ABSTRACT
The hostility of their enemies has rendered the reconstruction of the ideas and opinions of the Methodists difficult, but there can be little doubt as to the extent of their success and importance in the first and second centuries of the Roman Empire. The achievements of their rivals who favoured humoral theories are even more difficult to establish, for precisely the opposite reason. The suffocating friendship of Galen has tended to subsume all who agreed with him under the banner of Hippocrates and to imply that all were united in resisting the novelties of the Methodists and the Empiricists. Differences are downplayed, and Galen’s precursors are rarely allowed to speak for themselves, even to be contradicted. Galen’s egocentric rhetoric disguises his debts to his teachers, and developments within Hippocratism, so that it is often difficult to gain a comprehensive picture of what later medical writers called the Dogmatist viewpoint. Historians have until recently had to make do with a meagre collection of fragments in Greek and a handful of treatises, but the rediscovery of more writings of Rufus of Ephesus in Arabic translation, as well as others by Galen himself, has allowed a better understanding of Galen’s place within the humoral tradition. He no longer appears so isolated as he claimed to be, and several of his striking medical methodologies can be seen to have been inherited from his teachers or from his immediate predecessors. At the same time, a clearer picture emerges of the ways in which doctors who did not believe in corpuscular theories but in humours applied them to medicine. Among the most influential rivals of the Methodists of the first and second centuries were the Pneumatists, so called because they placed great emphasis on pneuma, or spirit, as the controlling factor in health and disease.1 A passage preserved only in later translations of a work by Galen reveals that their founder, Athenaeus of Attaleia (S.W. Turkey), was a pupil of a certain Posidonius.2 If this is the famous Stoic philosopher and scientist Posidonius of Apamea, and if Galen meant that Athenaeus actually sat at his feet (neither hypothesis is entirely proven), the sect would have been founded in the last century BC, and perhaps as early as 60 BC.3 But neither Pliny nor Celsus refers to it, and, where dates can be assigned with confidence to its most famous adherents, none can be shown to have flourished before the middle years of the first century AD. On
this argument from silence, Athenaeus will have lived in the early years of the Roman Empire, and his adherence to the doctrines of Posidonius will have resulted from his reading, not his attendance at philosophical lectures.4 Athenaeus’ opinions were a mixture of Stoicism and Hellenistic dogmatic, or Hippocratic, medicine. He rejected the atomistic views of Asclepiades in favour of a cosmos of matter acted upon by hot and cold (the more active qualities), and by wet and dry (the more passive qualities), and held together by pneuma, a refined airy element.5 He eagerly explored parallels between the microcosm of the body and the macrocosm. Just as a living being could not exist without taking in pneuma, so too the universe was a living entity imbued with all-permeating pneuma. Changes in the body’s pneuma both brought about and at the same time indicated changes in the body’s overall mixture and its properties, which produced illness when out of balance. The heart was the seat both of the governing pneuma and of the body’s innate heat, and was continually provided by the lungs with a fresh supply of cooling pneuma drawn in from outside.6 Hence, Athenaeus paid particular attention to the environment, including the seasons, the layout of towns and the design of houses, as a contribution to maintaining good pneuma and a healthy balance in the body.7 He wrote on a great variety of subjects, from the provision of a good water supply to embryology, dietetics and the best method of taking and interpreting the pulse.8 His most important work was his Boethemata, Helpful Advice, in at least thirty books, which was praised by Galen as the best general medical treatise by a modern author.9 Both here and in his more specialised clinical writings, he often began from a clear and simple definition of the disease before adding details and qualifications to provide a more nuanced picture.10 Although, in Galen’s opinion, Athenaeus was not always right, he had at least the great merit of reporting the views of his predecessors accurately. Such respect for those who had gone before him was only to be expected from a physician who recommended the universal study of medicine and its history, not just for practical reasons, but because it was an intellectual pursuit, the equal of philosophy, which allowed one the pleasure of communing with great minds of the past.11 His followers included two major writers on medicine, Claudius Agathinus and Archigenes of Apamea. Agathinus, from Sparta, adopted material from Empiricist and Methodist sources, as well as what he had learned from Athenaeus. His surviving fragments deal, among other things, with pulsation and with fevers, a topic on which he was singled out for approbation by Galen.12 Given the Roman passion for baths, it is hardly surprising that Agathinus devoted much space to the health aspects of bathing.13 His comments on this topic have a curiously modern (or at least Victorian) ring at times.14 In his opinion, although they could relieve tiredness and help digestion in the short term, warm baths were for wimps, those afraid of cold water or a brisk rubdown. Whereas cold baths were of enormous benefit, even for those
who thought little about their health, as they toned the body, sharpened the senses and preserved a good complexion even into old age, warm baths made one flabby, pale, weak and unable to digest properly. Agathinus contrasted the vigour of the barbarians who frequently plunged their children into cold water with the modern habit of bathing small children in warm water, largely because their nurses were glad to see their charges fall into a stupor and not disturb them during the night. Agathinus preferred to give his son a brisk rub before bed, since he was aware that warm baths might bring on epileptiform attacks and worse. Cold baths, as opposed to warm, could be taken at any time of the year, provided that the water was not too icy, muddy or otherwise dirty. Sea water was particularly good, as the salt gave it an added edge. Best of all was a mixture of cold baths and exercise, taken a little while after dinner. One should undress in the open, out of the wind, but if one was too afraid of the cold one should begin with some exercises or a brisk walk or run while half-undressed. A brisk rubdown by a slave wearing cloth gloves (but taking care to avoid burns from the rough joins of the gloves) should precede the first dip. This should be relatively short and be followed by a short walk. The second dip should be longer, possibly involving some swimming, but one should leave the bath before becoming too cold. In the third dip one should put one’s head and upper thorax under a cold spring of water or, if there was none at hand, scoop up handfuls of cold water over one’s head. Then comes a rubdown and a scraping-off of the oil with a reasonably sharp strigil, and one feels all the better for it, especially on a hot and sweaty day. Agathinus himself liked to take a bath in the evening, as it then gave him a good night’s sleep. The only drawback of a cold bath was that any water getting into the ears might damage the channels there, and one should try and protect them as far as possible. In this passage sound advice is mixed with personal experience, and the toughness of the barbarian contrasted with the effeminacy of the Romans. Above all, both here and in other fragments, Agathinus emphasises moderation, the best guide of all, and the need to attend to the patient’s fears and preferences, especially if he or she was afraid of stronger medicine. One of Agathinus’ most distinguished pupils was Archigenes of Apamea in Syria, who is said to have lived in the time of Trajan, around AD 100, and to have died at the age of sixty-three.15 He wrote at great length on the pulse, and, although Galen found his exposition of the eight different qualities of the pulse far too subtle to be helpful, some of the names he used to describe the various types of pulse – for instance the double hammer, the mouse-tail or the gazelle-like pulse – are well chosen.16 His therapeutics show a similar concern with precise differentiation, for example of the types of pain, sleeplessness or mineral baths. He also wrote a large work on pathology; an even larger collection of letters, in eleven books, in which he assembled his advice for his friends; and books on fevers, symptomatology, surgery and nosology. Finally, the two books of his Drugs Listed by Type were cited extensively by Galen in
his own pharmacological writings, frequently word for word.17 His remedies included amulets as well as herbal and mineral drugs, although what proportion of these was entirely of his own devising is obscured by his reluctance to name his sources.18 Despite his frequent criticisms, Galen derived more information and effective treatments from Archigenes than from any other author of the Roman period, with the exception of Rufus of Ephesus. Archigenes’ interest in nosology is mirrored also in the treatise on Chronic and Acute Diseases by Aretaeus of Cappadocia. When and where Aretaeus wrote is unclear. The older view, based on the absence of his name from the pages of Galen, was that the two authors were roughly contemporary, both active in the second half of the second century. Galen’s silence was thus explained on the grounds either of ignorance or of a reluctance to acknowledge contemporaries or near-contemporaries from whom he had taken much of his material. More recently, following the redating of Athenaeus and other Pneumatists, Aretaeus too has been relocated a century or so earlier, to around AD 50.19 Aretaeus himself makes no reference to authors of the Roman period in his surviving writings, although clearly influenced by Pneumatist and Stoic doctrines, and quotations taken from his writings are either much later or raise problems of their own. The author of a treatise on fevers that is attributed to Alexander of Aphrodisias (late second century) mentions a work by him devoted to prophylaxis, but this pseudonymous author’s own date is far from assured.20 Two further references, both by Galen, have more significant consequences for Aretaeus’ date and for Galen’s veracity. Discussing ‘elephantiasis’, Aretaeus told a charming story of a sufferer, abandoned in the wilderness by his friends, who was then unexpectedly cured by drinking wine from a barrel in which a viper had drowned.21 An identical story was narrated by Galen in one of his early works, but without giving any source or date.22 Thirty years later, in the 190s, Galen repeated the story, but this time he claimed that he had had personal experience of the incident in his youth in Asia Minor.23 If Galen’s second version is correct, the case occurred in the 140s or 150s, and fixes Aretaeus’ lifetime around then. Alternatively, and perhaps more plausibly, with the passing of time a story that Galen had once read or heard became one in which he was a participant. His source could still be Aretaeus or another author on whom they both drew, but Galen’s testimony is then of less value for dating Aretaeus. But the earlier Aretaeus is placed, the more the silence of the omnivorous Galen requires explanation. Although Aretaeus wrote on surgery and a treatise specifically on fevers, all that has come down to us is his four books On the Causes and Symptoms of Acute and Chronic Diseases and the parallel set of four on their cures.24 They are written in a highly stylised Hippocratic Greek dialect, full of allusions to the Hippocratic Corpus, and were long considered by doctors to offer the finest nosological studies to survive from Antiquity.25 They combine detailed and precise observation with a clear, well-structured exposition. Each disease is described carefully and systematically: first, the site of the
illness, including relevant anatomical information; then, the meaning of the name; the symptoms; and the causes, especially with regard to the age and sex of the patient and the season of the year. The therapies advocated by Aretaeus are typically Hippocratic: diet, simples, venesection and cupping, with surgery recommended only rarely. His descriptions of diseases, for instance of epilepsy, syncope or diabetes, are classics of their kind, combining acute observation, accurate description and clear exposition.26 In his account of asthma (or ‘orthopnoea, because the patient wants to stand and breathe upright’), Aretaeus notes the prevalence of childhood asthma and its frequent disappearance in adolescence.27 But if it continues into adulthood, especially among men, it can be extremely dangerous. Its cause, he believes, is a cooling and moistening of the pneuma, to be avoided or corrected by warmth. This explains why those engaged in jobs that involve heat, lime burners, workers in bronze or iron and furnacemen at the baths, can survive much longer than the average asthmatic, even when they too suffer from shortness of breath. (The fact that this explanation is wrong in modern terms should not obscure his correct differentiation between what we might term congenital asthma and dyspnoea brought on by exposure to harmful fumes.) Aretaeus describes the onset of an asthma attack with graphic clarity: the tightness in the chest, the reddening of the cheeks, the bulging eyes, the desperate attempt to stand and find fresh air, as if what was already in the room might not be enough. He compares the attack to that of epilepsy, noting the asthmatic’s cold sweats and foaming at the mouth. Gradually the asthma goes away, the body relaxes and there is a profound sense of relief – until the next time, for sufferers always carry about with them the ‘symbols’, mementos, of their condition. Aretaeus’ division into acute and chronic diseases is also found in an anonymous work written in the first or second century with a more overtly didactic intent. It is clearly organised, setting out the opinions on a range of diseases held by distinguished physicians, mainly of the fourth and third centuries BC.28 Its author’s interest in disease causation and therapy is shared with the somewhat later writer of the Anonymus Londinensis papyrus himself, who in his final section puts forward ideas that could be called ‘Pneumatist’.29 But the fluidity of Pneumatist doctrines and the obvious tendency towards eclecticism manifested, among others, by Agathinus and Archigenes place difficulties in the way of any clear estimate of the extent and influence of Pneumatism. Indeed, one may have considerable doubts about its very existence as a sect in any strong sense of the word.30 Its most famous adherents have links with Rome, but Aretaeus’ place of writing is unknown and Anonymus Londinensis (if he is to be considered a Pneumatist) was writing in Egypt.31 The subsequent rise of Galenic Hippocratism easily subsumed many of its ideas and therapies, and obscured the place that it had gained in the early imperial centuries as an alternative to Methodism. Pneumatists, Methodists and Empiricists were in agreement on one thing: that Hippocrates and the writings that circulated under his name
were worthy of great attention and respect. It is true that scurrilous stories were in circulation, alleging that Hippocrates had derived his medicine by copying down the treatments recorded on the cure tablets around the walls of the Asclepieion of Cos, or, even worse, that he had deliberately burned down the archive, presumably in order to prevent others challenging his superiority.32 But in general the ‘founder of our profession’, as Scribonius Largus called him, was regarded favourably.33 Far more papyri of texts from the Hippocratic Corpus survive from Graeco-Roman Egypt than of any other medical author.34 References to Hippocrates and the Corpus are found in the work of writers of all kinds, from the philosopher Demetrius Lacon in the first century BC to the grandiloquent epigrammatist Glycon of Pergamum and the theologian Clement of Alexandria three centuries later.35 More tangible representations of the great physician were likewise numerous, both public and private. The island of Cos issued coins bearing his image, and a beautiful mosaic from a Roman-period house there depicts him in conversation with Asclepius (see Figure 4.3). At Ostia, the port city of Rome, his portrait bust – now, alas, sadly battered – was placed in the family tomb of the (royal?) physician, Demetrius.36 At distant Tomi, on the shores of the Black Sea, the tombstone of one of its sons, Kladaios, proudly announced that he had practised the art of his divine master, Hippocrates.37 On Corcyra, a grateful pupil recorded his thanks to his dead teacher Theagenes in an epitaph replete with Hippocratic allusions.38 Memorials of other doctors around the Roman Empire proclaimed the Hippocratic ancestry of their profession by writing the word for doctor in Ionic, even if the rest of the inscription was in the normal ‘koine’ (‘common’) dialect.39 Since, as we have already seen, some medical men, most notably Aretaeus (see p. 210), took to writing their own books entirely in Hippocratic Greek, it is difficult to decide whether some of the later texts in the Hippocratic Corpus were gathered in accidentally or were intended as imitations, pastiches or forgeries.40 Scholars provided these often obscure writings with appropriate exegeses. Basing himself on Hellenistic predecessors, Erotian dedicated his Hippocratic glossary, equipped with parallels from poets as well as physicians, to a court doctor, Andromachus, in the hope that this would encourage others to take an interest in the Corpus as literature and to compare their own knowledge with that of Hippocrates.41 The antiquarian Aulus Gellius, around 160, did not hesitate to include a passage from Nutriment as one of his miscellaneous topics for erudite discussion.42 He had found it best explained by the commentator Sabinus, who was later characterised by Galen as the most thorough expositor of Hippocrates, even if inclined to attempt to explain everything, including the inexplicable.43 There was also a general belief that Hippocrates was the founder of the theory of the four humours and the author of The Nature of Man. Anonymus Londinensis reacted sharply to the alternative Aristotelian view of Hippocrates by interposing his own quotation from that text as proof
of what Hippocrates had really believed.44 Agreement on the Hippocratic authorship of some treatises led to disputes about the authenticity of other writings that could not easily be made to conform. Erotian’s comment in his preface to the effect that Prorrhetic 2 was not by Hippocrates is the earliest extant reference to such a debate, but he is unlikely to have been the first to raise the question.45 Around 120 an otherwise unknown Artemidorus Capito brought out an edition of Hippocrates that was well regarded by the Emperor Hadrian.46 Building on the work of his coeval and relative Dioscorides (not the celebrated pharmacologist), Artemidorus produced a large edition in many book-rolls, incorporating in its margins variant readings and textual observations by Alexandrian scholars. Although it was not strictly a commentary, Artemidorus discussed within it the authenticity of certain treatises, or parts of treatises, rejecting, for example, the last part of Regimen in Acute Diseases and dividing up the Epidemics among various authors. He made many stylistic changes – far too many, thought Galen – in an attempt to return the texts to their original Ionic dialect. Galen regarded the editions of Dioscorides and Artemidorus as standard in his own day, and it is likely, although far from certain, that their work lies at the base of the manuscript tradition of the Hippocratic Corpus as we have it today.47 Others attempted to emulate them, including Rufus of Samaria, a Jew who had moved to Rome about 150 and who collected together the variant readings and interpretations suggested by earlier scholars to produce his own edition of the Epidemics. According to Galen’s heavily biased account, it was an unoriginal and uncritical ragbag of information taken from Rufus’ own large library, although Galen himself did not scruple to draw on it for his reports about the textual preferences of earlier scholars.48 How this abundance of Hippocratic material was actually used is more difficult to determine. The huge commentary, forty-eight books long, on Hippocrates’ Aphorisms, by Julian the Methodist interpreted many of its sentences in a very different manner from that of the Hippocratic Sabinus.49 Galen’s general approval of the latter’s work is qualified by his listing of errors and misunderstandings, which, like many of Galen’s criticisms of other commentators, may mean little more than that Sabinus was starting from a different standpoint from Galen. Similarly, Galen’s complaints that, in his own day, few people followed the teachings of Hippocrates, especially on prognosis, are called into question by the existence of groups such as the Pneumatists, whose medicine, although differing in several important ways from his own, regularly cited Hippocratic precedent.50 Their interpretations of Hippocrates, even if derided by Galen, were not foolish. Indeed, much of the evidence proposed by Galen for what Hippocrates himself had believed in, most notably the primacy of anatomy and the tripartite division of the body’s systems, has very little basis in the Hippocratic Corpus itself, and is far more a wishful creation of Galen’s to serve his own purposes than an accurate representation of this great figure from the past.51
