Stomachikon, Hydrophobia and Other Eating Disturbances: Volition and Taste in Late-Antique Medical Discussions*

in Mental Illness in Ancient Medicine
Open Access

In this chapter I propose to explore one particular realm of pathology that has relevance to the sphere of mental health and the formation of mental disease concepts in ancient medicine: nutrition and eating/drinking behaviours, and their alteration as forms of mental disorder.1 These include appetite and lack thereof, pathological drives (or absence of drives) towards food, food restriction and pathological voracity, and a general distortion in one’s attitudes towards food. I suggest that this area of experience received increased attention in late-antique medical writings as part of a wider phenomenon, the inclusion of the themes of voluntariness, self-control and the management of needs and desires, so much so that specific diseases thus emerged in association with these areas of human subjectivity—a topic which has still not received the attention it deserves, unlike other aspects of subjective bodily needs and desires, notably sex.2

The case of disturbances in the area of nutritional behaviours is interesting for various reasons. First of all, this is a central aspect of human life, whose potential psychological relevance does not need argument: failure to eat under mental distress is topical in ancient literatures as it is in contemporary understanding. From a historical perspective, eating as meaningful beyond its fundamental function has been studied from all sort of perspectives by cultural studies, especially as social activity: the consumption of cooked food has long been regarded as specifically human and universally so, involving a number of social habits that characterize human communities. The psychology of eating as experience of the individual, by contrast, has received much less attention,3 perhaps also through concerns about anachronism and retrospective diagnoses of common eating disorders in contemporary developed societies, of which the most known labels are anorexia nervosa and bulimia nervosa.4

Secondly, nutrition (as well as appetite or lack thereof) is fundamental in ancient medicine from its beginnings: indeed, it lies at the centre of the dietetic theme that constitutes such an important part of Hippocratic doctrines and practices, and is one of the key areas of lifestyle where individuals are responsible, and in control—at least in part—of their own well-being and health.5 It is thus possible, and enlightening, to observe the trajectory followed by medical attitudes towards this sphere of human biology and experience through a wide set of sources. I shall not, however, dwell on the history of ancient dietetics and prescriptions about food and drink,6 just as I am not going to consider the philosophical tradition concerning moderation and self-control when it comes to pleasures such as eating and sex.7 Rather, I would like to focus on the medical evidence about the experience of ‘eating individuals’, on two key levels: eating as explicitly linked to factors of volition, as I shall label these for convenience from now on (drives, voluntariness, and self-control), and to taste (desire, pleasure, disgust and even the emotions associated with them). Through such an exploration an increasingly normative hue emerges in the clinical inquiries of the period, and a pathologisation of human behaviours and habits: an ‘ethics’ of mental health that is entirely absent from classical medicine. This ethical reflection has a long philosophical history, of course, but had not been integrated into medical discussion before the beginning of our era.

Volition, Taste and Mental Disease: The Key Philosophical Antecedents

Philosophical discussions of human flourishing and well-being and, in the negative, of mental impairment and ‘madness’ more generally had long made key reference to pleasures and drives, scrutinizing their object and degree and exploring ways to manage and police them. The most influential example with reference to mental health is the passage in Plato’s Timaeus 86b. Here the philosopher defines the νόσος behind the different forms of madness human beings can suffer as ἡδονὰς δὲ καὶ λύπας ὑπερβαλλούσας (Tim. 86b5–7), “excessive pleasures and pain”. Their pathological physiology is later illustrated through the master example of sexual incontinence (Tim. 86c3–d5); the point is however more general, and equally applicable to the nutritional drive. In Aristotle’s Eth. Nic. 3.13, in the context of a discussion of “self-control” (σωφροσύνη) the philosopher points out that temperance and its opposite apply specifically to the case of pleasures derived from taste and touch (1118a26)—implicitly, to food and sex. At 1118b9–14, in a psychological description of excessive eating, we find a clearer attribution of pathological desires to mental disturbance:

Desires seem to be of two kinds, one common to all men, the other peculiar to special peoples, and adventitious (ἴδιοι καὶ ἐπίθετοι). For instance, the desire for food is natural, since everyone desires solid or liquid nourishment, and sometimes both, when in need of them; and also sexual intercourse, as Homer says, when young and lusty. But not everybody desires this or that particular sort of nourishment, any more than everyone desires the same particular portion of food; hence these preferences appear clearly to be an individual peculiarity (τὸ δὲ τοιᾶσδε ἢ τοιᾶσδε, οὐκέτι πᾶς, οὐδὲ τῶν αὐτῶν. διὸ φαίνεται ἡµέτερον εἶναι). Still, there is also something natural in such tastes; for different things are pleasant to different people, but there are some special delicacies which all men like better than ordinary food.

In the case of the natural desires, then, few men err, and in one way only, that of excess in quantity; for to eat or drink to repletion of ordinary food and drink is to exceed what is natural in amount, since the natural desire is only to satisfy one’s wants. Hence people who over-eat are called “mad-bellies”, meaning that they fill that organ beyond the right measure; it is persons of especially slavish nature that are liable to this form of excess.

But in regard to the pleasures peculiar to particular people, many men err, and err in many ways. For when people are said to be “very fond of” so-and-so, it is either because they like things that it is not right to like, or like them more than most people do, or like them in a wrong manner; and the profligate exceed in all these ways. For they like some things that are wrong, and indeed abominable, and any such things that it is right to like they like more than is right, and more than most people.8

In summary, the philosopher recognizes the existence of ‘wrong’ pleasures, tastes and desires. He identifies such pathology as twofold: there is a type which is common to all (characterized by excess, and natural in kind) and one that is more idiosyncratic (directed towards the wrong object, or a less natural object; its kind is only in part natural). Elsewhere (Eth. Nic. 7.6, 1148b15–1149a20) he will clearly categorise these ill-directed pleasures as pathological, in a medical sense: they arise διὰ πηρώσεις (“through lesions”, 1148b17), διὰ νόσους … διὰ µανίαν (1148b24–5); he will also discuss the cases of omophagia (taking pleasure in eating raw meat), cannibalism, and teknophagia (the eating of one’s offspring). Already at the turn of the classical era, we can safely conclude, food and eating were seen, in philosophical quarters, as areas relevant to character, personal ethics and psychology, just as much as were sex and erotic desires.9 The attitude towards these two central components of dietetics, however, is altogether different in the early medical writings (mostly Hippocratic).

Food and Mental Health: The Medical Antecedents

Food and drink are such fundamental aspects of health and health preservation that they obviously loom large in dietetics (Hippocratic, but not only10) and clinical and nosological writings already in classical medicine. Thus, in various Hippocratic patient-reports refusal of food or drink—ἀσιτίη, ἀποσιτίη et similia—are a recurrent sign; in many cases they appear to go beyond mere physiology, and reflect a mental state; indeed, in some they characterize syndromes which are openly mental. Moreover, although the differentiation between refusal of food, lack of appetite, or just ‘lack of food intake’ neutrally registered is impossible to make, we sometimes find explicit reference to a strong refusal of food, which seems to confirm something more than lack of appetite caused by a bodily ailment.11 This is characteristic of the gynaecological treatises, where lack of appetite and food restriction are openly relevant to mental disturbance: very often ἀσιτίη is associated with ἀγρυπνίη, ‘troubled sleep’ and bruxism, teeth-gnashing, to form a syndrome of mental distress that returns several times. As a counterpart to food refusal or lack of appetite, in some cases (although far fewer) we find pathological food voracity (the patient at Int. 43, vii.274,4–7 L. = 216 Potter, for instance,12 in a description of what is presented as “acute typhus”), deranged thirst and the ‘mad’ grabbing of water-cups.

These Hippocratic discussions of food behaviour are not merely dietetic, and can surely be categorized as relevant to the mental sphere, in the sense that they are considered as part of a domain of human experience that mental alteration can interfere with. A thematisation of these as specifically relevant to one’s mental health, however, is not found; likewise, there is no emphasis on drives and desires as compromised functions, on individual continence as valuable to health and on volition as a feature of a moral self in any way comparable to the Aristotelian reflections in Eth. Nic. 7: in medical writings these are eminently late-antique themes, as we shall see.

Late-Antique Nosology: The Thematisation of Eating Disturbances

The key medical authors in this enquiry all belong to the first centuries of our era: Anonymus Parisinus (ap, first-second century ce);13 Aretaeus (second century ce)14 and Caelius Aurelianus15 (fifth century ce).16

In a number of diseases included in these nosological texts nutrition and behaviours towards food are thematised and problematized in an unprecedented way. In particular, they are associated with aspects of subjectivity and character and framed as concerns about voluntariness, drives, desires, and the exercise of restraint.

These aspects are evident already in the nosological discussions that address eating and drinking behaviours without placing particular emphasis on mental life: boulimos, atrophia, and polysarkia. There are however two particular cases in which the topic of food and drink intake is elaborated into syndromes that have an overt and strong mental component, both ethically and from a cognitive point of view: stomachikon and hydrophobia.17 We shall begin with the former group of more straightforward physiological diseases and turn then to those two syndromes that appear to be explicitly relevant to the mental sphere.

We should anticipate that these nosological authors are a precious source, but also one that can trick the historian into a false perspective as far as the construction of disease concepts is concerned. These texts, in fact, present diseases of different kinds, many of them explicitly indicated as affecting the mind, itemised into neat lists and obviously testifying to a classificatory intention. The format followed by this kind of texts may deceptively invite a reader to generalize taxonomic clarity to ancient approaches to pathology—and especially mental pathology. To give a major counterexample, however, Galen notably did not engage with nosological catalogues, and although he comments extensively on the definition of the entity disease from a methodological point of view,18 he did not offer consistent and exhaustive descriptions of individual mental diseases, let alone psychiatric definitions that might be compared with those of our authors;19 we should then consider the testimony of nosological texts as one aspect of medical literature, but not the only one, nor the dominant one.

Notwithstanding his lack of engagement with taxonomy, a keen interest in aspects of volition and taste vis-à-vis nutrition and diet is evident in Galen’s work too. One comment of his to an Epidemics case is very instructive regarding this shift, and worth some of our attention here. At Epid. 3.1, case 6 a female patient is described, the daughter of Euanax. The girl has fever, wandering and presents a variety of signs including silence and low mood; she does not eat or desire food, nor does she drink; the disease ends with death. Galen comments on the aspects of the illness that concern food, especially concentrating on the following words: “she remained without thirst until the end. She would not even taste food” (ἦν δὲ ἄδιψος διὰ τέλεος· γεύµατα οὐ προσεδέχετο, Epid. 3.1, case 6, iii.50 L. = 220,7–8 Kühlewein), and later: “no appetite for any food for the whole time, nor did she desire anything. No thirst, and she did not drink anything worth mentioning” (ἀπόσιτος πάντων παρὰ πάντα τὸν χρόνον, οὐδ’ ἐπεθύµησεν οὐδενός· ἄδιψος, οὐδ’ ἔπινεν οὐδὲν ἄξιον λόγου, iii.50 L. = 220,23–24 Kühlewein). Galen explores these details about the feeding habits of the patient and her lack of thirst, theorizing about the nuances between urge, revulsion, desire or fear to taste the food, the recollection of favourite dishes and their relationship with actual consumption, to an extent in no way justified by the lemmas he is addressing. These factors are regarded as revealing of the state of agony of this specific patient (Hipp. Epid ΙΙΙ 2, xviia.591–93 K. = 70,12–71,6 Wenkebach), and are seen as typical from a clinical point of view:

… but this alone, in itself, would not have killed her so quickly; rather, the terminal condition of the naturał capacity, combined with the illness, was the cause of her dying so quickly. This has been made clear in this sentence: “she was without thirst until the end, she did not even taste food”. I have already spoken about the aspect of bad habit [kakoētheia] involved with these symptoms […] Hippocrates himself points this out again at the end of the exposition, as is his habit, whereby he adds at the end the facts responsible for the death—or the survival—of a patient: “no appetite for any food for the whole time, nor did she desire anything. No thirst [nor did she drink anything worth mentioning]”; with these words he indicates that she developed a kind of extreme revulsion from food [and drink], to the extent that she felt no desire for any, a desire which some of those who suffer from lack of appetite retain when they think of the foods they previously used to enjoy. We see it all the time in the illnesses of those who have no appetite, that some shrink away from food upon tasting it, while others do not even dare to taste it. But all the same, the majority of the latter, even, when asked if they fancy anything, would reply with some particular food, following the memory of those foods which previously used to delight them. And you should take this as the most evident sign of the nutritionally appetitive power having reached a completely terminal state: if, when the food which they say they desire has been provided to them, upon tasting it they complain about it and can no longer stand it. This is already very bad; even worse is the case of those who do not even show desire for any kind of food: this indicates the ultimate extinction of the natural capacity by which we are driven towards food or drink … (my translation).

ἀλλὰ τοῦτο µὲν αὐτὸ καθ’ ἑαυτὸ µόνον οὐκ ἂν οὕτω ταχέως ἀπέκτεινεν αὐτήν, ἡ δ’ ἐπιπλακεῖσα τῷ παθήµατι τούτῳ νέκρωσις τῆς φυσικῆς δυνάµεως αἰτία τοῦ θᾶττον ἀποθανεῖν ἐγένετο. δεδήλωται δ’ | αὕτη διὰ τῆσδε τῆς λέξεως· ἦν δ’ ἄδιψος διὰ τέλεος, γεύµατα οὐ προσεδέχετο. προείρηται δέ µοι περὶ τῆς τούτων τῶν συµπτωµάτων κακοηθείας ἐν τῷ πρὸ τοῦδε γράµµατι. καὶ αὐτὸς δ’ ὁ Ἱπποκράτης ἐπὶ τῇ τελευτῇ τῆς διηγήσεως πάλιν ἐπισηµαινόµενος, ὥσπερ εἴωθε, τά τε τοῦ θανάτου καὶ τῆς σωτηρίας αἴτια τοῖς ἀρρώστοις γενόµενα προσέγραψεν· ἀπόσιτος πάντων παρὰ πάντα τὸν χρόνον, οὐδ’ ἐπεθύµησεν οὐδενός, ἄδιψος <οὐδ’ ἔπινεν οὐδὲν ἄξιον λόγου>, ἔσχατόν τι µῖσος αὐτῇ γεγονέναι σιτίων <τε καὶ ποµάτων> ἐνδεικνύµενος, ὡς µηδ’ εἰς ἐπιθυµίαν ἀφικέσθαι τινός, οἵαν ἴσχουσιν ἔνιοι τῶν ἀνορεκτούντων ἐξ ἀναµνήσεως, ἐφ’ οἷς ἔµπροσθέν ποτε διετέθησαν ἡδέως. ὁρῶµεν γοῦν ὁσηµέραι τῶν ἀνορεκτούντων ἐν νόσοις τινὰς <µὲν> ἅµα τῷ γεύσασθαί τινων ἀποστρεφοµένους αὐτῶν, τινὰς δ’ οὐδὲ γεύσασθαι τολµῶντας. ἀλλ’ ὅµως καὶ τούτων οἱ πλεῖστοι τοῖς πυνθανοµένοις αὐτῶν, εἴ τινος ἐπιθυµοῖεν, ἀποκρίνονταί τινα βρώµατα, κατὰ µνήµην τῶν ἔµπροσθεν εὐφρανάντων αὐτοὺς τοῦτο ποιοῦντες. καὶ µέγιστόν γέ σοι σηµεῖον ἔστω τῆς ὀρεκτικῆς τῶν σιτίων δυνάµεως ἐν νεκρώσει παντε|λεῖ γενοµένης, ἐὰν παρασκευασθέντων ὧν ἐπιθυµεῖν φασιν ἅµα τῷ γεύσασθαι µέµψωνταί τε καὶ µηκέτι προσενέγκωνται. κάκιστα δ’ ἐχόντων καὶ τούτων, ἔτι µοχθηρότερον αὐτῶν οἱ µηδ’ ἐπιθυµήσαντές τινων διάκεινται, νέκρωσιν ἐσχάτην ἐνδεικνύµενοι τῆς φυσικῆς δυνάµεως, ᾗ σιτίων τε καὶ ποµάτων ὀρεγόµεθα.

The subjective experiences of appetite and food rejection, which involve desire, memory, voluntariness and self-control as well as emotions such as fear and daring are here by far the most important factors, more than the actual consumption and assimilation of food as nutrition of the body. In the spirit of this Galenic interpretation of the Hippocratic case there is an emphasis on the subjective experience as clinical datum of explicit importance that was entirely absent from earlier medicine. The move is most evident in the descriptions of diseases in which nutritional disorders are at the centre—both food restriction and food excess—to which we now turn.

‘Eating Disturbances’

For the purpose of discussion the nosological entities that affect eating can be divided into two groups: diseases broadly concerned with food restriction and/or lack of appetite—a disorder of nutrition in the sense of deprivation—and diseases broadly concerned with excessive intake or absorption. The disease ἀτροφία, literally “lack of nourishment”’ is the most representative of the first group, pivoted as it is upon disproportionate food restriction and its adverse consequences for the body; it is a well-known chronic ailment in the medicine of the period. Anonymus Parisinus (ap) 30 (162,21–166,10 Garofalo) describes it entirely in bodily terms. Its signs are emaciation, weakness, weight loss and dry bowels; the outcome is often death. Although no mental sign is included, the therapeutics reveals an interesting distinction, which returns in several of the diseases we are considering: that between atrophia arising “from known causes” (ἐπὶ προφανεῖ αἰτίᾳ, 164,17 Garofalo) and that arising from unknown circumstances (ὡς ἀδήλῳ, 164,18 Garofalo). The former type is addressed by removing the obvious source of the disease, while in the latter the measures recommended are primarily soothing and occupational: the cure must be restorative (ἀναληπτικῶς), consisting of “walks, passive exercise, vocal exercises, massage and holding the breath”.

The existence of an atrophia that has no evident bodily cause—thus, with no localization nor precise physiology—is, I propose, a step towards recognition of a psychological quality to altered behaviours towards food. This is the case also for Caelius Aurelianus’ much longer description of atrophia, nutrimenti cessatio (Chr. Dis. 3.7.90–95 = 732,20–736,13 Bendz). To a pathological picture similar to the one of ap Caelius adds the contradictory symptom of an immoderate hunger, followed by “spoiling of food and sometimes loss of appetite/nausea” (plurimus cibi appetitus … tum corruptio, quibusdam fastidium). When it comes to therapy, in a similar, if not identical fashion to ap’s distinction Caelius differentiates between localised atrophia, which weighs on one specific part of the body, and an atrophia which occurs “alone”, sola: in the second case restorative measures are again suggested, in terms which repeat almost word for word the recommendations found in ap (a sign of textual dependence, or co-dependence, of course, as often in Caelius’ case; but nonetheless expression of which themes and sources the author selected as relevant to his intended account of the disease). Not far below we find further insistence on a holistic, even existential therapeutical approach: “a change of locale and climate is beneficial”; “a boat trip along the shore and swimming in the sea or in natural springs”; “also mental relaxation (animi laxatio, Greek diachysis20) after meals and clasping of the patient’s limbs by attendants with soft hands”. These curative measures recur elsewhere in psychological contexts: not only comforting activities such as bathing and receiving massage, but travelling, and the physical contact with another, suggest an emotional, psychological significance.21

A brief look at the symmetrical ailment, excessive food consumption, reveals some analogy. ap is the only surviving text to discuss explicitly a disease boulimos (80,21–84,10 Garofalo);22 indeed, he characteristically states that the ancients have failed to mention this affection ὀνοµαστί, by name. Unlike the modern use of the term, the disease is typified by intense appetite, chilling in the body, panting and weakness; it is a “huge famine”, linked to chilling of the blood, basically a symmetrical ὄρεξις to the “diminished famine” (ἀνειµένη λιµός) found in other affections. Among the signs we find also ἀσµάθειν καὶ ἀλύειν (“panting and wandering of the mind”), and “asking for food”, τροφὴν αἰτοῦσι, so a mental weakness and a behavioural trait (82,15 Garofalo).

Caelius Aurelianus mentions two diseases that concern feeding excess, polysarkia and phagedaina. The second is found at Chr. Dis. 3.3.46–8 (De phagedaena, 704,20–706,22 Bendz), and is described as a “ravenous appetite for food … that the Greeks call orexin”, and a “desire to take a great deal at one time, so that they swallow it without chewing”; distress and vomit follow, with emaciation and a general feeling of weakness. This disease is cured through appropriate diet and purging; thus, the pathological appetite is considered entirely on a bodily level, for its gastric and nutritional consequences. Galen, however, offers testimony to a different and more complex picture of this illness. At Hipp. Epid VI 3.41 (xviib.108 K. = 182,15–183,2 Wenkebach) he states that “some call phagedainai the act of consuming overabundant food, which may also derive from bad humours … it is identified with such immoderate drives towards food by me too; however, for these bad humours the haemorrhoids are no cure; that is the case rather with melancholy”.23 The parallel with melancholy serves here to comment on the therapeutic effects of haemorrhoids as outlet for a humoral surplus; the association however suggests a non-localised, holistic framing for this pathology that derives from humoral state, just as is the case for the mental disease melancholia.

Polysarkia, described at Chr. Dis. 5.11.129–41 (‘De superflua carne, quam Graeci polysarkian vocant’, 932,11–938,30 Bendz) is the acquisition of too much flesh, and as such the opposite of atrophia (hoc passionis genus contrarium nutrimento cessanti) which, in Caelius, also entails immoderate hunger, but combined with inability to retain nourishment. With polysarkia the therapy is twofold: part of it has to do with withdrawing nourishment through diet; a second measure is aimed at “changing the body”, demutandi corporis causa. The latter entails aspects that we have encountered already in the treatment of atrophia, and that suggest mental relevance: passive exercises, reading aloud and vocal exercises “as in contexts of poetry or song”; the usual rubbing and massaging; the practice of various sports that involve ‘role-playing’ and mock battles (corycomachia, hoplomachia). All these appear to go beyond mere physical workouts to propose forms of mental diversion, as also does sun-bathing on the beach; “most important in this disease”, we read, “is to get the patient to apply himself intensively, indeed more so than it is necessary, to mental concerns and problems” (animi officiis sive curis applicatio). In fact, “it is because of this type of application that studious individuals generally have thin bodies, for they are continually sharpening their minds with thought and discussion (limatione quadam animi iugium cogitationum atque disputationum). For the opposite reason those who lead a lazy and inactive life generally have fuller and fatter bodies”.

These two clusters of diseases, one built around deprivation (food restriction and/or malabsorption) and one around surplus (excessive hunger, over-consumption of food, obesity) elaborate on the symptomatology, and descriptions of the fundamental dietetic imbalances, known to ancient medical writings from their early days. In these nosological sources, however, the sphere of nutrition and the drives and appetites that are associated with it are placed for the first time in the centre as problem, and not just as a vehicle towards a final objective—the sustenance of the body. In this framework, these pathologies are increasingly interrogated beyond their bodily localization in the gastric organs or their impact on the digestive system in our definition, and now include non-physiological aspects as fundamental parts of the therapy: in particular, the adoption of occupational-recreational strategies, and the advocacy of mental diversion, confirm the psychological component in these pathologies.

The Disease Stomachikon24

The signs we have observed so far are developed in full in the disease stomachikon, the most interesting and clear-cut instance of mental disease in the area of nutrition. Although the adjective (“stomachic”, “affecting the stomach”) is used by several late-antique (mostly medical) authors, this disease proper is discussed only by Aretaeus, among the texts we have; in this author, however, it receives such a level of detail that one is led to think it must have been more widely acknowledged than the available sources show; in confirmation of this, Plutarch seems to imply that the disease was well known, including in its mental aspect.25 All in all, however, a disease stomachikon does not seem to have become one of the ‘classic’ diseases in ancient medicine, and references in later authors remain sparse and derivative.26 Aretaeus’ long discussion leaves the question of which sources he might be relying on, or responding to, open and calls for consideration of the possible philosophical positions that appear to have clearly influenced him in this—in many ways—unique nosological description.

The first aspect of interest concerns the name, which is locatively formed: “affections27 concerning the ‘stomach’ ” / “patients suffering in the ‘stomach’ ” (we adopt this translation here, although it would be better to translate with “affections of the belly” more generally, avoiding anachronistic anatomical superimpositions). The stomach, says Aretaeus, has a prime power (δύναµις): it “is the leader of pleasure and disgust, being an important neighbour to the heart for imparting tone, good or bad spirits, from the sympathy of the soul” (στόµαχος ἡδονῆς καὶ ἀηδίης ἡγεµών· καρδίης καίριον γειτόνευµα ἐς τόνον καὶ θυµόν, ἢ ἀθυµίην, τῆς ψυχῆς ξυµπαθείῃ, 72,6–8 Hude).28 Pleasure and disgust are not intended simply as reactions in terms of taste, but have a full psychological framework: “the offspring of pleasure are, good digestion, good condition, and good colour of the body; those of disgust, their contraries, and also sometimes depression of spirits (ἀθυµίη), when proper nutrition is wanting; and, in melancholic patients, want of food”. Rejection, and loathing of food (µῖσος and ἀποστροφή τῶν γευµάτων) when the stomach is damaged, Aretaeus points out, do not only occur when food is administered, “but also if the food is not seen … the very remembrance (ἀναπεµπάζονται) is attended with nausea, distress (ἀπορίη), fluid excess (πλάδος) and heart-ache (καρδιαλγίη) …” (72,11–13 Hude). A role is thus assigned to the mental reaction to nutrition, what is usually called phantasia by philosophers; this can be as intense as the bodily reaction. Conditioned by these nauseous thoughts, in fact, patients tend to abstain from food, so that weakness and malaise follow; if they are forced to eat, on the other hand, they suffer in their mouth and digestive tract a terrible pain, worse than hunger, whenever they eat or drink, by the very act of chewing (πολλὸν κακίων ὅδε <ὁ> πόνος τοῦ λιµοῦ ἐν τῷ στόµατι λεῆναι ἄλγος, καταπιεῖν µέζων ὀδύνη, 72,16–18 Hude).

We have then a full mental syndrome developing out of this disgust towards any kind of food, ἀχθηδὼν ἐς πάντα καὶ φυγὴ καὶ µῖσος σιτίων:29

loathing, distress, sight dull, noises of the ears, heaviness of the head, torpidity of the limbs, their joints sink under them; palpitation in the hypochondriac region; a fictitious impression (phantasiē), as if the spine were being moved towards the lower limbs; they feel as if they were being moved around here and there, whether they stand, or lie down, like reeds or trees shaken by a gale of wind; they belch out a cold and watery phlegm. But in case there is bile in bilious persons, they have dimness of sight, and no thirst, although they appear to be thirsty);30 are sleepless, torpid, drowsy, not from true sleep, but like those in comatose affections; emaciated, very pale, feeble, relaxed, imbecile, dispirited, timid, inactive, quick to passion, very moody; for such persons at times have fallen into a state of melancholy.

ἄση, ἀπορίη, ὄψιες ἀµαυραί, ὤτων ἦχοι, βάρεα κεφαλῆς, νάρκη µελέων. καὶ τὰ γυῖα λύονται· παλµὸς ἐν τοῖσι ὑποχονδρίοισι· φαντασίη τῆς ῥάχιος ἐς τὼ σκέλεε κινευµένης. ἄλλοτε ἄλλῃ τῇδε κἀκεῖσε φέρεσθαι δοκέουσι, κἢν ἑστήκωσι, κἢν κατακέωνται, ὅκως ὑπὸ αὔρης ἀνέµων κάλαµοι, ἢ δένδρεα. φλέγµα ψυχρόν, ὑδαρὲς ἀποβλύζουσι· ἐπὴν | δὲ καὶ χολὴ ᾖ, πικρόχολοι, σκοτώδεες· ἄδιψοι, κἢν ἐπ’ ἐδέσµασι διψῆν δοκέωσι. ἄγρυπνοι, νωθροί, νυσταλέοι, οὐχ ὕπνῳ ἀτρεκέϊ, κωµατώδεσι ὁµοιοπαθέες, ἰσχνοί, ἔξωχροι, ἀσθενέες, ἔκλυτοι, λειποδρανέες, ἄψυχοι, δειλοί, ἡσύχιοι, ἐξαπίνης δ’ ὀργίλοι· κάρτα µελαγχολώδεες, καὶ γὰρ ἐξώκειλάν κοτε ἐς µελαγχολίην οἱ τοιοίδε (72,22–73,4 Hude).

Apart from the reference to a possible melancholic outcome, the description of the symptomatology is eminently mental, and well documented in classical medicine for a variety of mental patients:31 not only bodily signs such as faintness or comatose weakness, but also hallucinatory fantasies and moral alterations, and character changes: ἄψυχοι, δειλοί, ἡσύχιοι, ἐξαπίνης δ’ ὀργίλοι. These mental facts are all caused by the sympathy between soul and stomach, it is specified: τάδε µέντοι τῆς ψυχῆς, τοῦ στοµάχου ἐνδιδόντος, εἶναι δεῖ τὴν πάθην—although someone misunderstands the stomach as their cause: the proximity between stomach and heart—the latter regarded by Aretaeus as the centre of mental life—determines the co-affection.

In line with his adoption of the plural to label the topic of this chapter—‘the stomachic affections’, ‘the stomachic patients’, Aretaeus adds that there are innumerable possible causes to this disease (αἰτίαι δέ τῆς νόσου και ἄλλαι καὶ µυρίαι, 73,11–12 Hude) besides the expurgation of pus through the stomach: here, as in the cases of atrophia and polysarkia, the acknowledgement of multiple aetiological possibilities alerts us to the mental implication of the ailment. It is precisely among these multiple causations, in fact, that Aretaeus inserts a unique picture of “familiarity”, or predisposing factors (ξύνηθες), constructing effectively a characterful depiction of an ethical and social type, the philosopher or student who devotes all of himself to intellectual life, shunning human relations and physical pleasures. What emerges from this portrayal are factors that appear to be causal, but also a detailed description of the illness in its manifestation:

[the disease] is familiar (ξύνηθες) to such persons as from their necessities live on a slender and hard diet; and to those who, for the sake of education (ἐς παιδείην), are laborious and persevering; whose portion is the love of divine science (θείης µὲν µαθήσιος ποθή), along with scanty food, want of sleep (ὀλιγοσιτίη δὲ καὶ ἀγρυπνίη), and the meditation on wise sayings and practices (µελεδώνη λόγων τε καὶ πρηγµάτων σοφῶν)—people who have a contempt for (ὑπεροψίη) a full and multifarious diet; to whom hunger is for food, water for drink, and watchfulness in place of rest; to whom in place of a soft couch, is a hammock on the ground without bed-clothes, a mean coverlet, a porous mantle, and the only cover to whose head is the common air; whose wealth consists in the abundant possession and use of divine thought (πλοῦτος δὲ ἐννοίης θείης περιουσίης τε χρῆσις) (for all these things they account good from love of learning, ἔρωτι παιδείης); and, if they take any food, it is of the most frugal kind, and not to gratify the palate, but solely to preserve life; no consumption of wine to intoxication; no pleasurable recreation (θυµηδίη); no roving or jaunting about; no bodily exercise nor plumpness of flesh; for what is there from which the love of learning will not allure one? from country, parents, brothers, oneself, even unto death. Hence, to them, emaciation of the frame; they are ill-complexioned; even in youth they appear old, and obtuse in understanding (ὑπ’ ἐννοίης κωφοί); in mind cheerless and inflexible (ψυχὴν δὲ ἀµειδέες, ἀµείλιχοι); through a depraved appetite, speedy satiety of the accustomed slender and ordinary food (στοµάχου δὲ κακοσιτίῃ ταχὺς ὁ κόρος τῆς ξυνήθεος), and from want of familiarity with a varied diet, a loathing (ὄκνος) of all kinds of food (πάντων γευµάτων); for if they take any unusual article of food, they are injured thereby, and straightway abominate (ἀπόστροφοι … ἐς πάντα) food of all kinds. It is a chronic disease of the stomach (73,13–31 Hude).

There is almost a touch of parody in this description, a unique occurrence in the medical texts; one is reminded of the famous (and also exceptional) ethical description of the melancholic in Problemata 30.1, where the patients affected by this disease are from the very beginning associated with extraordinary intellectual qualities;32 what we have here, however, is a far more extreme, and definitely derogatory version of this portrayal, in which being laborious and persevering, frugal life, and love of science degenerate into misanthropy and bitterness, and cause, paradoxically, dullness of the intellect: “even in youth they appear old, and obtuse in understanding; in mind cheerless and inflexible” (ἄχροοι καὶ ἐν νεότητι γηραλέοι καὶ ὑπ’ ἐννοίης κωφοί, ψυχὴν δὲ ἀµειδέες, ἀµείλιχοι, 73,26–27 Hude).33

This ethical-characteriological profile—aside from its possible humoristic overtones in the sketch of the obsessive over-serious and joyless scholar—is perhaps the first full psychiatric personality profile that has reached us from ancient medical literature. Predisposition, lifestyle, puritanical inclinations and an inflexible will are associated to a certain psychological character and a precise organic pathology. Aretaeus, it is true, concludes his account with a simplifying “it is a chronic disease of the stomach”, ἥδε ἐστὶ στοµάχου χρονίη νοῦσος; the reader, however, has received much more information on the ethics and personality of these sufferers than about their gastroenteric health. The therapeutics indicated by Aretaeus at Th. Chr. Dis. 2.6 (165,5–22 Hude) confirm the holistic approach to the disturbance: “however, in the case of the stomachic patients only (165,7 Hude, στοµαχικοῖσι δὲ µούνοισι)”, it is said, the cure should not be restorative of forces through diet (δίαιτα ἐς ἰσχὺν καὶ κράτος τοῦ σώµατος), but rather focus on “passive exercise, walks, gymnastics, the exercise of the voice (165,8–9 Hude, αἰώρη, περίπατοι, γυµνάσια, φωνασκίη), and food of easy digestion”; and again, “in these cases, more than usual (πολλὸν … µέζον, 165,11 Hude) the patient should be indulged with pleasant things, and everything done towards them in a clean/smooth way, the physician gratifying their desires” (165,11–13 Hude, πολλὸν δὲ µέζον ἐπὶ τουτέων ἔστων αἱ τοῖσι κάµνουσι χάριτες καὶ τὸ καθαρῶς ἅπαν δρῆν καὶ τῇσι ἐπιθυµίῃσι ἕπεσθαι τὸν ἰητρόν). Aretaeus regards certain measures to be appropriate only, or especially to these patients as they are suffering from an illness that exceeds the gastric sphere and appears to necessitate careful tending to the desires and subjectivity of the patient.

In summary, on the one hand the stomachikon is not categorized as a mental disease in any concrete way. If we compare it to the discussions of mania, or melancholia, in Aretaeus, it is clear that a mental quality is not stated here upfront as substantial to the disease. Mania, he says, is a form of “ecstasis”, ἔκστασις … ἐστι τὸ ξύµπαν χρόνιος, Chr. Dis. 1.6 (41,13 Hude); melancholia is described clearly as affecting the mind, ξυντρέπει … τὴν γνώµην, Chr. Dis. 1.5 (39,16 Hude). For stomachicon, he emphasizes that “it is a chronic disease of the stomach”. Nonetheless, the manifestations he cites as “stomachic” are traditionally mental, just as the psychology of the patient he elaborates belongs prominently to the make-up of the disease. The remarks about pleasure, pain and disgust, the morbid aberration of will, and the mental implications of all these, finally, framing the discussion leave no doubt to the fact that this disease, apart from its gastric relevance, is also mental and considered in a comprehensive psychological sense.

‘Fear of Water’

As Polito illustrates, pleasures, drives and restraint are philosophical themes on which a tension between medicine and philosophy remained unresolved still in the late-antique period. Polito focuses on another nosological example relevant to our analysis, that of hydrophobia—‘fear of water’—also a disease which, according to Plutarch was only mistakenly regarded as ‘a new one’.34

The earliest attestation of hydrophobia is possibly found in Celsus (5.27.1, 231,8–21 Marx), who discusses it only briefly, and without naming it. He says, discussing the bites of wild animals, that those of mad dogs are especially dangerous if left uncleansed:

… but when too little has been done for such a wound, it usually gives rise to a fear of water (the Greeks call this hydrophobia), a most distressing disease, in which the patient is tortured simultaneously by thirst and by dread of water. In these cases there is very little help for the sufferer. But still there is just one remedy, to throw the patient unaware into a water tank which he has not seen beforehand. If he cannot swim, let him sink under and drink, then lift him out; if he can swim, push him under at intervals so that he drinks his fill of water even against his will; for so his thirst and dread of water are removed at the same time. Yet this procedure incurs a good danger, that a spasm of sinews, provoked by the cold water, may carry off a weakened body. Lest this should happen, he must be taken straight from the tank and plunged into a bath of hot oil. But as an antidote we should give especially the one which I put first, when that is not at hand, another; it is to be given in a draught of water, if the patient does not dread water yet; and if the bitterness is objected to, honey is to be added; if dread of water has already seized him, the antidote can be swallowed as a pill.

This discussion places in the foreground the flawed intention and the distorted taste of patients, which were observed also in the pathological behaviour with regard to water of the Hippocratic patients, although never identified with a free-standing disease. Based on these testimonies both Plutarch, who says that indeed the disease always existed, and Anonymus Parisinus (12,85–89 Garofalo), who claims that “the ancients did not mention the affection”, are right in some respects. ap, in his discussion of hydrophobia, identifies it not by its aetiology, the bite—as Celsus does—but by its symptomatology, first and foremost fear of water (δεδοικάσι, 20.2.1 = 85,27 Garofalo). There is “trembling, terror, cold sweats, chattering teeth” in the presence of liquids or only through thinking of them, and later even without thought being involved (χωρὶς ὑγροῦ φαντασίας, 86,3 Garofalo). The sound of liquids, or any sudden cry cause intense aversion: ἀλλοτριοῦνται … δεδοίκασι … βαρύνονται (“they feel revulsion” … “they are afraid” … “they are vexed”, 86,3–4 Garofalo). There seems to be a struggle between loathing of drink and intense desire for it (22.2.3, 86,12–14 Garofalo), a paradoxical feature of drinking disturbance noticed in earlier medical sources too.35 Despite all other aspects—fever, distorted imagination and often alterations of thought—what appears to be at the core of this disorder is a pathological modification of will and taste: a normal drive is denied, there is ambivalence towards a primary human need, in concomitance with distorted strong urges.

The chapter devoted to the disease by Caelius Aurelianus’ (Acut. Dis. 3.9–11.98–106, ‘Hydrophobia’ (350,1–356,3 Bendz) is by far the most instructive, and brings together several key themes in the wider debate about the formation of ancient mental diseases.36 Caelius’ discussion of hydrophobia is also extraordinarily long. The discussion of the disease gives Caelius the chance to pose seminal questions: first, the interface between volition, drives, incontinence and ethical aspects; second, the interface in turn between these and the cognitive-rational faculties; thirdly, their relation to bodily etiology and symptomatology; finally, the verdict about utrumne animae an corporis passio sit hydrophobia, “whether hydrophobia is a disease of the soul or of the body” (13, 356,21–358,17 Bendz), and as a consequence the domain of action of the doctor or of the philosopher.

Although the disease’s symptoms of fear of, or mad attraction to, water were described by the Hippocratics too, it is only with the nosological authors that this pathological emotion becomes such a strong marker. Already ap describes the strong fear that can be aroused even by mere recollection of liquids (ὥστε καὶ µνησθέντες, 84,27 Garofalo), with tremors and terror. As the disease intensifies, fear emerges also without imagining (χωρὶς ὑγροῦ φαντασίας); there are screaming, agitation, howling and stress. Caelius opens his discussion by foregrounding the loathing and fear of water as the obvious marker, agnitio hydrophobia (Acut. Dis. 3.10.101, 352,5–7 Bendz): appetentia vehemens atque timor potus sine ulla ratione ob quandam in corpore passionem. The portrayal (3.11.102–3, 352,15–353,24 Bendz) is lively, with characterful details: the patient ‘does not drink’ and ‘can scarcely endure rain, which disgusts and nauseates him’ (taedium et recusatio imbrium). As the disease progresses, desire and fear escalate (appetentia … atque timor) and are aroused by the noise alone, or even by the mention of water, and later by any newcomer, for fear they might be carrying water—a reference to the phantasia of drinking and liquids, but also to a more complex pathological state that one might nowadays describe as having paranoid elements.37 Pathology affects imagination and reasoning in this way too; drive and self-restraint are however the central topic, as shown by the clinical examples Caelius selects from other authors: he quotes Soranus on a patient who would even exhort himself to drink water, but in vain—his fear and repulsion were stronger than his rational awareness and sound intention; Eudemus’ horror of his own tears; and Soranus’ baby who shrank away from his mother’s breast: in all these the perversion of an instinct and the deformation of a basic drive to pleasure are posited as the raw stuff of the disease.

These are followed by other impairments: at the very start (3.11.102, 352,16–17 Bendz) we read that the patients suffer anxietas quaedam sine ulla ratione, atque iracundia et corporis difficultas in solitos motus, besides the core phobic symptom. The similarity to other types of mental disturbance is exposed clearly by Caelius, as at 3.12.107 (356,5–20 Bendz) he discusses the differential diagnosis of hydrophobia against mania, phrenitis and melancholia. This fact is important in itself, as it reveals clear awareness of an implicit category ‘psychiatric’, with our definition, to which one might want hydrophobia to belong (although Caelius disagrees); in addition, Caelius mentions parallel examples of recognized phobias, such as ‘aerophobia’ (fear of light and darkness, he explains) and even ‘pantophobia’ (omnipaves), ‘fear of everything’: the hydrophobics are a more restricted group, insofar as their symptom only concerns liquids; nonetheless, the writer is obviously aware of a category of phobic symptoms that may afflict patients.

Caelius’ verdict (3.13.111, 358 Bendz) that hydrophobia should be a disease of the body since its cause—the animal bite, or a humoral imbalance—is rooted in the body does not, of course, change in the least the relevance of this illness to the mental sphere, and possibly further testifies to a debate about mental diseases that fall under the care of the philosophers, and those diseases of the mind that the doctors are still the most qualified to cure.38 The differential discussion testifies to this, as does the importance assigned to cognitive impairment and pathological imagination; especially, to the pathology of volition and taste as indicators of health.

Conclusions

All our examples have illustrated a thematisation of the basic drives to food and drink as possible areas of deviation, declined differently in different pathologies and variously elaborating on clinical accounts preserved by previous medical authors, with their descriptons of drinking disorders or variations in ἀσιτίη in the portrayals of certain mentally ill patients. A shift in later medicine is noticeable whereby these become important players in discussions of mental health, emphasizing a normative, moral idea of mental soundness, of which a proper perception of one’s drives, and control over them, become a fundamental part. For example, Aretaeus’ remark on mania (Chr. Dis. 1.6, 42,4–5 Hude), that “the diet that disposes to [it] is associated with voracity, immoderate repletion, drunkenness, lechery, venereal desires”, traces an ethical make-up that characterizes a category of mental patients, within which lack of restraint towards sex and food play a role.

This development will be very productive as far as the history of Western conceptions of mental health and disorder is concerned. Most notably, many aspects of Christian ideals of spiritual purity and fortitude are consonant with this particular direction in medical ideas about the mind and mental soundness; and I shall quote only one example to illustrate, by way of conclusion, the intellectual and philosophical associations promoted by this view, and their relevance to the ‘history of madness’ at the turn of the late-antique period. The example comes from The Miracles of Saints Cyrus and John (Th.) by Sophronius, a Christian author of the seventh century and bishop of Jerusalem. In his collection of the miracles performed by the two saints, where healing and medical imagery play an important role,39 we find also an illuminating discussion of voluntariness and pathology with particular reference to the health of the soul. At Th. xiv, Miracle 16, 2–3 Sophronius has just discussed how one should feel shame for the flaws of his soul, not of his body, as the latter are sent by god; and he goes on to differentiate between τὰ τῶν νοσήµατων ἀκουσία, “diseases which are independent from one’s will”, and concern the body; and τὰ … ἑκουσία καὶ γνώµης ἡµετέρας κυήµατα, ὅσα ψυχῃς αὐτεξουσίου καὶ νοερᾶς τὸ κάλλος λυµαίνεται, “voluntary diseases and offspring of our own mind, which defile the beauty of our soul, which is endowed with reason and free-will”. This brief definition encapsulates a worldview, and a view of human agency that is completely unimaginable in the tradition of Graeco-Roman medicine, not only if we consider it in its materialistic and perhaps ‘deterministic’ earlier foundations but also if we turn to its philosophical engagement with ethical themes and responsabilities (as, notably, in Galen).40 No-one within that medical tradition ever went as far as spelling out the possibility of a ‘voluntary’ pathology,41 a form of corruption of the will that is in itself a disease and worthy of professional attention; the discussions of food (and sexual life, in the next chapter) in the authors discussed here represent however a step in that direction.42

Of course, we are not proposing that Sophronius is here using the expression literally; rather, he employs the concept of ‘disease’ as a trope in the service of his project of religious edification. And yet, it is the interest in the interplay between aspects of volition, desire, and mental health, gradually incorporated by medical literature, that allows the viability of this medical trope and its application to the realm of mental and spiritual flourishing. The problematisation, and pathologisation of eating and drinking and experiences of the individual as moral agent and psychological subject, and not only as physiological entity, offer us a telling example of the medical history of mental diseases towards the end of the ancient world.

I would like to thank the Alexander von Humboldt Stiftung which financed my research for this chapter and the Wellcome Trust for its support in the final stages of revision; the audience at the workshop where it was first presented; Philip van der Eijk for his help and support.

I have labelled these ‘eating disturbances’ for the purpose of our discussion, without any retrospective identification of these experiences with current psychiatric taxonomies of eating disorders. By ‘mental’ I refer primarily to the ancient categorisations of pathological behaviours under disturbances of the mind variously labelled as forms of ‘madness’ (i.e., using vocabulary of mental disorder: see Thumiger, ‘The Early Greek Medical Vocabulary of Insanity’, in Harris, W. V. (2013) Mental Disorders in the Classical World, 61–95, for a survey) or in continuity with them; moreover, their relevance to psychopathology can be easily appreciated by modern readers too, as we shall see. For a discussion of the psychology of eating patterns in classical medicine see Thumiger, C. (2017) A History of the Mind and Mental Health in Classical Greek Medical Thought, 188–228.

In his cultural-historical discussion (1986. The Use of Pleasure, volume 2 of The History of Sexuality, 109–116, esp. 114) Foucault does mention food, emphasising a much less intense preoccupation, in classical personal morality, with its consumption and enjoyment than with sex in support of his own focus on sex and sexuality as the most loaded experience. Foucault refers especially to Xenophon, Plato and Aristotle to corroborate his thesis. Apart from the overstatement of certain sexual themes (see Nussbaum, M. C. (1985) ‘Affections of the Greeks’, New York Times Book Review 2,10.11, 13–14, Lloyd, G. E. R. (1986) ‘The Mind on Sex’, The New York Review of Books 13.3) the absence of the complementary discussion of food in late antique medicine appears to be a major fault in the picture: attention to the element of voluntariness in the experiences of appetite and its variations, in fact, is also noticeably absent from classical medicine, despite the topos of frugality cherished by earlier philosophical discussions, and Aristotle’s discussion of akrasia as impairment in strong medical terms in Eth. Nic. 7. (Flawed) desires are increasingly thematised in ethical discussions by Hellenistic and later philosophers as expression of a ‘disease of the soul’ and later attract the scrutiny of medicine (although the division between these two spheres remains an uncomfortable one: see Polito, R. (2016) ‘Competence Conflicts between Philosophy and Medicine: Caelius Aurelianus and the Stoics on Mental diseases’, Classical Quarterly 66, 1; we shall not however engage with the philosophical discussion of desires, pleasure and pain from Democritus onwards). I argue, here and in my chapter on satyriasis in this volume, that sex and food are in fact very similar cases, in which what is at stake is not sex specifically but the prominence gained by voluntariness, desires and drives in the definition of human (mental) life and health in the first centuries of our era.

For a complementary perspective see Laes, C. (2016) ‘Writing the History of Fatness and Thinness in Graeco-Roman Antiquity’, Medicina nei secoli. Arte e scienza 28.2, 583–658, an extensive exploration of the concepts of fatness and thinness in the ancient world and of the systems of values implied by them.

See dsm 5 (2013) 329–54: ‘avoidant/restrictive food intake disorder’, ‘anorexia nervosa’, ‘bulimia nervosa’ and ‘binge-eating disorder’.

See Tacchini, I. ‘Physiologie et pathologie de la nutrition dans la Collection hippocratique’, in Thivel, A. and Zucker, A. (2002) Le normal et le pathologique dans la collection hippocratique: actes du Xème colloque international hippocratique, 483–98 on nutritional processes in the Hippocratics and their disruptions.

See Bartoš, H. (2015) Philosophy and Dietetics in the Hippocratic on Regimen. A Delicate Balance of Health on Regimen and ancient dietetics, and among previous studies Wöhrle, G. (1990) Studien Zur Theorie Der Antiken Gesundheitslehre; King, H. (2005) Health in Antiquity.

See recently Wolfsdorf, D. (2013) Pleasure in Ancient Greek Philosophy. Key Themes in Ancient Philosophy; Cheng, W. (2015) Pleasure and Pain in Context: Aristotle’s Dialogue with his Predecessors and Contemporaries.

Trans. Rackham.

The categorisations of (bodily) desires as moral passions and examples of mental pathology located in an area of overlap between philosophy and medicine will be most fully developed by the subsequent philosophical tradition, especially Stoic, on which see Gill, C. (2010) Naturalistic Psychology in Galen and Stoicism; Ahonen, M. (2014) Mental Disorders in Ancient Philosophy, 103–231; and, most to the point of the ‘conflict of competence’ between philosophy and medicine in this respect, Polito, ‘Competence Conflicts’, 358–69.

Diocles also wrote on dietetics and regimen, under the title ῾Υγιεινὰ πρὸς Πλείσταρχον and ᾿Επιστολὴ προφυλακτικὴ πρὸς ᾿Αντίγονον (see van der Eijk, P., 2000–2001. Diocles of Carystus. A Collection of the Fragments with Translation and Commentary , vol. 1, xxx–xxxii for a list); at the turn of the first century ce Rufus stresses the importance of all aspects of eating and drinking among the questions of his Quaestiones Medicinales 201,16–26 Gärtner, referring to them as well-known key topics (on this work, see Letts in this volume).

Thumiger, C., History of the Mind, 204–13.

Whose drives and desires seems to be compromised on many levels: βόρος τῶν σιτίων µᾶλλόν ἐστιν ἢ ὑγιαίνων, καὶ λύχνου ἀπεσβεσµένου τῇ ὀσµῇ ἥδεται, καὶ ἐξονειρώσσει θαµινά, “he has greater hunger than when he was healthy, takes pleasure in the smell of the extinguished lamp and has frequent wet dreams”.

By this name goes the only surviving Greek text—alongside that of Aretaeus—‘on acute and chronic diseases’. Anonymus Parisinus takes its name from its sole complete ms, held in Paris; it is dated (with some uncertainty) between the first and second century ce.

Aretaeus, Chr. Dis. 2.6, Περὶ στοµαχικῶν (72,6–74,2 Hude, trans. Adams, 347–50). Aretaeus of Cappadocia (second century ce) was one of the most celebrated ancient physicians—Galen’s silence on him perhaps testifies to this—and has been traditionally ascribed to the Pneumatic sect or qualified as eclectic. He left two treatises, On Chronic Diseases and On Acute Diseases, and two treatises for the therapeutics of each respectively. His discussions and descriptions of diseases and symptoms are erudite and rich in details, and he is a talented writer at that—see Deichgräber, K. (1971) Aretaeus von Kappadozien als medizinischer Schriftsteller; Kudlien, F. (1964) Untersuchungen zu Aretaios von Kappadokien; Nutton, V. ‘Aretaeus’, in dnp i (1996), 1051–52.

Caelius Aurelianus of Sicca, Numidia was a Methodist doctor and medical author, active in the fifth century ce. His major On Acute Diseases and On Chronic Diseases preserve a great number of references to past medical authors, and in particular he is regarded as a fundamental source for Soranus’ lost treatise of the same name.

Aretaeus, Chr. Dis. 2.6, ‘On Stomachicon’ (72,6–74,2 Hude, trans. Adams 347–50); Anonymus Parisinus 11 ‘Boulimos’ (80,21–84,10 Garofalo); 12, ‘Hydrophobia’ (84,11–88,20 Garofalo); 30, ‘Atrophia’ (162,21–166,10 Garofalo); Caelius Aurelianus, Chr. Dis. 3.7.90, ‘De nutrimenti cessatione, quam atrophian Graeci vocant’ (732,20–736,13 Bendz); Chr. Dis. 5.11.129–41, ‘De superflua carne, quam Graeci polysarkian vocant’ (932,11–938,30 Bendz); Acut. Dis. 3.9–11.98–106, ‘Hydrophobia’ (350,1–356,3 Bendz).

The label ‘mental’ is here retrospective, and to be taken as a demonstrandum: these are not consistently labelled as “mental diseases”—morbi animae, or νόσοι τῆς ψυχῆς—indeed, in one instance precisely the opposite is the case (Caelius Aurelianus on Hydrophobia), as we shall see.

See the first section of his Hipp. Prorrh. I and the disease phrenitis; see above in the introduction, pp. 1–5.

See Polito, ‘Competence Conflicts’, 15–16 on the debate about the definition of mental disease in Galen’s time; Singer and Devinant in this volume.

διαχύσις τῆς ψυχῆς as a ‘relaxation’ or a ‘spreading’ of the soul is found in a materialistic sense in Epicurean contexts; medically, such ‘relaxation’ is a Methodist concept, and in connection with ψυχή it is used by Soranus, Gyn. 1.25 to comment on the care for the pregnant patients afflicted by pica, the desire to eat non-edible foods: various exercises and occupations are recommended, and ‘generally to divert the mind’, πᾶσα ψυχῆς διάχυσις; at Gyn 3.16.4, the same is prescribed to regulate menstruation, and at 2.28.2 in cases of interruption of lactation when disease is not the cause (so, again, in the presence of a cause other than a purely physiological blockage): “relaxing exercises, walks, rubbing, holding the breath and ψυχῆς διάχυσις”.

On occupational and philosophical therapy for mental disturbance in ancient thought see Gill, C. ‘Philosophical Therapy as Preventive Psychological Medicine’, in Harris, W. V. (2013) Mental Disorders in the Classical World, 339–60, as well as his chapter in this volume.

Nonetheless, ap quotes Hippocrates, Praxagoras, and Diocles as his sources on this disease. In the sections devoted to the causes of diseases this author offers doxographical surveys of the previous tradition which are often unreliable from a historiographical point of view; he tends to project his contemporary categories onto what are for him ‘the ancients’. ἀτροφίη is one such case (see van der Eijk, P., ‘The Anonymus Parisinus and the Doctrines of “the Ancients” ’, in van der Eijk, P. (1999) Ancient Histories of Medicine: Essays in Medical Doxography and Historiography in Classical Antiquity, 295–331 on this aspect). On the name boulimos, I follow Garofalo ad loc., 81, who includes Erasistratus’ mention of bulimia in Περὶ διαιρέσεων, fr. 283. Cf. ps.-Arist., Pr. 8.9 for the verb βουλιµόω; Asclepiades (Cael. Aur., Acut. Dis. 1.107), item bulimum magnitudine viarum stomachi atque ventris fieri sensit; Rufus, frr. 191 and 193 Daremberg-Ruelle.

τινές γε µὴν ἤκουσαν φαγεδαίνας τὰς τῶν πολλῶν βρωµάτων ἐδωδάς, ἃς καὶ αὐτὰς ὑπὸ κακοχυµίας γίνεσθαι *** ἀµέτρους ὀρέξεις σιτίων ὁµολογεῖται καὶ πρὸς ἡµῶν, οὐ µὴν τοιαύτης γε κακοχυµίας ἄκος εἶναι τὰς αἱµορροΐδας, ἀλλὰ τῆς µελαγχολικῆς µᾶλλον.

On this disease see also Lami, A. (2003) ‘Areteo e i delicati di stomaco (iv 6, 2)’, Filologia Antica e Moderna 24, xiii, 5–10.

Quaestiones convivales 612c–748d: Plutarch is discussing elephantiasis and hydrophobia, diseases—he reports—some regard as ‘new’ for lack of explicit mention by previous medical authors. Plutarch disagrees and claims that they must have always existed: “… nor is the water-dread (hydrophobia) distinguished from other melancholic and stomachical affections (τῶν στοµαχικῶν ἢ µελαγχολικῶν) but by degree”—which seems to suggest that the latter two categories are both traditional, and share with hydrophobia a mental quality.

Cf. Paul.Aeg., 3, 37, 3, 4, where it seems unclear whether a disease proper is being discussed: πρὸς δὲ τοὺς µὴ κατέχοντας τὴν τροφήν, οὓς ἰδίως οἱ παλαιοὶ στοµαχικοὺς ὀνοµάζουσιν, “whom the ancient call stomachic”; Epictetus, Dissertationes ab Arriano digestae 3.21.2.1, where a category of people who do not retain food and vomit are called “stomachic”: ὃτι τὰ θεωρήµατα ἀναλαβόντες ψιλὰ εὐθὺς αὐτὰ ἐξεµέσαι θέλουσιν ὡς οἱ στοµαχικοὶ τὴν τροφήν; ps.-Galen, De remediis parabilibus libri iii 14, 559, 1 K. recognises the pathological category [Πρὸς στοµαχικούς], as does Oribasius, Ec. Med. 43t2, according to whom too the disease was known to “the ancients”: Πρὸς τοὺς µὴ κατέχοντας τὴν τροφήν, οὓς οἱ παλαιοὶ ἰδίως στοµαχικοὺς προσηγόρευον.

It is not an individual disease he describes here, but apparently a cluster of affections in a certain area concerning the gastric location, nutrition, and attitudes to food.

On the association of the stomach with the soul and mental life, especially in pathological contexts see Galen’s discussion with reference to Diocles (fr. 109 vdE) in Loc. Aff. 3.9–10 (viii.185–190 K.), on the ‘hypochondriac’ type of melancholia (see however van der Eijk, P. ‘Melancholia and “Hypochondria”—Steps in the History of a Problematic Combination’, in Cazes, H. and Morand, A.-F. (2015) Miroirs de la Mélancholie/Mirrors of Melancholy, 16 for a reassessment of Diocles’ ideas in this passage); Rufus FF38–41 Pormann also on the ‘hypochondriac type of melancholy’. On the topic, van der Eijk, ‘Melancholia and “Hypochondria”‘, 22.

Lami in ‘Areteo’, 5–7 explicitly acknowledges the mental aspect of this disease.

Or: “they feel thirsty upon eating food”.

Thumiger, History of the Mind, 71–173.

See Kazantzidis, especially pp. 37–38 in this volume on this topos.

Almost reverse evidence on this topic is found in Caelius Aurelianus, who refers to the thinness of philosophical students (in his discussion of polysarkia, 5.129–41, 938,25–28 Bendz): studentium corpora fieri tenuiora … and on the contrary eorum … qui segni ac pigro ductu vitam trahunt solidiora atque pleniora fieri corpora.

See above p. 258 n. 25. Indeed, much of the symptomatology of this disease is found in various Hippocratic patient cases. The point is explored at length by Caelius Aurelianus, Acut. Dis.; here he poses the question utrum nova passio sit hydrophobia, to answer it strongly in the negative (3.13 =356,21–358,17 Bendz). The retrospective interpretation of ancient accounts of hydrophobia through the biology and epidemiology of the viral disease rabies, largely legitimate in my view, is irrelevant here; it is the emergence of a representation of ‘fear of water’ as a free-standing disease that is at stake.

See Thumiger, History of the Mind, 216–19.

On hydrophobia in Caelius Aurelianus see also Urso in this volume p. 292.

A similar sign is associated by Aretaeus with certain manic patients: “[the patients affected by mania] are also given to extraordinary forms of imagination … one will not drink, as fancying himself a brick, and fearing lest he should be dissolved by the liquid” (Chr. Dis. 1.6, 42,18–20 Hude).

Again, see Polito, ‘Competence Conflicts’ on this.

I thank Wolfgang Häfele for signaling this passage to me; on medicine and medical motifs in the work of Sophronius see his doctoral work (forthcoming, 2018).

See Devinant and Singer in this volume, 198–221; 381–420.

See my chapter on sex (next, 280–83) on the malthakoi in Caelius Aurelianus, perhaps the only example of ‘voluntary disease’ we can find in the medical tradition—however, exceptional in its unique categorization as ‘disease of the soul’ by Caelius; see 283 n. 35 on the term volentes with reference to these patients.

Here, and in the next chapter, I limit my discussion to the medical tradition, which is the subject of the present volume, thus considering only briefly discussions such as Aristotle’s account of ἀκρασία in Eth. Nic. 7.1–11, which consider voluntariness and responsibility as elements that can be pathologised, but not in a medical frame.

Mental Illness in Ancient Medicine

From Celsus to Paul of Aegina

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