, drew a direct link between it and medicine, openly chiding philosophers who did not discuss matters of health at Mor. 122E. There is only an oblique reference to philosophy in Pliny’s account of the early history of medicine (NH 29. 4), but even Gellius took great pains to preserve the ideas of “both physicians and philosophers of distinction” (et medici etphilosophi inlustres): the philosopher Favorinus invoked the name of Erasistratus, an important Hellenistic physician and anatomist; the 56 The contributors to the two volumes of Philosophia Togata, which were devoted to exploring the “mutual interaction of philosophy and Roman life,” did not examine health and illness as an aspect of Roman life which intersected with philosophy, but clearly this component of Roman culture could have fallen into their purview)68 The long and complex relationship between Graeco-Roman medicine and its philosophical traditions is one which cannot be examined in full here, but two aspects do warrant some discussion in considering the medical culture of second century Rome: firstly, the philosophical underpinnings of the medical sects, and secondly, the mutual influence of the two disciplines upon each other. As Nutton has pointed out, the differences between the various medical sects were in essence theoretical.’69 The medical debates and demonstrations in Rome and other cities of the empire centred around systems of ideas, not those of practice. At the therapeutic level, the same range of therapies were used by most Graeco-Roman healers, including biomedical physicians: diet, rest or exercise, pharmaceuticals (herbs or minerals), purgings of various kinds, baths, and surgery or cauterization as the painful last resorts.170 It was on the question philosopher Calvisius Taurus, who in one passage scolded a physician for not knowing the difference between a vein and an artery, discussed a friend’s illness with another physician in a second passage; Aristotle is cited on the effect of cold or terror on human physiology, and Cameades the Academic on the emetic use of hellebore. Gellius, NA 3. 16, 16. 3, 18. 10, 19. 4, 19. 5. Gellius also mentioned Socrates’ regimen for health (2. 1), the agreement of both physicians and philosophers on the diet of immature children (4. 19), and the philosophic debates on vision (5. 16). A passage from Plutarch’s Moralia, set at a symposium in which a physician criticized Plato’s understanding of anatomy, found its way into Gellius’ work at NA 17. 11. See Plutarch, Mor. 698A — B. Galen openly worried, however, that among the wealthy and powerful of the large cities, and in Rome in particular, knowledge of medicine was relegated to its socially functional capacity and that its intersection with philosophy was being ignored. Galen, Praecog. K. 604 — 605. Some modem scholars, however, are apparently ill at ease with the close relationship between medicine and philosophy. Dover 1996: 35, for example, expresses concern that the writers of the Hippocratic treatises were often “dismayingly philosophical.” 168 Griffin and Barnes 1989: vi. ‘69Nutton 1991: 14—15. 170 Scribonius summed up the ancient therapeutic progression tidily: nam primum cibis ratione aptoque tempore datis temptat prodesse languentibus; deinde, si ad hos non respondent curatio, ad medicamentorum decurnit vim: potentiora enim haec et efficaciora quam cibi. post, ubi ne ad haec quidem cedunt d4fflcultates adversae valetudinis, tunc coacta adsectionem vel ultimo ad ustionem devenit. (At first the physician attempts to benefit the weak by giving them food in a reasonable manner and at appropriate times. Then, if the patient has not responded to this treatment, the physican has recourse to the power of drugs since these are more potent and 57 of aetiology that biomedical physicians parted ways with each other, and to a great degree these differences reflected the various philosophical schools of the day. The degree to which a direct connection between philosophical schools and the medical sects can be made is a matter of some scholarly discussion, but certainly it is necessary to view the medical sects within the context of the contemporary epistemological debates of the Hellenistic and Roman philosophers.’7’ The medical sects were not rigidly or fonually organized groupings of physicians, but were informal alliances of thinkers, and within any given sect there was a spectrum of both theory and practice. Three main divisions of thought, however, emerged during the time of the Roman late republic and early empire: Dogmatism, Empiricism, and Methodism.172 The Dogmatist sect (Galen’ s own word, but the members of this sect are also called Rationalists, Analogists or Logicalists’73)was the most diverse, the oldest of the three, and the one which, because of Galen’ s influence, is still often erroneously considered, even by many classicists, to represent the medicine of the Graeco-Roman world against which the other sects have more efficacy than food. After that, if the patient’s symptoms have not given way to health, then the physician is forced on to surgery, and ultimately he arrives at cauterization.) Comp. pref. 6. Cf. Plutarch, Mor. 974A—B. 171 Jaeger 1944: (vol. 3) 21 argues that it was not the particulars of philosophical theories which were adopted as much as it was the methodology. Hankinson 1999 offers a helpful survey of the intersection between Hellenistic biological sciences, chiefly medicine, and the contemporary philosophical debates. See also Frede 1987: 225 —242; Edelstein 1967: 349—366; and Longrigg 1993, 1995 for scholarship on philosophy and medicine. Van der Eijk 1999: 56 reminds scholars to take care, however, not to approach medical sects as if they were simply applied forms of philosophy. 172 The sources for understanding the major sects are generally scattered amongst the extant medical writers, but there are two works in particular which provide contemporary assessments of the sects’ histories, theories and practices: Celsus’ preface to De Medicina and Galen’s De sectis ingredientibus (On the Sects for Beginners). Celsus is the less polemical in nature and therefore likely more balanced. Pliny’s NH 29. 2—5 gives a brief and highly critical account. 173 Galen, Sect. intr. = K. 1. 64. 58 rebelled.’74 Under this broad heading were placed those physicians who believed with Galen that the best medicine combined two particular features: The art of healing was originally invented and discovered by the logos in conjunction with experience. And today also it can only be practised excellently and done well by one who employs both of these methods.’75 The unifying feature of Dogmatism was its use of logos or deductive reasoning in healing: a biomedical theory of aetio logy was combined with a sound understanding of human anatomy and both of these were used in conjunction with a knowledge of the individual patient—his physical temperament, his environment and his symptoms.’76 Under this rubric fell the Hippocratics as well as notable Hellenistic physicians such as Herophilus, Diodes and Erasistratus (each with their own followers), and it was to this loose grouping which Galen was allied, although he stated that he was purposely uncommitted to any philosophical or medical sect.’77 Galen and the majority of the Dogmatists tended to be Platonists (references to the Timaeus appear frequently in Galen’s medical discussions) with strong Aristotelian leanings, particularly to Aristotle’s physics, but there were significant exceptions to this.’78 174 Singer 1956: xv strongly cautions scholars against the notion, once quite prevalent, that the various sects “arose as heresies from a pure and primitive ‘Hippocratic’ original,” a misreading which is likely based on the ascendancy of Hippocratic Galenism in the western medical tradition. Von Staden 1982: 80, moreover, in tracking the use of the very term thp6atç (choice)—from which the English word “heresy”—for the medical sects as a group referent in the Greek medical texts, notes that almost every rival sect claimed Hippocrates as its founder (the exception was Methodism). ‘ Galen, Med. exp. Waizer and Frede 1985: 49. Translated from Arabic. 176 See Celsus, Med. pref 13 — 17 on Dogmatist tenets on aetiology. On the importance of anatomy, see Galen, Anat. K. 2. 220 — 227. The Hippocratic text De aere aquis locis is the classic example of the Dogmatist belief in the importance of external environment. 177 On Galen’s essential Platonism, see De Lacey 1972, Singer 1997: xxvi xxvii and Nutton 2004: 222 223. Galen said in Cognosc. K. 5. 42 —43 that he was following the advice of his father in not declaring an allegiance to any sect, but rather subjecting them all to examination while striving for the qualities ofjustice, temperance, courage and prudence which are universal to them all. Although Galen was a Dogmatist, he did not completely reject some of the arguments of the Empiricists, nor did Celsus; both men were comfortable with taking the best of both schools of thought. 178 Compare Phdr. 270B — C in which Plato asserted that medicine should be practised rationally and not on the basis of knack and experience. He further argued in favour of Hippocrates’ position that the physician needs to 59 The Dogmatists’ aetiological theories were disparate. The most influential and, thanks to Galen, the most historically-persistent theory was that of the humours and qualities, though it should be noted that the four humours (bile, black bile, phlegm and blood) were not canonical, and that the contrasting qualities of hot/cold and wet/dry received variable emphasis. One sub-group of the Dogmatists which arose in the first century AD rejected the power of the humours in favour of that ofpneuma, the “breath” or “spirit” which was believed to fill the arteries of the human body.’79 The Pneumatists believed that the internal environment of the body was highly influenced by its external environment, and their theoretical basis was in fact strongly compatible with Stoicism’s credo of “life in accordance with nature.”80 The most significant dissenting theoretical voice among the Dogmatists, however, was that Asclepiades of Bithynia, the physician who caused such a sensation in republican Rome.’8’ Asclepiades dismissed humoural theory and argued instead for a more materialistic theory of causation: the body possessed corpuscles and channels through which the corpuscles had to flow, and it was blockage of that flow which resulted in disease.’82 Many scholars have opted to align Asciepiades’ hypothesis with Democritean atomism, and it must be noted that Galen himself placed Asclepiades among the Epicureans.183 A number of modern scholars, including Nutton, dispute this placement, and J. T. Valiance makes the determine the nature of the body before applying any remedies. See Longrigg 1995 on medicine’s place in the Lyceum. The founder of the sect was Athenaeus of Attalela. See Nutton 2004: 202 —203. The appearance of the arteries during dissection, which is flat and apparently empty since the heart is no longer supplying the pressure to keep them inflated, misled ancient anatomists, who rejected any role of the arteries in the circulation of blood. The function of the arteries in blood circulation was not made clear in the West until Harvey’s demonstration of circulation in the early seventeenth century. Hankinson 1999: 340. No works by Pneumatist physicians have survived. 18 I See Valiance 1990 and 1993 for a comprehensive overview of our still-limited knowledge of Asclepiadean theory. 182 Celsus, Med. pref. 16. Galen, Ther. Pis. = K. 14. 250. 60 point that the corpuscles of Asciepiades’ theory were composite bodies and therefore by definition not atomic.’84 Nevertheless, Galen’s contemporary assessment cannot be ignored, as Valiance acknowledges.185 Even if no unbroken link between Democritean atomism and Asciepiades’ theory can be proved, the influence of Epicurean thought can readily be discerned. Empiricism held a position which, in contrast to Dogmatism’s combination of logos and experience, devaluated the role of logos in healing.’86 It was not a rejection of logos as a means of establishing aetiology, however, but rather a repudiation of the very need for considering aetiology, of the merit of searching for causes of disease when they were hidden in the body’s ultimately unknowable interior. Causes were deemed to be irrelevant to treating symptoms: the search for them was time-consuming and ultimately unrelated to the therapy applied. The Empiricist physician relied solely upon observation (autopsia); he compared his observations of the presenting symptoms of a case with previous cases to find similarities, without pondering the causation of these symptoms. Repeated observation and experience, both individual and collective, produced a body of knowledge upon which the physician could draw.’87 Empiricism in fact honoured Hippocrates as an empirical observer, while firmly rejecting the Hippocratic belief in using logos to discover hidden causes.188 It ‘84Nufton 2004: 168. Nutton’s position appears to be somewhat contradictory, however, as a few chapters on in the same work (p. 190) he refers to Asciepiadean theory and its “links with the corpuscular philosophy of the Epicureans.” Valiance 1990: 145. The atom is literally “uncuttable” in Greek, a quality upon which true Democritean atomism depends. ‘85Vallance 1990: 10—11. Celsus, Med. pref. 27 — 35 outlined the beliefs of qui se Empiricos ab experientia nominant (those who call themselves Empiricists from their [use ofj experience). Trans. mine. Both Galen’s SubJIguratio Empirica (An Outline ofEmpiricism) and De sectis ingredientibus and Pliny’s NH 29. 4 contain discussions on Empiricism. 187 Empirists argued that cures for disease were discovered in three ways: by chance, by an individual decision related to a unique set of circumstances, or by action inspired by the presenting symptoms. See Galen, Subf Emp. = Diechgraber 45 —46 ( Walzer and Frede 1985: 24 —5). Note that the Empiricist model of consulting the combined experiences of others would require frequent and ready access to medical texts. ‘8tt 2004: 149. The Hippocratic corpus, written by a variety of physicians over a lengthy period of time, was not completely consistent on the value of theory. De antiqua medicina (Ancient Medicine), for example, is 61 vehemently disputed the worth of anatomical studies, as knowledge of the internal body was deemed irrelevant to symptoms which largely presented themselves externally.’89 It was foolish to believe that the living interior of the body could be understood from the examination of a dead body or to suggest a relationship between internal organs and external symptoms. In its challenge to the ability of Dogmatists to discern correctly the unseen and the unknowable interior of the human body or to produce a single aetiology for disease, the Empiricist mode of thinking fell in line with that of the Sceptical school of philosophy. Galen made a direct connection between the two in the opening sentence of his Subfiguratio Empirica (Outline ofEmpiricism).’90 Both the Sceptic and the Empiricist were wary of theory, though of course the latter did build up a general theoretical basis of medical knowledge through inductive reasoning. Scepticism had a more profound effect upon biomedicine in the Roman empire than Empiricism alone, however, for it also provided the philosophical basis for the Methodist sect. The second-century Sceptic Sextus Empiricus, a physician whose cognomen is inaccurately applied since he was in fact a Methodist, highly critical of those natural philosophers who attempt to impose a unifying theory of nature upon the art of medicine. The Hippocratic text De epidemias (Epidemics) (which, despite its title, is not a discussion of contagious diseases which strike a population, but is rather a description of illnesses prevailing in a particular place under particular atmospheri
UBC Theses and Dissertations
"The first dispensation of Christ is medicinal" : Augustine and Roman medical culture Reid, Shelley Annette 2008
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