Saturday, April 11, 2009

2009.04.36

Version at BMCR home site
Susan P. Mattern, Galen and the Rhetoric of Healing. Baltimore: Johns Hopkins University Press, 2008. Pp. x, 279. ISBN 9780801888359. $55.00.
Reviewed by Shelley Reid, University of British Columbia

Susan Mattern's monograph on Galen of Pergamum is perhaps slightly mistitled: she may have been more justified in replacing the phrase "the rhetoric of healing" with "the narratives of healing," since the focus of her work is a close examination of the medical narratives found in the writings of Galen. This opening quibble about the title, however, is just that: a very minor criticism of a work which successfully renders an interesting and readable portrait of the varied complexities of the social aspects of ancient medicine. Mattern's work is not, as she rightfully stresses, a book about medicine; it is rather a detailed picture of the place and role of the physician in Greco-Roman society of the second century, one produced by drawing upon the admittedly subjective, but nonetheless valuable, evidence of its most famous medical practitioner.

As any researcher who has approached the works of Galen can attest, the sheer volume of his writings can be both immensely exciting and rather intimidating (Vivian Nutton has estimated that the Galenic corpus accounts for almost ten percent of extant Greek literature up to 350 AD).1 Galen's writings have of course been frequently mined by historians of medicine, who are looking for a greater understanding of the medical theories and practices of the classical world, both those of Galen himself and those of his rivals, whom he frequently excoriates. Mattern, for her part, narrows in on those sections of Galen's work which she reasonably equates with the modern medical case history: the narrative account of the patient and his (only occasionally her) presenting symptoms, the diagnosis and prognosis offered, the therapeutic actions taken by Galen and others, and the outcome of these actions. (An appendix is very helpfully supplied, in which is listed all of the narratives to which Mattern makes reference. This is not an all-inclusive list of the narratives to be found in Galen's writing, for she excludes the Hippocratic case histories to which Galen refers and those which are clearly hypothetical or which do not pertain to a particular individual.) Galen's narratives do not always include all of the elements of a case history; now and then, for example, he will fail to include the outcome of a case, which is the sort of detail likely to frustrate the modern reader. Mattern contends, however, that Galen often wrote with more than one aim in mind: on most occasions he employs narrative to display or convey his medical knowledge, but on other occasions his purpose is far more obviously literary or social, and sometimes two or three motives are evident in a given narrative.

The value of medical narrative as social and cultural evidence has long been noted by both anthropologists and historians, but Mattern is the first, to my knowledge, to place Galen's medical narratives in this particular spotlight. Medical narrative has a long tradition in the ancient world; Mattern cites not only Hippocrates' Epidemics (for which Galen himself wrote commentaries) but also works as varied as those of Aelius Aristides and the votive inscriptions offered to Asclepius and other gods of healing. The fact that Galen's narratives lack the sort of precision and regularity which modern medical case histories contain is duly noted by Mattern; she argues, however, that while these passages from Galen may be of dubious quality as historical or even medical documents (and she wisely eschews the practice of retrospective diagnosis in these narratives), it is precisely their anecdotal and subjective quality which renders them valuable as evidence of Galen's own perception of his position and status as a physician within his society, from which one can draw further inferences about his society at large.

The bulk of the first chapter is taken up by a more general discussion on medical narrative and its place in Galen's writings. This is accompanied by a brief but useful overview of the demographics of disease, both urban and rural, in the Roman empire, as well as some biographical background on Galen himself. The second chapter seeks to provide some temporal and spatial context for the narratives; this is a daunting task, as the evidence from Galen's narratives is sparse, but Mattern does well with the limited material with which she is working. Most notably, she argues that the vagueness of Galen's references to time and space implies a close connection between the writer and his audience, which she identifies as being composed of not just his fellow physicians but also of the pepaideumenoi, that class of educated men who considered a grasp of medicine an important aspect of their education.

This audience of physicians and fellow pepaideumenoi plays a crucial role in Mattern's third chapter, in which she outlines the strongly agonistic aspect of ancient medicine. Medicine was an activity which was highly competitive (and almost exclusively masculine) in nature; the practice of medicine was a social, often even a public, event, not the private and closeted activity of today. Mattern sets Galen's writings upon the broader canvas of the Second Sophistic (and thus, no doubt, her titular reference to rhetoric). The physicians of Galen's day not only competed with each other at the patients' bedsides, but also readily participated in the rhetorical and competitive performances -- medical debates, demonstrations, dissections and lectures -- to an audience which came to cheer or jeer, depending upon their loyalties and the persuasive efforts of the competitors. These public performances might occur in front of an audience of a half dozen (in the sickroom, for example) or of sufficient numbers to fill a theatre, but Mattern notes that whatever the venue, victory was predicated upon a therapeutic outcome, a purely intellectual exercise of diagnosis and prognosis, or a verbal debate, or at times upon any combination of these elements.

Mattern's account of this competitive aspect of ancient medicine is well done, but it is in the final two chapters that the book takes full shape and becomes most interesting. In these chapters, she turns her scrutiny away from the audience and rivalries surrounding medical performances and refocusses it on the main actors: the patient and the physician. Even in agonistic settings, the highly intimate relationship between these two "characters" is evident in Galen's narratives, and, unlike the medical narratives of Hippocrates or those of the modern physician, the patient himself is able to provide his own perspective in many of Galen's narratives, through the means of indirect discourse. There is even evidence for a modicum of patient-physician negotiation, as revealed in narratives in which the patient's and Galen's voices alternate with one another. Galen's patients were no doubt drawn from the entire spectrum of society, but Mattern demonstrates that Galen places marked emphasis upon the adult, urban male of the leisure class, particularly one with a warm, dry temperament, setting this patient up as the archetypal patient (and even seeing himself, she argues, in this ideal patient). Mattern argues for a correlation between this ideal Galenic patient and the Greek conception of a citizen. She notes that Greco-Roman regimens of health held both moral and social significance as much as they held medical meaning; she points, for example, to the psychological connection between gymnastic exercise, an activity vigorously promoted by Galen as part of a healthy lifestyle for men, and Greek civic life, in the competitive, masculine, and highly public nature inherent in both.

Galen's characterization of his patients, which could include aspects of their emotional temperaments, is dealt with in the fourth chapter; the final chapter examines his self-representation as a physician. Mattern discusses Galen's narrative emphasis on his own ability to "read" his patients, sometimes "at a glance." She also highlights the intriguing manner in which Galen depicts his interactions with fever, which was considered by ancient physicians as a disease in its own right and not merely a symptom, noting his use of military metaphors but also persuasively suggesting that Galen on many occasions depicts fever as an animal whose movements the physician must track and outwit. It is Mattern's exploration of the delicacy of the physician's power and status in relation to the patient, however, which is of particular note. Medical therapies require intimate physical contact with a patient: bathing, drying, massaging, feeding. Galenic theory, moreover, demanded a thorough inspection of the bodily wastes produced by the patient. Galen's narratives are strangely ambiguous about who in fact is performing these chores: whether he undertook these essentially servile tasks himself or delegated these tasks to slaves (his own or those belonging to the household) is seldom clear. Galen further portrays himself frequently acting in concert with household slaves, gaining from them "inside" information about the family which helps determine his diagnosis and therapeutic response. This close connection with servility, therefore, prompts a clear power struggle in many of the narratives, in which he strives not to overcome competitive rivals, but rather to assert his power over the patient and the household. The ancient physician seems to have walked a fine line between servility and authority, at least when dealing with members of the ruling classes.

Mattern's work is well-organized, well-argued, and clearly presented, with minimal editorial problems (only four typographical errors were spotted). The book will appeal equally to historians, whether of ancient medicine in particular or of the social history of the time period, and to the general reading public; Mattern clearly aspires to attract some of the latter, particularly physicians, whom she hopes will "see through what must seem the absurdity of [Galen's] doctrines and the outrageousness of his arrogance to the ancient human drama at the heart of medicine" (162).



Notes:


1.   Vivian Nutton, Ancient Medicine (London 2004): 390 n. 22.

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