Health

ox for d phi losophica l concepts

 OX FOR D PH I LOSOPH IC A L CONCEP TS
Christia Mercer, Columbia University
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ox for d phi losophica l concepts

Health
A History

j
Edited by Peter Adamson

1
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Names: Adamson, Peter, 1972– editor.
Title: Health : a history / edited by Peter Adamson.
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 Contents

Contributors vii

Introduction 1
Peter Adamson

1. Health and Philosophy in Pre-​and Early Imperial China 7

Michael Stanley-​Baker

2. Medical Conceptions of Health from Antiquity to the Renaissance 43

Peter E. Pormann

3. The Soul’s Virtue and the Health of the Body

in Ancient Philosophy 75
James Allen

Reflection: Phrontis: The Patient Meets the Text 95

Helen King

4. Health in Arabic Ethical Works 103

Peter Adamson

Reflection: The Rationality of Medieval Leechbooks 136

Richard Scott Nokes
vi Contents

5. Health in the Renaissance 141

Guido Giglioni

Reflection: Early Modern Anatomy and the Human Skeleton 174

Anita Guerrini

6. Health in the Early Modern Philosophical Tradition 180

Gideon Manning

7. Health in the Eighteenth Century 222

Tom Broman

Reflection: Pictures of Health? 246

Ludmilla Jordanova

8. Freud and the Concept of Mental Health 251

Jim Hopkins

Reflection: Portrait of the Healthy Artist 282

Glenn Adamson

9. Contemporary Accounts of Health 289

Elselijn Kingma

Bibliography 319

Index of terms 353

Index of Authors and Works 359

 Contributors

Glenn Adamson is the twin brother of Peter Adamson. He is also a cu-

rator, writer, and historian who works across the fields of design, craft, and
contemporary art. Currently Senior Scholar at the Yale Center for British Art,
Adamson has been Director of the Museum of Arts and Design, New York;
Head of Research at the V&A; and Curator at the Chipstone Foundation in
Milwaukee. His publications include Fewer Better Things: The Importance of
Objects Today (2018); Art in the Making (2016, co-​authored with Julia Bryan
Wilson); Invention of Craft (2013); Postmodernism: Style and Subversion (2011);
The Craft Reader (2010); and Thinking Through Craft (2007).

Peter Adamson is the twin brother of Glenn Adamson. He is also Professor

of Late Ancient and Arabic Philosophy at the Ludwig Maximilians Universität
in Munich. With G. Fay Edwards, he is the co-​editor of another volume in
the Oxford Philosophical Concepts Series, entitled Animals: The History of
a Concept (2018), and the author of the book series A History of Philosophy
Without Any Gaps, published by Oxford University Press. Two volumes
collecting his papers on late ancient philosophy and philosophy in the Islamic
world appeared recently with the Variorum Series published by Ashgate.

James Allen is Professor of Philosophy at the University of Toronto and

was formerly Professor of Philosophy at the University of Pittsburgh. He is the
author of Inference from Signs: Ancient Debates About the Nature of Evidence
(2001) and the co-​editor of Essays in Memory of Michael Frede (special issue
of Oxford Studies in Ancient Philosophy, 2011). He has published articles about
ancient skepticism, Stoicism, Epicureanism, Plato, Aristotle and the relations
viii Contributors

between ancient medicine and philosophy spanning topics in ethics, logic, and
natural philosophy.

Tom Broman is Emeritus Professor of History of Science and History of

Medicine at the University of Wisconsin, Madison. He is the author of The
Transformation of German Academic Medicine, 1750–​1820 (1996) and co-​editor
of Science and Civil Society (2002). He has authored articles that analyze the
constitution of scientific and medical expertise, the early history of scientific
journals, and the history of the public sphere in the eighteenth century. He
is currently writing a comprehensive survey of science in the Enlightenment.

Guido Giglioni is Associate Professor of History of Philosophy at the

University of Macerata, Italy. His research is focused on the interplay of life
and imagination in the early modern period, on which he has written and ed-
ited several contributions. He has published two books, on Jan Baptiste van
Helmont (2000) and Francis Bacon (2011).

Anita Guerrini is Horning Professor in the Humanities and Professor

of History at Oregon State University. She has published widely on the his-
tory of animals, medicine, food, and the environment. Her books include
Experimenting with Humans and Animals: From Galen to Animal Rights
(2003) and The Courtiers’ Anatomists: Animals and Humans in Louis XIV’s
Paris (2015). Current research projects concern skeletons as scientific and his-
torical objects (for which she recently won a grant from the National Science
Foundation) and the role of history in present-​day ecological restoration. She
blogs at anitaguerrini.com/​anatomia-​animalia.

Jim Hopkins is Reader Emeritus in Philosophy at King’s College and Visiting

Professor in the Psychoanalysis Unit of the Research Department of Clinical
and Health Psychology at University College London. His main work has been
on psychoanalysis, consciousness, Wittgenstein, and interpretation.

Ludmilla Jordanova is Professor of History and Visual Culture and

Director of the Centre for Visual Arts and Culture at Durham University. Her
books include Lamarck (1985), Sexual Visions (1989), History in Practice (2000,
2006, with the third edition near completion), The Look of the Past (2012), and
Physicians and their Images (2018). Her research interests include portraiture
and the cultures of science and medicine since 1600.
 Contributors ix

Helen King is Professor Emerita in Classical Studies, the Open University,

and a Visiting Professor in Politics and International Studies, University of
Warwick. She has published widely on gender and sexuality, myth, and an-
cient gynecology and obstetrics, and their reception into the early modern pe-
riod and beyond. Her books include The One-​Sex Body on Trial: The Classical
and Early Modern Evidence (2013) and, co-​edited with M. Horstmanshoff and
C. Zittel, Blood, Sweat and Tears: The Changing Concepts of Physiology from
Antiquity into Early Modern Europe (2012).

Elselijn Kingma is Associate Professor in Philosophy at the University

of Southampton and Socrates Professor in Philosophy and Technology in
the Humanist Tradition at the University of Eindhoven in the Netherlands.
She leads a major research project on the metaphysics of pregnancy and has
published numerous articles on the philosophy of medicine and biology.

Gideon Manning is a Visiting Scholar at the Claremont Graduate

University, having previously taught at the University of Pittsburgh, the
College of William and Mary, and the California Institute of Technology. His
recent publications include “Descartes and the Bologna Affair,” “Descartes’
Metaphysical Biology,” and the edited volume Professors, Physicians and
Practices in the History of Medicine: Essays in Honor of Nancy Siraisi (2017). He
is co-​editor with Lisa Jardine of the forthcoming volume Testimonies: States of
Body and States of Mind in the Early Modern Period.

Richard Scott Nokes is an Associate Professor of Medieval Literature at

Troy University and founder of Witan Publishing. He is co-​editor of Global
Perspectives on Medieval English Literature, Language, and Culture and
Conflict in Southern Writing (2007), and is the academic editor and publisher
of multiple volumes of medieval scholarship on subjects as varied as medieval
combat, manuscript production, and linguistics.

Peter E. Pormann is Professor of Classics and Graeco-​A rabic Studies at

the University of Manchester. Recent publications include special double is-
sues The Arabic Commentaries on the Hippocratic “Aphorisms” co-​edited with
Kamran I. Karimullah (2017), and Medical Traditions (co-​edited with Leigh
Chipman and Miri Schefer-​Mossensohn, 2017–​2018); and edited books: La
construction de la médecine arabe médiévale (with Pauline Koetschet, 2016);
Medicine and Philosophy in the Islamic World (with Peter Adamson; 2017); 1001
x Contributors

Cures: Contributions in Medicine and Healthcare from Muslim Civilisation

(2017); and the Cambridge Companion to Hippocrates (2018).

Michael Stanley-​Baker is an Assistant Professor in the History Program

at Nanyang Technological University, Singapore, and formerly a postdoctoral
researcher at the Max Planck Institute for the History of Science, Berlin. With
Vivienne Lo, he is the co-​editor of the Routledge Handbook of Chinese Medicine
(2017), and also co-​editor with Pierce Salguero of a volume provisionally titled
Situating Religion and Medicine Across Asia. He is project lead for the Drugs
Across Asia digital platform, in collaboration with the Max Planck Institute,
National Taiwan University and Dharma Drum Institute for Liberal Arts,
and serves as the Vice-​President of the International Association for the Study
of Traditional Asian Medicine. He publishes on Daoism and Chinese med-
icine in early imperial China, on practice theory, close reading, and Digital
Humanities.
 Health

ox for d phi losophica l concepts

Plate 1 Detail of a woodcut, illustrating the Latin translation of the Almanac of
Health (Strasburg: Apud Ioannem Schottum librarium, 1531), p. 103. © University of
Manchester

Plate 2 Avicenna, Canon, MS Tritton 12, fol. 1b. Royal College of Physicians, London.
plate 3 Liber chronicarum, “Dance of Death,” 1493. Wellcome Library, London.

plate 4 Anatomia humani corporis, engraved plate by Gerard de Lairesse, 1685.

Wellcome Library, London.
plate 5 Paris Catacombs (bones deposited 1787–​1859). Wikimedia Commons.

plate 6 William Hogarth, Marriage à la Mode: The Lady’s Death, ca.1743. National
Gallery, London.
plate 7 George Richardson, Iconologia: “Health,” “Infirmity,” “Patience,” and
“Solicitude,” 1779.

plate 8 Gutsave Courbet, Le Déséspère (The Desperate Man), 1845.

 Introduction
Peter Adamson

A striking feature of the history of philosophy, stretching from the

ancient period through medieval times and up to the modern period,
is the fact that so many great philosophers had interests in medicine
or were practicing doctors. Ancient and medieval examples include
Empedocles, Aristotle, Sextus Empiricus, Philoponus, Avicenna, and
Maimonides—​not to forget the intertwining of medical and philo-
sophical ideas in Indian Ayurveda and the Chinese traditions studied
in this volume by Stanley-​Baker.1 As for the modern period, a few
striking examples include Descartes, who commented to the Marquess

1 For Ayurveda see the texts gathered in D. Wujastyk, The Roots of Āyurveda (New Delhi: Penguin,
1998), and for connections to philosophy G. J. Larson, “Āyurveda and the Hindu Philosophical
Systems,” in T. P. Kasulis et al. (eds), Self as Body in Asian Theory and Practice (Albany: SUNY
Press, 1993), 103–​21; Dagmar Wujastyk, Well-​mannered Medicine: Medical Ethics and Etiquette
in Classical Ayurveda (Oxford: Oxford University Press, 2012); Dominik Wujastyk, “Medicine
and Dharma,” Journal of Indian Philosophy 32 (2004), 831–​42; K. Zysk, Asceticism and Healing
in Ancient India: Medicine in the Buddhist Monastery (New York: Oxford University Press, 1991).

1
2 Peter Adamson

of Newcastle, “the preservation of health has always been the prin-

cipal end of my studies”; Locke, who served as a personal physician and
worked closely with Sydenham; Boyle, who wrote about the methods
of Galen; Berkeley, who worked on tar water; and Leibniz, who
claimed repeatedly that he was a Hippocratic. Conversely, prominent
figures who were primarily doctors had interests in philosophy. In the
ancient and medieval periods one could name Hippocrates (or at least
some authors of the Hippocratic Corpus), Galen, and Abū Bakr al-​
Rāzī, whose translated works made him a medical authority for readers
of Latin under the name “Rhazes.” For the modern period, examples
would include English physicians like Harvey and Charleton, and early
Cartesians like Regius and de la Forge. It is thus unsurprising that phil-
osophical ideas often affected medical ones and vice versa.
At the heart of this fruitful interchange between medicine and phi-
losophy is the concept of health. Needless to say, health is a medical
concept, indeed, the concept that gives medicine both its definition
and its raison d’être. Yet it is also a philosophical concept, and an
intriguing one at that. Health is unusual in seeming to straddle the
divide between descriptive, empirical concepts and normative, value-​
laden concepts. When your doctor gives you a clean bill of health, you
probably think of her as just giving you an objective scientific descrip-
tion of the state of your body. Yet it is almost irresistible to think of
health as a way we “ought” to be, that there is some standard the un-
healthy person is failing to meet. After all nearly everyone wants to be
healthy, and we go to great lengths to avoid or recover from illness and
injury.
The interrelation between these two ways of thinking about health
is something of a leitmotif in the papers collected here. We will see
thinkers of different cultures offering a range of scientific accounts
of what it means to be healthy, from the idea of circulating qi in an-
cient China, to the humoral theory of Galen and the long-​lived tra-
dition of Galenic medicine he inspired, to the new physiological and
pyschotherapeutic theories that emerged in the nineteenth century.
 Introduction 3

At the same time, we will see how normative implications were rou-
tinely drawn from these descriptive theories, as when the balance
of humors was compared to (and seen as a causal basis for) a good
balance in the soul by Galen and his heirs in the Islamic world. As
shown in the chapters by Giglioni and Manning, robust connections
between “sound mind” and “sound body” were still fundamental to
Renaissance philosophy and lived on as a “medicine of the mind” in
early modernity.
The contrast between normative and descriptive accounts of health
is however addressed most explicitly by Kingma in her concluding
chapter. As she shows in her examination of modern-​day attempts to
define health, both approaches face serious objections. The descrip-
tivist must meet the challenge of giving objective criteria for meas-
uring health, but the criteria suggested by philosophers of medicine
would seem vulnerable to counter-​examples. For instance defining
health as adherence to a statistical average would mean saying that
high-​performance athletes are unhealthy. The normative account of
health has its own problems though, not least because of its implied
prescriptivism. The doctors, scientists, and philosophers who deter-
mine what it means to be healthy would effectively be telling us how to
live our lives. Kingma’s paper opens with a notorious example, namely
the fact that homosexuality was until recently considered a disease.
Kingma also reminds us of debates over how we should conceive of
people who have “disabilities.” Is it really useful to conceive of, say,
blindness as a lack of “health”?
Such difficulties notwithstanding, most of the figures covered in
this volume would have taken it for granted that health is a concept
with both a normative and a descriptive dimension. In this sense
health is like nature, another scientific concept that has often been
taken to have normative standing. Again homosexuality would be a
case in point, given that its supposed sinfulness has often been linked
to its purportedly being “unnatural.” The kinship between health and
nature is no coincidence. As we shall see, many thinkers identified the
4 Peter Adamson

healthy state of the body or soul with a natural state. Another pow-
erful intuition that encourages us to think of health as a value-​laden
concept emerges from the aforementioned fact that nearly everyone
wants to be healthy. In this respect, health is unusual among life goals.
It is easy to imagine someone preferring not to be wealthy or pow-
erful. Nor is it difficult to think of people who have no wish to be
virtuous, given that the tyrannical souls so vividly described by Plato
still thrive on the contemporary political scene. By contrast, having a
preference for illness over health would in itself probably be taken as
a sign of mental illness. Beginning in the ancient tradition, the phil-
osophical schools sought to explain the nearly undeniable goodness
of health, with some schools finding the challenge easier than others.
Aristotelians gave health as a key example of the way normativity
applies to physical states and saw health as illustrating their teleolog-
ical approach to nature. The Stoics agreed about the value of nature but
saw human normativity as being grounded in virtue. So they had to
devise a special category to handle health and a few other goals: these
are “preferred indifferents,” which are rational to pursue even though
their absence does not preclude happiness.
Even though health is most obviously a concept applied to bodies,
we already noted that in the history of philosophy it has often been
applied to psychological states too. We still speak today of “mental
illness” of course, but in the ancient, medieval, and early modern
periods even ethical vice was seen as a sort of disease. Many authors
have envisioned a kind of medicine that applies to souls rather than,
or in addition to, bodies. One might be tempted to take this as a mere
metaphor. On this reading, talk of “health” in the case of the soul
would simply be a way of referring to the soul’s best state. But authors
also detected an intimate causal relationship between bodily health
and psychological health, such that a temperate body is a necessary
(even sufficient?) condition for a temperate character. Some thinkers
also exploited the parallel between physical and psychological health
to suggest that bodily treatments have analogues at the psychological
 Introduction 5

level. Because of these powerful links between the health of body and
the health of soul, the skilled doctor can manipulate both. In both an-
cient Chinese texts and in Galen, it is thus said that a good diet leads
to physical well-​being and wisdom or virtuous character.
Because the history of philosophical reflection on health is bound
up with the development of medicine—​and because, as noted at the
outset, so many authors were both doctors and philosophers—​the
contributors to this volume include both historians of philosophy and
historians of medicine. In examining the history of health, they touch
on many philosophical questions raised by the discipline of medicine.
To take just one example, one reason to discount medicine’s claims to
be a “science” in the full and proper sense was that effective medical
treatment was seen as highly responsive to the particularities of each
patient. A good doctor would tailor the cure to the victim of the ill-
ness, not just the illness itself, and the same for prescriptions of pro-
phylactic regimen. Indeed many doctors prided themselves on their
patient-​sensitive expertise and emphasized the need for long practice
to achieve it. But the same feature of medicine could be used to suggest
that medicine is more like a knack than a proper science. A related no-
tion, which again raises the question of how medicine relates to ethics,
is that doctors had themselves to be virtuous in order to perform suc-
cessful diagnosis and to effect a cure.
The concerns of ancient and medieval authors lived on into the early
modern period, which is no wonder given that some of these authors
(especially Hippocrates, Galen, and Avicenna) remained key sources
into the seventeenth century and even later. As late as the nineteenth
century, Galen, Hippocrates, and even Paul of Aegina were still
printed, at least in part with medical ends in mind and not simply
for antiquarian interest. And as Hopkins reminds us in his study of
Freud in this volume, the Freudian approach to the mind is apt to re-
mind us of the Platonic tripartite soul. Yet significant changes in phi-
losophy did bring changes in medicine, and vice versa. As we move
into the Renaissance and the early modern period, we find that the
6 Peter Adamson

emerging naturalistic, even mechanistic, world picture had significant

implications for medicine. To the extent that early modern thinkers
moved away from a teleological or normative understanding of nature
and toward a physical conception in which bodies simply interacted
according to laws of nature, their conception of health was bound
to change. Here we see authors grappling with the problem of de-
fining health in the absence of a teleological account of the nature of
the human.
Nowadays, when it would be a rare person who could claim spe-
cialism in both medicine and philosophy, the old philosophical issues
regarding health remain with us. Just consider the movement toward
emphasizing a holistic and patient-​specific understanding of health
or disputes about how health should be balanced with other human
goods. Debates about the quantity of life as opposed to the quality of
life cannot be resolved simply by an account of what health is. It is our
hope that a better understanding of health as a concept in the history
of philosophy will help shed some light on such issues. At the same
time, our ambition has been is to survey attitudes toward health across
an unprecedentedly broad chronological range, which we hope will be
of interest to both historians of philosophy and of medicine, and, of
course, to the general reader.2

2 My thanks to Gideon Manning for help with this introduction, to Hanif Amin for extensive
assistance in getting the volume ready for press, and to Michael Lessman for preparing the index.
I would also like to thank King’s College London for hosting an initial workshop on the topic.
 CH A PTER ONE

Health and Philosophy in

Pre-​and Early Imperial China
Michael Stanley-​Baker

Freedom from disease, physiological signs of well-​being, and avoid-

ance of death appear as consistent themes in many writings from pre-​
imperial and imperial China, but there were no direct analogues to a
conceptual category like the English term “health.” These themes do
not appear under a universally consistent term or bounded theoret-
ical formulation. Instead they appear as common technical terms or
practical foci across different literary genres. Chinese writers refer to
material forces like breath (qi 氣), the force of life (sheng 生), and inner
nature (xing 性), which are cultivated or nourished (yang 養) in the
body, to lengthen one’s life (ming 命). Engagement with health was as
a quantitative object that could be stored in the body, as a processual
goal rather than a conceptual object. While the term “nourishing life”
(yangsheng 養生) only came to refer to a common, recognizable set of
practices after the first century CE, the practices and goals themselves
were understood to be coherent in sources as early as 400 BCE.

7
8 Michael Stanley-Baker

In this chapter I argue that three major periods in pre-​and early

imperial China produced dominant modes of writing on bodily ideals
that have continued until the present day. These include philosoph-
ical works, self-​cultivation manuals, canonical medical writings, tran-
scendence writings, and formal Daoist texts. While different authors
and communities adopted a variety of positions regarding the political,
social, and moral values of robust bodily function, these negotiations
took place through a roughly common and emergently coherent set
of terms, concepts, and assumptions about the nature of the body, its
functions, and relatedness to the cosmos. The three periods include
two periods of political disunity—​the Warring States 戰國 (475–​221
BCE) and the early period of the Northern and Southern dynasties
南北朝 (220–​589 CE)—​and the first founding and expansion of
the unified Chinese empire under a relatively stable, centralized, and
highly bureaucratized government during the Qin-​Han 秦漢 period
(221 BCE–​200 CE). The discourses and practices that emerged during
this time set the tone for the rest of imperial Chinese history, which
built on and grew out of these earlier currents.1

Qi in Warring States Philosophical Works

Although writings on health and philosophy differed at many points,

there is one central topic that they shared in common—​the material
force called qi, and the best way to cultivate it. The Warring States
period saw the most wide-​ranging and varied debates on philosophy,

1 I would like to gratefully acknowledge financial support during the writing of this paper from the
Max Planck Institute for the History of Science in Berlin, and the KFG for Multiple Secularities
at Leipzig University. Thanks are also due for comments on earlier versions of this paper are due
to Vivienne Lo, Pierce Salguero, and Dolly Yang. I found particularly useful for structuring this
paper, L. Raphals, “Chinese Philosophy and Chinese Medicine,” in E. N. Zalta (ed.), The Stanford
Encyclopedia of Philosophy, 2015, http://​plato.stanford.edu/​entries/​chinese-​phil-​medicine/​#Rel.
An in-​depth study worth consulting on the transition of embodiment theory through the period
covered is O. Tavor, “Embodying the Way: Bio-​Spiritual Practices and Ritual Theories in Early and
Medieval China” (PhD diss., University of Pennsylvania, 2012).
 Pre- and Early Imperial China 9

ethics, and statecraft, which was referred to as the Hundred Schools

(Baijia 百家). During this time, the various fiefdoms and principalities
of the Zhou 周 dynasty became consolidated into seven major states,
each embroiled in heightened rivalry and factionalism in their bids
for power.2 Nobles of the various duchies and marquisates would
host at their courts “masters” or “nobles” (zi 子) of warfare, eco-
nomics, statecraft, as well as “technical masters” ( fangshi 方士) of
divination, medicine, and dietary culture. It is in these contexts that
much of the philosophical and technical literature that survives was
produced.3 This culture is evidenced in a number of texts excavated
from numerous sites in central China, mostly in Hubei, dating from
the fourth to the second century BCE.4 These texts are often mixed or
appear in collections containing manuals of different types. Practices
advocated in these texts include breathing exercises, diet, stretching,
massage, sexual cultivation, numerological divination, drug therapy,
and hemerology.

2 M. E. Lewis, “Warring States Political History,” in M. Loewe and E. L. Shaughnessy

(eds), The Cambridge History of Ancient China: From the Origins of Civilization to 221 B.C.
(Cambridge: Cambridge University Press, 1999).
3 Variously translated as “recipe masters,” “masters of esoterica,” “masters of methods,” fangshi
have been the subject of biographical studies and broad histories of technology. K. J. DeWoskin,
Doctors, Diviners, and Magicians of Ancient China: Biographies of Fang-​shih (New York: Columbia
University Press, 1983); G. Lloyd and N. Sivin, The Way and the Word: Science and Medicine in
Early China and Greece (New Haven, CT: Yale University Press, 2002). Sivin argues that the pe-
jorative connotations of fangshi as subaltern to elite literati meant that no actors self-​identified
with the moniker, and therefore it had no coherence or social force and did not refer to a dis-
crete, identifiable, body of actors. N. Sivin, “Taoism and Science,” Medicine, Philosophy and
Religion in Ancient China (Aldershot: Variorum, 1995), 303–​30. Also see M. E. Lewis, Writing
and Authority in Early China (Albany: State University of New York Press, 1999), 53–​98. The de-
finitive studies on the technical arts ( fangshu 方術) are Li Ling 李零, Zhongguo fang shu xu kao
中国方术续考 (Beijing: Zhonghua shuju, 2000); Li Ling 李零, Zhongguo fang shu kao (xiuding
ben) 中国方术正考 (修訂本) (Beijing: Dongfang chubanshe, 2001).
4 D. Harper, “The Textual Form of Knowledge: Occult Miscellanies in Ancient and Medieval
Chinese Manuscripts, Fourth Century B.C. to Tenth Century A.D,” in F. Bretelle-​Establet
(ed.), Looking at It from Asia: The Processes That Shaped the Sources of History of Science
(Dordrecht: Springer, 2010); D. Harper, Early Chinese Medical Literature: The Mawangdui Medical
Manuscripts (London: Kegan Paul, 1998); V. Lo 羅維前 and Li Jianmin 李建民, “Manuscripts,
Received Texts, and the Healing Arts,” in M. Nylan and M. Loewe (ed.), China’s Early Empires: A
Re-​appraisal (Cambridge: Cambridge University Press, 2010).
10 Michael Stanley-Baker

Many philosophical works that survived from this early period were
catalogued by the libraries and histories of later dynastic empires as
“Master [Literature]” (zi 子).5 “Masters” was not an exclusively literary
category, denoting discursive or argumentative style such as “philos-
ophy” or “rhetoric.” It was also a social category that referred to the
literature of authoritative experts.6
Many works in the master literature refer to embodied practices and
means to produce beneficial physiological responses or an ideal rela-
tion among the body, the self, and the cosmos. They refer to breathing
and meditation exercises designed to cultivate qi 氣—​the vital breath,
a material considered to permeate and give substance and structure
to all existence. Earlier on in the Warring States period, qi referred
to weather and climatic conditions, qi bearing some similarities to
the Greek pneuma and Sanskrit prana (wind, air, breath) as the lively
fluid substance that “vitalizes the body, in particular as the breath, and
which circulates outside us as the air.” By the third century BCE, it
became “adapted to cosmology as the universal fluid, active as Yang
and passive as Yin, out of which all things condense and into which
they dissolve.”7

5 Dagmar Schafer writes of the zi category in late imperial China as “the main Chinese biblio-
graphic category of matters where the Chinese intellectual world assembled exceptional thinkers
who had a comprehensive, sometimes encyclopaedic approach to fields of knowledge . . . aimed
at revealing essential truths about the relation between heaven, earth and men.” D. Schäfer,
The Crafting of the 10,000 Things: Knowledge and Technology in Seventeenth-​Century China
(Chicago: University of Chicago Press, 2011). For a brief overview of Chinese historical bibliog-
raphy, see E. P. Wilkinson, Chinese History: a New Manual (Cambridge: Harvard University Asia
Center, 2012), 936–​40.
6 In the Han dynasties (206–​220 CE), medical literature was gathered under a distinct section
titled “Methods and Techniques” ( fangji 方技), but by the Sui dynasty (581–​618) it was included
as a form of masters literature, along with mathematics, astronomy, military tactics, and others.
Han shu 漢書, by Ban Gu 班固, Yan Shigu 顏師古, and Ban Zhao 班昭. (Beijing: Zhonghua
shuju, 1962), 10/​30.1776–​78, and Suishu 隋書, by Wei Zheng 魏徵. Xin jiao ben Suishu fu suoyin
新校本隋書附索引, ed. 楊家駱 Yang Jialuo. (Taibei: Ding wen shuju, 1980), 34/​29.1040–​51.
7 A. C. Graham, Disputers of the Tao: Philosophical Argument in Ancient China (La Salle, IL: Open
Court, 1989), 101. On the observation of qi in the human body in medical and yangsheng literature,
and the production of a regularized theory of its movements, see V. Lo, “Tracking the Pain: Jue and
the Formation of a Theory of Circulating Qi through the Channels,” Sudhoffs Archiv 83/​2 (1999),
191–​211. A set of papers on how qi has been differently conceptualized and applied throughout
 Pre- and Early Imperial China 11

Qi came to be considered to have a direct relationship with con-

sciousness and the mind, so that its cultivation was considered to de-
velop not only physiological well-​being but also perspicacity and moral
force. Through embodied meditations on qi, elites participated in a
higher moral and philosophical order, which Mark Csikszentmihalyi
describes as a culture of “embodied virtue.”8 The Confucian moralist
Mengzi 孟子 (372–​289 BCE), for example, famously describes a di-
rect relationship between his ability to function as a moral actor and
his ability to cultivate “radiantly bright qi” (haoran zhi qi 浩然之氣),
which gives him the resources to engage with the difficult ethical is-
sues of his time.9 The attainment of this radiance was considered not
only a visible sign of the attainment of sagehood but also partook in
the luminosity of heaven.

Inscription on Circulating Qi (Xingqi ming 行氣銘)

An early example of the practice of circulating qi within the body

is the Xingqi ming, a short, thirty-​six character inscription on the
twelve sides of a jade knob dated to the Warring States period (453–​
221 BCE).10 While the ornamental value of the knob, which probably

Chinese history, in medicine, philosophy, religious rituals, and self-​cultivation, is Onozawa Seiichi
小野沢精一, Fukunaga Mitsuji 福永光司, and Yamanoi Yū 山井湧 (eds), Ki no shisō: Chūgoku
ni okeru shizenkan to ningenkan no tenkai 気の思想: 中国における自然観と人間観の展開,
(Tookyo: Tōkyō daigaku shuppankai, 1978). For a recent selection of papers on the topic, Sakade
Yoshinobu, Taoism, Medicine and Qi in China and Japan (Osaka: Kansai University Press, 2007).
8 M. Csikszentmihalyi, Material Virtue (Leiden: Brill, 2004).
9 Csikszentmihalyi, Material Virtue, 150–​57. Csikszentmihalyi argues cogently for the transla-
tion as “radiant” in contrast to the “flood-​like qi” more commonly found in secondary literature,
on the basis of many contemporary allusions to luminescence, the heavens, sun and stars, in ritual
and other texts.
10 Earlier in the possession of the collector Li Mugong 李木公 from Hefei, it is now stored in the
Tianjin Museum. In dating the piece to the middle sixth century, J. Needham and Ling Wang,
in Science and Civilisation in China, vol. 2 (Cambridge: Cambridge University Press, 1956), 143,
follow H. Wilhelm, “Eine Chou-​Inschrift über Atemtechnik,” Monumenta Serica 13 (1948).
An argument dating it to 380 is Guo Moruo 郭沫若, “Gudai wenzi zhi bianzheng de fazhan
古代文字辯證的發展,” Kaogu xuebao 考古學報 29 (1972). Chen Banghuai dates it to the late
Warring States period. Chen Banghuai 陳邦懷, “Zhanguo xingqi ming kaoshi 战国行气铭考释,”
Guwenzi yanjiu 古文字研究 7 (1982), (cited in Li Ling 李零, Fang shu zheng kao, 344, n.3).
12 Michael Stanley-Baker

adorned the end of a staff, likely outweighed its role as a communica-

tive device, it is one of the earliest testimonies to the high regard with
which breath cultivation was held. The inscription describes breathing
deep into the body, holding the breath there, and building it up until
it rises upward again, and thereupon cycling it downward once again.

To circulate the breath (xing qi), breathe deeply so there is great

volume. When the volume is great, the breath will expand. When
it expands, it will move downwards. When it has reached the lower
level, fix it in place. When it is in place, hold it steady. Once it is
steady, it will become like a sprouting plant. Once it sprouts, it will
grow. As it grows, it will retrace its path. When retracing its path,
it will reach the Heaven area. The Heaven impulse forces its way
downward. Whoever acts accordingly will live, whoever acts con-
trariwise will die.11

Texts from the period argue for a relationship between moral cultiva-
tion and its physiological effects. Where the texts disagree, however, is
on whether these meditations should or could be used for nourishing
the body’s well-​being for its own sake. Some argue that the physio-
logical benefits of qi cultivation are demonstrable, while others argue
that there is a wide gap between the meditations they advocate and the
nourishing life exercises promoted by technical experts.

Guanzi 管子

For example, the Guanzi 管子 places an emphasis on the combined

physiological and spiritual benefits of qi cultivation. Although tra-
ditionally attributed to Guan Zhong 管仲 (d. 645 BCE), this work

11 There has been considerable debate over the orthography and the precise meaning of the text
among the authors in the previous note. The rendering is from W. A. Rickett, Guanzi: Political,
Economic, and Philosophical Essays from Early China: A Study and Translation, vol. 2 (Princeton,
NJ: Princeton University Press, 1998), 19, with minor modifications.
 Pre- and Early Imperial China 13

is now thought to be most mainly composed in the fourth century

CE.12 It is predominantly concerned with government and the art
of rulership, and it emphasizes the virtue of the ruler as a model for
his followers and the use of ritual combined with a clear and strict
legal code. It appears to have circulated within or been produced by
specialists at Jixia 稷下, an academy of sorts in the city of Linzi 臨淄
(in modern-​day Shandong province), a community that also hosted
authors and editors of other important received works such as the
Zhuangzi, Mengzi, and Daodejing.13
In addition to a primary focus on statecraft, the Guanzi contains
the earliest received texts dealing with the cultivation of qi. Four
chapters discuss metaphysical meditations on the Way (Dao 道), a
cosmic guiding principle within all things. In contrast to the other
contemporary philosophical works that survive, the Guanzi placed a
strong emphasis on the physiological benefits of internal cultivation.
The Guanzi is considered to be informed by the communities of tech-
nical experts on longevity, whose expertise in later centuries came to
be referred to as “nourishing life” (yangsheng).
In addition to arguing that meditation grants insight into universal
processes and increases the ability to avoid harm and excessive toil, one
chapter titled “Inner Training” (Neiye 內業) advocates the positive
benefits of abundant, flowing qi and vital essence ( jing 精).14

For those who preserve and naturally generate vital essence,

On the outside a calmness will flourish.

12 Although the stable version of the text was compiled as late as 26 BCE by the bibliographer
of the Han court, Liu Xiang 劉向 (77–​6 BCE), the earliest sections of these chapters are gen-
erally considered to be as old as the oldest parts of the Daodejing or older. H. D. Roth, Original
Tao: Inward Training and the Foundations of Taoist Mysticism (New York: Columbia University
Press, 1999); Rickett, Guanzi; W. A. Rickett, “Kuan tzu,” in M. Loewe (ed.), Early Chinese Texts: A
Bibliographical Guide, Early China Special Monograph Series (Berkeley: Society for the Study of
Early China, 1993).
13 Rickett, Guanzi, 16–​17.
14 Jing was considered to be a vital fluid that circulated through and nourished the body and when
expelled took the form of semen or menses.
14 Michael Stanley-Baker

Stored inside, we take it to be the well spring.

Floodlike, it harmonizes and equalizes
And we take it to be the fount of qi.
. . . The four limbs are firm . . . Qi freely circulates through the
nine apertures. . . . 15
When you have no delusions within,
Externally there will be no disasters,
Those who keep their minds unimpaired within,
Externally keep their bodies unimpaired.16

Meditation was considered not only to calm the mind but also to im-
prove complexion, vision, and hearing, as well as strengthen the body.
In addition, it was considered to provide great stamina, endurance,
wisdom, and perspicacity.

If people can be aligned and tranquil,

Their skin will be supple and smooth,
Their ears and eyes will be acute and clear,
Their muscles will be supple and their bones will be strong.
They will then be able to hold up the Great Circle
[of the heavens]
And tread firmly over the Great Square [of the earth]
They will mirror things with great purity,
And will perceive things with great clarity.
Reverently be aware [of the Way] and do not waver,
And you will daily renew your inner power. 17

15 That is, the two ears, two eyes, two nostrils, mouth, anus, and genitals.
16 Li Mian 李勉 (ed.), Guan Zhong 管仲: Guanzi Jin zhu jin yi 管子今註今譯. (Taibei: Taiwan
shangwu yinshuguan, 2013), 49.777–​78; Roth, Original Tao, 74; also see Rickett, Guanzi, 47–​48.
17 Guanzi Jin zhu jin yi, 49.778; Roth, Original Tao, 76; Rickett, Guanzi, 48–​49.
 Pre- and Early Imperial China 15

The relationship among self-​control, calm mental focus, and good

bodily function is reiterated throughout the text:

When the four limbs are aligned

And the blood and qi are tranquil;
Unify your awareness, concentrate your mind,
Then your eyes and ears will not be overstimulated
And even the far-​off will seem close at hand.18

The text even goes so far to suggest dietary advice, detailing the phys-
iological effects of proper or improper diet. Moderation in eating and
fasting was considered critical for the production of vital essence and
knowledge, the quintessential materials of body and mind.

Overfilling yourself with food will impair your qi,

And cause your body to deteriorate.
Overrestricting your consumption causes the bones to wither
And the blood to congeal.
The mean between overfilling and overrestricting:
This is called “Harmonious Completion.”
It is where the vital essence lodges
And knowledge is generated.19

In the end, breath control grants long life.

Just let a balanced and aligned [breathing] fill your chest

And it will swirl and blend within your mind,
This confers longevity.20

18 Guanzi Jin zhu jin yi, 49.778; Roth, Original Tao, 82; Rickett, Guanzi, 51.
19 Guanzi Jin zhu jin yi, 49.779; Roth, Original Tao, 90, Rickett, Guanzi, 53.
20 Guanzi Jin zhu jin yi, 49.778; Rickett, Guanzi, 52.
16 Michael Stanley-Baker

Zhuangzi 莊子

The Zhuangzi, a roughly contemporaneous work, is traditionally

attributed to the fourth-​century BCE intellectual Zhuang Zhou
莊周, also an erstwhile visitor at Jixia. Textual scholars now agree
it is a multiauthored work that later became identified as “Daoist,”
with textual layers dating from between the late fourth century and
early second century BCE. Some of these, the “Inner Chapters” are
thought to be original to Zhuang Zhou himself.21 Contrary to the
Guanzi, the authors of the Zhuangzi create much more distance
between meditations for spiritual insight and exercises for physical
cultivation.
The essays directly engage with contemporary philosophical
positions, such as the utilitarianism of Mozi 墨子; the social con-
servatism of Confucius and Mencius or Mengzi 孟子; and the ego-
istic hedonism of Yang Zhu 楊朱.22 The Zhuangzi authors adopted a
skeptical relativist position, maintaining that philosophical argument

21 H. D. Roth, “Chuang tzu,” in Loewe, Early Chinese Texts, 56–​66.

The English-​language term “Daoism” is one of the most misleading terms in the history of Chinese
religions and philosophy. The twentieth century saw considerable debate about later “religious”
Daoism being a degradation of a nobler, and earlier “philosophical” variety. With better research
into imperial era Daoism, and recognition of the presence of much philosophical reflection in
later works, and of meditative practice (as described below) in earlier literature, this distinction
has largely been disregarded as the product of late imperial and early republican scholarly bias (ca.
1800–​1949). I refer to these early works as “philosophical” simply to mark their inclusion in a set of
texts about morality, statecraft, and cosmological order by scholarly traditions since the Warring
States and Han dynasty, but not to set them against later so-​called religious texts.
On the other hand, there is still ongoing debate about the origin of a self-​conscious Daoist tra-
dition, ranging from the Warring States, to ca. 180–​150 CE or as late as the fifth century CE, and
thus whether these early texts should rightly be considered part of those later traditions. While in
this chapter I point out continuities and tensions between texts from multiple periods, no claims
are made here about continuities or genealogies between these traditions and periods, or their role
in identifying “Daoism” as a continuous tradition.
The seminal article on this problem is N. Sivin, “On the Word ‘Taoist’ as a Source of
Perplexity: With Special Reference to the Relations of Science and Religion in Traditional China,”
History of Religions 17/​3–​4 (1978), 303–​30. Also see R. Kirkland, “The Taoism of the Western
Imagination and the Taoism of China: De-​colonializing the Exotic Teachings of the East” (paper
presented at University of Georgia, October 20, 1997).
22 For a survey of these positions, see various essays in V. H. Mair (ed.), Experimental Essays on
Chuang-​tzu, Asian Studies at Hawaii, no. 29 (Honolulu: University of Hawai’i Press, 1983).
 Pre- and Early Imperial China 17

is always positional with regard to the assumptions of the speaker, and

that it is impossible to adjudicate a universal position on the basis of
any one of them. The Zhuangzi is also naturalist, emphasizing that
humans and their social ways are part of the larger order of nature
rather than opposed to it. It draws on the same physiological and cos-
mological notions that inform the Guanzi and other texts of the time.
Thus the cultivation of qi takes an important role, as can be seen in
passages such as these:

Man’s life is a coming-​together of breath. If it comes together, there

is life; if it scatters, there is death.

The True Man breathes with his heels; the mass of men breathe
with their throats.23

Despite this reliance on qi practice for personal cultivation, the

various hands in the text do not advocate yangsheng practices per
se and deliberately distance themselves from them. For example a
later school of “syncretist” authors derides practitioners who delib-
erately adopt practices to lengthen life, because these will fail to
attain long life naturally, and use unnecessary and artificial extra
effort. 24

23 Guo Qingfan 郭慶藩 and Wang Xiaoyu 王孝魚(eds), Zhuang Zhou 莊周: Zhuangzi jishi
莊子集釋 (Beijing: Zhonghua shuju, 1995), 22.773 and 6.228. Translation from B. Watson, The
Complete Works of Zhuang Zi (New York: Columbia University Press, 2013), 22.177 and 6.43.
24 Graham identifies c­ hapters 12–​16 as composed by the “Syncretist School,” an eclectic group
who likely compiled the text in 180. Guan Feng considers these to have been composed in the late
fourth or early third century by the school of Song Xing (?360–​?290 BCE) and Yin Wen (fourth
century BCE), based at the Jixia academy in Linzi, the capital of Qi (present day Shandong). See A.
C. Graham, “How much of Chuang tzu did Chuang Tzu write?” in Studies in Chinese Philosophy
and Philosophical Literature (New York: State University of New York Press, 1986), 283–​321;
and Guan Feng 關鋒, “Zhuangzi ‘Wai, za pian’ chu tan 《莊子：外雜篇》初探,” in Zhuangzi
zhexue yanjiu bianji bu 莊子哲學研究編輯部 (ed.), Zhuangzi zhexue taolun ji 莊子哲學討論集,
(Beijing: Zhonghua, 1962) cited in Roth, “Chuang tzu,” in Loewe, Early Chinese Texts, 56–​57.
18 Michael Stanley-Baker

To pant (chui 吹), to puff (xu 嘘), to hail (hu 呼), to sip (xi 吸), to
spit out the old breath and draw in the new, practicing bear-​hangings
and bird-​stretchings, longevity his only concern—​these are favoured
by the masters who practice guiding and pulling exercises (daoyin), the
man who nourishes his body, who hopes to live to be as old as Ancestor
Peng. To attain . . . long life without guiding and pulling . . . this is the
Way of Heaven and Earth.
The coming of life cannot be fended off; its departure cannot be
stopped. How pitiful the men of the world, who think that simply
nourishing the body is enough to preserve life!25

These passages, by different hands within the work, criticize those who
sought to artificially preserve life through breathing and stretching
techniques and argue that following the Way should spontaneously align
one with the forces of life without such effort. Deliberately nourishing
the physical form of the body (xing 形) is not the same as nourishing life,
and it will not achieve the desired goal.
In the chapter titled “Nourishing Life” (Yangsheng), thought to be
original to Zhuang Zhou, he does not mention breathing exercises
or physiological meditations but instead focuses on the technical,
embodied skills of a butcher. Through the practice of cutting up oxen,
Cook Ding learns deftness of hand and subtlety of spirit, discovering
how to send forth his spirits to sense the gaps between the joints, until
he is so skilled he never has to sharpen his blade. This, says his inter-
locutor Lord Wen Hui, is the secret to nourishing life. The Way in
the Zhuangzi is often found in the practical non-​theoretical skills of

25 Zhuangzi jishi, 19.630 and 15.535–​37; Watson, Zhuang Zi 19.145 and 15.119.
On daoyin in later Daoist regimens, L. Kohn, “Daoyin among the Daoists: Physical Practice and
Immortal Transformation in Highest Clarity,” in V. Lo (ed.), Perfect Bodies: Sports, Medicine and
Immortality: Ancient and Modern (London: British Museum, 2012).
 Pre- and Early Imperial China 19

peripheral figures: craftsmen, carvers, bug-​catchers, butchers, and the

like, but notably never physicians.26
The question in the Zhuangzi is not how to collect qi to live a long
life. Nor is it the nature of life or life force (sheng 生) itself. Rather
the text elucidates how to know and deal with life, as embodied, as
something known through skilled practice and not easily rendered in
language.

Daode jing 道德經

The Daode jing, often referred to by the name of its putative author
Laozi 老子, was similarly compiled by multiple hands over time.
Archaeological discoveries over the last forty years have unveiled
buried editions in tombs that have changed scholarly understanding of
the text as a fairly unitary and stable work to that of an emerging set of
discourses, layered over time.27 This work survives in various received
editions, as well as copies recently excavated from Warring States and
Han dynasty tombs in Guodian 郭店 of Jingmen, Hubei (ca. 300
BCE), in Mawangdui 馬王堆 in Changsha, Hunan (168 BCE), and
in a set purchased in 2009 by Peking University (ca. 141–​87 BCE).28

26 Raphals, “Philosophy and Medicine”; L. Raphals, “Craft Analogies in Chinese and Greek
Argumentation,” in E. Ziolkowski (ed.), Literature, Religion, and East-​West Comparison: Essays in
Honor of Anthony C. Yu (Wilmington: University of Delaware, 2005), 181–​201.
27 Traditional dates for an original ur-​text are unreliable, and the variation within the excavated
and received editions, as well as citations in other contemporary works, indicates that while the
text(s) circulated likely as early as the fifth century CE, they were only compiled into a recognized,
named edition in the late third century. W. G. Boltz, “Lao tzu Tao te ching,” in Loewe, Early
Chinese.
28 On the Mawangdui edition, W. G. Boltz, “Textual Criticism and the Ma Wang tui Lao tzu, re-
view of Chinese Classics: Tao Te Ching, D. C. Lau,” Harvard Journal of Asiatic Studies 44/​1 (1984),
185–​224; R. G. Henricks, “On the Chapter Divisions in the Lao-​tzu,” Bulletin of the School of
Oriental and African Studies 45 (1982), 501–​24. On the Guodian version, S. Allan and C. Williams,
The Guodian Laozi: Proceedings of the International Conference, Dartmouth College, May 1998
(Society for the Study of Early China and Institute of East Asian Studies, University of California,
2000). On the Peking edition Han Wei 韓巍 (ed.), Laozi—​Beijing Daxue cang Xi Han zhushu
老子—​北京大學藏西漢竹書, vol. 2 (Shanghai: Shanghai guji chubanshe, 2012).
20 Michael Stanley-Baker

The Daode jing, which came to be venerated by later traditions as

the quintessential Daoist text, calls for quiescence, humility, and
dispensing with complex technology, values, and social hierarchy,
arguing for a return to simplicity in a golden age of the past, simul-
taneously reversing the trends of both old age and of the corruption
of society. It advocates politically for rulership that uses “non-​action”
(wuwei 無為), that is, spontaneous action that introduces no artifi-
ciality or contrivance, and aligns this with a meditative focus on
“embracing the One.” As part of this process it advocates an apophatic
reduction of external stimuli and focus on interior qualities and
breathing. While earlier versions of the text foregrounded strategies
for dealing with political exigencies, later editions encapsulated these
strategies into an overarching philosophy of following the Way.29
New passages that appear in the second-​century BCE Mawangdui
edition are not extant in the earlier Guodian edition and appear to
introduce a stronger emphasis on embodied meditation than previous
layers. Three of these mention the ideal of an “infant” (ying’er 嬰兒),
an image that evokes spiritual and physiological return to the supple-
ness and vitality of a newborn, and mesh this idea with the return to
the political and social simplicity that is the goal of earlier layers of the
text.30

Stably securing and nourishing the whitesouls and embracing the

One, can you avoid separation? Focusing on qi until you produce
suppleness, can you become like an infant?31

29 A. Kam-​leung Chan, “Laozi,” in Zalta, The Stanford Encyclopedia of Philosophy, 2014, http://​
plato.stanford.edu/​archives/​spr2014/​entries/​laozi/​
30 These are c­hapters 10, 20, 28. I use the numbering and divisions in the received edition,
based on the Heshang gong zhangju 河上公章句. On the Guodian and Mawangdui, see D.
Murphy, “A Comparison of the Guodian and Mawangdui Laozi Texts” (MA thesis, University of
Massachusetts, 2006), 10.
31 Daode jing, chap. 10. Translation amended from D. C. Lau, Dao de Jing (Penguin Books, 1963).
 Pre- and Early Imperial China 21

This image of the infant set the stage for the text’s future adoption
by specialists of cultivating vitality and immortality. The opening
phrase used in this passage, zai ying po 載營魄, directly draws on
technical language from earlier mediumistic traditions of the state of
Chu 楚. The trance reverie “Far-​off journey (yuanyou 遠遊),” found
in the fourth-​century BCE poetry collection Songs of the South (Chu
ci 楚辭) uses the phrase to describe preparation for a visionary, out-​of-​
body spirit journey through ethereal realms. David Hawkes’s transla-
tion renders it as follows:

I restrained my restless spirit and mounted the Empyrean;

I clung to a floating cloud to ride aloft on.32

By the time the term appeared in the Han dynasty Daode jing, the
phrase zai ying po came to refer not to practices of out-​of-​body travel,
but to inward-​looking, embodied cultivation of spiritual unity. By the
Han dynasty the whitesouls (po 魄) were paired with the cloudsouls
(hun 魂) and became the subject of a great deal of anxiety.33 These
souls respectively numbered seven and three, departed to the earth
and to the heavens at the time of death, and were thought by med-
ical writers to reside in the lungs and the liver. They were also the
cause of dreams, the souls’ impressions as they left the body at
night and thus opened their owner to harm from ghosts and spirits,

32 The italics indicate Hawkes’s translation of the same phrase. D. Hawkes, Ch’u Tz’u, The Songs of
the South: An Ancient Chinese Anthology (New York: Beacon Press, 1962), 84; Bai Huawen 白化文
and Wang Yi 王逸 (eds), Chuci buzhu 楚辭補注: Yuanyou 遠遊 (Beijing: Zhonghua shuju, 1983),
5.168. I do not contend that his rendering was “wrong,” but rather, that the insertion of the term
into a Han edition of the Daodejing, and also into a new ontological nexus, probably adapts it to a
new practice, which requires retranslation.
33 This pairing became widespread, so that the second century CE commentator, the Venerable on
the Riverside (Heshang gong 河上公), found it natural to argue that the opening phrase obliquely
implied the cloudsouls as well. Daode zhen jing zhu 道德真經註 DZ 682 1.4b. On this commen-
tary, Alan Kam-​leung Chan, Two Visions of the Way: A Study of the Wang Pi and the Ho-​Shang
Kung Commentaries on the Lao-​Tzu (Albany: State University of New York Press, 1991).
DZ refers to index numbers in Schipper and Verellen (eds), The Taoist Canon: a Historical
Companion to the Daozang, (Chicago: University of Chicago Press. 2004).
22 Michael Stanley-Baker

which manifested as disease and ill-​fortune. Thus practitioners devel-

oped a broad array of visualization and ritual techniques to constrain
them and keep them from leaving the body.
This shift in emphasis is clear in the Han Daode jing practice that
consolidates and nourishes, and keeps things from splitting up and
breaking apart—​reflecting the anxieties of the then-​recently unified
state trying to maintain central control—​and marking a clear contrast
to the ecstatic, disembodied, heavenly journey by the wild shamans of
the fringe state of Chu. In the passage from the Daode jing just cited
above, the po-​stabilizing practice is complimented by the qi practice
which follows it, producing “suppleness” like that of an infant—​at
once a bodily sensation, a subjective attitude of compliance, and a po-
litical stance of non-​engagement. These qualities converge in the image
of the baby, who is politically inactive, and whose body possesses abun-
dant vitality in the flush of rapid growth, highly vulnerable, requiring
nourishing and security through seclusion. These qualities recursively
evoke the practices of “nourishing” and “embracing the One” in the
first line, and an emphasis on inwardness, passivity, and growth rather
than outward journeying.
From the Eastern Han onward (25–​220 CE), this Daode jing pas-
sage became the locus classicus for a host of Daoist, yangsheng, and im-
mortality traditions that focused breathing and attention to the navel
area, such as: “fetal breathing” (taixi 胎息); another practice called
“clenching the fists” (wogu握固) where one clenches the thumbs,
often while in a fetal position; the visualization and inner cultivation
of a “ruddy infant (chizi 赤子)” within the body; or simply meditation
on the breath in the lower abdomen or elixir field (dantian 丹田).34

34 Fetal breathing practices appear in biographies of first-​century individuals and hosts of

traditions are attested in Tang dynasty Daoist texts. C. Despeux, “Taixi,” in F. Pregadio (ed.),
The Encyclopedia of Taoism (London: Routledge, 2008). The Laozi zhongjing 老子中經 (Central
Scripture of the Laozi) was highly influential on early body-​god visualization practices, as well as
containing the earliest attested reference to the elixir field in the abdomen. A. Iliouchine, “A Study
of the Central Scripture of Laozi (Laozi zhongjing)” (MA thesis, McGill University, 2011); K. M.
Schipper, “The Inner World of the Lao-​tzu chung-​ching,” in Chun-​chieh Huang and E. Zurcher
 Pre- and Early Imperial China 23

Although these developments began toward the end or after the

Han dynasty, the appearance of the fetal passages in the Mawangdui
Daode jing indicates that their roots lay in the expansion of interest in
yangsheng in the early Han.

Han Dynasty Nourishing Life Literature

and the Sciences

The broader sea-​changes in yangsheng and medical culture that are

reflected in the new physiological emphasis of the Daode jing took
place at many levels of Han culture. Although yangsheng practices
such as breathing, stretching, diet, drugs, and sexual hygiene existed
long before the Han dynasty, they experienced a surge in popularity
among Han elites and at court.35 The cache of texts at Mawangdui is
perhaps the best exemplar of this transition and provides an on-​the-​
ground view into scientific knowledge in the Han.36 This collection
marks a pivotal stage in the development of medical theory in the first
200 years of the unified Chinese empire, just prior to the development
of classical medicine in the late first century BCE. In the following
section, I outline how recent scholarship has located the Mawangdui

(eds), Time and Space in Chinese Culture (Leiden: Brill, 1995); J. Lagerwey, “Deux écrits taoïstes
anciens,” Cahiers d’Extrême-​Asie 14 (2004).
35 Harper, Early Chinese Medical Literature 30–​31; Ngo Van Xuyet and Fan Ye, Divination, magie
et politique dans la Chine ancienne: Essai (Paris: Presses universitaires de France, 1976).
36 Harper, Early Chinese Medical Literature. The facsimiles and transcripts of the original
manuscripts are in MWD zhengli xiaozu (ed.), Mawangdui Hanmu boshu 馬王堆漢墓帛書
(Beijing: Wenwu chubanshe, 1985); Ma Jixing 馬繼興, Mawangdui gu yishu kaoshi
馬王堆古醫書考釋 (Changsha: Hunan kexue jishu chubanshe, 1992); Zhou Yimou 周一謀 and
Xiao Zuotao 蕭佐桃, Mawangdui yi shu kao zhu 馬王堆醫書考注 (Tianjin: Tianjin kexue jishu
chubanshe, 1988); Zhou Yimou 周一谋, Mawangdui yixue wenhua 马王堆医学文化, Di 1 ban.
ed. (Shanghai: Wenhui chubanshe, 1994).
There are many other such finds that inform our knowledge in addition to the finds at Guodian
and Mawangdui. Those with medical literature include Zhangjiashan 張家山 in Jingzhou,
Hubei (196–​186 BCE); Shuanggudui 雙古堆 at Fuyang, Anhui Province (165 BCE); Baoshan
包山 near Jingzhou, Hubei (323–​292 BCE); Shuihudi 睡虎地 at Yunmeng, Anhui Province (217
BCE); Fangmatan 放馬灘 at Tianshui, Gansu (230-​220 BCE) and Wuwei 武威 in Gansu (first
century BCE).
24 Michael Stanley-Baker

literature within this broader emergence of medicine and scientific

theory more generally.
The classical medical corpus of the late Western Han dynasty drew
on and consolidated in new ways a set of cosmological theories—​
yinyang 陰陽, the five phases (wuxing 五行), and qi—​to interpret
the structure and internal workings of the body, disease formation,
and ideal practices to keep the body attuned to the changes of the
seasons.37 These systems organized the complex multivariate phe-
nomenal world into small sets of categorical groups of two (yinyang),
three (heaven, earth, and man tian di ren 天地人), or five (five
phases wuxing 五行). The homologies between objects of the same
class were not just based on similar material properties but also be-
cause of their relational status in dynamic states of change. Thus, the
same material when descending might be considered yin and when
ascending yang.38 Five phase theory holds that different phases of qi
generate or control each other successively—​so that wood generates
fire, which generates earth, then in turn metal, water, and finally
wood. In the controlling cycle, wood controls or constrains earth,
which controls water, which controls fire, which controls metal,
which controls wood.39
However, the use of yinyang, the five phases, and qi in complement
with one another was not standard prior to the formation of clas-
sical medicine. Scholars in recent years have clarified the separate
applications of these theories within excavated manuscripts and traced

37 P. U. Unschuld and H. Tessenow, Huangdi Neijing Suwen: An Annotated Translation of

Huang Di’s Inner Classic—​Basic Questions (Berkeley: University of California Press, 2011); P. U.
Unschuld, Huangdi Neijing Suwen: Nature, Knowledge, Imagery in an Ancient Chinese Medical
Text (Berkeley: University of California Press, 2003).
38 Yang Weijie 楊維傑 (ed.), Huangdi neijing suwen yijie 黄帝内經素問譯解 (Taibei: Tailian
guofeng chubanshe, 1984), chaps. 5, 6, 7.42–​75. Translated in Unschuld and Tessenow, Suwen
5–​7.95–​154.
39 Huangdi neijing suwen yijie, 4.34–​41, see translation in Unschuld and Tessenow, Suwen
4.83–​94.
 Pre- and Early Imperial China 25

how they gradually became combined into a composite theory of

nature that has been utilized since the first century BCE.40 Prior to
this convergence, these theories played critical roles in diverse tech-
nical domains, such as divination, astronomy, calendrics, cosmogen-
esis theory, and ritual practice and were adopted in critical arguments
about the legitimacy of the state.41
Prior to the late third century CE, five phase theory was an
omenological praxis used to divine the transmission of the heavenly
mandate to different dynastic states. Although Zou Yan 鄒衍 (305–​
240 BCE) is credited with first developing and promoting five phase
theory, none of his works survive. It was only with the Spring and
Autumn Annals of Mr. Lü (Lüshi chunqiu 呂氏春秋), by the Qin 秦
chancellor Lü Buwei 呂不韋 (291–​235 BCE), that qi became associ-
ated with five phase theory in discussions of political legitimacy and
ritual theory. Organized as advice on political strategy and managing
the state, the Spring and Autumn Annals was submitted circa 239
BCE, to Yin Zheng 嬴政 (260–​120 BCE), before Yin became the first
emperor of China. This complex encyclopedia contains many subjects
on natural science, ranging across astronomy, ritual and music, agri-
culture, and natural and political philosophy. The following passage
is the locus classicus most often cited for associating qi with the five
phases.

40 An overarching survey of the development of technical theory during this period is Harper,
“Warring States,” in Loewe and Shaughnessy, Cambridge History of Ancient China. For an impor-
tant corrective demonstrating how the appearance of the term for five phases (wuxing) in technical
literature does not in each case denote the dynamic relational theory described above but only
clearly emerges in late first-​century BCE textual sources, M. Nylan, “Yin-​yang, Five Phases, and
Qi,” in Nylan and Loewe, China’s Early Empires. For a survey of all of the technical arts and thor-
ough review of archaeological materials, see Li Ling 李零, Zhongguo fangshu xu kao; Li Ling 李零,
Fang shu zheng kao.
41 On the overlaps between divination technology and pre-​classical medicine, V. Lo, “The Han
Period,” in T. J. Hinrichs and L. L. Barnes (eds), Chinese Medicine and Healing: An Illustrated
History (Cambridge: Belknap Press of Harvard University Press, 2013); Harper, Early Chinese
Medical Literature.
26 Michael Stanley-Baker

Whenever a true king is about to rise, Heaven invariably sends

omens to the people below first. In the time of the Yellow Emperor,
Heaven first made large earthworms and mole crickets appear. The
Yellow Emperor said, “The qi of earth is getting strong and so he
took yellow as his colour and earth as pattern for his activities. In
the time of Yu, Heaven first made grass and evergreens appear. Yu
said, “The qi of wood is getting strong,” and so he took deep blue-​
green as his colour and wood as his pattern for his activities.42

The passage portrays the other three phases in similar form. Lü then
describes the principle of stimulus-​response (ganying 感應) by which
materials in these corresponding categories were thought to interact.

Things belonging to the same category naturally attract each

other; things that share the same qi naturally join together; and
musical notes that are close naturally resonate with one another.
Strike the note gong on one instrument, and other strings tuned to
the note gong will vibrate; strike the note jue and the other strings
tuned to the note jue will vibrate. Water flowing across levelled
earth will flow to the damp places; light evenly stacked firewood,
and the fire will catch where it is driest.43

By creating a link between state authority, the five phases, and the nat-
ural processes of qi, Lü’s work brought together state succession and
principles for divination with the undergirding forces of the natural

42 Chen Qiyou 陳奇猷 (ed.), Lü Buwei 呂不韋: Lüshi chunqiu jiao shi 呂氏春秋校釋
(Shanghai: Xuelin chubanshe, 1984), 13/​2.1; translation from Nylan, “Yin-​yang, Five Phases, and
Qi,” 399–​400. See also J. Knoblock and J. Riegel, The Annals of Lü Buwei (Stanford: Stanford
University Press, 2000), 13.2.282–​83.
43 Lüshi chunqiu jiao shi, 13/​2.1., Knoblock and Riegel, Annals, 13.2.283–​84. A parallel passage to
this appears elsewhere in an extended discussion of resonance theory. Lüshi chunqiu jiao shi, 20/​
4.1. Knoblock and Riegel, Annals, 522. For a brief overview of varieties of stimulus-​response theory,
see Franklin Perkins, “Metaphysics in Chinese Philosophy,” Zalta, The Stanford Encyclopedia of
Philosophy 2015, http://​plato.stanford.edu/​archives/​sum2015/​entries/​chinese-​metaphysics/​.
 Pre- and Early Imperial China 27

world, a move that went on to have far-​reaching influence on tech-

nical thought and its relation to state power.44 During the first two
centuries of the Han dynasty, considerable debate arose concerning
omenology when ritual specialists and political theorists sought to es-
tablish the emperor’s divinity, while at the same time constraining his
behavior and limiting his movements, encouraging him not to leave
the court.45
However, Lü’s intervention did not constitute the all-​encompassing
composite of cosmological correlative theory that was to become the
legacy of Han thought—​the interconnections between these theories
took time to emerge. The medical works of the Mawangdui collection
provide a close view of the development of yangsheng and medical cul-
ture at or before 168 BCE.46 Although yinyang theory is applied in
numerous places within the corpus, there is only one instance of five
phase theory, indicating that the theories in the Lü shi chunqiu had not
yet become widely incorporated.47 The largest number of texts discuss
how to diagnose or treat bodily channels (mai or mo 脈/​脉), through
which qi and blood circulated; also important are the yangsheng texts
that discuss (or contain pictures of) techniques for augmenting, cir-
culating, and storing qi in the body. Such techniques also included
dietary and exercise regimens and sexual hygiene. Many techniques
relied on a proprioceptive or tactile sense of the body’s interior and
heightened attention to the superficial conditions of the body: cold,
heat, pain, redness.48 Sexual hygiene was largely concerned not only

44 N. Sivin, “State, Cosmos, and Body in the Last Three Centuries B. C.,” Harvard Journal of
Asiatic Studies 55/​1 (1995); Harper, “Philosophy and Occult Thought”; Lo, “The Han Period.”
45 Aihe Wang, Cosmology and Political Culture in Early China (Cambridge: Cambridge
University Press, 2006); Tavor, “Embodying the Way,” 143–​81.
46 The authoritative translation and exegesis is Harper, Early Chinese Medical Literature.
47 Harper, “Philosophy and Occult Thought,” 866. This occurs in a text on fetal gestation and
birth, Taichan shu 胎產書. Mawangdui Hanmu boshu, vol.4, 376, and translation and commentary
in Harper, Early Chinese Medical Literature, 379–​81.
48 Lo, “Tracking the Pain.” V. Lo, “The Influence of ‘Yangsheng’ Culture on Early Chinese
Medicine” (PhD diss., School of Oriental and African Studies, 1998).
28 Michael Stanley-Baker

with the cultivation of qi, vital essence and spirits, but also with
attaining a state of ecstatic and numinous insight (shenming 神明),
which was associated with the attainment of sagehood.49
This literature on nourishing life had a strong structuring influence
on the formation of classical medical literature in the next century,
from which only the Yellow Emperor’s Inner Classic (Huangdi neijing
黃帝內經) survives in the received tradition.50 Compiled circa the
first century BCE from older texts, such as those found in Mawangdui,
the Inner Classic was formed at the same time that significant debates
took place at court concerning correlative cosmology and ritual prac-
tice.51 In this work, we find the most complete expression of five phase
theory in the Chinese corpus. It integrates and correlates a host of
phenomena under the notion of five phasal qi, including seasons,
colors, flavors (of food and drugs), animals, weather patterns, as well
as the internal organs, their related channels (mai), and acupuncture

49 V. Lo, “Spirit of Stone: Technical Considerations in the Treatment of the Jade Body,” Bulletin
of the School of Oriental and African Studies 65/​1 (2002), 99–128; V. Lo, “Crossing the Neiguan
内關 ‘Inner Pass:’ A Nei/​Wai 内外 ‘Inner/​Outer’ Distinction in Early Chinese Medicine,” East
Asian Science Technology and Medicine EASTM 17 (2000), 15–​65. Spirit (shen 神) had a double va-
lence as both anthropomorphic spirits that could be embodied (in the living) or disembodied (i.e.,
the dead), as well as referring to the substance of cognition, located in the chest region, most often
the heart (xin 心). Shenming could thus refer to the numinous spirits or to an expanded cognitive
and ecstatic bodily state. The most thorough study of shenming in Warring States literature and
scholarship is S. P. Szabó, “The Term Shenming: Its Meaning in the Ancient Chinese Thought and
in a Recently Discovered Manuscript,” Acta Orientalia Academiae Scientiarum Hungaricae, 56/​
2–​4 (2003), 251–​74.
50 The Yellow Emperor’s Inner Classic survives in three recensions: the Simple Questions (Suwen
素問), the Numinous Pivot (Lingshu 靈樞), and the Grand Basis (Taisu 太素). These are all
recombined passages from an originary work or works now lost. On textual filiation within these
works, D. J. Keegan, “The Huang-​ti nei-​ching: The Structure of the Compilation, the Significance
of the Structure” (PhD diss., University of California, 1988). On the dating and provenance of
surviving editions, N. Sivin, “Huang ti nei ching 黃帝內經,” in Loewe, Early Chinese Texts. On
the influence of yangsheng culture, Lo 羅維前 and Li Jianmin 李建民, “Manuscripts, Received
Texts, and the Healing Arts;” V. Lo, “The Influence of Nurturing Life Culture,” in E. Hsu (ed.),
Innovation in Chinese Medicine (Cambridge: Cambridge University Press, 2001).
51 For a comprehensive study of the Yellow Emperor’s Inner Classic, see Unschuld and Tessenow,
Suwen; Unschuld, Nature, Knowledge, Imagery. On debates surrounding the five phases in the late
Western Han court, see Wang, Cosmology and Political Culture in Early China.
 Pre- and Early Imperial China 29

points along the channels.52 The relationships between these phases

structured notions of physiological operations, etiology, and curative
practices such as acupuncture, diet, and seasonal habits and behaviors.
Although the relationships between qi, yinyang, and the five phases
are given their fullest expression in the Yellow Emperor’s Inner Classic,
they are taken up in a broad swath of scientific thought, ritual, and
political theory. Under this scheme, none of these domains could ever
be fully separate.53
These patterns of nature were never far off from the cosmo-​
political sphere. One of the most frequently used terms for curing
is zhi 治, a politically resonant term meaning to control or govern.
It was frequently contrasted with luan 亂, literally “chaos,” which
had overtones of rebellion and political uprisings that needed to be
controlled in order to sustain the health of the state. These terms
converged the curing of disease with the maintenance of political
order, and frequent analogies were made between the state and the
body, as in the chapter “Regulating the Spirit in Accordance with the
Four Seasons”:

The sages did not treat those who were already ill, but treated
those not yet ill,
They did not put in order what was already chaotic, but put in
order what was not yet in chaos.54

Homologies for governance abound within the text: the liver is

described as a general, the heart as a ruler, the lung as a chancellor; qi,

52 E. Hsu identifies this composite as a “Body Ecologic,” defined in relation to climatic factors.
She distinguishes this from the earlier emphasis on moral cultivation tied to the cultivation of
qi, which she identifies as the “Sentimental Body” of felt feelings, emotions, and values. E. Hsu
許小麗, “Outward Form (xing 形) and Inward Qi 氣: The “Sentimental Body” in Early Chinese
Medicine,” Early China 32 (2009).
53 Sivin, “State, Cosmos, and Body”; Raphals, “Philosophy and Medicine.”
54 Amended from Unschuld and Tessenow, Suwen 2.56.
30 Michael Stanley-Baker

which circulates to the exterior defensive layer of the body, is referred

to as a military camp and its supplies (ying qi 營氣).55
By the time the Han imperial “Bibliography of Arts and Letters”
(Yiwen zhi 藝文志) was completed in the first century by the dynastic
historian Ban Gu 班固 (32–​92 CE), we find a clearer arrangement of the
Chinese sciences.56 As Nathan Sivin argues, there was no unified no-
tion of science per se; rather the sciences were singular and individual.57
This can be seen in the catalogue titles in the bibliography: “Arts and
Calculations” (shushu 術數), which contained subsections on math-
ematics, divination, and “Methods and Techniques” ( fangji 方技).
The latter contains four subsections: “Medical Classics” (yijing 醫經);
“Classic [drug] Recipes” ( jingfang 經方); “Arts of the Bedchamber”
( fangzhong 房中); and “Divine Transcendence” (shenxian 神仙).58
This catalogue, argues Miranda Brown, is the earliest recorded in-
stance when the notion of medicine (yi 醫) was articulated as a uni-
fied, historical field of knowledge, and this framing was very influential
on later medical writers, becoming a mainstay of medical orthodoxy.59
Originally compiled by the court official and scholar Liu Xiang 劉向
(77–​8 or 6 BCE) and edited by his son Liu Xin 劉歆 (50 BCE–​23 CE),
and later incorporated by Ban Gu into his work, the Lius’ catalogue

55 Huangdi neijing suwen yijie, 8.76–​80; Yang Weijie 楊維傑 (ed.), Huangdi neijing lingshu yijie
黃帝内經靈樞譯解 (Taibei: Tailian guofeng chubanshe, 1984), 16.186.
56 Ban Gu based his catalogue on work begun by his father Ban Biao 班彪 (3–​54 CE) that
assimilated the Seven Summaries (Qilüe 七略). A. F. P. Hulsewé, “Han shu 漢書,” in Loewe, Early
Chinese Texts.
57 N. Sivin, “Science and Medicine in Chinese History,” in P. S. Ropp and T. H. Barrett (eds),
Heritage of China: Contemporary Perspectives on Chinese Civilization (Berkeley: University of
California Press, 1990); N. Sivin, “Why the Scientific Revolution Did Not Take Place in China—​
or Didn’t It?” Chinese Science 5 (1982). See discussion in Raphals, “Philosophy and Medicine.”
58 Han shu, 30.1776–​81.
59 M. Brown, The Art of Medicine in Early China: The Ancient and Medieval Origins of a Modern
Archive (Cambridge: Cambridge University Press, 2015), 95–​96, 106ff and passim. Brown argues
that references to an yidao 醫道 (Way of Doctors/​Medicine), as in Yellow Emperor’s Inner Classic
­chapter 75, were rare exceptions that proved the rule, and the majority of depictions of medicine as
a body of thought emphasized variety and heterogeneity of the various schools, as in Inner Classic,
12. See Huangdi neijing suwen yijie, 12.104–​07 and 75.670–​72. For translations, see Unschuld and
Tessenow, Suwen 12.211–​18 and 75.645–​50.
 Pre- and Early Imperial China 31

described medicine (yi 醫) as a collective, historical body of medical

knowledge not limited to personal, lineage transmission but directly ac-
cessible through ancient texts. This framing of medicine as an historical
body of knowledge reflected the intellectual politics of the Lius, who
were sympathetic to the “old text” school, a group of academicians who
argued that authoritative knowledge was better transmitted through
early editions of classical texts. This position shaped the school’s polit-
ical outlook, which held the ruler as a rational actor who ought to be
advised to take decisions based on logical argument. They were opposed
to the “new text” school that argued orthodoxy was only transmitted
through lineages of initiated academicians and supported a charismatic
image of the ruler as a sage-​king with divine powers.60
Alongside this framing of “Medical Classics” and “Classical
Recipes” as historical categories, the general catalogue of “Methods
and Techniques”—​a title more suggestive of practical knowledge and
skills than theoretical categories—​exhibits tensions with regard to
other kinds of knowledge. The two other subcategories, the “Arts of the
Bedchamber” and “Divine Transcendence,” receive no such historical
framing and include texts on skills closely associated with the attain-
ment, preservation, and enhancement of essence and qi for longevity,
and for paranormal powers and immortality. Sexual cultivation was, as
in Mawangdui, an important part of yangsheng practice, and this cat-
alogue contained over 800 fascicles, or juan, dwarfing the other three,
which contained roughly 200 each. Transcendence refers to the attempt
to achieve supernaturally long life or immortality and miraculous bodily
powers, and the editors were quite ambivalent about their status:61

Transcendence is the perfection by which to guard one’s inner na-

ture and destiny, and thus wander, seeking, in the outer regions.
60 M. Nylan, “The ‘Chin Wen/​Ku Wen’ Controversy in Han Times,” T’oung Pao 80/​1.3 (1994).
61 A major topic in the history of religions, it is impossible to describe even a representative bib-
liography here. A preliminary introduction is B. Penny, “Immortality and Transcendence,” in
L. Kohn (ed.), Daoism Handbook (Leiden: Brill, 2000). For a significant recent translation of
transcendent biographies R. F. Campany, To Live as Long as Heaven and Earth: A Translation
32 Michael Stanley-Baker

These gentlemen, free of cares and calm of mind, regard as equal

the realms of life and death, and harbour no tremulous fears in
their breast. However, there are those who make this their sole la-
bour, and fill their writings with great lies and wondrous exotica
to make them seem grander, these are not the teachings of the sage
kings. Confucius said: “As for studying the occult and practicing
wonders, later generations will record it, and I do not perform
them.”62

Liu Xiang argues here that while transcendents (xianren 仙人) are
experts in preserving life and living at ease, there are also charlatans and
fakers among their ranks, and thus unsuitable literature for the literate
elite or for governing the state. They cite the authority of Confucius him-
self to create distance from this literature. This double-​edged assessment
makes it ambiguous whether it is acceptable literature—​it is not so dis-
tant that it was excluded from the catalogue. While it is clear the Lius
did not wholly embrace transcendent writings, it appears that some of it,
probably that which was kept in the imperial library, was regarded as ac-
ceptable. Nevertheless, having been collected within the overall category
of “Methods and Techniques,” it is clear that these writings were thought
to be part of a common body of related knowledge and thus related to
medicine.
The roughly contemporaneous Arrayed Traditions of Transcendents
(Lie xian zhuan 列仙傳), also shows transcendence and medicine
to be related domains of activity.63 This collection of biographies
of immortals and wonder-​workers included many of the health

and Study of Ge Hong’s Traditions of Divine Transcendents (Berkeley: University of California

Press, 2002). For a study of their social standing in medieval China, see R. F. Campany, Making
Transcendents: Ascetics and Social Memory in Early Medieval China (Honolulu: University of
Hawai’i Press, 2009).
62 Han shu, 30.1779–​80. The passage cited from Confucius is from the Doctrine of the Mean
Zhongyong 中庸 verse 11.
63 Lie xian zhuan 列仙傳 DZ 294, attributed to Liu Xiang. Because material in the text is ver-
ifiably from the second century CE, and the earliest attribution to Liu Xiang does not occur
 Pre- and Early Imperial China 33

practices witnessed in the Mawangdui collection, newly adopted

into the regimes of transcendents. These included grain-​fasting,
sexual cultivation, breathing exercises, and stretching (daoyin 導引)
for the attainment of supernatural longevity, immortality, and su-
pernatural powers. It also describes transcendents as highly visible
in curing and in the drug trade in local marketplaces.64 While we
cannot take the Arrayed Traditions as a veritable record concerning
real events and real people, it certainly is a cultural record and
attests to the imagination of what these practices were thought to
achieve.65 The catalogue was consistent with wider cultural notions
that made no clear break between medicine and these broader col-
lected health practices, which included those expressly used for reli-
gious cultivation.

The Religio-​M edical Marketplace of

the Six Dynasties

The decline of the Han dynasty took place amid the political, eco-
nomic, and social upheaval of the second century CE, bringing famine,
widespread epidemics, and an ideological vacuum—​the destabiliza-
tion of relations between heaven and humanity, individuals and their
destiny.66 The indiscriminate nature of disease, which strikes without
regard to the moral worth of the individuals affected, gave rise to a

until the fourth century, this attribution and the early date are suspect. B. Penny, “Lie xian
zhuan,” in Pregadio, The Encyclopedia of Taoism. The seminal study of the Arrayed Traditions is
M. Kaltenmark, Le Lie-​sien Tchouan: biographies légendaires des Immortels taoïstes de l’antiquité
(Pékin: Centre d’études sinologiques de Pékin, 1953). For a comparison of existing editions of the
work, KUBO Teruyuki 久保 輝幸, “‘Retsu sen den’ no bōshitsu shita senden ni soku nitsuite
『列仙伝』の亡失した仙伝2則について,” Jinbun gaku ronshyū 人文学論集 29 (2011).
64 As argued by Ogata Toru 大形 徹, “Rensen den ni miru doutokuteki sennin no houga
『列仙傳』にみる道徳的仙人の萌芽,” Jinbungaku ronshou 人文学論集 33 (2015). Thanks to
KUBO Teruyuki for this reference.
65 Campany, Making transcendents, 15–​22.
66 Lin Fushi 林富士, “Donghan shiqi de jiyi yu zongjiao 東漢時期的疾疫與宗教,” in
Zhongguo zhonggu shiqi de zongjiao yu yiliao 中國中古時期的宗教與醫療 (Taibei: Lianjing
chubanshe, 2008).
34 Michael Stanley-Baker

moral question about why bad things happen to good people. The the-
odicy of disease became a central question with which most religions
of the time were concerned. In this climate, religious and technical
actors of all stripes became involved in curing, caring, and embodied
salvation.67 Millennial cults such as the Celestial Masters (Tianshi
Dao 天師) and the Great Peace (Taiping 太平) movement arose in the
east and west of China respectively and became involved in fighting
the Han government and attempting to set up sovereign theocratic
states.68 These movements identified the cause of disease in personal
and familial sin, which were punished by the celestial bureaucracy, a
divine simulacrum of the earthly state that resided in celestial realms
and hidden caverns. The cure for such sin involved confessional rites
and petitions to heavenly officials through rituals.69 Transcendents
such as those described in Arrayed Traditions and later works were
well known for their skills in curing disease, as their search for lon-
gevity and immortality relied on many curative arts.70 They sought to

67 On the religio-​medical marketplace in medieval China, see C. P. Salguero, Translating

Buddhist Medicine in Medieval China (Philadelphia: University of Pennsylvania Press, 2014); M.
Stanley-​Baker, “Daoists and Doctors: The Role of Medicine in Six Dynasties Shangqing Daoism”
(PhD diss., University College London, 2013).
68 M. Loewe, “The Religious and Intellectual Background,” in D. C. Twitchett and M. Loewe
(eds), The Cambridge History of China, vol. 1: The Ch’ in and Han Empires, 221 B.C.–​A .D. 220
(Cambridge: Cambridge University Press, 1986); P. Demiéville, “Philosophy and Religion from
Han to Sui,” in Twitchett and Loewe, The Cambridge History of China, vol. 1. On the Daoist for-
mation of a theocratic state, see T. F. Kleeman, Great Perfection: Religion and Ethnicity in a Chinese
Millennial Kingdom (Honolulu: University of Hawai`i Press, 1998), and most recently T. F.
Kleeman, Celestial Masters: History and Ritual in Early Daoist Communities (Cambridge: Harvard
University Asia Center, 2016).
69 B. Hendrischke, “Religious Ethics in the Taiping jing: The Seeking of Life,” Daoism: Religion,
History and Society 4 (2012); Li Jianmin 李建民, “They Shall Expel Demons: Etiology, the Medical
Canon and the Transformation of Medical Techniques before the Tang,” in J. Lagerwey and M.
Kalinowski (eds), Early Chinese Religion (Leiden: Brill, 2009); M. Strickmann, Chinese Magical
Medicine (Stanford: Stanford University Press, 2002); P. S. Nickerson, “The Great Petition for
Sepulchral Plaints,” in S. R. Bokenkamp (ed.), Early Daoist Scriptures (Berkeley: University of
California Press, 1997).
70 Lin Fushi 林富士, “Zhongguo zaoqi daoshi de ‘yizhe’ xingxiang: yi Shenxian zhuan wei
zhu de chubu tantao 中國早期道士的「醫者」形象： 以《神仙傳》為主的初步探討,” in
Zhongguo zhonggu shiqi de zongjiao yu yiliao 中國中古時期的宗教與醫療 (Taibei: Lianjing,
2008); Lin Fushi 林富士, “Zhongguo zaoqi daoshi de yiliao huodong ji qi yiliao kaoshi: yi Han
Wei Jin Nanbeichao shi de ‘zhuanji’ ziliao weizhu de chubu tantao 中國早期道士的醫療活動
 Pre- and Early Imperial China 35

escape the forces of destiny through alchemical drugs or arcane burial

rituals.71 In these writings, the ingestion of herbs was on a continuum
with the ingestion of rare minerals, alchemical products, or the light
of the sun, moon, and stars. Buddhists brought in foreign drugs, new
disease treatments, and set up hospitals and hospices.72 The notion of
generating and spreading good karma, or merit, formed a broad ide-
ological basis for extensive medical missionizing.73 Health-​related
practices were widespread and straddled the (modern) line between
normal good health and religious attainment.

Nourishing Life and Inner Nature

Within this broader context, no singular unified term emerged as a

conceptual category directly parallel to “health.” However, practices
of the sort first evinced in Warring States yangsheng literature and the
philosophical texts, such as breathing, bodily awareness, stretching,
and diet, became adapted in late Han literature on transcendence.74

及其醫術考釋：以漢魏晉南北朝時期的「傳記」資料為主的初步探討,” in Zhongguo
zhonggu shiqi de zongjiao yu yiliao 中國中古時期的宗教與醫療 (Taibei: Lianjing, 2008).
71 On these methods, U.-​A . Cedzich, “Corpse Deliverance, Substitute Bodies, Name Change,
and Feigned Death: Aspects of Metamorphosis and Immortality in Early Medieval China,”
Journal of Chinese Religons 29 (2001); S. R. Bokenkamp, “Simple Twists of Fate: The Daoist Body
and Its Ming,” in C. Lupke (ed.), The Magnitude of Ming: Command, Allotment, and Fate in
Chinese Culture (Honolulu: University of Hawai’i Press, 2005); R. F. Campany, “Living off the
Books: Fifty Ways to Dodge Ming 命 in Early Medieval China,” in Lupke, The Magnitude of Ming;
M. Stanley-​Baker, “Drugs, Destiny, and Disease in Medieval China: Situating Knowledge in
Context,” Daoism: Religion, History and Society 6 (2014).
72 Salguero, Translating Buddhist Medicine in Medieval China, and Liu Shufen 劉淑芬,
“Tang, Song shiqi sengren, guojia, he yiliao de guanxi—​Cong Yaofangdong dao huiminju
唐、宋時期僧人、國家和醫療的關係—​從藥方洞到惠民局,” in Li Jianmin 李建民(ed.),
Cong yiliao kan zhongguo shi 從醫療看中國史 (Taipei: Lianjing, 2008).
73 C. P. Salguero, “Fields of Merit, Harvests of Health: Some Notes on the Role of Medical Karma
in the Popularization of Buddhism in Early Medieval China,” Asian Philosophy 23/​4 (2013); Liu
Shufen 劉淑芬, “Yaofangdong”; Zhang Ruixian 張瑞賢, Wang Jiakui 王家葵, and M. Stanley-​
Baker徐源, “The Earliest Stone Medical Inscription,” in Lo, Imagining Chinese Medicine.
74 An early study of Daoist health practice is F. A. Kierman (trans.), H. Maspero: Taoism and
Chinese Religion (Amherst: University of Massachusetts Press, 1981); On exercises and health
cultivation after the Han, C. Despeux, “Gymnastics: The Ancient Tradition,” in L. Kohn and Y.
Sakade (eds), Taoist Meditation and Longevity Techniques (Ann Arbor: Center for Chinese Studies
36 Michael Stanley-Baker

Sects differed on how they understood the full potential of these

practices, and this marked different types of practitioners and sec-
tarian affiliation. The goals of achieving “long life” (changsheng
長生/​changshou 長壽) and “immortality” (busi 不死) overlapped,
since “long” life is an indefinite term.75 By the fourth century CE, a
clear hierarchy became quite widely established that distinguished
between curing, yangsheng, and transcendence as three successive
stages of progress on the spiritual path. This structure informed not
only transcendent writings, like those of Ge Hong 葛洪 (?283–​?343)
and early Shangqing 上清 (Upper Clarity) Daoism, but also the ma-
teria medica, the Shennong bencao jing 神農本草經.76 These created
clear distinctions not just between the practices but also among their
practitioners and the sects in which they were situated. The status of
yangsheng practices was thus the focus of hot contestation—​as dif-
ferent claims were made by competing sects about specific practices
and what they could do. Thus the term yangsheng came to refer to a
dynamic field of health practice consisting of many different actors
and practices—​practices that were also adopted into regimes of im-
mortality and the attainment of divine powers.
While yangsheng literature in the main consisted of collections of
techniques with little commentary, in the manner of recipe ( fang 方)
literature, increasingly over time the topic of “inner nature” (xing 性)
came to the forefront of philosophical reflections. From the Han dy-
nasty onward, the terms for “life” or “vitality” (sheng 生) and “inner
nature” were treated as cognate terms and often interchangeable in

University of Michigan, 1989); U. Engelhardt, “Qi for Life: Longevity in the Tang,” in Kohn and
Sakade, Taoist Meditation.
75 M. Stanley-​Baker, “Cultivating Body, Cultivating Self: A Critical Translation and History of
the Tang Dynasty Yangxing yanming lu (Records of Cultivating Nature and Extending Life)” (MA
thesis, Indiana University, Bloomington, 2006), 34–​47.
76 On the place of drugs and other curative strategies within formalized cultivation regimes,
Stanley-​Baker, “Drugs, Destiny, and Disease.”
 Pre- and Early Imperial China 37

variant editions of the same text.77 Intellectuals in the Mystery School

(Xuanxue 玄學) from the third to the fifth centuries came to engage
in questions about inner nature and life force and their relationship
to cognition, the self, morality, and individual agency.78 In the sev-
enth century, the medical prodigy Sun Simiao 孫思邈 (581–​681?
CE) argued that the cultivation of inner nature was more than just
breathing exercises, rather it was rooted in ethical behavior.79 Within
the Daoist tradition of inner alchemy (neidan 內丹), which emerged
in the tenth century, xing and ming came to refer to the two poles
of inner consciousness and the material body, in which a complex of
philosophical and personal and health were enmeshed. Xing referred
to non-​being, inner nature, humanity, innate nature, and original
Buddha-​nature, while ming referred to being, personal destiny, vital
force, health, and the material world.80

Knowing Styles: On How and Not Why

Throughout this chapter I emphasized that while social and intellec-

tual differences were made between different schools and disciplines,
there were continuities of practice across these different domains. The
practices of yangsheng—​whether breath meditation, heightened bodily
awareness, stretching, or diet—​were adopted, adapted, and redefined
within multiple communities, who thus situated them within or beyond

77 Witnessed by the commentarial traditions on the Baopuzi neipian 抱朴子內篇 in Wang Ming
王明 (ed.), Ge Hong 葛洪: Baopuzi neipian jiaoshi 抱朴子內篇校釋 (Taibei: Liren shuju, 1981).
The Shennong bencao also refers to the middle level of cultivation as nourishing xing, not sheng.
78 See discussion of Ji Kang below.
79 Sun Simiao 孫思邈, Beiji qianjin yaofang 備急千金要方 (Taibei: Guoli zhongguo yiyao
yanjiusuo, 1990), 28.476a–78b; S. Wilms, “Nurturing Life in Classical Chinese Medicine: Sun
Simiao on Healing without Drugs, Transforming Bodies and Cultivating Life,” Journal of Chinese
Medicine 93 (2010).
80 F. Pregadio, “Destiny, Vital Force, or Existence? On the Meanings of Ming in Daoist Internal
Alchemy and Its Relation to Xing or Human Nature,” Daoism: Religion, History & Society 6 (2014);
C. Despeux, Immortelles de la Chine ancienne: Taoïsme et alchimie féminine (Puiseaux: Pardès,
38 Michael Stanley-Baker

their own repertoires. The need to differentiate them arose precisely be-
cause of their similarity.81 Historians have agreed that reference to epis-
temology was not commonly used to distinguish medicine or health
practices from other kinds of knowledge, rather critiques were made
of their character or genealogy.82 Liu Xiang’s critique of transcendents
serves as an example: he differentiates the excessive sort, who told tall
tales, from the noble type, who were above distinctions of death and life,
and who knew the secrets of sustaining life. Liu did not foreground their
knowing styles but their trustworthiness and their decorum.
While historians have noted the absence of epistemological argu-
ment, anthropologists observing similar habits in modern-​day tra-
ditional Chinese medicine hospitals and clinics argue that a lack of
focus on epistemology and metaphysics does not signify absence of
reflection. Judith Farquhar argues that a deepened practical logic is
situated in the bodies, institutions, materials, and methods by which
Chinese doctors give treatment.83 The knowing practice of medicine
takes place within a temporal, processual domain that subordinates
arguments about first causes to the exigencies of the clinic. Studied
from this perspective, doctors’ recourse to genealogies of practitioners
is not merely social polemic but tacitly evokes inherited, collective ex-
perience. The metaphysics of the transformation of yinyang and the
five phases are revealed not as static first principles that stand outside
of time but as guiding orientations within the contingencies of the
clinical encounter. Farquhar’s emphasis on embodied practice and

1990), 223–​27; I. Robinet with Chang Po-​tuan, Introduction à l’alchimie intérieure taoïste: de
l’unité et de la multiplicité (Paris: Editions du Cerf, 1995), 165–​95.
81 On the construction of categories as an act of comparison and hierarchy-​making, J. Z. Smith,
“On Comparison,” in Drudgery Divine: On the Comparison of Early Christianities and the Religions
of Late Antiquity (Chicago: University of Chicago Press, 1990), 36–​53.
82 Lloyd and Sivin, The Way and the Word, 205; Harper, Early Chinese Medical Literature, 156–​
83. Other scholars have also noted an absence of emphasis on analytical philosophy in traditional
Chinese thought and the reframing of “philosophy.” J. Kurtz, The Discovery of Chinese Logic
(Leiden: Brill, 2011).
83 J. Farquhar, Knowing Practice: The Clinical Encounter of Chinese Medicine (Boulder,
CO: Westview Press, 1994); J. Farquhar, “Problems of Knowledge in Contemporary Chinese
 Pre- and Early Imperial China 39

experience reveals classificatory strategies as strategic tools used in

context, not as cosmological abstractions.
In this vein, modern Chinese doctors distinguish between the
knowing practice of well-​ heeled clinicians and the measuring,
standardizing, and objectifying the knowing style of western medical
science. This is epitomized in the phrase “Knowing the why, but not
the how” (Zhi qi suo yi ran, er bu zhi qi ran 知其所以然，而不知
其然。), which contrasts arguments from western scientific medicine
to the clinical know-​how and textual traditions of China.84
This processual orientation toward knowledge as embodied and con-
tingent is reflected in early texts like the Zhuangzi and expanded on
in later commentaries, which anticipate the knowing styles of Chinese
medicine today. The following passage from the chapter on “Nourishing
Life” argues against the acquisition of knowledge for knowledge’s sake:

This life of ours, it has its limits but knowledge is limitless. You are
already in danger if you chase the limitless by means of the limited.
If you already know this, and still strive for knowledge, then you are
in danger for certain!85

Commentators in the medieval period argued that one should strive

for virtuosity in nourishing inner nature (xing), and that this was an
intuitive, skillful, and embodied praxis. Ji Kang 嵇康 (style name
Shuye 叔夜, 223–​262 CE) writes:86

To have desire without thinking is a movement of one’s inner na-

ture (xing). [But] to first recognise something and then to produce

Medical Discourse,” Social Science & Medicine 24/​12 (1987). For a study of how the Daoist avoid-
ance of excessively abstract, theoretical knowledge informs modern debates.
84 J. Farquhar and Wang Jun, “Knowing the Why but Not the How: A Dilemma in Contemporary
Chinese Medicine,” Asian Medicine 5/​1 (2011).
85 Zhuangzi jishi, 2.3.115.
86 Style names were a formal term of address, usually given at coming-​of-​age rituals.
40 Michael Stanley-Baker

a stimulus is a function of knowing (zhi 智). When inner nature

moves, it is satisfied when it meets its object, there is no excess. But
knowing follows a stimulus, and does not get exhausted; it is unable
to stop. Thus the problems of the world are always to be found in
knowing, not in the stirrings of xing.87

For Ji Kang, excessive fascination with the intellect and knowledge

(both zhi 智) leads one to lose touch with the wisdom of inner na-
ture (xing). Both are known through self-​reflection. The intellect is
portrayed as one step removed from the present moment—​a n initial
cognitive recognition that only subsequently prompts activity. Inner
nature moves spontaneously, without thought, and is intuitively
and accurately responsive to the environment. This framing evokes
the notion of enskilment, development of a fine-​tuned sensitivity
that reacts immediately, and is comparable to recent arguments for
understanding knowledge as practice.88 This is especially apparent
when we consider that Zhuangzi’s heroes are craftsmen and skilled
workers who, trained in seemingly lowly tasks, in fact portray a
practical knowledge of the Dao as it moves through the world.
How one knows has a direct impact on health. Inner nature’s
desires are limited; they are framed by the possibility of the moment

87 The translation is informed by R. G. Henricks, Philosophy and Argumentation in Third-​

Century China: The Essays of Hsi K’ang (Princeton, NJ: Princeton University Press, 1983), 44–​45.
Henricks adds an alternate subject in places, a “one” that desires and seeks satisfaction. I choose to
keep the subject as “intelligence,” which has agency—​it desires and seeks satisfaction. Note that
Hsi Kang is an alternative spelling for Ji Kang. Not originally written as a commentary on the
Zhuangzi, this passage was compiled by Zhang Zhan 張湛 (stylename Chudu 處度, fl. 370) along
with other third-​and fourth-​century commentaries in his “Collected Essentials of Nourishing
Life” (Yangsheng yaoji 養生要集), now lost. It survives in the redacted Yangxing yanming lu
養性延命錄 DZ 838 1.1.2b–​3a. Stanley-​Baker, “Cultivating Body, Cultivating Self.”
88 On enskillment and practice as means to understand knowledge as embodied and performative,
rather than abstract, subjective cognition, J. Lave and E. Wenger, Situated Learning: Legitimate
Peripheral Participation (Cambridge: Cambridge University Press, 1991). On knowledge as on-
tological assemblage, in contrast to epistemological theory, as in B. Latour, “A Textbook Case
Revisited. Knowledge as Mode of Existence,” in E. J. Hackett, et al. (eds), The Handbook of Science
and Technology Studies (Cambridge: MIT Press, 2007).
 Pre- and Early Imperial China 41

and satisfied when they achieve their object. But the search for knowl­
edge, which is abstract, knows no bounds, and can exhaust the body.
Whereas the spontaneous movement of inner nature nourishes health,
attachment to artificial knowledge can destroy it.

Conclusion

The material terms qi and sheng were rarely subjected to epistemo-

logical inquiry—​these terms were taken for granted, unlike xing and
ming, which became hotly debated in both philosophy and inner
alchemy. The majority of writings regarding qi and sheng were con-
cerned with pragmatic issues of how to nurture them, whether and
why the practices work, and with axiological or valuative frameworks
within which to couch such practice regimes. Thus the object of in-
quiry was not epistemological or causal, that is, how to know what qi
and sheng are, but rather how to cultivate them, and what it meant to
do so. All of these questions implicitly or explicitly reflected on the
status of experts in this knowledge, as we can see in early philosophers
distinguishing themselves from those who merely cultivate the body,
in the formation of medical theory, and in the bustle and jostle of the
post-​Han religio-​medical market.
I have reviewed three main periods of writing on health, and how
they have construed qi practices to nourish or protect life force
(sheng), and thus lengthen lifespan (ming) and improve or transform
destiny (also ming). After the Han dynasty, these deliberations also
placed increased emphasis on the role of inner nature (xing) within
this complex. Beginning with early philosophical writings that
mention qi practices, different authors in the Guanzi and Zhuangzi
sought to emphasize proximity or distance between physical and
spiritual health. Different layers in the same texts, such as the
Daode jing, evinced different periods of thinking about the body
in relation to spiritual cultivation. A significant change in thinking
about bodily cultivation and in how the body was conceived took
42 Michael Stanley-Baker

place just prior to and during the Han dynasty, with the emergence
of five phase thought and its eventual confluence with yinyang and
qi theories. These configured bodily cultivation in much closer rela-
tion to conceptions of the natural world that reflected not just cos-
mological but also political powers. With the collapse of the Han
dynasty and its ideological underpinnings, numerous new religions
entered the scene, organizing healing, cultivation, and theodicy
within different schemes.
In this regard, the early philosophers—​who debated whether or not
deliberate cultivation of the body was equivalent to cultivation of the
mind and spirit—​bear great similarity to the post-​Han aspirants to
transcendence—​who evaluated whether yangsheng practices could
lead to transcendence or whether they were merely useful for curing
disease and achieving a normal lifespan. Both questioned whether
practices of the interior body could lead to a transformed subjectivity,
the status of a sage or superior being, while at the same time being anx-
ious to distance such meditations from exercises that simply improved
bodily function. These practices were not analyzed on the basis of their
metaphysics, but on how to do them, who did them, and what they
achieved. Knowledge about health in China was predominantly pro-
cessual and embodied, rather than abstract; and it is better analyzed
through theories of ontology and practice theory than through episte-
mological reflection.
 CH A PTER T WO

Medical Conceptions of Health

from Antiquity to the Renaissance
Peter E. Pormann

To counter the massive outbreak of foot-​ and-​mouth disease in

England in 2001, the government decided to resort to a massive cull.
The strategy was not just to eliminate infected animals but also those
that could potentially carry the disease. The massive pyres of burning
lambs and sheep shocked the nation, and in letters and interviews,
people expressed their revulsion at the “slaughter of innocent ani-
mals.” Diseased animals were “guilty,” whereas healthy ones were
“innocent.” A semantic shift occurred from bodily health to moral
rectitude. The equation of bodily and moral integrity is an old one and
goes back at least to the times of Homer, as illustrated by the example
of Thersites from book 2 of the Iliad. In an assembly of the Achaeans,
he was the only one who dared criticize Agamemnon for his greed and
warmongering. Thersites is an antihero: he wants to go home rather
than gain glory by taking Troy. “He was the most shameful man who
came to Troy. He had crooked legs, a limp in one leg, bent shoulders

43
44 Peter E. Pormann

slanting towards the chest, and moreover a pointed head, crowned

with lank thin hair.”1 The shame resulted both from his bodily de-
formity and his moral depravity. In later times, the Greeks coined the
term kalokagathia for the fact of being both “beautiful (kalos) and
(kai) good (agathos).” This theme of linking moral and physical health
is found not just in the Greek tradition but also in Latin and Arabic.
Other themes linked to the body that appear in Greek culture and
then continue to be of importance in later traditions, both East and
West, are those of purity and balance. In the Hippocratic Oath, for
instance, the physician vows to keep his life and the art “in a pure and
holy way (ἁγνῶς δὲ καὶ ὁσίως).”2 Pythagoreans and other early Greek
thinkers enjoined to abstain from eating beans (κυάμων ἀπέχεσθαι),
in part, undoubtedly because they cause flatulence. The physician
and philosopher Alcmaeon, who probably lived toward the end of the
sixth century BCE, stressed the importance of balance in a famous
fragment:3

Alcmaeon says that what maintains health is the equality (isonomia)

of the powers, of the moist and dry, cold and hot, bitter and sweet,
and the other [opposites], whilst the monarchy of only one among
them causes sickness, for the monarchy of the one of the two is
destructive for the other. And sickness occurs, with regard to the
agent, from excess of heat or cold; with regard to the [material] or-
igin, from abundance or lack of nourishment; and with regard to
place, blood, marrow, or the brain; it is also sometimes produced by
external causes, certain kinds of water, the country, blows, dearth,
and other causes similar to these, whilst health is the proportionate

1 Homer, Iliad 2.216–​19.

2 H. von Staden, “‘In a Pure and Holy Way’: Personal and Professional Conduct in the Hippocratic
Oath?” Journal of the History of Medicine and Allied Sciences 51 (1995), 404–​37.
3 A. Laks and G. W. Most (ed. and trans.), Early Greek Philosophy, 9 vols. (Cambridge,
MA: Harvard University Press, 2016), 5:762–​65.
 Antiquity to the Renaissance 45

mixture of the qualities (τὴν δὲ ὑγιείαν τὴν σύμμετρον τῶν ποιῶν

κρᾶσιν).

This fragment contains one of the earliest extant definitions of

health: it is the proportionate mixture of the qualities. We find a po-
litical metaphor here as well: equality sustains health, whereas mon-
archy removes it. This balance of opposing qualities and humors will
play a major role in the conception of health from antiquity to the
Renaissance.
The need to keep the body in balance was even realized by
philosophers who generally disdained the body. For instance, the
Greek physician Galen of Pergamum (129–​216) reports the following
anecdote about the Cynic philosopher Diogenes of Sinope (fourth
century BCE). Diogenes reportedly lived in a barrel, ate with the dogs
(hence the name “Cynic,” from Greek kynes, dogs), and despised all
material comforts.4 And yet, in order to get rid of an excess of sperm,
he went to see a prostitute. The prostitute in question, however, was
too slow, so that he “touched his penis with his hand and dismissed
her, when she later entered, saying that his hand made him sing the
wedding song already (τὴν χεῖρα φθάσαι τὸν ὑμέναιον ᾆσαι).”5 Another
philosophical school, that of the Stoics, had a similar approach. For
them, bodily health belongs in the “indifferent (adiaphoron)” cate-
gory: it does not matter whether one is healthy. And yet, they created
a subcategory of the “preferable indifferent (adiaphoron proêgmenon),”
under which health falls.6
Many of these ideas and principles found in ancient Greek thought
about health and disease influenced later cultures. The purpose of this
chapter is to highlight some of the developments in Greek medical

4 O. Overwien, Die Sprüche des Kynikers Diogenes in der griechischen und arabischen Überlieferung
(Stuttgart: Franz Steiner, 2005).
5 Kühn, Galen: Opera Omnia, 8.419.
6 M. Forschner, Die stoische Ethik (Darmstadt: Wissenschaftliche Buchgesellschaft, 1995), 114–​23.
46 Peter E. Pormann

literature, beginning with the Hippocratic Corpus, then moving to

Galen’s work, and the writing of late antiquity. I shall then trace ideas
about health in the medieval Islamic world, offering a few vignettes
on thinkers such as Abū Bakr al-​R āzī (d. ca. 925), Avicenna (d. 1037),
and Ibn Buṭlān (d. ca. 1063). Likewise, two commentators on the
Hippocratic Aphorisms will come under scrutiny, as they show how
health could be defined in different manners. The Arabic medical tra-
dition had a profound impact on the Latin Middle Ages, and I shall
discuss some Latin translations of Arabic texts and see how they were
adopted and adapted to suit the needs of a different cultural, religious,
and linguistic context. I shall end my analysis with a short outlook
on the Renaissance, when the Arabic heritage, although still domi-
nant, came under ever increasing pressure. But first let us turn to the
Hippocratic Corpus at the beginning of the Greek medical tradition.

Greece
Hippocratic Corpus

The Hippocratic Corpus is a collection of writings attributed to

Hippocrates but which must, in reality, have been written by many
different authors over a long period of time: the earliest date to the
fifth century BCE, whereas the latest were perhaps written as late as
the first or second century CE.7 They also differ, sometimes radically,
in their theoretical and practical approach. For instance, the treatise
Nature of Man (fourth century BCE) sets out the doctrine of what is
nowadays known as “humoral pathology.” Health consists in the bal-
ance (eukrasia) of the four humors: blood (haima), phlegm (phlegma),
yellow bile (xantê cholê), and black bile (melaina cholê). Each of the
four humors has two primary (or “cardinal”) qualities: blood is warm

7 For an up-​to-​date overview on the Hippocratic Corpus and the medical traditions contained
in it, see the chapters by E. Craik and J. Jouanna in P. E. Pormann, Cambridge Companion to
Hippocrates (Cambridge: Cambridge University Press, 2018).
 Antiquity to the Renaissance 47

and moist; phlegm is cold and moist; black bile is cold and dry; and
yellow bile is warm and dry. Therefore, an excess of one of the humors
also leads to an imbalance in the temperature and moisture of the
body. Or, as the author of On the Nature of Man puts it:8

Man’s body contains in itself blood, phlegm, and yellow and black
bile. These things make up the nature of his body, and through
them, he suffers disease and enjoys health. He enjoys the greatest
health, when these are in balance to each other in terms of mixture,
power, and quantity, and when they are most mixed. He suffers
disease, when there is too much or too little of one of them, or when
it is separated in the body and not mixed with all of them.

Yet, another Hippocratic text, On Ancient Medicine, rejects as facile

the notion that health can be reduced to a balance of warm and cold,
and dry and moist. Rather, there are many more opposites that lead to
health and disease:9

For since they [sc. the first discovers of medicine] thought that it is
not the dry or the wet or the hot or the cold or any other of these
things that harms man—​or that man has any need of them—​but
rather the strength of each thing and that which is more powerful
than the human constitution, they regarded as harmful that which
the human constitution was unable to overcome, and this they
sought to remove. And the strongest of the sweet is the sweetest, of
the bitter the bitterest, of the acid the most acidic, and of each one
of all the things present, the extreme degree. For they saw that these
things are also in the human being and cause it harm: for there is in

8 J. Jouanna, Hippocratis De natura hominis, Corpus Medicorum Graecorum 1:1.3 (Berlin: De

Gruyter, 2002), 172, line 13, 174, line 3 [6.38–​40 Littré].
9 M. J. Schiefsky, Hippocrates: On Ancient Medicine, Studies in Ancient Medicine, no. 28
(Leiden: Brill, 2005), 90–​93 (translation slightly modified).
48 Peter E. Pormann

the human being salty and bitter and sweet and acid and astringent
and insipid and myriad other things having powers of all kinds in
quantity and strength.

We therefore see that although the author of On Ancient Medicine

rejected humoral pathology as developed in On the Nature of Man,
he still embraced the notion of balance. Likewise, the author of On
Affections opens his work with a statement that since “health is the
greatest good (πλείστου ἄξιόν ἐστιν ἡ ὑγιεία)”10 one needs to know
about blood and phlegm, as these two cause diseases.
Therefore, health depends on the body being well balanced: an ex-
cess of a humor or a quality leads to disease. Yet, there are other factors
beyond the mixture of the body that come into play as well. For in-
stance, the Hippocratic author of Airs, Waters, Places investigates the
effect of the environment on human health. Some locations, for in-
stance, are more salubrious than others: if you live by a swamp or in
a place where air is stale or water stagnant, this will have a negative
effect. Bad air, so-​called miasmas, causes diseases such as malaria (the
Italian for “bad air”). Not only does the environment have an impact
on health, but it also determines one’s character traits. In the second
half of Airs, Waters, Places, the author sets out an anthropology of
different peoples according to where they live and contrasts Europe
with Asia.
The Hippocratic Corpus remained highly influential throughout
the centuries. Generations and generations of physicians read it,
commented on it, and interpreted it in light of their own doctrines.11
Likewise the historical figure of Hippocrates grew in stature, as
more and more stories were told about him, most of them clearly

10 Affections 1, 6.208 ed. Littré. P. Potter (trans.), Hippocrates, vol. 5: Affections. Diseases 1. Diseases
2 (Cambridge, MA: Harvard University Press,), 6–​7, translates this as “health is of the utmost
value to human beings.”
11 This lively tradition has been traced in A. Anastassiou and D. Irmer, Testimonien zum Corpus
Hippocraticum (Götingen: Vandenhoeck and Ruprecht, 1997–​2012).
 Antiquity to the Renaissance 49

apocryphal.12 One man did more than any other to perpetuate

Hippocrates’s fame and to ensure that his works continued to be
read: Galen of Pergamum.

Galen

Whereas Hippocrates is nowadays the most famous Greek physician,

Galen of Pergamum (ca. 129–​216) was certainly the most influential.13
He studied medicine and philosophy in Pergamum and Alexandria,
and then headed to Rome, where he served as physician to the emperor
Marcus Aurelius and his son Commodus. He reportedly wrote over
400 books in the course of his long life, and, today, his extant works
make up a significant portion of the classical Greek literature that has
come down to us. Toward the end of his life, he wrote not only a text ti-
tled About His Own Opinions but also About His Own Books and About
the Order of His Own Books. He thus organized his works into a canon,
and they certainly became canonical in later times. We can roughly di-
vide Galen’s oeuvre into three categories: works “for beginners” (τοῖς
εἰσαγομένοις) with a mainly didactic purpose; monographs on indi-
vidual topics such as simple and compound drugs, therapeutics, and so
forth; and commentaries on Hippocratic works.
The first and key introductory text by Galen is On the Sects for
Beginners. A short treatise on medical epistemology, it defines med-
icine as follows:14

The aim of the art of medicine is health, and its end is the acquisi-
tion of health. Physicians ought to know by which means to bring

12 W. D. Smith, The Hippocratic Tradition (Ithaca, NY: Cornell University Press, 1979).
13 For an overview about Galen, see R. J. Hankinson (ed.), The Cambridge Companion to Galen
(Cambridge: Cambridge University Press, 2008).
14 R. Walzer and M. Frede (trans.), Galen: Three Treatises on the Nature of Science
(Indianapolis: Hackett, 1985), 3, with modification.
50 Peter E. Pormann

about health, when it is absent, and by which means to preserve it,

when it is present.

Therefore, health and medicine are intrinsically linked in Galen’s mind,

much as the Hippocratic author of On Affections linked man’s greatest
good, health, to the “greatest benefit to mankind,” medicine. According
to Galen’s definition, medicine has a twofold purpose: to retain health
(prophylactic medicine) and to restore health (therapeutic medicine).
Galen was, above all else, a good Hippocratic, yet he shaped his
Hippocrates in his own image. He achieved this not least by writing
commentaries on some Hippocratic works to the exclusion of others.
For instance, he authored an influential commentary on Nature of
Man but considered On Ancient Medicine as spurious. Even where
he regarded a text as genuine, he reinterpreted it in light of his own
thinking. For instance, when commenting on the passage from On
the Nature of Man quoted above, Galen paraphrases Hippocrates
as saying that health ensues through the “symmetry (συμμετρία)” or
“good mixture (εὐκρασία)” of the “elements (στοιχεῖα).”15 None of
these three technical terms, however, appears in the Hippocratic text;
by using his own language, Galen simply overlays his ideas onto the
Hippocratic original.
Therefore, a cornerstone of Galen’s notion of health remains humoral
pathology: the balance of the four humors (or “common elements,” as
Galen calls them here) takes center stage. We have already seen that
the four humors are each linked to two of the four primary (or “car-
dinal”) qualities, warm and cold, and dry and moist. In his work On
Mixtures, Galen elaborated a typology of mixture, with one good mix-
ture, resulting in health, and eight bad mixtures, resulting from an
excess or a deficiency in one or two of the primary qualities.16

15 J. Mewaldt, Galeni In Hippocratis De natura hominis commentaria (Leipzig: Teubner,

1914), 32–​33.
16 P. Singer (trans.), Galen: Selected Works (Oxford: Oxford University Press, 1997), 202–​89.
 Antiquity to the Renaissance 51

In this way, health depends on a balance within the body, a balance

of primary qualities linked to the four humors. There are, however,
also external factors that influence health according to Galen, namely
the so-​called six non-​naturals.17 These six things that are not part of
the nature of the individual are ambient air; food and drink; sleep
and wakefulness; exercise and rest; excretion and retention (e.g., of
urine, feces, and semen); and sadness and joy. Health is achieved by
regulating these six non-​naturals. For instance, excessive sex, leading
to too much evacuation of semen, results in disease, whereas sex can be
beneficial for certain conditions such as melancholy.
To preserve health means first and foremost to prescribe the right
diet. Galen wrote a treatise On the Powers of Foodstuff, in which he
arranges various food items according to their powers,18 such as sweet
or salty; beneficial or harmful to the stomach; favoring individual
humors; digestible with ease or difficulty, and so on. In many cases,
Galen provides recipes on how to prepare specific meals, saying that
the physician “should be well versed in [the art of cookery].”19
Galen is also interested in other non-​naturals. For example, he
wrote a short and charming treatise On Exercise with a Small Ball,
advocating physical activity. Toward the end of his life, he also
penned an epistle On the Avoidance of Grief, in which he draws on
Stoic and Epicurean philosophy to free the reader from distress;
this text was recently (in 2005) rediscovered and has attracted much
scholarly attention.20
According to Galen, the second main objective of medicine is
the restoration of health when it is lost. In this area of therapeutics,

17 Galen sets out his theory in his On the Medical Art, chap. 23; see I. Johnston (ed. and trans.),
Galen: On the Constitution of the Art of Medicine. The Art of Medicine. A Method of Medicine to
Glaucon (Cambridge, MA: Harvard University Press, 2016), 246–​49.
18 M. Grant, Galen on Food and Diet (London: Routledge, 2000), 11.
19 Kühn, Galen: Opera Omnia, 6.609.
20 See V. Nutton, “Avoiding Distress,” in P. N. Singer (trans.), Galen: Psychological Writings
(Cambridge: Cambridge University Press, 2014), 43–​106.
52 Peter E. Pormann

Galen wrote numerous works focusing on a variety of themes. His On

Therapeutics for Glauco in two books, for instance, is a beginner’s guide
to the subject, whereas his massive On the Method of Healing in sev-
enteen books exhaustively discusses how to treat diseases. Restoring
health of course involves manipulating the six non-​naturals and,
most importantly, adjusting the balance of the primary qualities and
humors. One way is to employ simple and compound drugs. Galen
wrote a sizeable work on the former, in which he develops a theory
of degrees for different drug properties, such as primary (warm/​cold;
dry/​moist), secondary (affecting the whole body), and tertiary (af-
fecting a specific part of the body, e.g., diuretic). Galen insists that a
competent physician ought to know these degrees:21

The same applies to the drugs which have drying or moistening

powers: one ought to know not only their general action, but also
which is the first to depart from the balance and the mean between
the opposite powers; and then which is the next one. Next, one
ought to distinguish the third, fourth and fifth degree, if possible,
by differentiating between them with clear definitions. Through
such an accurate knowledge of their powers, we shall be able to use
the simple drugs themselves with professional expertise [technikôs],
and to compose compound drugs methodically [kata methodon],
and, in addition, to use the drugs correctly [orthôs] that have al-
ready been composed.

The example of rue can illustrate how the different qualities and
degrees combine in a simple drug:22

21 Kühn, Galen: Opera Omnia, 6.429; trans. C. Petit, quoted in P. E. Pormann, “The Formation of
the Arabic Pharmacology: Between Tradition and Innovation,” Annals of Science 68 (2011): 493–​
515, at 502.
22 Kühn, Galen: Opera Omnia, 7.100–​101; trans. in Pormann, “The Formation of the Arabic
Pharmacology,” at 502, with modifications.
 Antiquity to the Renaissance 53

Wild rue is even of the fourth degree of heating [drugs], and culti-
vated rue is the third [degree]. Not only does it taste sharp, but also
bitter, and it therefore is able to cut and remove thick and viscous
humours. Through the same power it is diuretic. It is also composed
of small particles and removes flatulence [aphysos], so that it is fit-
ting for flatulence, reduces and disperses the desire for sexual in-
tercourse [aphrodisia], and dries well. For it belongs to the strongly
drying drugs.

The actions of a simple drug can thus restore the balance in the body,
or one can resort to the use of compound drugs. Compound drugs are
made according to sometimes elaborate recipes, and Galen wrote two
seminal works on them, On Compound Drugs According to Places and
On Compound Drugs According to Genera. The former is arranged ac-
cording to the place in the body that is affected, such as the brain, the
eye, the lungs, or the reproductive organs; the latter according to the
type of compound drug.
Health of the body and health of the mind are interlinked
for Galen. The psychic state of the patient is one of the six non-​
naturals, discussed above. Galen is also keen to point out “that
the faculties of the soul follow the mixtures of the body,” as a fa-
mous treatise by Galen is entitled. This interplay between mind
and body is particularly visible in the area of mental health. There
are a number of conditions affecting the brain such as phrenitis,
lethargy, madness, and melancholy, all extensively discussed in his
On the Affected Parts. Phrenitis, for instance, is characterized by
the onset of delusions accompanied by severe fever (undoubtedly
sometimes overlapping with what we call meningitis), whereas
melancholy lacks fever. We shall return to the topic of melancholy
in greater detail when discussing medieval medicine. For now, suf-
fice it to say that Galen’s system of health—​how to preserve it and
how to restore it—​became dominant in late antique Alexandria
and beyond.
54 Peter E. Pormann

Before turning to that topic, however, it is worth mentioning that

in Roman imperial times, ideas of humoral pathology were by no
means the only ones about health. One major challenge to Galen
was Methodism—​obviously the medical variety, not the Christian
one due to the ministry of John Wesley.23 Health, according to the
Methodist school, ensued when the passageways of the body were
moderately open. Disease, by contrast, occurred in three states: flux,
when the passageways were too wide open; stricture, when they were
too closed; and a mixed state, in which there is flux in some parts
of the body and stricture in others. By the time of late antiquity in
the Greek-​speaking East, however, Methodism had given way to
Galenism.

Late Antiquity

Late antique Alexandria was a bastion of Galenism.24 So-​called

Iatrosophists, professors of medicine, taught the subject in its
amphitheaters.25 They resorted to a canon of books by Hippocrates
and Galen that were core curriculum there. They include the
Hippocratic Aphorisms and Prognostic and Galen’s On the Sects
for Beginners, On the Elements According to Hippocrates, and On
Therapeutics for Glauco. Three genres of medical writing rose to prom-
inence: abridgments, commentaries, and encyclopedias. The first two
served didactic purposes: the commentaries were often verbatim notes
taken during lectures (ἀπὸ φωνῆς); and the abridgments gave succinct
summaries of these lectures. In both these genres, the principle of di-
vision (dihairesis) was a powerful mnemonic tool. For instance, in the

23 M. Tecusan, The Fragments of the Methodists, vol. 1: Text and Translation (Leiden: Brill, 2004).
24 O. Temkin, Galenism: Rise and Decline of a Medical Philosophy (Ithaca, NY: Cornell University
Press, 1973) remains fundamental.
25 P. E. Pormann, “Medical Education in Late Antiquity: From Alexandria to Montpellier,” in
H. F. J. Horstmanshoff and C. R. van Tilburg (eds), Hippocrates and Medical Education: Selected
Papers Read at the XIIth International Hippocrates Colloquium, Universiteit Leiden, 24–​26 August
2005 (Leiden: Brill, 2010), 419–​41.
 Antiquity to the Renaissance 55

Alexandrian Summary of Galen’s On the Sects for Beginners (extant

only in Arabic, although most likely of Greek origin), the author sums
up Galen’s discussion of medicine as follows:26

Soranus said in the context of defining medicine: “Medicine

consists in knowing the matters of health and illness.” Herophilus
said: “Medicine consists in knowing the matters of health, that is,
healthy bodies, the causes which preserve and effect health, and
the signs indicating health; the matters of disease, that is, diseased
bodies, the causes which effect disease, and the signs indicating dis­
ease; and the matters which are neither related to health nor dis­
ease, that is: the body, which is in this state [i.e. either health or
disease]; the cause effecting this [either health or disease]; and the
signs indicating it [i.e. either health or disease].” The causes com-
prise two groups: (1) health-​related, and (2) disease-​related. The
health-​related [sc. causes] comprise two sub-​groups: (1a) [causes]
preserving existing health, and (1b) [causes] restituting and bringing
health after it [sc. health] has been lost. Disease-​related [causes] also
comprise two sub-​groups: (2a) [causes] preserving existing disease,
and (2b) [causes] creating disease which previously did not exist.
The [subject of] causes of health which preserve existing health
[i.e. (1a)] is called “regimen of healthy people”; it is effected through
food and drink, venesection, exercise, and bathing. The [subject
of causes] creating health which is non-​existent [before, i.e. (1b)]
is called “cure.” Some of these causes expel from the body things
which need expelling, like for instance venesection and purging
through medication; others change the form as far as necessary,

26 O. Overwien (ed.), “Zur Funktion der Summaria Alexandrinorum und der Tabulae
Vindobonenses,” in U. Schmitzer (ed.), Enzyklodädie der Philologie: Themen und Methoden der
klassischen Philologie heute (Göttingen: Ruprecht, 2013), 187–​207, at 191–​92; the end of the quota-
tion has been supplied by collation of two manuscripts: Istanbul, Süleymaniye Kütüphanesi, MS
Fatih 3538, reproduced by F. Sezgin, Ǧawāmiʿ al-​Iskandarānīyīn, 2 vols. (Frankfurt: Maʿhad Taʾrīḫ
al-​ʿUlūm al-​ʿArabīyah wa-​l-​Islāmīyah fī iṭār Ǧāmiʿat Frānkfūrt, 2001), 1:5; and London, British
Library, MS Add. 23407, fol. 4a.
56 Peter E. Pormann

either from the outside, like for instance a bandage, or from the in-
side like drinking cold water.

We thus encounter Soranus, a methodist physician flourishing

around 100 CE, and Herophilus, the great Greek anatomist of the
third century BCE, who represents here the rationalist (or dogma-
tist) point of view. The latter defines medicine as knowledge of bodies,
causes and signs, relating both to health and disease, with further
subdivisions. We also find a similar division in the so-​called Viennese
Tables, containing medical branch diagrams. Here “healthy things (τὰ
ὑγιεινά)” are divided into “things preserving an existing health; they
are called healthy dietary measures” and “cures and remedies which
restore non-​existent health;” the former are further subdivided into
“balanced food; drink; exercise; baths” and the latter into “phle-
botomy; purging; drinking cold water; enemas; soft bandages.”27 This
predilection for division also characterizes the development of medi-
cine in the medieval Islamic world.

Medieval Islamic World

The late antique medical curriculum and medical practice in that pe-
riod more generally had a profound impact on medicine in general and
concepts of health in particular. In order to show some of the ways
in which the Greek tradition persists and also is transformed, I shall
offer four vignettes. First the oeuvre of the physician and philoso-
pher Abū Bakr al-​R āzī offers insights into how he wanted to preserve
health and how he innovated testing new ways of doing this. Second,
Avicenna’s definition of medicine and his debate about health being
one of two states of the body illustrate a more fundamental (and the-
oretical) question. Third, the Almanac of Health by Ibn Buṭlān shows

27 Overwien, “Zur Funktion der Summaria Alexandrinorum,” 197.

 Antiquity to the Renaissance 57

how the theoretical principals are put in to practice. Fourth, two

commentators on the Hippocratic Aphorisms illustrate some of the ex-
egetical strategies that help in the evolution of how health is conceived.
To look at conceptions of health in the medieval Islamic tradition, let
us first turn to an author who is arguably the greatest clinician of the
medieval period and also an accomplished philosopher.

Abū Bakr al-​R āzī

Abū Bakr Muḥammad ibn Zakariyyāʾ al-​R āzī (d. 925) from the Persian
city of Rayy wrote a large number of works on both philosophy and
medicine, yet many of the former have not come down to us or only
survive indirectly in the form of reports by usually hostile witnesses.
On the medical side, however, we are far better served. We have a
number of short treatises on a variety of topics, ranging from med-
ical ethics and charlatans to whether one should consume mulberries
after watermelons.28 Al-​R āzī’s massive medical encyclopedia, the Book
for al-​Manṣūr (al-​Kitāb al-​Manṣūrī), and his notes posthumously
published as the Comprehensive Book (al-​Kitāb al-​Ḥāwī) also survive,
as do two monographs on sexual intercourse and case notes published
by his students after his death. In these works, al-​R āzī discusses health
on numerous occasions. For the present purpose, I shall focus on his
medical encyclopedia, the Book for al-​Manṣūr, and notably on book 4,
“On the Preservation of Health ( fī ḥifẓ al-​ṣiḥḥa).”29 I shall also add a
few remarks about al-​R āzī’s interesting stance regarding medical epis-
temology, insofar as it concerns this topic.
Al-​R āzī’s Book for al-​Manṣūr continues a tradition of medical
encyclopedias that dates to late antiquity. Oribasius (late fourth

28 P. E. Pormann and E. Selove, “Two New Texts on Medicine and Natural Philosophy by Abū
Bakr Muḥammad ibn Zakarīyāʾ al-​R āzī,” Journal of the American Oriental Society 137 (2017),
279–​99.
29 The following references are to the edition by Ḥāzim al-​Ṣiddīqī al-​Bakrī, Al-​Kitāb al-​Manṣūrī
fī l-​ṭibb [Book for al-​Manṣūr on Medicine] (Kuwait: Maʿhad al-​Maḫṭūṭāt al-​ʿarabīya, 1987).
58 Peter E. Pormann

century), Aëtius of Amida (sixth century), Aretaeus (sixth cen-

tury), and Paul of Aegina (fl. seventh century) all wrote medical
encyclopedias that also include long sections on the preservation of
health. At the beginning of his Book for al-​Manṣūr, al-​R āzī defines
medicine as the science through which one can preserve present,
and restore absent, health, echoing Galen’s earlier definition. For
al-​R āzī, medicine is an art that everybody ought to know because
disease can strike at any time and physicians are not always in
attendance.
In book (maqāla) 4 of his encyclopedia, al-​R āzī deals with the topic
of how to preserve health. He largely covers in it various aspects of the
six non-​naturals. He discusses movement and rest (p. 203), sleep (204),
food (204–​6), drink (207), purging superfluities (208–​9), location
(209–​10), chronic pain (210–​13), worries and habits (213), countering
damage caused by food (214–​15) and drink (215–​16), blood-​letting
(217), enemas (217–​19), vomiting (220), sexual intercourse (220–​21),
bathing (221–​22), care for the teeth (222–​23), eyes (223–​24) and ears
(224), plague prevention (225–​ 27), regimen according to seasons
(227–​28), and care for children and pregnant women, as well as ob-
stetrics (229–​34). He concludes this book with a page on how to test
physicians ( fī miḥnat al-​ṭabīb).
In his discussion of wine, for instance, he has a paragraph on “how
to replace wine (in prescriptions).” There, al-​R āzī gives the following
advice:30

Wine warms the stomach and the liver, dissolves flatulence, digests
food, and has a diuretic and purging effect. Moreover, it makes one
joyful and it entertains. This property cannot be replaced by any
substitute to it.

Ṣiddīqī al-​Bakrī, 26.

30 Al-​
 Antiquity to the Renaissance 59

Other properties can be partially replaced, although they, too, fall

short of the original action. Al-​R āzī then provides a recipe for such a
replacement for wine. Yet, he clearly thinks that there cannot be any
real substitute.
In book 8 of his Book for al-​Manṣūr, al-​R āzī lists various substances
that harm one’s health; they include venom of snakes and scorpions,
bee and wasp stings, insect and spider bites, and so on. He also
discusses the harmful effects on plants and medicinal substances such
as arsenic, hellebore, hemlock and mercury. Al-​R āzī was not, however,
content with merely quoting from past authorities; rather, he tested
the damage that these substances cause in a variety of ways to health.
For mercury, for instance, he gave a dose to an ape and observed its
effects. Although the animal suffered pain, it merely secreted the mer-
cury through the stool, and al-​R āzī therefore concluded that the harm
to human health is not that great.31 This animal experiment has been
hailed by some as a precursor to modern medical testing.
Such Whiggish analysis is rather unhelpful,32 yet it does raise the
question of medical epistemology: how can we know that certain
practices, therapies, or recipes contribute to the restoration of health?
It is to this topic that al-​R āzī made quite significant contributions. His
greatest claim to fame is undoubtedly his use of a control group in a
medical experiment, which he describes as follows:33

According to what I have seen by way of experience [taǧriba] and

what I have seen in this book, regarding constant fevers: If [the pa-
tient] suffers from heaviness and pain in the head and neck lasting

31 Al-​ Ṣiddīqī al-​Bakrī, 368; see A. Z. Iskandar, “Ar-​R āzī, the Clinical Physician (Ar-​R āzī aṭ-​Ṭabīb
al-​Iklīnī),” in P. E. Pormann, (ed.), Islamic Medical and Scientific Tradition, Critical Concepts in
Islamic Studies, 4 vols. (Routledge: London, 2011), 1: 207–​53, at 225–​26.
32 P. E. Pormann, “Medical Methodology and Hospital Practice: The Case of Tenth-​century
Baghdad,” in P. Adamson (ed.), In the Age of al-​Farabi: Arabic Philosophy in the 4th/​10th Century
(London: Warburg Institute), 95–​118, at 111–​12; reprinted in P. E. Pormann, Islamic Medical and
Scientific Tradition, 2:179–​206, at 193–​94.
33 Pormann, “Medical Methodology and Hospital Practice,” 109–​10.
60 Peter E. Pormann

for two, three, four, five days or more; and he avoids looking [di-
rectly] into the light, whilst tears flow; and he often yawns and
stretches his body, having severe insomnia; and he perceives a
feeling of extreme exhaustion, then the patient will progress to
brain fever. He becomes daring like a drunkard, not paying any at-
tention to food or drink, until the crisis supervenes. . . . So when
you see these symptoms, resort to bloodletting. For I once saved one
group [of patients] by [bloodletting], whilst I intentionally left an-
other group, so as to remove the doubt from my opinion through
this. Consequently all of these [latter] contracted brain fever.

The health of one group of patients is here preserved through blood-

letting, whilst the control group contracted the condition. In this way,
al-​R āzī innovated in the area of medical epistemology in order to pre-
serve and restore health. Although this medical encyclopedia by al-​
Rāzī, and especially the ninth book, had great success both East and
West, its popularity is eclipsed by Avicenna’s Canon of Medicine.

Avicenna

Avicenna (d. 1037) is arguably the most influential medical writer of

all times or at least of the medieval period.34 His Canon of Medicine,
a medical encyclopedia in five books, spawned a massive tradition of
commentaries and abridgments, not just in Arabic but also in Persian,
Latin, and Hebrew, among other languages. At the very beginning
of this work, Avicenna defines medicine in terms that are very much
reminiscent of Galen at the beginning of his On the Sects for Beginners,
quoted above:35

34 See: P. Adamson (ed.), Interpreting Avicenna (Cambridge: Cambridge University Press, 2013).
35 Ibn Sīnā, Kitāb al-​Qānūn fī l-​ṭibb, 3 vols. (Būlāq, 1877), 1:3, lines 13–​14.
 Antiquity to the Renaissance 61

Medicine is the science through which one knows the states of the
human body insofar as they are healthy or unhealthy, in order to
preserve health when it is present, and to restore it when it is absent.

Avicenna continues to divide medicine into theory and practice,

stating that he is concerned with theoretical knowledge and practical
knowledge, but not actual practice. Then he offers an interesting argu-
ment against a tripartite division of human health:36

An opponent cannot claim that the states of the human body are
three: health [ṣiḥḥa], disease [maraḍ], and a third state that is nei-
ther health nor disease, saying “you [sc. Avicenna] have fallen short
by only dividing into two [sc. into health and disease].” If such an
opponent were to think, he would notice that neither of the fol-
lowing two things are necessary: neither the tripartite division, nor
our abandoning it. For if such a tripartite division were necessary,
we would say that absence of health [al-​zawāl ʿan al-​ṣiḥḥa] includes
[both] disease [maraḍ] and this third state which they made not to
fall under the definition of health. For health is a natural disposi-
tion [malaka] or a state [ḥāla] through which the actions proceed
from a subject in a sound way [salāmatan]. It [this third state] does
not have an equivalent definition [muqābil hāḏā l-​ḥadd], unless
they define health as they desire and attach to it [sc. the definition]
conditions that they do not require. Physicians have no issue with
this and do not argue about such things, nor does such a discussion
provide them or anybody else with any benefit. The truth of the
matter is more appropriate for the fundamental principles [uṣūl]
of another art, namely fundamental principles of the art of logic; it
should be studied under that heading.

36 Ibn Sīnā, Kitāb al-​Qānūn fī l-​ṭibb, 1:3,3–​4 .

62 Peter E. Pormann

In other words, Avicenna maintains the dichotomy of health and

disease, already found in Galen, and argues against the position
that there is an intermediary, third state, which, incidentally, he
calls taṯlīṯ—​a term denoting not just the division into three but
also the Christian Trinity. At the end, Avicenna dismisses debates
about whether the states of the body are two or three to the
realm of logic; having no practical applications, physicians don’t
really care.
This discussion of where a particular question sits in the hier-
archy of knowledge is of concern to Avicenna. He argued that med-
icine is a corollary branch of knowledge (or “science” in the sense
of Latin scientia, Arabic ʿilm), akin to agriculture.37 Questions of a
higher ontological order, for instance about the makeup of matter,
or even the existence of the four humors and the interplay of the
four primary qualities, fall outside the purview of medicine; rather,
they belong in the realm of physics (ṭabī ʿīyāt). We shall return to
Avicenna and his definition of medicine and health later, but now,
let us turn to a highly practical work that aims at preserving and
restoring health.

Ibn Buṭlān’s Almanac of Health

Health is rectified through the six [non-​natural] causes which everyone who
wants to have lasting health needs to balance and employ. [They are] first,
improving the air reaching his heart; second, measuring food and drink; third
balancing movement and rest; fourth preventing oneself from sinking into sleep
or wakefulness; fifth measuring the expulsion and retention of superfluities; and
six moderating one’s joy, anger, fear, and despondency. This is how to have them in
balance and through it, these six [non-​natural] causes preserve health, yet when they
depart from [this moderate state], they cause disease.

37 D. Gutas, “Medical Theory and Scientific Method in the Age of Avicenna,” in D. C. Reisman
(ed.), Before and After Avicenna: Proceedings of the First Conference of the Avicenna Study Group
(Leiden: Brill, 2003), 145–​62; reprinted in Pormann, Islamic Medical and Scientific Tradition,
1:33–​47.
 Antiquity to the Renaissance 63

Thus begins Ibn Buṭlān’s Almanac of Health, and we find here again
the six non-​naturals encountered earlier.38 His Almanac is, in fact, a
collection of tables with fourteen columns specifying “nature,” “de-
gree,” “best type,” “usefulness,” “harmfulness,” and so on until the last
column, containing a brief narrative about “choice (iḫtiyār),” which is
a catch-​all category allowing Ibn Buṭlān to add his own comments.
He lists 280 substances and activities coming under the heading of
non-​natural causes: numbers 1–​ 210 are largely varieties of food,
ranging from figs (no. 1) and raisins (no. 2) to rice (no. 36), chickpeas
(no. 57), asparagus (no. 71), and different types of meat (nos. 92–​5, 97–​
100), honey (no. 170), and different types of wine (nos. 190–​94). Other
things include music (nos. 211–​13); joy, fearfulness, and anger (nos.
214–​16); vomiting (no. 219); sleep (no. 221), sleep companion (no. 222),
nightly entertainment (no. 223), and wakefulness (no. 224); sexual in-
tercourse (no. 227) and sperm (no. 228); different types of exercise (nos.
232–​38); different types of baths (nos. 239–​44); seasons (nos. 271–​74);
locations (nos. 275–​78); plague-​infested air (no. 279), and the the-
riac (no. 280). For instance, Ibn Buṭlān describes sexual intercourse
(ǧimā ʿ) as follows:

1. number: 227; 2. name: “sexual intercourse;” 3. nature: uniting two

partners to project seed; 4. degree: none; 5. good variety: when the
destination of the sperm has been chosen; 6. usefulness: preserva-
tion of the species; 7. harmfulness: to people having cold and dry
testicles; 8. removing its harm: through drugs generating sperm;
9. effect: none; 10. mixture: warm and moist; 11. age: adolescence and
youth; 12. time: spring after having been cleansed from menstrual
blood; 13. location: moderate; 14. people’s opinions: H[ippocrates];
G[alen]; Ru[fus of Ephesus]; 15. choice: for procreation, nature

38 H. Elkhadem, Le Taqwīm al-​ṣiḥḥa (Tacuini sanitatis) d’Ibn Buṭlān: Un traité médical du XIe
siècle (Leuven: Peeters, 1990); all subsequent references are to this edition.
64 Peter E. Pormann

has made a base pleasure leading to a noble goal in the universe.

Through [this base pleasure], some people are seen to be jumping
like brute beasts, especially when bitten and tickled, when the ob-
ject [of the sexual encounter] is seen or thought about in a dream
or whilst awake; what brings energy and happiness is prepared
for him. The active [partner in the sexual intercourse] should be
neither replete [with food] nor hungry, lest a blockage or dryness
occur. The time should be balanced, the air not plague-​like, and the
location not conducive to disease.

In the margin, Ibn Buṭlān provides further astrological guidance:

To produce a boy, one chooses male-​producing signs [of the zodiac],

the best of which are Libra and Sagittarius; for girls, Pisces and Virgo;
Taurus is not bad either.

This arrangement in columns with marginal astrological notes proved

extremely popular in both East and West. It made it easy to look up an ac-
tivity or a substance to see how it fit one’s own regimen and disposition. It
was a practical solution to the problem of preserving one’s health. Before
looking at how Ibn Buṭlān and others influenced the Latin tradition, we
will first briefly consider some more theoretical debates about health in
Arabic commentaries on the Hippocratic Aphorisms.

Hippocratic Commentaries

Medical debate in Arabic flourished in particular in a genre that

modern readers do not always associate with innovation, namely
that of the commentary. In fact, there is a rich Arabic tradition on
the Hippocratic Aphorisms, ranging from the ninth century to the fif-
teenth century.39 The commentator who wrote by far the longest and

39 P. E. Pormann and N. P. Joosse, “Commentaries on the Hippocratic Aphorisms in the Arabic

 Antiquity to the Renaissance 65

most thorough work on the Aphorisms was the Christian physician

Ibn al-​Quff (d. 1286). He offers particularly interesting discussions of
health as a concept. In the commentary on aphorism 2.19, he argues
that health is beneficial not just in temporal but also in spiritual terms,
saying:40

We said that health is nobler than disease based on two reasons.

First, health is achieved through balance while diseases occur due
to a deviation from balance. Balance is nobler than its opposite.
Second, through the presence of health, we can achieve happiness
in this life and the next. Disease, however, prevents this. What
helps achieve these two forms of happiness is nobler than that
which prevents them.

Christians (just like Muslims) believed in the resurrection of the body,

and therefore bodily health is important even for the afterlife; this, at
least, appears to be al-​Quff’s point here. In his commentary on an-
other aphorism, 2.1, he states that the parts of the body reach perfec-
tion (their ultimate aim or entelecheia) when they are healthy (ṣaḥīḥa),
and continues:

Health is brought about by two factors, first balanced mixture, and

second a well-​preserved structure. Therefore, whatever opposes this
state of perfection constitutes pain. What opposes the condition
of mixtures is what is called “noxious mixture” and [what opposes]
the composite structure is the dissolution of continuity. Therefore,
both [these things] are painful.

Tradition: The Example of Melancholy,” in P. E. Pormann (ed.), Epidemics in Context: Greek

Commentaries on Hippocrates in the Arabic Tradition (Berlin: De Gruyter, 2012), 211–​249;
and P. E. Pormann and K. Karimullah, “The Arabic Commentaries on the Hippocratic
Aphorisms: Introduction,” Oriens 45/​1–​2 (2017), 1–​52.
40 The corpus of Arabic commentaries on the Aphorisms is now available at Manchester’s institu-
tional repository: www.research.manchester.ac.uk; the quotations from Ibn al-​Quff’s commentary
on book 2 are available here: dx.doi.org/​10.3927/​52131995.
66 Peter E. Pormann

We have already talked about an imbalanced mixture as a cause for dis­

ease; here Ibn al-​Quff adds the “dissolution of continuity (tafarruq al-​
ittiṣāl)” as an impediment to health. By this, he means blows, cuts, and so
forth that clearly have a negative effect. Furthermore, Ibn al-​Quff makes
an interesting point about what degree of health is achievable. We cannot
have absolutely perfect health, where all parts of our body are totally in
sync. He calls this kind of health “imagined” (ṣiḥḥa mutawahhama). He
continues:

Such a type of health does not exist in the world outside us, owing
to the fact that causes that change the body in this state surround
it and influence it. This [type of] health is the one against which
others are measured and which is used by physicians as a guide to
whatever deviates from it. Then there is [health] that [really exists];
it has two types: that which is close to [the ideal type of health],
and that which is far away from it. The former is called “best struc-
ture” and “balanced health,” whereas the latter is, for instance, the
health of someone suffering from a fever or cold, a boy or old man,
or a convalescent person. Thus, health has a range within which it
varies. The closer it is to imagined health the better; and the fur-
ther the worse; and what lies between is mediocre health. Now
that you know this, we can say that [health] which is close to the
imagined health can be preserved by using that which is similar
[to it].

In this rich quotation, Ibn al-​Quff’s predilection for division is vis-

ible. In each of the three texts quoted above, health is subject to a
twofold division: temporal and spiritual; mixture and structure;
perfect and imagined, and imperfect and really existing. More inter-
estingly, Ibn al-​Quff insists that health is an ideal that one can try
to get close to but never reach. In this, he resembles other physicians
and philosophers such as al-​R āzī and ʿAbd al-​Laṭīf al-​Baġdādī who
insist that medicine is an approximate science in which one can never
 Antiquity to the Renaissance 67

obtain absolute certainty, just as it is impossible to obtain absolute

health.41

Latin Middle Ages

In the Latin West, Methodism remained popular in late antiquity and

the early Middle Ages. Things, however, changed dramatically with
the arrival of Arabic medical texts in Latin translation. The three focal
points of what one might call the Arabo-​Latin translation movement
were southern Italy, Spain, and the Crusader States, especially the city of
Antioch. With this translation movement, notions of health also traveled
across the linguistic barriers.

Constantine the African

The first major translator was Constantine the African (d. before
1099), working mostly in southern Italy.42 He translated numerous
works, especially originating in his native North Africa. For instance,
he rendered the medical encyclopedia Provisions for the Traveller and
Sustenance for the Sedentary (Zād al-​Musāfir wa-​Qūt al-​Ḥāḍir) into
Latin, often in a paraphrastic way. There also is a Greek translation
of this work—​entitled Ἐφόδια τοῦ ἀποδημοῦντος—​by a Constantine
the Protosecretary of Rhegion, who should not be confused with
Constantine the African. The Provisions for the Traveller was written by
Ibn al-​Ǧazzār, a Tunisian physician who died in 980 CE. Constantine
the African translated two other texts without acknowledging author-
ship. The first is a monograph on melancholy by the North African

41 P. E. Pormann, “Qualifying and Quantifying Medical Uncertainty in 10th-​ century

Baghdad: Abu Bakr al-​R azi,” Journal of the Royal Society of Medicine 106 (2013), 370–​72; N. P.
Joosse and P. E. Pormann, “Archery, Mathematics, and Conceptualising Inaccuracies in Medicine
in 13th Century Iraq and Syria,” Journal of the Royal Society of Medicine 101 (2008), 425–​27.
42 C. S. F. Burnett and D. Jacquart, Constantine the African and ʿAlī ibn al-​ʿ Abbās al-​Maǧūsī: the
Pantegni and Related Texts (Leiden: Brill, 1994).
68 Peter E. Pormann

physician Isḥāq ibn ʿImrān (d. 907),43 and the second on sexual inter-
course by an unknown author.44 Both illustrate the continuity of ideas
from the Greek to the Arabic and Latin traditions.
Melancholy is a disease caused by an excess of black bile (Greek
melaina cholê).45 It is characterized by delusion, groundless fear, and de-
spondency, all occurring without the presence of any fever. Therefore,
in the case of melancholy, health appears to be impaired because of a
natural cause, the excess of a humor, and one would imagine that it
can be cured by restoring this humoral balance. In fact, the picture is
much more complicated. In the Greek, Arabic, and Latin traditions,
we find different types of melancholy, innate and acquired, and among
the acquired type various subtypes, such as gen­eral, hypochondriac,
and encephalic.46 The treatment, likewise, did not just encompass
medication but also diet, entertainment, and lifestyle more gener-
ally. For his own On Melancholy (De melancholia), Constantine the
African largely drew on Isḥāq ibn ʿImrān’s work.47 Yet, Constantine
adds a section on therapy, in which he recommends the moderate con-
sumption of wine and sexual intercourse.
Sexual intercourse is also the topic of Constantine’s On Sexual
Intercourse (De coitu). This work is, again, an unacknowledged transla-
tion of an Arabic original, although the source has not been identified.
The treatise is divided into 17 chapters: 1–​12 deal with theory and 13–​
17 with practical advice. Chapters 8–​10, for instance, deal with the

43 A. Omrani [ʿĀdil ʿUmrānī], Maqāla fī l-​ mālīḫūliyā (Traité de la mélancolie)

(Carthage: Académie tunisienne des Sciences, des Lettres et des Arts Beït al-​Hikma, 2009).
44 Translated in F. Wallis, Medieval Medicine: A Reader (Toronto: University of Toronto Press,
2010), 511–​23.
45 There is an overabundance of literature on melancholy; however, the classical study remains
R. Klibansky, E. Panofsky and F. Saxl, Saturn and Melancholy: Studies in the History of Natural
Philosophy, Religion, and Art (London: Nelson, 1964).
46 See P. E. Pormann (ed.), Rufus of Ephesus on Melancholy (Tübingen: Mohr Siebeck, 2008).
47 K. Garbers (ed.), Ishāq ibn ʿImrān: Maqāla fī l-​mālīḫuliyā, Abhandlung über die Melancholie,
und Constantini Africani libri duo de melancholia: Vergleichende kritische arabisch-​lateinische
Parallelausg (Hamburg: Buske, 1977).
 Antiquity to the Renaissance 69

benefits of sexual intercourse and when the best time to have it is.
Constantine begins his discussion as follows:48

In their books, the ancients said that the things that preserve health
are exercise, baths, food, drink, sleep, and sexual intercourse. We
should say how sexual intercourse is beneficial and when it ought to
be carried out, and how it benefits or harms, and what happens to
those who do it frequently. . . . But there is a suitable time for inter-
course: when the body is in a tempered state with respect to all ex-
ternal influences, that is, it is neither full of food nor totally empty,
nor cold nor warm nor dry nor moist, but tempered . . . intercourse
is better before sleep than after sleep, because when one falls asleep,
one rests from exertion.

We thus have here a list of six items, modified from the six non-​naturals
discussed above, and again, the idea of balance dominates. At the end
of his On Sexual Intercourse, Constantine provides recipes for var-
ious aphrodisiacs, and it is for this reason that he is called “the cursed
monk” in the “Merchant’s Tale,” one of Chaucer’s Canterbury Tales
(v. 1810). Be that as it may, the Latin translations by Constantine had
a profound impact on notions of health, as they displaced Methodism
in favor of humoral pathology. Even greater, however, was the influ-
ence of Avicenna’s Canon of Medicine.

The Latin Avicenna

It was through the Latin translation by Gerard of Cremona (1114–​

87) that Avicenna’s Canon would have a lasting influence on western
medicine. It formed a major part in the curriculum of the nascent
universities of Europe, and, during the Renaissance alone, it was

48 Translated in Wallis, Medieval Medicine, 516–​17.

70 Peter E. Pormann

printed more than sixty times in various editions.49 Avicenna’s defini-

tion of medicine and health, quoted above, also featured prominently
in the Latin tradition. In Latin it runs:

Dico quod medicina est scientia qua humani corporis dispositiones

noscuntur ex parte qua sanatur uel ab ea remouetur ut habita sanitas
conseruetur.

This definition is quoted verbatim, for instance, by the great

Spanish physician Arnald of Villanova (d. 1311),50 and, as part of the
Generalities, became core curriculum in the Italian universities from
the High Middle Ages onward.51 Teaching the Canon also inspired a
vast commentary literature, where, again, we find notions of health
transmitted and discussed in the new Latin context. One of the most
famous commentators on Avicenna in Latin was Gentile Da Foligno
(d. 1348), who devoted most of his life to writing an enormous com-
mentary on Avicenna’s Canon.52 Whereas Avicenna’s aims are largely
theoretical—​as we saw, he refrains from discussing actual practice—​
other more practical texts also had a great impact on the Latin tradi-
tion, including the fertile regimen of health literature.

Tacuinum Sanitatis (Almanac of Health)

In the late thirteenth century, we see another wave of Arabo-​Latin

translations, notably in Norman Sicily. The Jewish translator and phy-
sician Faraǧ ibn Sālim, known as Farragut, translated Abū Bakr al-​
Rāzī’s Comprehensive Book (al-​Kitāb al-​Ḥāwī) into Latin at the behest

49 N. G. Siraisi, Avicenna in Renaissance Italy: The Canon and Medical Teaching in Italian
Universities after 1500 (Princeton, NJ: Princeton University Press, 1987; repr. 2014).
50 Arnoldus de Villa Nova, Hec sunt opera Arnaldi de Villanova que in hoc volumine continentur
(Lyon: Fradin, 1504), sig. a1r.
51 Siraisi, Avicenna in Renaissance Italy, 1250–​500, 160.
52 R. K. French, Canonical Medicine: Gentile da Foligno and Scholasticism (Leiden: Brill, 2001).
 Antiquity to the Renaissance 71

of Charles I of Anjou, king of Sicily (d. 1285); he also translated the

Almanac of Bodily Health (Taqwīm al-​abdān) by Ibn Ǧazla.53 These
translations date back to 1279 and 1280, respectively. One manuscript
of the Latin translation of Ibn Buṭlān’s Almanac of Health attributes it
to the same Faraǧ ibn Sālim, again at the behest of Charles I of Anjou;
another claims it was carried out on the order of Manfred, king of
Naples and Sicily from 1258 to 1266.54
Be that as it may, arranging information in tables relating to reg-
imen and preserving health proved very popular in the European tra-
dition. The Latin version of Ibn Buṭlān’s Almanac was first printed in
1531 in Strasburg, and then reprinted there in 1533. Vernacular versions
also appeared, such as the German Chessboard Tables of Health
(Schachtafelen der Gesuntheyt), which appeared in the same year. The
Latin version is charmingly illustrated at the bottom of each page
with pictures of the foodstuff or activities in question; plate 1 below
purging and constipation; sexual intercourse and sperm; cleansing;
drunkenness; and foca, a transliteration of the Arabic fawqāʿ, a sort of
hangover drink. Ibn Buṭlān’s Almanac of Health marked the begin-
ning of a fertile genre of Latin texts on regimen.55 It is just one of the
many Arabic works in Latin translation that remained popular during
the Renaissance, when the Arabic heritage remained highly relevant
but also became fiercely contested.

Renaissance Medicine

We have seen that Avicenna’s Canon continued to dominate medical

discourse during the Renaissance and remained highly popular, not
just in its Latin translation but also in its original Arabic. In fact, it is

53 M. Steinschneider, Die hebraeischen Uebersetzungen des Mittelalters und die Juden als
Dolmetscher, (Berlin: Kommissionsverl. des Bibliographischen Bureaus, 1893), sec. 582, 974–​75.
54 Elkhadem, Le Taqwīm al-​ṣiḥḥa, 43.
55 M. Nicoud, Les régimes de santé au Moyen Âge: Naissance et diffusion d’une écriture médicale en
Italie et en France (XIIIe–​X Ve siècle), 2 vols. (Rome: École française de Rome, 2007).
72 Peter E. Pormann

one of the earliest books printed in Europe with Arabic type (Rome,
1593). We find an interest in Avicenna’s definition of medicine and of
health in the oldest Arabic manuscript now in the possession of the
Royal College of Physicians, London, MS Tritton 12.56 There on the
first page of the text (see plate 2), a Renaissance hand adds the Latin
translation to the Arabic. Yet, perhaps the same western hand, or,
more likely another one, added in Arabic a definition of health (taʿrīf
al-​ṣiḥḥa), which runs as follows:

Health is a bodily state from which all functions proceed at all

times in a sound [salīma] fashion, without there being any imme-
diate disposition for it to cease.

This shows that interest in the Arabic legacy continued. Yet there
were also significant challenges to this Arabic heritage, which some
physicians wanted to expunge from their own medical tradition. As
time went on, fewer and fewer Arabic texts in Latin translation formed
part of the medical curriculum, and by the nineteenth century, a lot
of this Arabic heritage had been forgotten—​or rather expunged for a
variety of reasons.57

Conclusions

This brief survey has shown the common threads that run through
notions of health from classical Greece to Renaissance Italy and be-
yond. We have often only briefly touched on the main aspects of
health: balance of humors and qualities; the interaction between

56 P. E. Pormann, Mirror of Health: Medical Science during the Golden Age of Islam (London: Royal
College of Physicians, 2013), 20–​24.
57 P. E. Pormann, “The Dispute between the Philarabic and Philhellenic Physicians and the
Forgotten Heritage of Arabic Medicine,” in Pormann, Islamic Medical and Scientific Tradition,
2:283–​316.
 Antiquity to the Renaissance 73

body and soul (as illustrated in the six non-​naturals); and the shift
of physical and moral health, which can even have effects on one’s
afterlife. This picture hides the many different approaches to health
and medicine that existed over the centuries. I could only briefly al-
lude to the differences, for instance, between works included in the
Hippocratic Corpus (On Ancient Medicine versus On the Nature of
Man); between the various schools of medicine, for instance those ac-
tive in the Roman Empire (Methodism versus Galenic medicine); or
among Renaissance physicians, for instance, between those favoring
Arabic medical ideas and those advocating a return to the Greek and
Roman sources.
We have also seen that health has philosophical implications. In the
area of medical epistemology, for instance, al-​R āzī innovated in inter-
esting ways, while drawing on debates that began in antiquity. Much
more could have been said about the topic of “spiritual medicine,” of
philosophy as a means of keeping both body and soul healthy, just as
Ibn al-​Quff and others realized that health is a necessary condition
for moral rectitude—​mens sana in corpore sano.58 The focus here was
largely on written works, on medical texts with both theoretical and
practical aims, and, again, a lot more could be said about the actual
practice on the ground. To what extent, for example, did the ideas
of Hippocrates, Galen, al-​R āzī, Avicenna, or Ibn al-​Buṭlān really af-
fect the fates and fortunes of individual patients along the centuries?
Undoubtedly they did have a significant practical impact, although
it is also clear that many treatments, recipes, and prescriptions were
probably never or hardly ever employed.
“Health is the greatest good (πλείστου ἄξιόν ἐστιν ἡ ὑγιεία),” as the
Hippocratic author of Affections 1 put it.59 Medicine aims at preserving
and restoring health. This is the most fundamental division of med-
icine: into prophylactics and therapy, more fundamental perhaps

58 For more on this topic see the contribution of Peter Adamson in the present volume.
59 See note 10 this chapter.
74 Peter E. Pormann

than even the division into theory and practice. The Hippocratic and
Galenic framework of humoral pathology defined notions of health
and disease over the centuries. And yet, we find subtle differences
and new developments across cultures and creeds. This, perhaps, is
the greatest lesson that this investigation about health can teach us: a
shared common discourse, whether in Greek, Arabic, or Latin, united
physicians and philosophers in their quest to understand and improve
this “greatest good.”
 CH A PTER THR EE

The Soul’s Virtue and the Health

of the Body in Ancient Philosophy
James Allen

Already in the fifth century BCE, medicine (iatrikê) enjoyed a high

reputation among philosophers as an art dedicated to a manifestly val-
uable goal, health, and which, in the hands of the best practitioners,
satisfied the highest scientific standards. It became commonplace for
philosophers to hold up medicine as a model for their own discipline
in two ways. They compared the function of philosophy to the cur-
ative or therapeutic function of medicine, and they viewed the kind
of knowledge achieved in, or aspired to by, medicine as a standard
against which to measure the knowledge to be achieved in their own
discipline.
The aim of this essay is to explore—​selectively—​the two ways in
which medicine served philosophy as a model together with some of
their implications and the problems they raise. The point of departure
for my first set of reflections is the analogy to the therapeutic func-
tion of medicine, the way in which it imparts health and cures disease.

75
76 James Allen

I shall be especially concerned to discover whether the content of the

knowledge that belongs to philosophy corresponds or fails to corre-
spond to that belonging to the art of medicine in ways suggested by
the analogy. The point of departure of the second is the way in which
the standards satisfied by medical knowledge were held up as an ex-
ample for philosophy to follow. I shall be especially interested in cer-
tain reflections in and about the discipline of medicine regarding the
character of the knowledge needed by medicine to discharge its func-
tion and their implications for philosophy conceived as a counterpart
to medicine, occupied with the care of the soul.

Medicine and Philosophy as Philosophy

The analogy between the functions of the two disciplines belonged to a

family of comparisons. To the object of medicine’s “care” (a translation
of the Greek term, therapeia, often but not exclusively used with med-
ical treatment), the body, corresponds the object of philosophy’s care,
namely the soul. The end of medicine is health; that of philosophy,
virtue (aretê), regarded as the health of the soul (or the happiness that
virtue produces).1 The Roman Stoic Seneca (first century CE) even
held that human beings owe the original acquisition of the concept
of virtue to an analogy with bodily health and strength.2 Opposed to
health in the body are diseases; their counterparts in the soul are un-
ruly passions and false judgments about good and evil, which it is the
task of philosophy to cure or expel.
“While medicine cures the sicknesses of the body, wisdom (sophia)
rids the soul of its affections (pathê).” This observation, which is due
to Democritus, the fifth-​century BCE atomist and ethical thinker, is

1 See J. Pigeaud, La maladie de l’ âme (Paris: Les Belles Lettres, 1989).

2 Letter 120, 5; translation in B. Inwood (trans.), Seneca: Selected Philosophical Letters
(Oxford: Oxford University Press, 2007).
 Ancient Philosophy 77

an early but representative example of the philosophers’ attitude.3 And

this sentiment was to be echoed repeatedly in the centuries to follow,
constituting common ground between philosophers who agreed about
little else. In the Charmides, often regarded as one of Plato’s early
dialogues meant to depict the historical Socrates roughly as he was,
Socrates seizes the opportunity afforded by the young Charmides’s
headache to cite the view of a Thracian physician, who holds that the
body should properly be treated as part of the whole consisting of soul
and body and turns the discussion to the soul and one of its virtues,
temperance (156d). He proceeds to describe the dialectical examina-
tion to which he then subjects Charmides as “doctoring” or “physic”
(158e).
In Plato’s Sophist, usually regarded as a later dialogue incorporating
new and distinctively Platonic ideas, we find an account of a “noble
form of sophistry,” which resembles nothing so much as Socratic di-
alectic (226aff.). Like medicine, to which it is explicitly compared, it
discharges a purgative function, freeing the soul of errors by refutation
as medicine cures the body of disease by therapy. In Plato’s Gorgias,
Socrates elaborates an especially detailed analogy, to which we shall
return, between, on the one hand, the arts that care for the body (med-
icine and gymnastics), and on the other, their counterparts in the care
of the soul, which he treats as a highly philosophical form of politics, if
not philosophy itself. Justice, which is a part of politics in this scheme,
he calls “medicine for wickedness” (iatrikê ponêrias, 478d, meaning by
“medicine” the discipline, not the medications it applies).
Epicurus, who because of his hedonism and rejection of divine prov-
idence was in other ways something of an odd man out in ancient phi-
losophy, is in perfect accord with his rivals on this point.

3 H. Diels and W. Kranz (eds and trans.), Die Fragmente der Vorsokratiker, Grieschisch und
Deutsch, 3 vols. (Berlin: Weidmann, 1951–​1952), B 31; A. Laks and G. W. Most, (eds and trans.),
Early Greek Philosophy, 9 vols. (Cambridge, MA; London: Harvard University Press, 2016) vol. 7,
pt. 2, D 235. Unless otherwise noted the translations are my own.
78 James Allen

The logos of that philosophy is vain by which no affection (pathos)

of a human being is treated. For just as there is no benefit to medi-
cine if it does not heal the sicknesses (nosos) of bodies, so too there is
none to philosophy unless it expels the affections of the soul.4

Chrysippus, the third head of the Stoa (third century BCE)—​whose

views about providence and pleasure could not have been more
different from those of Epicurus—​embraced the same system of
analogies. “It is not the case,” he maintained, “that that there is an art
called medicine, which is occupied with the diseased body, and not an
art occupied with the diseased soul.” He went on to speak of the “phy-
sician of the soul,” of the “affections” (pathê) treated by both types of
physician and to develop an analogy between the therapies (his word)
employed by each.5
Philo of Larissa (late second to early first century BCE), the last
head of Plato’s Academy and a so-​called Academic skeptic, worked
out a detailed and systematic comparison between medicine and phi-
losophy, and their concerns, methods, and goals.6 His student Cicero
(106–​43 BCE) made extensive use of the analogy between philosophy
and medicine, and the maladies of the soul and the diseases of the
body the treatment of which is their object, above all in the Tusculan
Disputations, which tackles some of the most pressing issues faced by
human beings, such as the fear of death, pain, mental distress, other
dangerous emotions, and the sufficiency of virtue for happiness.7

4 H. Usener (ed.), Epicurea (Leipzig: Teubner, 1887), frag. 221.

5 P. H. De Lacy (ed. and trans.), Galen: On the Doctrines of Hippocrates and Plato, 3 vols.
(Berlin: Akademie Verlag, 1978–​84) vol. 1, 298, 27–​300, 12.
6 Text, translation and discussion in C. Brittain, Philo of Larissa: The Last of the Academic Sceptics
(Oxford: Oxford University Press, 2001), 278–​90. More in M. Schofield, “Academic Therapy: Philo
of Larissa and Cicero’s Project in the Tusculans,” in G. Clark and T. Rajak (eds), Philosophy
and Power in the Graeco-​Roman World: Essays in Honour of Miriam Griffin (Oxford: Oxford
University Press, 2002), 91–​109.
7 Tusculan Disputations 2.43, 3.6, 4.23, 58; text and translation in J. E. King (trans.),
Cicero: Tusculan Disputations (Cambridge MA; London: Harvard University Press, 1927).
 Ancient Philosophy 79

Sextus Empiricus, who was active in the second century CE and is

the best known to us as one of the Pyrrhonian skeptics and a member
of the empirical school of physicians, maintained that the enormous
mass of skeptical arguments collected by his school over the course of
its existence were comparable to the doctor’s therapies and like them
an expression of philanthropy, meant to free mankind of mental dis-
tress analogous to bodily disease.8
The main analogies gave rise to others. Antisthenes, a fifth-​century
BCE follower of Socrates who inspired the Cynics, defended his se-
verity toward his students by comparing it with physicians’ treatment
of their patients, and he pointed to the fact that physicians spend time
in the company of the ill without contracting their illnesses to explain
his, and more generally the philosopher’s, willingness to converse with
the wicked.9 Epictetus, the second-​century CE Stoic philosopher,
compared the philosopher’s school to the doctor’s surgery, and he
observed that, like the patients who leave the latter still in pain from
their treatment, the philosopher’s pupils should expect their studies to
be tough going.10
Health is the object of medicine both in the sense of its end or aim
and in the sense of the subject of the knowledge or understanding by
which it is constituted—​together with, and in systematic relation to,
the human body, the unhealthy affections to which it is liable and the
measures by which they can be counteracted. The ancient philosoph-
ical authorities cited above insist that the function of philosophy is
likewise therapeutic. Epicurus uses the verb therapeuein. Sextus speaks

8 Outlines of Pyrrhonism (hereafter PH) 3.280–​81, translation in J. Annas and J. Barnes (trans.),
Sextus Empiricus: Outlines of Scepticism (Cambridge: Cambridge University Press, 2000). See
A.-​J. Voelke, “Soigner par le Logos: La Therapeutique de Sextus Empiricus,” in A.-​J. Voelke (ed.),
Le Scepticisme antique: perspectives historiques et systématiques (Geneva: Cahiers de la revue de
Théologie et Philosophie), 1990.
9 Diogenes Laertius 6.4, 6; text and translation in R. D. Hicks (trans.), Diogenes Laertius: Lives of
Eminent Philosophers, 2 vols. (Cambridge, MA: Harvard University Press, 1925).
10 Discourses, 3.23. 30; text and translation in W. A. Oldfather (trans.), Epictetus: Discourses
(Cambridge, MA; London: Harvard University Press, 1925–​1928).
80 James Allen

of “curing” (iasthai), the verb from which the terms for doctor or phy-
sician (iatros) and the art of medicine (iatrikê) are derived. As disease
is to the body, so “affection,” pathos, meaning passion, emotion or psy-
chic disturbance, is to the soul. Though Democritus and Epicurus use
the term nosos for bodily diseases and pathos for affections of the soul
in the above passages, as they were well aware, the term pathos can also
be used of bodily disease (whence our term “pathology”). Chrysippus
chose to emphasize the affinity between medicine and philosophy
by using pathos for both bodily disease and psychic affection, and he
spoke of the diseased body and the diseased soul using the verb corre-
sponding to nosos. Cicero entertained the idea of translating pathos,
meaning affection of the soul, as morbus (disease), before opting for
perturbatio (disturbance).11 Unstated but implied is an analogy be-
tween medical therapy—​bleeding, dieting, cauterization, cold baths,
and other measures in the ancient physician’s therapeutic repertoire—​
and philosophical therapy—​argument, instruction, and explanation.
Democritus and Epicurus, especially the latter, use the medical
analogy to emphasize the instrumental value of the knowledge or
wisdom pursued by philosophy. There is, then, a possible tension be-
tween philosophy, on a certain lofty elevated or exalted conception
of the discipline, and philosophy conceived along therapeutic lines.
Notoriously, Epicurus has no interest in knowledge for its own sake.
Part of the burden of his observation cited above is to reject the idea
that there might be such a thing as philosophical knowledge that is of
value in its own right.
It seems fair to ask, is the knowledge that medicine needs in order
to discharge its therapeutic function of a relatively low, ordinary, or
garden variety, as regards its content, its character, or both? As we shall
see, on some conceptions of the discipline the answer is yes. If this is
so, might not the same be true of philosophy mutatis mutandis? At

11 De finibus 3.35; translation in J. Annas (ed.) R. Woolf (trans.), Cicero: On Moral Ends
(Cambridge: Cambridge University Press, 2001).
 Ancient Philosophy 81

least in the case of Epicurus, the answer is no. The knowledge philos-
ophy needs to perform its therapeutic function is an exalted business,
embracing a complete grasp of the fundamental atomic nature of the
universe along with the capacity to explain and specify the causes of
all the major natural phenomena, which include but are not confined
to life and the soul. Nothing less will serve as a means to the end in
view, namely to dispel false opinions about the gods, death, and the af-
terlife that are the chief impediments to happiness. These opinions are
the affections of the soul that need to be cured or expelled. Still, the
reasons for Epicurus’ commitment to natural philosophy may appear
peculiar to his own distinctive outlook and, from the perspective of an
outsider, accidental, so that the question may be worth raising again.
We shall come back to it.
For the time being, let us accept that, at least for many ancient
philosophers, to secure the good of the beings with whose care they
were charged, both medicine and philosophy had to command
knowledge or understanding of a high and serious order, satisfying
the strictest standards. This is certainly true of Plato’s version of the
analogy, which is set out in most detail in the Gorgias. The presenta-
tion there makes explicit much that was left implicit elsewhere, while
adding some new and idiosyncratic elements of Plato’s own. The con-
text is a scathing examination of rhetoric’s pretensions to the status of
an art (technê). In order to explain his view that rhetoric is not a true
art at all, but is rather an imposter that professes knowledge it does not
have and flatters instead of caring for the object in its charge, Socrates
erects the imposing system of correspondences that I mentioned.
Two pursuits are counterparts by standing in the same relation to
different objects or domains. Thus rhetoric’s place is that of a coun-
terpart (antistrophos) to “cookery,” because rhetoric and cookery are
false likenesses or counterfeits of the true arts of justice and medicine
respectively. Justice belongs to politics, which cares for the soul, while
medicine is one of the arts that care for the body. They are counterparts
to each other by discharging a corrective function, as contrasted with
82 James Allen

the regulative function of legislation and gymnastics, whose tasks are

to set the soul and the body in good order in the first place. Medicine
and justice possess genuine knowledge of the body and soul, the res-
toration of whose good conditions, health and virtue respectively, are
their objects. By contrast rhetoric and cookery aim not at the good,
but at pleasures of soul and body. They lack genuine understanding
and rely instead on mere experience (empeiria) (463b, 499e–​501b).
As we shall see, the disparaging attitude toward “experience” here is
highly tendentious, both in the context of the dialogue and that of
ancient epistemology more generally.
For the present, especially worth noting is how, in the scheme laid out
by Socrates, an inferior goal, pleasure, is paired with an inferior form
of knowledge, experience—​or rather, to do justice to the view taken by
Socrates in the dialogue, a cognitive condition inferior to knowledge.
The analogy between philosophy and medicine appears to reach its
high watermark here. Objects of concern, the soul and the body, lofti-
ness of aims, virtue and health, and the demand for knowledge of the
highest order in both arts are all in harmony, as I put it above. Caution
may be called for, because the dialogue speaks not of “philosophy” but
of “politics” and its two species, “legislation” and “justice.” On any ac-
count, politics as conceived by Socrates in the dialogue is exceedingly
philosophical business, but is it identical to philosophy or a part of
it? Evidence that it is comes from Socrates’s assertion, late in the di-
alogue, that he is one of few present day Athenians, perhaps the only
one, to practice the true art of politics, apparently by doing what he
is depicted doing here and in other dialogues, namely philosophizing
(521d ff.). That is what Callicles, the third and most formidable of the
interlocutors Socrates faces in the dialogue, calls it in his word to the
wise, warning Socrates to desist from philosophizing for his own good
(484c–​486d).
There is, however, an issue concerning the content of philosophical
knowledge raised by the use of the medical or therapeutic model. In
the Gorgias there gradually emerges a picture illustrated by appeal
 Ancient Philosophy 83

to the example of other arts, above all medicine, beginning with

Socrates’s efforts to elicit an answer to the question “what is the (al-
leged) art of rhetoric about?” (449c). Each art gives rise to character-
istic activities or performances by the artist (450bc). It is productive of
some good, for instance health in the case of medicine (451e–​452d).
As we have observed, each has an object of concern, such as the body.
It must, if it has a corrective function like medicine, also know about
the defective conditions to which the object of its concern is liable,
for instance diseases, and know how to remedy them (449e–​450a). Of
central importance in the knowledge that belongs to a true art is the
form or order that constitutes the good condition of its object of con-
cern (506de).
Alongside his principal, therapeutic function, the physician, like
the practitioners of other arts, has a second, complementary func-
tion: he makes or produces other physicians by instructing them
in his art (449b, 455c, 458a). He does this by transmitting the
knowledge that enables him to discharge his primary, therapeutic
function. On this model, we would expect the philosopher or the
philosophical politician above all to have, and to convey to his
pupils, knowledge of the form or order that is the soul’s good condi-
tion. If however the soul is, in whole or in part, mind or reason, its
good or virtuous condition will be, in whole or in part, knowledge,
and the soul will be treated or cared for by instruction. The primary,
therapeutic function of philosophy may, then, not be distinct from
its didactic function. This raises an inevitable question: When the
philosopher teaches and cares for the soul by imparting knowledge,
what is this knowledge about? It was easier to answer the analogous
question about the content of the knowledge conveyed in medical
instruction. In that case, it is easy to draw a clean distinction be-
tween the knowledge that belongs to the trained physician’s mind
and the condition of his patients’ bodies, about which it is knowl­
edge. With philosophy, by contrast, we are threatened with a regress
of knowledge that is about knowledge.
84 James Allen

A version of this puzzle occupies a prominent place in Plato’s

Euthydemus, which contains two sustained interventions by Socrates.
The purpose of the first is protreptic, or exhortatory. In collaboration
with his principal interlocutor, Clinias, Socrates argues that human
beings who would be happy by securing what is good for themselves
must pursue knowledge or wisdom, that is, practice philosophy. In
the second, he takes up a question left unanswered at the end of the
first intervention: what is the knowledge that will make us happy
(288d ff)? It appears that the knowledge they seek is the art of poli-
tics, which they agree is the same as the kingly art. It is further agreed
that each art furnishes a product (ergon) in the sphere of that which it
governs; medicine and its product, health in the body, are Socrates’s
first example (291e). The product of the kingly art must, it appears,
be knowledge, but not just any kind of knowledge. Apparently it is
the knowledge in which it consists itself, and this is the knowledge by
which one makes other human beings good (292d). This one will do
by imparting the knowledge of how to make others able to impart the
knowledge . . . and so on apparently without end. Approached in this
way, the knowledge that is our soul’s virtuous condition, which is anal-
ogous to the body’s health, threatens to elude our grasp.
In the Republic Plato has Socrates complain about those (possibly
including the real life Socrates himself) who hold that the good is
knowledge or wisdom, namely knowledge of the good (505bc). And
in another dialogue, the Clitophon (which may not be by Plato), after
paying sincere homage to Socrates’s mastery of protreptic and his
ability to inspire ardor for virtue in his auditors, the title character
complains that Socrates fails to say anything about the knowledge at
whose acquisition their new-​found zeal for virtue should be directed.
This, he maintains, puts Socrates at a disadvantage compared with the
professors of other arts, notable among them medicine.
I conclude that the analogies between medicine and philosophy and
between bodily health and virtue will take us only so far. Useful and
illuminating though the likeness between philosophical instruction and
 Ancient Philosophy 85

medical therapy may be, to the extent that the condition of the soul that
is analogous to the health of the body is knowledge or wisdom, “knowl­
edge of the soul and its good condition” will not serve to specify the
content of philosophical wisdom and philosophical teaching as “knowl­
edge of the body and the health of the same” serves to specify that of
the medical art and medical instruction. As we have seen, in the case of
Democritus and Epicurus, both of whom subscribed to the family of
analogies with which we began, philosophical wisdom must range far
beyond this. The same is true in different ways of Plato, the Stoics, and
others.

The Character of Medicine and Philosophy

So far I have pursued some of the implications for the content of phi-
losophy of the first of two affinities philosophers recognized between
their discipline and medicine, that based on their shared therapeutic
function. I now turn to the second, the way in which the nature and
character of medical knowledge served as a model for the character
of philosophical wisdom. As we have seen, in Plato’s Gorgias, to the
correspondences between the object of concern and ends pursued by
medicine and justice, Socrates joined another between the kinds of
knowledge they employ. It embraces genuine understanding of the
natures of the matters that fall under its care, on which its choice of
measures is based; by contrast, the imposter arts, rhetoric and cookery,
rely on mere experience, or as Socrates puts it, the memory of what is
accustomed to happen divorced from an understanding of the causes of
what happens (499e–​501a).
Plato’s Phaedrus, which again takes up questions about the possibility
of a rhetorical art, contains a famous appeal to the method of Hippocrates
(271c). If we are guided by Hippocrates, it is agreed, we cannot hope to
understand the soul or the body satisfactorily without knowledge of “the
whole.” It is a matter of scholarly controversy whether the whole in ques-
tion is that of the body or of the universe, and also whether this clue can
86 James Allen

throw light on the Hippocratic problem, namely which, if any, of the het-
erogeneous collection of medical works ascribed to Hippocrates in antiq-
uity were actually written by him. There can however be no mistaking
Plato’s respect for medical knowledge at its best.12
Aristotle, whose father was a physician, turns to medicine to il-
lustrate the grasp of causes and principles—​t he mark of real knowl­
edge, which sets it apart from mere experience—​to illuminate the
nature of wisdom or first philosophy, the subject we have come to call
metaphysics (Metaphysics 981a7–​2 0). What is more, he holds not
only that there is an analogy between the knowledge of medicine
and of philosophy but also that the content of medical knowl­
edge and natural philosophy overlap. Where natural philosophy
leaves off, medicine begins, and natural philosophers will con-
clude their studies by tackling medicine, while physicians, at
least of the more serious and better sort, will begin with natural
philosophy.13
Nevertheless one might wonder, does a physician really need
knowledge of such an exalted order to discharge his therapeutic
responsibilities? As we saw, in the Gorgias superior knowledge was
paired with a superior end. There could be no true knowledge or sci-
ence of pleasure, because genuine knowledge of the nature of the body
or soul has to be, in the first instance, knowledge of its good, not some-
thing as superficial as pleasure (though it might well include knowl­
edge of pleasure as a consequence). A pursuit concerned simply with
pleasure would have to rely on an inferior form of cognition, mere ex-
perience. In the Laws, however, Plato allows that experience can serve
as the basis of medical treatment directed toward health, the same
end as medicine founded on real knowledge of the nature of the body
(720a–​e; cf. 857c–​d). He pictures slaves or servants of doctors, called

12 J. Mansfeld, “Plato and the Method of Hippocrates,” Greek, Roman and Byzantine Studies 2
(1980), 341–​62. Cf. King, Cicero: Tusculan Disputations 3:7.
13 On Sense and Sense-​Objects 463a19–​b1; On Youth and Old Age 481b21–​30.
 Ancient Philosophy 87

“doctors” themselves in a manner of speaking. By observing their mas-

ters at work, they will have acquired the ability to treat many kinds
of patients for many kinds of illness. Their patients will, to be sure,
typically be drawn from the lower ranks of society, and these so-​called
doctors will lack the ability to converse with them about the nature of
the body, the diseases from which it suffers, and the like, in the way
true doctors can with their patients, who will be drawn from more
elevated and better educated strata of society. Still, Plato seems to con-
cede that they will be to a high, if not perhaps the highest, degree ef-
fective. The fact that it may be possible to achieve the end of medicine
without possessing knowledge satisfying the highest standards gains
added importance if such knowledge, apart from being unnecessary,
is also unattainable, either in present conditions or ever. Patients need
effective treatment when they are ill and cannot afford to wait until
the art of medicine has satisfied all the expectations that philosophers
and some of its philosophically minded practitioners have entertained.
Physicians and medical writers also had much to say about their disci-
pline and its relation to philosophy. Paradoxically they were never more
philosophical than when defending the autonomy of medicine from
encroachments by the discipline of philosophy—​for it is then that they
tackled fundamental questions about the scope and nature of medical
and other forms of knowledge. These defenses did not have to insist that
medical knowledge should meet lower or different standards than those
held up by the philosophers whose views we have been exploring. Indeed,
on some plausible interpretations, the author of the Hippocratic trea-
tise On Ancient Medicine thinks that the kind of hypothesis-​based in-
quiry, as he styles it, pursued by natural philosophers and the physicians
influenced by them is not merely out of place in the medical realm but
also incapable of achieving genuine knowledge in any sphere, unlike
medicine itself, whose discoveries put it ahead of all other disciplines.14

14 M. Schiefsky (trans.), Hippocrates: On Ancient Medicine (Leiden: Brill, 2005).

88 James Allen

By contrast, other medical authors were willing to set a lower bar for
their discipline. Diocles of Carystus, probably active in the fourth cen-
tury BCE and one of the most eminent physicians of the age, is an es-
pecially important case in point. In a fragment about the properties of
foodstuffs from a book on dietetics, he sets out several objections to the
ways in which other physicians have tackled the subject.15 Diocles objects
in particular to those who think it is always necessary to specify the un-
derlying cause why a foodstuff is, for instance, a diuretic or a laxative.
They fail to realize that effective practice often does not require this and,
further, that many existing things are in a certain way like principles by
nature without satisfying the expectations of his opponents. He goes on
to say that some physicians—​meaning presumably those in the grip of
this picture—​tend to appeal to causes that are unknown, disputed, and
implausible, and he maintains that, instead of following them or those
who demand that a cause be specified in every case, it is better to put
one’s faith in what has been discovered through long experience. He
takes this position despite acknowledging that in some cases the cause
can, indeed, be discovered and despite thinking that inquiry into causes
is worth pursuing.
On Diocles’s view, then, it seems that there is a place, even a per-
manent place, in the art of medicine for precepts that, though in a
certain way like principles because they serve the doctor as a basis
for diagnostic and therapeutic reasoning, are not true principles of
the kind demanded by philosophers like Plato and Aristotle. Such
precepts would not comprehend fundamental natures or causes. Some
of these quasi-​principles will be empirical generalizations, based on
the observation and memory of what is accustomed to happen, for
which they are able to provide no explanation. In other words, Diocles
countenances including as part of the art of medicine truths of the

15 P. J. van der Eijk, Diocles of Carystus (Leiden: Brill, 2000), frag.176. On Diocles and
Herophilus, see M. Frede, “An Anti-​A ristotelian Point of Method in Three Rationalist Doctors,”
in K. Ierodiokonou and B. Morison (eds), Episteme etc. Essays in Honour of Jonathan Barnes
(Oxford: Oxford University Press, 2011), 115–​37.
 Ancient Philosophy 89

kind many philosophers had excluded from it, and which they had
contrasted with principles of the kind that are fit objects for genuine
knowledge and understanding. For Diocles the therapeutic function
of medicine can be, indeed must be, discharged by relying on a mix-
ture of precepts of different types.
Herophilus, a physician and medical theorist of the late fourth and
third centuries BCE whose eminence was at least equal to Diocles’s,
theorized freely about natures and causes and thought it appropriate
to appeal to them in medical reasoning, but he also raised doubts about
the truth of the causal explanations that he employed, even perhaps
the possibility of discovering true causal explanation at all.16 A stu-
dent of his, Philinus of Kos, active in the mid-​third century BCE, is
credited with founding the school of medical empiricism, which
counted among its members many figures like Sextus Empiricus who
were also members of the philosophical school of Pyrrhonian skeptics.
Citing the enormous mass of conflicting theories produced by those
who claimed to understand the nature of the body and the causes that
produce health and disease, and the seemingly unending disputes to
which they had given rise, they too argued that it was difficult and
perhaps impossible to obtain the knowledge that Plato and those who
agreed with him regarded as indispensable to an art of medicine. And
they tried to show that, in any event, such knowledge was unnecessary,
arguing for the possibility of an art of medicine dispensing with in-
sight into the nature of the body and based solely on experience.
Far from requiring deep reflection and profound insight, a med-
ical theorem—​their term—​might owe its discovery to a chance ob-
servation and its status to confirmation by subsequent observation,
while the underlying causes because of which it obtained remained
completely unknown. Galen (second century CE) illustrated the
empiricists’ ideas with a story about the chance discovery of a cure for

16 On him see H. von Staden, Herophilus: The Art of Medicine in Early Alexandria
(Cambridge: Cambridge University Press, 1989).
90 James Allen

elephantiasis. A sufferer who unwittingly consumed water in which

a dead snake had decayed recovered from the illness afterward; later
attempts to duplicate the result intentionally also met with success,
and the resulting therapeutic theorem, unexpected and inexplicable as
it was, could be accepted as a perfectly sound basis for treating cases of
elephantiasis.17
We have come a long way from the picture with which we started, ac-
cording to which philosophy and medicine are set over soul and body,
whose excellent conditions, virtue and health, can be obtained only by
means of the most profound knowledge of the relevant domain. If we
are swayed by the lines of argument that moved the empiricists, and in
a different way Diocles and Herophilus, we will be persuaded that the
art of medicine can and perhaps must do without a full understanding
of the nature of its defining object of concern, the body and its healthy
condition. Can medicine so conceived and the health of the body it
pursues, divorced from any deeper understanding, serve any longer as
models for philosophy and the excellent condition of the soul that is
its object?
For many philosophers the answer must obviously be no, but I shall
conclude by mentioning some for whom the answer was yes, though with
an important qualification. These were the Pyrrhonian skeptics, some
of whom, as I mentioned, were also members of the empiricist school of
medicine, most notably Sextus, whose works on Pyrrhonism survived to
become our main source for this form of skepticism. Their attachment to
the therapeutic ideal is plain from the passage I cited above, comparing
the Pyrrhonists use of arguments to the doctor’s therapies. It repays closer
attention.18

17 Galen, “Subfiguratio Empirica,” in Deichgräber (ed.), Die griechische Empirikerschule: Sammlung

der Fragmente und Darstellung der Lehre (Berlin: Weidmann, 1965), chap. 10, 75ff. Translation in
R. Walzer and M. Frede (trans.), Galen: Three Treatises on Science (Indianapolis: Hackett, 1985).
18 PH 3.280–​81, trans. Annas and Barnes lightly modified. On this topic see also J. Allen,
“Pyrrhonism and Medicine,” in R. Bett (ed.), The Cambridge Companion to Ancient Scepticism
(Cambridge: Cambridge University Press, 2010), 232–​34.
 Ancient Philosophy 91

Sceptics are philanthropic and wish to cure by argument the con-

ceit and rashness of the Dogmatists. Just as doctors for bodily
affections have remedies which differ in potency, and apply severe
remedies to patients who are severely afflicted and milder remedies
to those mildly afflicted, so the sceptics propound arguments that
differ in strength—​they employ weighty arguments, capable of
vigorously rebutting the dogmatic affections of conceit, against
those who are distressed by severe rashness, and milder arguments
against those who are afflicted by a conceit that is superficial and
easily cured and which can be rebutted by a milder degree of
plausibility.

It is noteworthy that, in the hands of the Pyrrhonists, the analogy to

medical treatment extends to the individualized treatment of patients,
which was such an important part of the Greek medical ideal. This is
true despite the fact that the analogue on the side of philosophy is an
odd one: the use of arguments of different levels of cogency adjusted to
the spiritual sufferer’s particular needs, not to persuade those to whom
they are addressed, but rather to help them suspend judgment by bal-
ancing them against opposing arguments.
Analogous to the diseases that the physician aims to cure is the target
at which Pyrrhonian philanthropy directs its fire, namely rashness or
dogmatism. The analogue to bodily health that the Pyrrhonists aim to
produce is tranquility or freedom from mental distress (ataraxia), which
they sometimes identify as the end or goal of life.19 The puzzlement we are
likely to experience upon learning that a school of self-​professed skeptics
could have identified an “end of life” may be diminished if we keep in
mind that they seem to have regarded the desirability of ataraxia as a
given, akin to a desire for a healthy body, an assumption no one would
question, rather than the deliverance of a deep insight into human na-
ture or a contentious theory. That this happy condition was promoted by

19 PH 1.25, 215.
92 James Allen

suspension of judgment for the sake of which the Pyrrhonists made use
of therapeutic arguments of different strengths, was likewise not a con-
clusion derived from insight into human nature, but they maintained, a
chance discovery.

What is said about the painter Apelles belongs also to the sceptic.
They say that he was painting a horse and wanted to represent in his
picture the lather on the horse’s mouth; but he was so unsuccessful
that gave up, took the sponge on which he had been wiping off the
colours from his brush, and flung it at the picture. And when it hit the
picture, it produced a likeness of the horse’s lather. Now the sceptics
were hoping to achieve tranquility by resolving the anomalies in
what appears and is thought, but being unable to do this they sus-
pended judgment. When the suspended judgment, however, tran-
quility followed as it were by chance as a shadow follows a body.20

The medical empiricists did not have a monopoly on the idea of

chance discovery confirmed by subsequent experience, but the resem-
blance between the two schools on this point is striking, even more so
if we attend to the way they were willing to base a philosophy or way
of life, on the one hand, and a system of medicine, on the other hand,
on something as insubstantial and unsatisfying—​from the point of
view of other philosophers and physicians—​as chance observations
and experience entirely divorced from any deeper understanding of
causes.
A significant part of Pyrrhonian skepticism as presented by Sextus
corresponds nicely to the therapeutic method of medicine. Drawing
on the work of his Pyrrhonian predecessors, Sextus describes in con-
siderable detail techniques or modes for the production of arguments
that can be opposed to those put forward by the school’s dogmatic

20 PH 1.27–​9; trans. Annas and Barnes, modified.

 Ancient Philosophy 93

opponents, the better to bring about suspension of judgment and the

tranquility attendant upon it. And he devotes substantial parts of
his oeuvre to the exposition and skeptical examination of competing
dogmatic views on a full range of philosophical issues from all three
standard parts of philosophy—​ethics, physics, and logic—​as well as
in the disciplines of rhetoric, grammar, astronomy, and mathematics.
Among many other things, he tackles questions about the nature and
possibility of truth, knowledge, and proof; about the nature and ex-
istence of the gods; and about the nature and reality of number and
motion and change.
The Pyrrhonians are called “skeptics” from the term skepsis,
meaning inquiry. They contrast their way of philosophizing with that
of dogmatists, on the one hand, who, they maintain, have called off
the search for truth prematurely because they think they have discov-
ered and grasped it, and the Academics, on the other, whom they ac-
cuse (unfairly) of having given up the search for the opposite reason,
because they are convinced that knowledge is unobtainable. By con-
trast they, the skeptics, continue inquiring.
The Pyrrhonists were no less attached to the therapeutic model of
philosophy than any other school of ancient philosophy. But if their
affinity with medical empiricism led them to think that tranquility,
the health of the soul, could be achieved without discovering the
fundamental truths about the world and human beings’ place in it,
which their dogmatic rivals regarded as an indispensable means to
the same end, the suspension of judgment that they, to their sur-
prise, find so congenial is not the result of disengagement or with-
drawal from philosophical activity. On the contrary, it is produced
and sustained by continual, energetic engagement in the business of
philosophy. As a result, the condition desirable for human beings
according to Pyrrhonism resembles that envisaged by many of their
dogmatic opponents. To be sure, people realizing the Pyrrhonian
ideal will not have knowledge in the way required by dogmatic phi-
losophy, but they will know about, in the sense of being familiar
94 James Allen

with, or well versed in, all the major philosophical questions and
the answers the philosophers have proposed, and they will be oc-
cupied with thinking and arguing about them, even if they never
achieve (and are perfectly content not to achieve) the settled condi-
tion of knowing where the truth lies. The life of psychic health for
the skeptics, no less than for many of the dogmatists, will be the life
of philosophical theory.
Reflection
Phrontis: The Patient Meets the Text
Helen King
p

Perhaps the best-​known parts of the Hippocratic Corpus are

the case histories collected in the seven treatises known as the
Epidemics.1 Like the other medical texts from the Corpus,
which date from the fourth century BCE onward, these are
mostly concerned with disease, but it is not difficult to read
between the lines to identify what is thought to constitute
“health.”
The Epidemics bring into sharp focus one of the challenges of
using historical materials on health and disease; finding ways to
avoid making assumptions based on our experience of medicine.
For us, and for generations of earlier readers of these texts, the
naming of the individual patients, the account of the symptoms—​
often following a day-​by-​day format—​and the strong authorial
presence of the writer make the most obvious label for them that
of “case histories.” Yet these accounts appear to have been written
more as “notes to self ” than as records for others. Institutionally,
within ancient societies, who can have been intended as the
audience? There is a longstanding historical myth that the case
histories of Epidemics 1 and 3 were written by Hippocrates himself,

1 For the Greek edition see E. Littré (ed.), Oeuvres complètes d’Hippocrates, 10 vols.
(Amsterdam: Adolf M. Hakkert, 1973–​1982).

95
96 Helen King

with the Aphorisms coming later as a distillation composed for

teaching purposes of the conclusions he had drawn inductively
from the case histories. But as Volker Langholf showed, the reverse
is more likely, with the Epidemics assuming a nosology already
established by other “Hippocratic” treatises, including the theory
of “critical days.”2 This suggests that the process is not inductive;
instead, the theories predate the observations.
At the same time, the Epidemics also reveal features specific
to the culture that produced them. In addition to allowing us to
detect the range of ancient theories about the body that underpins
the comments made about the progress of illness in a particular
named individual, they also reflect the social context within
which ancient medicine functioned. For example, although
female patients are described, they are not directly named,
instead featuring most commonly as “the wife of x.” As David
Schaps argued in 1977, women in ancient Greek culture were not
mentioned in public, unless they were dead or of “ill repute.”3 This
makes even more striking those passages in which a woman is
named; for example, in Epidemics 6.8.32, Phaethousa and Nanno,
who grow beards and then die, are doubly identified (“Nanno, wife
of Gorgippos”) or even triply identified (“Phaethousa of Abdera,
wife of Pytheas”).
Disorders affecting women feature in many Hippocratic
treatises, along with issues about how a male physician can have
access to the body of a female patient, and how far that physician
should believe a woman’s account of her health and illness. Most
of the evidence for the male physician’s engagement with such
disorders, as well as for how women’s bodies are interpreted,

2 V. Langholf, Medical Theories in Hippocrates: Early Texts and the “Epidemics” (Berlin: de
Gruyter, 1990).
3 D. Schaps, “The Woman Least Mentioned: Etiquette and Women’s Names,” Classical Quarterly
27/​2 (1977), 323–​30.
 Phrontis: The Patient Meets the Text 97

comes not from the Epidemics but from the three volumes of
Gynaikeia: “Women’s Matters.” Whereas the Epidemics accounts
often close with the death of a specific patient, the various sections
of the Gynaikeia sometimes end with general comments about the
restoration of a healthy condition. For example, “If she becomes
pregnant, she is healthy.” Case histories, however, do not feature in
the Gynaikeia; its women remain generalized, not specific.
There is one apparent exception to this rule of the absence of
specific patients from the Gynaikeia, and it is another account of
restoring health; and, here, also restoring fertility. In Gynaikeia
1.40 (8.96–​98) we read about the patient Phrontis who examined
her own vagina, recognized there was a problem (the verb is egnô)
and reported it to the Hippocratic physician (ephrase, “she made it
known”):

Phrontis suffered those things that women suffer when the lo-
chia are not flowing, and from this had pain in the private parts
(aidoion), and having touched (it) she recognized that there was
a blockage, and she made it known, and having been treated she
purged and became healthy (hygiês) and fertile (phoros). If she had
not been treated and if the lochia did not flow naturally, the ul-
ceration would have been bigger and there would be a danger, if
there was no treatment, that the ulcers would become cancerous.
(Hippocrates, Gynaikeia 1.40, 8.96–​98)

This section comes at the end of a passage describing how the

“mouth of the aidoion” can become ulcerated after childbirth, as a
result of the inflammation caused by the baby passing through the
birth canal, so that the aidoion sticks together and causes closure;
this provides the general context in which this isolated example of
a patient features.
The great nineteenth-​century French editor of the Hippocratic
Corpus, Emile Littré, examining the variations in the manuscript
98 Helen King

tradition for the introductory part of this account, commented

that “one easily recognizes that this concerns a particular
observation which the author recounts” (Gynaikeia 1.40, 8.87,
note). Manuscript C, downplayed by Littré but now considered
the best surviving manuscript, adds the words “hê gynê panta,” so
that the start of the passage would read: “Phrontis. The woman
suffered all those things that women suffer when the lochia are not
flowing . . . ”4
I am not alone in having previously presented Phrontis as a
model for the ideal female patient, aware of her own body and
when health becomes disease.5 Aline Rousselle cited this example
to support her claim that “in general, women examined themselves
while they were in good health.”6 Three other passages, not
mentioned by Rousselle, perhaps support this. In two of them,
women examine the mouth of the womb and find it narrow and
moist (Gynaikeia 1.59/​L 8.118 and 2.155/​L 8.330), and in another
a woman examines herself and finds the mouth of the womb is
closed or tilted (Gynaikeia 3.213/​L 8.410).
Seeing Phrontis in this way, as a model patient, is consistent
with the boundaries of Ann Hanson’s category of “the
experienced woman,”7 as she has given birth; we know this
because her problem is that the lochia (the discharge following
birth) have not flowed as they should. Hanson argued that, while

4 H. Grensemann, Hippokratische Gynäkologie (Wiesbaden: Franz Steiner, 1982), 134.

5 H. King, “Medical Texts as a Source for Women’s History,” in A. Powell (ed.), The Greek World
(London: Routledge, 1995), 199–​218, at 203 and 214 n.30; King, Hippocrates’ Woman: Reading the
Female Body in Ancient Greece (London: Routledge, 1998), 48.
6 F. Pheasant, (trans.), Aline Rousselle: Porneia: On Desire and the Body in Antiquity
(Oxford: Blackwell, 1988), 25.
7 A. E. Hanson, “The Medical Writers’ Woman,” in D. M. Halperin et al. (eds), Before
Sexuality: The Construction of Erotic Experience in the Ancient Greek World (Princeton,
NJ: Princeton University Press, 1990), 309–​38, at 309–​10; L. Dean-​Jones, “Autopsia, Historia and
What Women Know: The Authority of Women in Hippocratic Gynaecology,” in D. Bates (ed.),
Knowledge and the Scholarly Medical Traditions: A Comparative Study (Cambridge: Cambridge
University Press, 1995), 41–​58, at 55.
 Phrontis: The Patient Meets the Text 99

women’s experience is denigrated as a reliable source in many

types of ancient literature, the Hippocratic writers construct a
“female counterpart to the idealized male patient, the intelligent
layperson who works with the doctor to maintain health or to
combat illness.”8 Women are graded on a scale based on their
experience, and those who have such experience can be trusted
as accurate witnesses to their own bodies and as partners in their
own therapy, as in the description of inserting a tube so that
milk can be poured into the womb, where this can be entrusted
to the patient because “she herself will know where it is to be”
(Gynaikeia 3.222/​L 8.430). In this example too, the patient is
clearly experienced, as she is married and has previously conceived.
Her report that the womb is receiving the seed correctly can
therefore be trusted.
But back to Phrontis, who appears to be “the only named woman
in the Hippocratic gynaecological treatises.”9 Not only does her
presence seem odd, as a named individual in a world of “wives of x,”
but her name itself does seem remarkably convenient for this story.
Normally it is a male name, but another female Phrontis is known
in classical Greek literature. In the middle of the fourth century
BCE, Philiscus of Miletus wrote a funeral elegy for the Athenian
orator Lysias. Here, Phrontis is the daughter of the Muse Calliope.
Phrontis is called upon to give birth to a son, a hymn for Lysias
that will spread his name across the world (preserved in Plutarch,
Lives of the Ten Orators, 836c = fr. 1.5 West) 10. David Leitao, who
has examined the theme of “poetic paternity,”11 the male who gives
birth to songs or ideas, suggests that “this fictitious daughter of

8 Hanson, “The Medical Writers’ Woman,” in Halperin, 309–​38, at 310.

9 L. M. V. Totelin, Hippocratic Recipes: Oral and Written Transmission of Pharmacological
Knowledge in Fifth-​and Fourth-​Century Greece (Leiden: Brill, 2009), 116.
10 D. Leitao, The Pregnant Male as Myth and Metaphor in Classical Greek Literature
(Cambridge: Cambridge University Press, 2012), 123.
11 Leitao, The Pregnant Male as Myth, 124.
100 Helen King

Calliope is really just a personification of the poet Philiscus’s own

phrontis.”12 Phrontis, literally “thought,” can be used in the sense of
“reflection;” but it can also mean “anxiety.”
We should not automatically discount “Phrontis” as a real
patient’s name, of course; everyone has to be called something.
But finding that the only named woman in the Gynaikeia is
apparently called “Thought” should give us pause.13 If she is not
simply the ideal “thoughtful” patient, a further possibility is that
this was not originally a name, but rather a symptom, or even
the name of a disease. In his edition of the Hippocratic Diseases
2.72, Littré opened with “Phrontis, a dangerous disease,”
translating this as “worry” and adding his own diagnosis of
“hypochondria” (L 7.108), but he also noted that the gloss “a
dangerous disease” was not found in all manuscripts. Potter’s
1988 edition and translation favored a different manuscript
tradition here, one which omitted “a dangerous disease,” and in
addition he chose to emend the text to read “phrenitis” rather
than “phrontis.”
There is a common pattern in the Hippocratic Corpus by
which diseases take their names from the part of the body
in which they are situated,14 and here both words come from
the same root: the phrên, the part of the body responsible for
reasoning, located at the midriff. Because it is a described as a
thin and wide part with no cavity (Sacred Disease 17, L 6.392=
20, Loeb 2.180), the term is translated today as “the diaphragm.”

12 Leitao, The Pregnant Male as Myth, 123.

13 There are many textual variants in the manuscript for the opening of this case. Even Littré,
who was responsible for making this into a named woman, had his doubts about the text. Not
all manuscripts even include the word “phrontis”; the earliest Latin translation, the 1525 complete
Hippocratic Corpus by Marco Fabio Calvi, opened this section with “however for this woman
the very same things will arise” (Huic autem foeminae eadem venient), using the sixteenth-​century
manuscript Vaticanus Graecus 278. See M. F. Calvi, Hippocratis Coi medicorum omnium longe
principis, Octoginta volumina . . . (Rome: Franciscus Minitius, 1525), cxxi.
14 S. Byl and W. Szafran, “La phrénitis dans le Corpus Hippocratique: Etude philologique et
médicale,” Vesalius 2/​2 (1996), 98–​105, at 102.
 Phrontis: The Patient Meets the Text 101

Phrenitis was thought to be a dangerous acute condition

characterized in the Hippocratic Corpus by fever and by what
we would call delirium: disordered thought. In Diseases 2.72 the
area of the phrenes swells and is painful, and the patient is afraid
and has hallucinations. However, while Potter’s emendation to
“phrenitis” here makes sense, there is no manuscript justification
for it.15
So, instead of Gynaikeia 1.40 offering us a unique reference
to a named individual in the midst of a treatise about general
conditions, or even a conveniently named ideal patient, we may
here have a manuscript corruption in which the original was
a description of “worry,” as a further consequence of lochial
retention, and “Phrontis” being an error for phrenitis. However,
phrenitis is a condition of confused thought in which the patient
goes “out of their mind”: Phrontis thinks clearly and is very
much in control. One of the symptoms of phrenitis is inability
to speak16: yet Phrontis is able to communicate what is wrong
with her.
While women patients do feature on many occasions in the
Hippocratic Corpus, in some cases even having their words
reported, we should be cautious how we handle the evidence
in this particular case. Rather than a real, named individual
who illustrates a general principle of health and disease, or an
ideal “thoughtful patient” who provides a model for patient-​
physician interaction, these third-​person descriptions could state
what a generalized woman suffers, rather than anyone’s specific
experiences. Phrontis, whether real or ideal, does not provide the

15 G. C. McDonald, “Concepts and Treatment of Phrenitis in Ancient Medicine” (PhD diss.,

Newcastle University, 2009), 17 n. 9, notes that no other modern editor has made this amendment.
Byl and Szafran, “La phrénitis dans le Corpus Hippocratique,” note that retrospective diagnoses
of phrenitis included, in the nineteenth century, encephalitis or meningitis and, in the early twen-
tieth century, malaria.
16 Byl and Szafran, “La phrénitis dans le Corpus Hippocratique,” 101.
102 Helen King

complete picture. In other medical texts, women are doubted

as reliable authorities on their own bodies. Deconstructing
Phrontis suggests that we should treat our sources for the body
with considerable caution, resisting our hope of connecting with
real people, with real bodies just like ours.
 CH A PTER FOUR

Health in Arabic Ethical Works

Peter Adamson

Conceptions of health in the medieval Islamic world often take their

cue from Galen. This will come as no surprise as concerns medical lit-
erature. Less expected is Galen’s crucial role as a source for the idea of
“psychological,” as opposed to bodily, health—​that is, the health of
the soul. Galen devoted several works to ethics, which were translated
into Arabic. Particularly influential was a work called On Character
Traits, lost in Greek but retained in the form of a summarizing Arabic
paraphrase with the title Fī l-​Aḫlāq.1 Here Galen explicitly draws a
parallel between the health of the soul and bodily health:

1 Arabic text in P. Kraus, “Kitāb al-​a ḫlāq li-​Jālīnūs [On Character Traits, by Galen],” Bulletin of
the Faculty of Arts of the University of Egypt 5 (1937), 1–​51; J. N. Mattock (trans.), “A Translation
of the Arabic Epitome of Galen’s Book Peri Ethon,” in S. M. Stern et al. (eds), Islamic Philosophy
and the Classical Tradition (Oxford: Cassirer, 1972), 235–​60. Revised English trans. in P. N. Singer
(ed.), Galen: Psychological Writings (Cambridge: Cambridge University Press, 2013). Discussed in
R. Walzer, “New Light on Galen’s Moral Philosophy,” The Classical Quarterly 43 (1949), 82–​96. On
Galen’s influence on the Arabic ethical tradition see also G. Strohmaier, “Die Ethik Galens und
ihre Rezeption in der Welt des Islams,” in J. Barnes and J. Jouanna (eds), Galien et la Philosophie
(Vandoeuvres: Fondation Hardt, 2003), 307–​29. All translations are mine unless otherwise noted.

103
104 Peter Adamson

Just as the body is beset by illness and ugliness (for example epilepsy
or, for ugliness without illness, being a hunchback), so the soul is
beset by illness and ugliness. Its illness is, for instance, anger; its ug-
liness, for instance, ignorance. (Galen, On Character Traits, 42–​43)

The parallel suggests that we might conceptualize ethics as follows: just

as the doctor can treat the body, helping the patient to maintain or re-
store its health, so the ethicist or ethical adviser can help people main-
tain or restore the “health of their body.”2 The example given here is
that a soul that is prone to anger has a sort of illness; other examples we
will meet later include sadness, weakness in the face of pleasure, and
obsessive thoughts.
The task of treating such ailments of the soul was taken up in a
group of works that form a kind of mini-​genre in early Arabic phi-
losophy. They draw on direct acquaintance with Arabic translations
of Galen and base themselves partly or wholly around the notion
that there could be a kind of medicine for the soul. In this chapter
I will be looking at three such texts. In chronological order they
are Abū Zayd al-​Balḫī’s Maṣāliḥ al-​Abdan wa-​l-​Anfus (Benefits for
Souls and Bodies, hereafter Benefits),3 Abū Bakr al-​R āzī’s al-​Ṭibb al-​
Rūḥānī (The Spiritual Medicine),4 and Miskawayh’s Tahḏīb al-​Aḫlāq

2 The parallel is not only Galenic but is also pervasive throughout antiquity. See J. Pigeaud, La
maladie de l’ âme: Étude sur la relation de l’ âme et du corps dans la tradition médico-​philosophique
antique (Paris: Belles Lettres, 1981). Nonetheless, Galen seems to be the main source for the idea
in Arabic texts.
3 Arabic text in two facsimile editions in the series overseen by F. Sezgin, Abū Zayd al-​
Balḫī: Sustenance for Body and Soul (Maṣāliḥ al-​Abdan wa-​l-​Anfus) (Frankfurt a.M.: Institute for
the History of Arabic Islamic Science,1984 and 1998). I will cite according to the page number
of the 1984 facsimile. German translation of the section on the health of soul in Z. Özkan, Die
Psychomatik bei Abū Zaid al-​Balḫī (gest. 934 AD) (Frankfurt a.M.: Institute for the History of
Arabic Islamic Science, 1990). On Abū Zayd see H. H. Biesterfeldt, “Abū Zayd,” in U. Rudolph
(ed.), Philosophie der Geschichte der Philosophie: 8.–​10. Jahrhundert (Basel: Schwabe, 2012), 156–​67.
4 Arabic text in P. Kraus (ed.), al-​R āzī: Rasā’ il falsafiyya (Opera philosophica) (Cairo: Barbey,
1939), 15–​96. English translation in A. J. Arberry (trans.), The Spiritual Physick of Rhazes
(London: John Murray, 1950). French translation in R. Brague (trans.), Al-​R azi: La médecine
spirituelle (Paris: Flammarion, 2003).
 Ar abic Ethical Works 105

(The Refinement of Character Traits, hereafter Refinement).5 We can

possibly trace all three works to the founding father of the Islamic
philosophical tradition, al-​K indī. He was the teacher of al-​Balḫī
(850–​934), and it may be that the latter was in turn a teacher of al-​
Rāzī (d. 925).6 Certainly the ethical projects of al-​Balḫī and al-​R āzī
are strikingly similar. Where al-​Balḫī’s work is split into two sections,
dealing respectively with physical and psychological medicine, al-​
Rāzī’s Spiritual Medicine is explicitly presented as a companion piece
to his encyclopedia on bodily medicine, the Book for al-​Manṣūr. The
later Miskawayh (d. 1030) accesses a wider range of sources and fuses
the themes of Galenic ethics with passages drawn from Aristotle’s
Nicomachean Ethics. Yet he too looks back to al-​K indī, ending his
Refinement with a lengthy quotation from his writings, and drawing
on al-​K indī elsewhere when discussing the soul.7
It is therefore worth looking briefly at the work Miskawayh saw fit to
quote as a conclusion to the Refinement. It is a nice example of “medi-
cine for the soul,” albeit that it does not seem to draw on Galen as our
other authors do. This is an epistle by al-​K indī entitled On Dispelling
Sorrow, which says about sadness or grief (ḥuzn) much the same thing
that Galen remarked about anger. In this epistle al-​K indī says that
sadness is an ailment of the soul:

5 Arabic text in C. Zurayk (ed.), Miskawayh: Tahḏīb al-​Aḫlaq (Beirut: al-​Nadin al-​Lubnāniyya,
1966). English translation in C. Zurayk (trans.), Miskawayh: The Refinement of Character
(Beirut: American University of Beirut, 1968).
6 The Fihrist (List) of the book merchant Ibn al-​Nadīm reports that al-​R āzī studied with an al-​
Balḫī, but it is not clear whether this is the same man as our Abū Zayd. See further on this P.
Adamson and H. H. Biesterfeldt, “The Consolations of Philosophy: Abū Zayd al-​Balḫī and Abū
Bakr al-​R āzī on Sorrow and Anger,” in P. Adamson and P. E. Pormann (eds), Philosophy and
Medicine in the Formative Period of Islam (London: Warburg Institute, 2018), 190–​205.
7 See P. Adamson, “Miskawayh’s Psychology,” in P. Adamson (ed.), Classical Arabic
Philosophy: Sources and Reception (London: Warburg Institute, 2007), 39–​54, and P. Adamson and
P. E. Pormann, “More than Heat and Light: Miskawayh’s Epistle on Soul and Intellect,” Muslim
World 102 (2012), 478–​524.
106 Peter Adamson

Every pain for which one does not know the causes is incurable. We
therefore ought to set out both what sadness is and what causes it in
order to find a cure and to apply it with ease. (Sec. 1.1)8

Although al-​ K indī is here concentrating on one particular psy-

chological illness, he does at one point suggest a broader project of
psychological medicine, such as is carried out by the later authors
mentioned above:

The welfare of the soul and curing it from its diseases is superior to
the welfare of the body and curing it from its diseases, in the same
way as the soul is superior to the body. (Sec. 4.1)

We have already seen how al-​Balḫī and al-​R āzī explicitly planned their
works around the parallel between medicine for body and for soul.
This is less true of the Refinement in its entirety, but Miskawayh does
use the theme to structure the sixth book of his work:

We will discuss in this discourse the cure of the diseases which af-
fect the soul of man and their remedies, as well as the factors and
causes which produce them and from which they originate. For
skilled physicians do not attempt to treat a bodily disease until they
diagnose it and know its origin and cause. (Miskawayh, Refinement,
175, trans. Zurayk)

Notice that in none of these texts is the notion of “medicine for the
soul” presented as a metaphor. Rather, the goal is to combat literal
diseases of the soul.

8 Translation and section numbers from P. Adamson and P. E. Pormann (trans.), The Philosophical
Works of al-​Kindī (Karachi: Oxford University Press, 2012).
 Ar abic Ethical Works 107

Medicine for Bodies and Souls

Why, then, would it make sense to see psychological deficiencies—​

especially ethical ones—​as ailments and to envision a kind of medicine
that treats the soul the way the more familiar kind of medicine treats
the body? First and most obviously, we have the concept of health it-
self as a target of both bodily and psychological medicine. As noted
in the introduction to this book, health is a normative notion. That
might license the immediate inference that, insofar as the soul is in a
good (or even ideal) state, we can think of the soul as “healthy.” After
all, we commonly extend the notion of health to the normative states
of things other than human bodies, speaking for instance of “healthy
trees,” where this does not seem to be a mere metaphor. In the Arabic
tradition, this consideration supported not only a parallel between
“ethical treatment” and medicine but also between political rule
and medicine. In particular, we find al-​Fārābī repeatedly comparing
the care that a good ruler has for his city to the doctor’s care for his
patients.9 So far, though, we seem to have insufficient grounds for the
idea that there is a “medicine” for souls. There are any number of arts
that similarly operate with normative constraints, for instance car-
pentry (compare Plato’s remarks on this art and the “form of Bed” at
Republic 597a–​d). But we do not find our authors saying that there is a
carpentry of the soul or of the city.
Yet more specific parallels can be drawn. One is that medicine,
both for bodies and for souls, has the twofold task of preserving and
restoring health. This is of course a commonplace in medical literature.
It is asserted for instance on the very first page of al-​R āzī’s aforemen-
tioned medical encyclopedia for his patron al-​Manṣūr ibn Ismāʿīl, gov-
ernor of Rayy:

9 See for instance M. Mahdi (ed.), Al-​Fārābī: Kitāb al-​Milla (Beirut: Dār al-​Mashriq, 2001), 56–​
7. A recent PhD has examined this topic in depth: B. El-​Fekkak, “Cosmic Justice in al-​Fārābī’s
Virtuous City: Healing the Medieval Body Politic” (PhD, diss., King’s College, London, 2011).
108 Peter Adamson

The art required for the care (siyāsa) of the body and its preservation
is called “medicine.” It has two parts: regimen (tadbīr) for the healthy
body, so that its health continues, and restoration of the ailing body to
a state of health.10

Al-​Balḫī and Miskawayh explicitly extend the twofold purpose to the

case of medicine for the soul:

In the first treatise (maqāla) of this book, we have dealt with that
which one needs to know and utilize in the regimen (tadbīr) of
benefits for bodies: the preservation of their health, when it is present,
and its restoration, when [health] has been ruined by the incidence of
illnesses and maladies. . . . In this treatise, we intend to give an account
of how to manage benefits for souls, how to keep their faculties in a
good and balanced condition (ʿalā sabīl al-​ṣalāḥ wa-​l-​iʿtidāl), and how
to manage the removal of psychological affections (aʿrāḍ nafsānī) that
befall them. (Al-​Balḫī, Benefits, 269–​70)

As the medicine of bodies is divided primarily into two parts, the first
to preserve health if it is present and the second to restore it if it is ab-
sent, so also we should divide the medicine of souls in this same way,
trying to restore their health if it is missing and proceeding to preserve
it if it is already there. (Miskawayh, Refinement, 176, trans. Zurayk)

The idea of taking steps now to prevent or minimize future psycho-

logical difficulties also dates well back to antiquity. One might think
here, for instance, of the Cyrenaic technique of “pre-​rehearsing”

10 Ḥ. al-​Ṣiddīqī al-​Bakrī (ed.), Abū Bakr al-​R āzī: Al-​Kitāb al-​Manṣūrī fī l-​ṭibb (Kuwait: Maʿhad
al-​Maḫṭūṭāt al-​ʿarabīya, 1987), 17–​18.
 Ar abic Ethical Works 109

possible future pains, a suggestion the Epicureans dismissed as

counterproductive.11
Because both kinds of medicine are future directed and look to the
preservation, not just the restoration, of health, both involve a reg-
imen of recommended habitual behavior.12 In the case of the body,
this would include such things as a certain diet and exercise regime.
It is less obvious what the regimen for the soul might be. Al-​Balḫī
distinguishes between “interior” and “external” remedies applied to
the soul (Benefits 276, 283, 317–​18). An external remedy might be lis-
tening to something calming (277, he presumably means something
like music),13 while an “interior” technique would be choosing “a mo-
ment when the soul is peaceful and at rest” to focus on useful thoughts.
For instance one might think about the inevitability of suffering and
hence the pointlessness of wishing it would never occur (277; also 283,
318). External influences can also involve this kind of consideration,
as when we seek sound advice from others (283, cf. 285, quoted below,
and 318). We will return to this idea that remedies for the soul would
often involve some kind of thought process.
Another substantial parallel between the two types of medicine is
that, in both cases, the healthy state being pursued is defined in terms
of balance (iʿtidāl). As followers of Galen, our Arabic authors, of
course, accepted the idea that bodily health involves a proper balance
of the four humors. The soul too needs balance, in this case between
three elements and not four: reason, spirit, and desire, the three aspects
of soul established by Plato in the Republic and also accepted by Galen.

11 On this see T. O’Keefe, “The Cyrenaics on Pleasure, Happiness, and Future-​Concern,”

Phronesis 47 (2002), 395–​416.
12 The word tadbīr and other words of the same root are used to translate the Greek term δίαιτα,
for instance in the Arabic translation of Galen’s The Dependence of the Soul on the Body. See the
glossaries in H. H. Biesterfeldt, Galens Traktat “Dass die Kräfte der Seele den Mischungen des
Körpers Folgen” in arabischer Übersetzung (Weisbaden: Franz Steiner, 1972).
13 Compare the passage cited by F. Rosenthal, The Classical Heritage in Islam (London: Routledge,
1994), 265–​66, where al-​R āzī is said to have described paintings in baths as having an effect on all
three aspects of the soul. My thanks to Hinrich Biesterfeldt for this reference.
110 Peter Adamson

Galen himself already explained psychological health in terms of the

balance of the three aspects of soul:

The motions caused by the two bestial souls, insofar as they are
imbalanced (ʿalā ġayr iʿtidāl), are unnatural to the human being.
For they are imbalanced, and what is imbalanced departs from the
proper condition of health (ḫāriğ ʿan istiqāmat al-​ṣiḥḥa). (Galen,
On Character Traits, 27)

Al-​Balḫī likewise compares the soul’s health to humoral balance

(Benefits, 276). Al-​R āzī and Miskawayh, meanwhile, base their ethical
reflections explicitly on the tripartite soul.14 Here is al-​R āzī ascribing
to Plato a conception of what he calls “spiritual” medicine, which
strives to confer balance on the soul:

[Plato] holds that man should, by means of bodily medicine,

which is the sort of medicine that is widely recognized (maʿrūf ),
and spiritual medicine, which is achieved by means of proofs and
demonstrations, give equilibrium (taʿdīl, same root as iʿtidāl) to the
actions of these souls, so that they may neither exceed nor fall short
of what is intended. (Spiritual Medicine, 29)

Two caveats should be noted here, though. First, one might see the
notion of “balance” or “harmony” between the three aspects as cor-
responding more narrowly to the virtue of justice rather than to psy-
chological well-​being in general. This would, of course, be close to

14 Al-​R āzī, Spiritual Medicine, 27, Miskawayh, Refinement, 15–​16. Actually, as Miskawayh
notes, it is not clear what terminology to use for the three aspects: he allows that both “souls” and
“powers” would be possible terms (Refinement, 15). Al-​R āzī introduces the division by saying that
Plato recognized three “souls,” and himself frequently speaks of “rational soul,” “desiring soul,”
and so on. I will continue to speak more neutrally of three “aspects.” Of course the question of how
to understand these three aspects in the Platonic text is a much-​d iscussed one. See for instance
J. Moss, “Appearances and Calculations: Plato’s Division of the Soul,” Oxford Studies in Ancient
Philosophy 34 (2008), 35–​68.
 Ar abic Ethical Works 111

the discussion of justice in the Republic. Miskawayh duly equates jus-

tice with the peaceful cooperation (musālama) of the three aspects
(Refinement, 18). A second caveat is that health in the soul is not strictly
speaking “balance,” at least, not in the sense that the three aspects
are equal in strength, the way that the humors might be equally bal-
anced in a healthy body.15 Rather, the rational aspect of soul should
dominate the other two aspects and especially the lowest, desiring or
“bestial” soul. Thus Miskawayh goes on to add that there must be not
only peaceful cooperation but that also the entire soul must capitu-
late (istislām) to the discerning faculty, which belongs to the rational
soul (Refinement, 18). This would be as if health in the body were, for
instance, that blood dominated the other three humors or that heat
dominated cold, which is obviously not the case. One might none-
theless speak of “balance” in the soul (as Galen does) to mean that
the lower parts have their appropriate degree of influence. This would
mean that they still carry out their functions but are completely sub-
ordinated to the rational soul.16
A final reason, and perhaps the best reason, to envision medicine
for souls as well as for bodies is that the cases of soul and body are not
merely parallel. They are causally connected. For, as Galen famously
argues in That the Soul Depends on the Body, the states of the soul de-
pend on those of the body.17 Thus a disease on the side of the body can
lead to a disease on the side of the soul, and vice versa:

15 See further below, in the section called “Particularism,” for a reason why this might be too
simple a conception of bodily health.
16 The goal is certainly not that the lower parts of soul cease entirely to be active. As al-​R āzī points
out, the desiring soul’s function is to help keep the body alive through nutrition. This is reasonable
enough in Platonic terms—​if one had no desire for food, one might starve to death, and Plato him-
self speaks of some desires as “necessary” in this sense (Republic 558d–​e). But we also see here an
assimilation of Plato’s tripartite soul (reason, spirit, desire) to that of Aristotle (reason, animal, veg-
etative), which is also evident in Miskawayh. See further Adamson, “Miskawayh’s Psychology,” 42.
17 One of Galen’s best illustrations of this is drunkenness, where consumption of wine is able to
affect even the workings of the rational soul (Kühn 6.777–​78, 811–​12). Compare al-​R āzī’s polemic
against the evils of excessive drink in Spiritual Medicine, which includes the remark that drinking
can lead to the “loss of reason ( faqd al-​ʿaql)” (72).
112 Peter Adamson

The human being is constituted from his soul and his body,
and one cannot imagine him surviving without the union of
the two . . . when the body ails and suffers, and is affected by
harmful maladies, this hinders the faculties of the soul (in-
cluding understanding ( fahm), knowledge (maʿrifa) and others)
from performing the activity in their [proper] way. (Al-​Balḫī,
Benefits, 273)

As the soul is a divine, incorporeal faculty and as it is, at the same

time, used for a particular constitution (mizāğ ḫāṣṣ) and tied to
it physically and divinely . . . you must realize that each one of
them is dependent upon the other, changing when it changes, be-
coming healthy when it is healthy and ill when it is ill. (Miskawayh,
Refinement, 175, trans. by Zurayk)

This gives us a strong reason to agree that deficiencies on the side of

the soul are literal illnesses. After all such deficiencies result directly
from, and can cause, bodily illnesses. In some cases it might even be
reasonable to say that one and the same illness has manifestations at
both the bodily and psychological level. Indeed al-​Balḫī recognizes
such illnesses. He remarks for instance that the obsessive thoughts
called wasāwis are both a bodily and a psychological malady
(aʿrāḍ, 323).

Objective and Subjective Deficiency

All this gives us strong grounds for the signature idea of Galenic
ethics: medicine contains two parts, one for preserving and restoring
the health of body, the other doing the same for the health of soul.
If that is the case, though, then familiar tensions that arise when
thinking about bodily health—​such as discussed throughout this
book—​will also arise when considering psychological health. One
such tension is between objective and subjective notions of health.
 Ar abic Ethical Works 113

When we think about medicine in its restorative capacity, we typically

imagine a patient who has presented with a complaint—​the doctor’s
goal is to diagnose the source of the patient’s suffering and treat it. But
people who are ill or in bad bodily condition are frequently unaware
of their parlous state. A person of a dissolute lifestyle might have badly
balanced humors, yet think he is doing very well because his life is so
pleasant (until, suddenly, it isn’t). Drawing on Plato, al-​R āzī gives us a
theoretical basis for understanding this phenomenon. In general, we
are not aware of bodily health because it is simply the maintenance of
a natural state, with no defect (Spiritual Medicine, 66). On the other
hand, neither do we necessarily perceive our own defective states, es-
pecially at first—​the slowness of changes from the neutral state makes
it hard to tell that one is gradually becoming, for example, too dry or
simply hungry, and thus occasions no pain even though what is hap-
pening could be harmful. The same is true in the other direction, as
when a wound is healing slowly so that we do not feel pleasure. Only
sudden changes away from or toward the natural state will give rise to
pain and pleasure.18
With respect to the soul, it is perhaps even more obvious that people
are imperfectly aware of their own deficiencies. The same dissolute
person who is unaware that he is unhealthy in body may be quite sat-
isfied with his way of life, unaware that it is vicious and harmful. At
the same time, it is, of course, also common for people to find their
psychological ailments agonizing. This tension accounts for a differ-
ence amongst our works of Galenic ethics. Al-​Balḫī seems to direct
most of his attention to people who have psychological complaints.
For instance, people who are plagued by obsessive thoughts, or by
grief or anxiety, are well aware that they have a problem. Perhaps for
this reason, the closest thing he offers to a definition of psychological

18 For all this see P. Adamson, “Platonic Pleasures in Epicurus and al-​R āzī,” in P. Adamson
(ed.), In the Age of al-​Fārābī: Arabic Philosophy in the Fourth/​Tenth Century (London: Warburg
Institute, 2008), 71–​94.
114 Peter Adamson

health speaks only of the absence of maladies, with the soul being
at rest (Benefits, 275), and not of virtue. One might hesitate, there-
fore, to think of al-​Balḫī’s Benefits as a work about ethics—​it seems
more like the work of an advice columnist, albeit one possessed of
unusual literary sophistication. By contrast, al-​R āzī and Miskawayh
clearly think they are doing ethics. Al-​R āzī is highly judgmental
about people who display such shortcomings as gluttony or frequent
drunkenness—​he’s even hard on people who fidget, as we’ll see
shortly. Miskawayh meanwhile feels no tension in weaving material
from Aristotle’s Ethics into a work with substantial borrowings from
the Galenic ethical tradition.
We can rescue the unity of the genre by reminding ourselves that
ancient ethics, and later the Arabic ethical tradition based on such
Hellenic sources as Galen and Aristotle, are “eudaimonistic.” What is
at stake is the flourishing of the person, in this case the person’s flour-
ishing in respect of her psychological states. This means simply that
the psychological states are as they should be. Just as on the bodily
side, deficient states (that is, failures to flourish) may be subjectively
perceived and cause distress, but they need not. If al-​Balḫī focuses
largely on cases where actual distress has arisen, this is more a matter
of emphasis than a deep difference between his approach and that of
al-​R āzī or Miskawayh. In fact some kinds of maladies covered in his
Benefits, like anger, would not necessarily give rise to complaint on the
part of the sufferer.19 Conversely, al-​R āzī and Miskawayh deal with
problems, such as sadness, that inevitably are bound up with a subjec-
tive experience of suffering. We can therefore say that perceived dis-
tress is a sufficient, but not necessary, condition for needing treatment
by psychological medicine.

19 When he introduces the topic, he says merely that anger leads to harm (aḏā, 293) and not, for
instance, pain.
 Ar abic Ethical Works 115

Particularism

A second tension is the one that will occupy our attention for the rest
of this chapter. Again, it is one that arises in both bodily and psycho-
logical medicine; I will introduce it by considering the bodily case. As
mentioned, health in the body is often defined positively in terms of a
physical “balance.” In this sense, there is a universal notion of health
that describes the ideal state for each and every human. On the other
hand, a familiar claim in ancient medicine is that the ideal healthy
state may vary from one person to another. It may be that your ideal
state involves a higher degree of heat than mine, and even that a given
person’s healthy state differs at certain times of year or depends on the
climate and other factors related to their location. This is why Galen
is so insistent that the expert doctor will tailor his treatment to each
patient he sees.20 Let us call this aspect of Galenic (bodily) medicine
“particularism.”21
To what extent does particularism also apply to psychological
medicine? Might the health of your soul differ from the health of
my soul in significant ways? There are good reasons to expect our
Arabic authors to think so. For one thing, the theme of particu-
larism is very emphatic in Galenic bodily medicine. So it would

20 For an introductory discussion of this see P. van der Eijk, “Therapeutics,” in R. J. Hankinson
(ed.) The Cambridge Companion to Galen (Cambridge: Cambridge University Press, 2008), 283–​
303, especially 286–​88. The possibility of individual variation in the ideal humoral balance is noted
at 298, citing De santitate tuenda 1.1, 6.2, and 1.5, 6.13–​15.
21 Here I should clarify that I am not using the word “particularism” with the sense it often has in
contemporary ethics, namely that moral judgments do not rely on the application of universal prin-
ciples. The notion of “bespoke” medicine I discuss here may seem close to that notion. Our texts do
not, however, seem to rule out the idea that each individual’s healthy state may be a function of the
universal features that describe them—​even if the combination of a given person’s features is, as it
happens, unique. (Thus, one can work out from universal principles that anyone with such-​a nd-​
such symptoms, with such-​a nd-​such dispositions, in such-​a nd-​such a location, needs such-​a nd-​
such treatment. This will be the right treatment for anyone who satisfies all the relevant criteria,
even if in fact there is only one such person.) On contemporary moral particularism see the rele-
vant entry in the online Stanford Encyclopedia: J. Dancy, “Moral Particularism,” in E. N. Zalta
(ed.), The Stanford Encyclopedia of Philosophy, 2013; B. W. Little and M. Little, Moral Particularism
(Oxford: Oxford University Press, 2000).
116 Peter Adamson

rather undermine the parallel our authors want to draw with med-
icine for the soul if there were no grounds for particularism on the
psychological side. Furthermore, at least in Miskawayh’s case, there
is the influence of Aristotle to consider. He famously cautions us
not to expect too much precision in ethics, on the basis that in
practical affairs we deal with particular situations:

The whole account of matters of conduct must be given in outline

and not precisely (τύπῳ καὶ οὐκ ἀκριβῶς), as we said at the very
beginning that the accounts we demand must be in accordance
with the subject-​matter. Matters concerned with conduct and
questions of what is good for us have no fixity (οὐδὲν ἑστηκός),
any more than matters of health. The general account being
of this nature, the account of particular cases (περὶ τῶν καθ᾽
ἕκαστα) is yet more lacking in exactness. (Nicomachean Ethics
2.2, 1104a1–​7)

The variety between particulars includes variation in ethical agents

themselves, something Aristotle makes clear with his famous example
of the outsized diet appropriate to Milo the wrestler (Nicomachean
Ethics, 1106a26–​b4).22
Miskawayh does not fail to recognize this aspect of Aristotle’s
teaching. Miskawayh makes it crystal clear we are dealing here with a
difference in what ethics will mean to different people:

The means of these extremes should be sought separately for each

person. Our own task here is to note the all of these means [be-
tween extremes] and the rules governing them according to the
requirements of our art, and not for each individual (šaḫṣ), for this

22 Translations taken from D. Ross (trans.), Aristotle: the Nicomachean Ethics (Oxford: Oxford
University Press, 2009).
 Ar abic Ethical Works 117

would be impossible. The carpenter, the jeweler, and all the artisans
acquire in their minds rules and principles only, for the carpenter
knows the form of the door and that of the bed and the jeweler the
form of the ring and that of the crown, in the absolute. Then each
of them derives by these laws the individual things which he has in
mind, but he cannot master all the individual things because they
are infinite in number. . . . The art ensures the knowledge of princi-
ples only. (Miskawayh, Refinement, 25–​26, trans. Zurayk, modified,
my emphasis)

This seems to give us both a universal and particular element in ethics,

just as we saw in bodily medicine. For both there will be general rules
or principles, but the application of those principles to individuals will
be, as Aristotle puts it, “inexact.”
Furthermore, both Aristotle and Galen, of course, emphasize that
people vary in terms of their inborn and acquired ethical tendencies,
what Galen calls their “character traits”—​which gives the title to the
work already mentioned several times. In it he remarks:

The praiseworthy states of the human soul are called “virtue,” the
blameworthy states “vice.” These states are divided into two types.
First, those that arise in the soul after the onset of thought, delib-
eration, and discernment (al-​fikr wa-​l-​rawiyya wa-​l-​tamyīz)—​these
are referred to as knowledge, opinion, and judgment. Second, those
that occur in the soul without thought, and these are referred to
as character traits (aḫlāq). Some character traits appear in infants
as soon as they are born, before the time of thought. (Galen, On
Character Traits, 28)

[Some character traits arise] prior to education (taʾaddub). In gen­

eral, none of the activities, affections (ʿawāriḍ), or character traits is
present in any mature human unless it was already present in him
118 Peter Adamson

at the time of his childhood. So it is false that all affections arise

through opinion and thought, for opinion and thought are not af-
fection, but rather either true or false belief. (Galen, On Character
Traits, 30)

This again suggests that psychological medicine might need to tailor

treatments to individual “patients,” bearing in mind tendencies they
may have had since birth.
But we need to be careful here. The last two points just considered
(the one Aristotle illustrates with reference to Milo, and the one Galen
illustrates with reference to babies) would support different kinds of
particularism. Galen is not saying that each individual has a certain
set of ethical predispositions that would be ideal for them, but simply
that individuals vary in their character traits, ideal or not. The ethical
significance of this would seem only to concern the steps one should
take to bring someone closer to the ideal. For instance, there is no need
to train a naturally abstemious person to avoid gluttony, and doing
so could be harmful if it leads them too far in the opposite direction.
Aristotle, by contrast, may at least be taken to say (and Miskawayh
clearly did take him to say) that what is ethically ideal for one person
may differ from the ideal for another person. In light of this we need
to distinguish between two kinds of particularism that could be ap-
propriate to psychological medicine: particularism concerning (1) the
remedy offered, or (2) the goal sought. The analogous distinction in
the physical case would be the difference between saying (1) different
people need different kinds of treatment (e.g., the right drug or diet
for one person may not be right for another person), and (2) different
people will vary in terms of the state that counts for them as “health”
(e.g., I might have an ideal degree of warmth that is different from
yours).
With the exception of Miskawayh’s remark quoted above, it turns
out that there is remarkably little in our Arabic works of Galenic
 Ar abic Ethical Works 119

ethics to support particularism of type (2) regarding the soul. There is

a good reason for this. As we have seen, two of our authors, al-​R āzī and
Miskawayh, think that the health of the soul consists in the rational
soul’s domination over the body. This is not merely a general principle,
but rather a robust conception of the good that does not vary from
person to person. One might suppose that there could nevertheless be
room for type (2) particularism, if one person’s reason should rule his
soul in light of one set of beliefs, while another person should have a
different set of beliefs ruling her soul. But there is an obvious problem
with that: surely we all should have the same beliefs, namely the ones
that are true. The ideal case, then, will not be broadly the same but ex-
actly the same for everyone: it will be for the rational soul to have true
beliefs (or even better, knowledge) and to rule the rest of the soul in
light of those beliefs.
Even here, one could find room for a kind of type (2) particularism,
by suggesting that even if every ideal agent forms only true beliefs,
each agent will have to form beliefs relevant to their own partic-
ular context. For instance I, but not you, am in a position to think,
“I should not eat this almond croissant,” because I am the one in a
position to eat the croissant. This would, I think, be a good way of
reconciling Aristotelian type (2) particularism with the Platonic con-
ception of virtue as the rule of reason. But it is not one we find an-
ywhere in our Arabic texts. As we will see in the next section, they
think that the beliefs that psychological medicine inculcates are gen­
eral ones, and they are intellectualist enough to think that bestowing
health on someone is essentially a matter of inculcating the right
beliefs. Nonetheless, they do give particularism an important place
in their versions of Galenic ethics. It is always type (1) particularism,
that is, particularism with regard to the kind of treatment each person
needs to receive. In the final two sections of the chapter, I will explain
why the treatment needs to be particular, even if the goal is always
the same.
120 Peter Adamson

Cognitive Therapy

A striking feature of these works on Galenic ethics is the extent to

which they describe the soul’s health in purely intellectualist terms.
This is faithful to Galen himself:

When the soul reaches the aim which it seeks, namely the under-
standing (maʿrifa) of things, it is balanced and fine (ḥasana), but
when it misses it, then it is perturbed and imbalanced. Thus the
beauty of soul arises through knowledge, and its ugliness through
ignorance. . . . The soul’s understanding, through which it is fine,
understands the elements from which the body is composed, and
which generate, compose, and augment the affections of the soul.
The discovery of their cures follows on the knowledge of this. Thus
we never see a fine soul that is ill, as we see a very fine body affected
by a severe illness. This cannot be otherwise, given that the knowing
and beautiful soul first of all keeps itself healthy, and only then
takes care of the body, because of its need to use it for its actions.
But the body knows nothing of the essence of its own health, and
cannot preserve it. (Galen, On Character Traits, 43)

Here we finally have an admission that psychological and bodily med-

icine do differ in at least one crucial respect. The body is not under the
soul’s control, the way that the soul is under its own control.23 Rather,
the soul is in charge of seeking the health of both itself and its body,

23 It may seem surprising that Galen, who was famously critical of the Stoic idea that the soul is
rational through and through, should seem to be saying that knowledge is sufficient for good eth-
ical condition. I do not, however, take him to be assuming that acquisition of true beliefs is by itself
sufficient for the subduing of the lower soul. Rather, as we will see later in the paper, both Galen
and his followers in the Arabic tradition think that the rational soul can be hindered if the lower
soul is too powerful, something the Stoics would never have admitted since they didn’t recognize
a non-​rational aspect of the human soul. What Galen is describing here, then, is a soul that is both
knowledgeable and unimpeded by the lower aspects. Evidence for this can be found at Character
Traits 39, where Galen says that someone who has achieved dominance of the rational soul can then
go on to help others through advice and serving as a role model.
 Ar abic Ethical Works 121

albeit that it prioritizes its own health—​as we saw al-​K indī saying
above, the soul’s welfare is simply more important.
In keeping with this, all three of our authors concentrate much of
their attention on persuading the reader (or hypothetical “patient”)
to modify their beliefs. Al-​Balḫī often speaks as if the analogue to
bodily medicine were specifically helping someone to have the right
“thoughts”:

It was the habit of judicious kings to be attended by wise men, who

could cure them of maladies of the soul (aʿrāḍ nafsāniyya) . . . through
advice (waṣāya) and exhortations (mawāʿiẓ). . . .They depended on
[the wise advisors] just as they depended on proficient doctors, who
cured them of maladies of the body, since they knew enough to
realize that they could not do without having both groups simul-
taneously, and that at some point there would be a need to get nour-
ishment and medicine from both. (Al-​Balḫī, Benefits, 285)
We have said above that, just as bodily sicknesses are such as to
be treated by means of bodily cures, so sicknesses of the soul are
treated by means of psychological remedies, either by exhortations
and reminders, or through thoughts ( fikar), through which the
person trains his soul and which he uses as a weapon and imple-
ment for keeping the pains of fears and sorrows away from himself.
(Al-​Balḫī, Benefits, 335–​36)

Similar, albeit more technical, is al-​R āzī’s conception of the process

by which reason subdues the lower parts of the soul. He frequently
speaks of the need to make “thought and deliberation ( fikr and
rawiyya)” lead the way, rather than letting desire push us into action.
For instance:

[The philosophers] offer a proof, based on the very constitution of

man, that it is not constituted for preoccupation with pleasures and
urges, but rather for the use of thought and deliberation ( fikr wa
122 Peter Adamson

rawiyya), given [man’s] weakness concerning this [sc. the pursuit of

pleasure] compared to irrational animals. (Spiritual Medicine, 24)

It’s also worth noting that in a passage quoted above (Spiritual

Medicine, 29), al-​R āzī says (on Plato’s behalf) that medicine for the
soul is “achieved through arguments and proofs (bi-​l-​ḥujaj wa-​l-​
barāhīn).” One might suppose this means only that there are secure
principles for psychological medicine, not that ethical agents are ac-
tually meant to rely on rationally proven beliefs when they deliberate.
But as al-​R āzī says in the opening section of the Spiritual Medicine, it
is reason (ʿaql) and reason alone that leads us to a good life. The intel-
lectualist consequences are spelled out in later passages of the work,
for instance when he remarks that whereas desire pushes us to choose
on the basis of what is agreeable, ʿaql chooses on the basis of argument
(ḥujja, 89). Or again:

Know that the judgment (ḥukm) of reason (al-​ʿaql) that the state of
death is better than that of life is in accordance with [reason’s] con-
viction (iʿtiqād) in the soul, but it can happen that one continues to
follow desire in respect of this. For the difference between desirous
opinion and intellectual opinion is that one chooses, is influenced
by, follows, and adheres to desirous opinion without clear argument
(ḥujja) or evident rationale, but only out of some sort of inclination
(mayl) towards this opinion, and agreement and affection for it in
the soul. Whereas one chooses intellectual opinion through clear
argument and evident rationale, even if the soul finds it hateful and
deviates from it. (Spiritual Medicine, 94)

One might therefore take the Spiritual Medicine to be a long sequence

of “arguments” and “proofs” that will help the rational soul of the
reader to have the right beliefs, which can then give rise to appropriate
actions. Actually, as we’ll see below, this would be to underestimate
the complexity of al-​R āzī’s strategy, but his emphasis on reasoning
 Ar abic Ethical Works 123

does provide us with good grounds to see him as upholding an intel-

lectualist ethics.
That Miskawayh would be no less intellectualist is hardly surprising,
given his broad allegiance to the tradition of late ancient Platonists
like Plotinus. Like al-​R āzī, he defines man’s perfection in terms of
“discrimination and deliberation” (tamyīz and rawiyya, at Refinement,
12). Furthermore, he seems to put a high degree of trust in the power of
belief and knowledge to guarantee good action:

When a person realizes (ʿalama) that [passions and lusts] are not
virtues but vices, he will avoid them and be loathe to be known
for them. But if he believes (ẓanna) that they are virtues, he will
pursue them and become accustomed to them (ṣārat la-​hu ʿāda).
(Miskawayh, Refinement, 10, trans. Zurayk, my emphasis)

Wisdom is the virtue of the rational and discerning soul. It consists

in the knowledge of all existents qua existing, or if we wish to say so,
the knowledge of things divine and human. This knowledge bears
the fruit of understanding which of the possible actions should
be performed and which should not be. . . . In order to grasp the
essences of these divisions [sc. of the virtues], we must have recourse
to their definitions, for it is by the knowledge of definitions that
we understand the essences of things sought, which are always con-
stant. This is demonstrative knowledge which never changes and is
not impaired by doubt in any way, for just as the virtues which are
in essence virtues do not become, under any condition, other than
virtues, so also is the knowledge of them [always the same and never
changing]. (Miskawayh, Refinement, 18–​19, trans. Zurayk)

How can he say these things, though, given that we saw him following
Aristotle in acknowledging a gap between universal knowledge and
the indefinite multiplicity of particular cases? As it turns out, he can
be remarkably insouciant about this difficulty:
124 Peter Adamson

Man attains his perfection and is able to perform his own distinc-
tive activity when he knows all the existents. By this I mean that
he knows their universals and their definitions which are their
essences, not their accidents or their properties which render them
infinite [in number]. For if you know the universals of existents,
you come also to know their particulars in a certain way, since
particulars do not depart from their universals. (Miskawayh,
Refinement, 41, trans. Zurayk)

This seems to take most of the wind out of the sails of type (2) partic-
ularism: Miskawayh is the only one of our three authors to recognize
the problem of applying reason to particulars in the ethical sphere, and
now it looks as if he doesn’t think it is much of a problem after all.24

Curing Sorrow

To illustrate how the intellectualism of these works is carried out in

practice, I would like to consider a specific psychological “ailment,”
namely sorrow or grief (ḥuzn, ġamm). This case will incidentally allow
us to see the close textual relationship between all four texts. The
founding text for the treatment of sorrow in the Arabic tradition is, of
course, the aforementioned On Dispelling Sorrow by al-​K indī. It puts
forward many considerations about why one should never succumb to
sorrow, providing everything from stringent philosophical argument
to memorable anecdotes about Alexander the Great and Socrates. But
one particularly central idea is the following one:

Sensible things which we love and seek out, can be interrupted

by anyone and seized by any power. It is impossible to protect

24 For an interesting and more detailed discussion of the relation between intellect and
particulars, see Miskawayh’s On Soul and Intellect, trans. in Pormann and Adamson, “More than
Heat and Light,” sec. 1.
 Ar abic Ethical Works 125

them, and one cannot be sure that they do not perish, fade away,
or change. . . . If we want something corruptible to be not incor-
ruptible . . . then we want from nature something which is not nat-
ural. He who wants something unnatural wants something which
does not exist. Someone who wants what does not exist will seek in
vain. And he who seeks in vain, will be distressed. (Al-​K indī, On
Dispelling Sorrows 1:4–​6, trans. Adamson and Pormann)

Al-​K indī wants us to see that if we make our happiness dependent on

the continuation of perishable things, we are guaranteeing our future
unhappiness. This is a familiar point from ancient ethics, common
to both Stoics like Epictetus, who inferred that we should value only
our own will, and Platonists, who inferred (as al-​K indī does) that we
should instead value eternal, intelligible things. But there is a more
distinctive idea at work here too: wanting the permanence of imper-
manent things is incoherent, since one is both valuing the nature of
what one wants and rejecting that nature insofar as it guarantees tran-
sience. This would be like wanting to have a bath without wanting to
get wet.
Whatever we might make of this argument, it was apparently a big
success with later readers. We find it in all three works I discuss in this
chapter:

Another [remedy] is to think about the constitution and construc-

tion of this world (al-​dunya): that it does not belong to anyone to
spend their whole life having what they want and love, so that they
would never lose what they love or miss out on what they seek. This
being so, everything he loves and any felicity that does come to him
is an advantage ( fāʾid) and luxury (ġinya). (Al-​Balḫī, Benefits, 319)
When a reasonable person examines and considers that in this
world which is subject to generation and corruption, and sees that
their elements change and flow with no stability or permanence
as individuals—​rather they must all vanish . . . he should reckon
126 Peter Adamson

the period of their continuation to be a bonus ( faḍl) for him,

and his savoring of them a profit (ribḥ), since they inevitably dis-
appear and cease to be. When someone longs for the permanent
continuation of [these things subject to corruption], he wants what
cannot possibly exist. But someone who longs for what cannot exist
thereby brings grief upon himself, and turns away from his reason
towards his desire. Furthermore, grief and sorrow do not last con-
cerning things that are unnecessary for continued life, because they
are quickly replaced and come around again. (Al-​R āzī, Spiritual
Medicine, 67–​68)
If [someone] knows that in this world of generation and corruption
nothing is stable or continuous—​there is stability and continuity
only in the world of the intellect—​then he will not crave for what is
absurd, nor pursue it. If he does not pursue it, he will not feel sorrow
in missing out on what he desires. (Miskawayh, Refinement, 217)

We know that Miskawayh was acquainted with al-​K indī’s epistle

since, as mentioned, he quotes from it at the end of the Refinement.
It stands to reason that al-​Balḫī was also familiar with his master al-​
Kindī’s writings. Al-​R āzī presents more of a challenge when it comes
to determining historical influence; here I will content myself with
noting the striking similarities between the passages just quoted from
him and al-​Balḫī (especially the idea that the term of survival for any
worldly good is a kind of “profit”).
But the main point is not one about historical influence. It is that
the repeated use of this argument points to a shared intellectualism.
All our authors seem to presuppose that one can dispel or avoid sorrow
about worldly things simply by realizing the implications of the perish-
ability of those things. To put this another way, insofar as one is rational,
one will not experience such sorrow. For, as al-​K indī already pointed
out, the sorrow implicitly involves something “absurd”: wanting the
 Ar abic Ethical Works 127

perishable to be imperishable. This is stated explicitly in Miskawayh,

and it seems to be the same reason that al-​R āzī considers sorrow an
abandonment of reason (the sorrowful person “wants what cannot
possibly exist”). The obvious rejoinder to this whole line of thought
is that one could well understand the impossibility of a state of af-
fairs and still wish it would come about. One might wish that a dead
loved one would come back to life, for instance, without being under
any illusions about the impossibility of such an event. More gener-
ally, it would seem to be simply false that laying out arguments—​no
matter how compelling—​is sufficient to change humans’ desires and
behaviors.
Galen acknowledges this in On Passions of the Soul, complaining that
he has often persuaded people with good advice, only to see them lapse
into their old ways thereafter (ed. Kühn, 5.52).25 Of course, someone
who is in the business of writing a book of ethical advice is not apt to
stress the inefficacy of ethical advice. But al-​R āzī, at least, displays a
rather subtle approach to this problem, by mentioning “second-​best”
considerations that might have more impact on a vicious person than
more perspicuous arguments. For instance, despite believing that
reason leads us to accept the soul’s immortality, he gives a battery of
arguments against the fear of death that would work for someone who
thinks they will cease to exist upon the death of the body (Spiritual
Medicine, 93).26 Similarly, he at one point recalls trying to persuade a
glutton that overeating will ultimately cause them pain greater than
the pleasure they take in eating. This is not the real reason to avoid
overeating (the real reason is that it involves domination of desire over
the rational soul). But it has a better chance of being effective than the
real reason:

25 At On Character Traits, 31, he similarly remarks that judgments that arise from habit and nature
are difficult to eliminate merely through rational argument.
26 By contrast Miskawayh (at Refinement, 209) simply says that the fear of death is occasioned by
false belief.
128 Peter Adamson

This and other such remarks are of more benefit to someone who
has not engaged in philosophical training (riyāḍāt al-​falsafa) than
proofs (ḥujaj) built on philosophical foundations (uṣūl falsafiyya).
(Al-​R āzī, Spiritual Medicine, 71)

Particularism and the Lower Soul

Obviously, then, the intellectualist account cannot be the whole story.

Rational arguments, naturally enough, can affect only the rational
soul—​the lower soul and especially the desiring soul remain unmoved
by them. Galen says as much:

The vegetative soul is not susceptible to being educated (taʾdīb) nor

does it steer a straight course through training and discernment
(tamyīz); it is improved and subdued only through taming (qamʿ).
(Galen, On Character Traits 42)

In this he is followed by Miskawayh who likewise says that the “bes-

tial” soul is not “susceptible to education (adab)” (Refinement, 54). In
a sense this leaves the intellectualism of our authors standing: psy-
chological health will still be understood as the correct functioning
of reason. It is just that this correct functioning can be undermined
by the contrary impulses of the lower soul. Again, Galen makes this
particularly clear:

Since errors arise from false opinion, while affections arise from
irrational impulse (τὰ μὲν ἁμαρτήματα διὰ [τὴν] ψευδῆ δόξαν
γίγνονται, τὰ δὲ πάθη διά τιν’ ἄλογον ὁρμήν), I judged that one
should first (πρότερον) free oneself from the affections. For we
are probably led by these too somehow into false opinion. (Galen,
Passions of the Soul, ed. Kühn, 5.7, trans. Singer, modified, my
emphasis)
 Ar abic Ethical Works 129

Notice that Galen already makes the crucial inference: even if health
lies in knowledge, as we have seen him claim, health presupposes more
than straightening out one’s beliefs. It also demands an antecedent
process, in which the lower soul is brought to heel so that it cannot
interfere with reason’s functioning.
There are two potential sources of trouble in the lower soul. First, a
person may simply be born with bad tendencies (e.g., toward anger or a
certain kind of desire). Second, regardless of their innate dispositions,
they may have been habituated to allow their lower soul too much free
rein. Only once these sources of vice are eliminated can we be sure that
true beliefs will lead to happiness. Meanwhile, good nature and habit-
uation will be of no avail if one’s beliefs are false. Galen lays this out in
a crucial methodological remark:

In this book I base all that I investigate on what is evident in

small children, in order more easily to discriminate the purely bes-
tial motions from what has some admixture of the opinions and
doctrines that belong to the rational soul . . . Among people, some
live their life with what is naturally appropriate for them, avoiding
what is not, without deliberation (rawiyya). Others apply deliber-
ation and thought to the natures of things, so as to form the view
that the appropriate thing is to follow what is naturally appro-
priate, and avoid what is not, or the other way around. So develops
the way of life (sīra) of each of them, from that moment on, and for
the rest of their lives they are led to actions through natural incli-
nation and by acquired belief. . . . You must consider those who are
past the age of childhood, regarding their actions and the causes
of those actions. You will find that the cause of some is character
(ḫulq) and of others belief (raʾy). That which derives from nature or
habit is caused by character, but that which derives from thought
and consideration is caused by belief . . . The character trait comes
to be through constant habit. (Galen, On Character Traits, 30)
130 Peter Adamson

This passage confirms a threefold analysis of the potential sources of

vice: in the non-​rational soul, innate dispositions and habit form our
“character.” Good character is a necessary condition for happiness,
simply because bad character will undermine the rational soul. But
it is not a sufficient condition, since even a person of good character
will need to have true beliefs (or ideally knowledge), such as the beliefs
propounded by Galen and the authors of our Arabic works in Galenic
ethics.
The slipperiness of this distinction may account for the fact that
our authors seem torn between two accounts of virtue. We have
seen both Galen and Miskawayh defining virtue (what Galen calls
the “beauty” or “fineness” of the soul in a passage cited above, On
Character Traits, 43) in purely intellectualist terms as true belief,
knowledge, or wisdom. But virtue is frequently explained in terms of
the balance of the soul or taming the irrational soul. The soul’s health
is likewise identified with such a balance, or even, as in al-​Balḫī, in
terms of the mere absence of psychological maladies. Strictly speaking
though, the absence of such maladies and/​or domination by the ir-
rational soul are not constitutive of virtue, but the mere removal of
an impediment. Still, if we want a formula that captures both the
positive and negative sides of the conception of psychological health
that runs through this Galenic tradition, this would be not be hard
to give. We could say that it is the good functioning of reason, both
in terms of its domination of (i.e., it is not being undermined by) the
lower soul and in terms of its having knowledge. This is, perhaps,
why al-​R āzī begins his Spiritual Medicine with a passage in praise of
the usefulness and importance of reason (ʿaql) in human life.
Meanwhile, the capacity of the lower soul to undermine reason
gives us a place for particularism in Galenic ethics. For even if, as
I have argued, the positive functioning of the rational soul is the
same for everyone (that is, we should all have the same beliefs—​e .g.,
that worldly things are not to be valued, or death not to be feared),
 Ar abic Ethical Works 131

the threat posed to reason by the lower soul will vary from person to
person. Since mere rational argument will not work on the desiring
soul (as we have seen it is immune to “education,” adab), we need an-
other strategy: habituation. This provides Miskawayh with the op-
portunity to integrate Aristotelian with Galenic ethics. He defines
character (ḫulq) as “a state of the soul which causes it to perform
its actions without thought or deliberation” (Refinement, 31, trans.
Zurayk) that can come from two sources. On the one hand it may
arise “naturally, on the basis of [bodily] mixture (mizāğ),” on the
other hand through habit (ʿāda). This gives us two reasons why eth-
ical treatment needs to be tailored to each individual person: the
variation in their bodies, and the variation in their preexisting ha-
bitual dispositions.
I will return to the issue of bodily mixture in the next section; now
let us briefly consider the point about habituation. The role of habit
in ethical life provides a confirmation of the idea that medicine for
souls, like medicine for bodies, has to do with a good “regime”—​
for instance, one that will habituate the soul to restrain its desires.
A good example is the way we fear what is unfamiliar, a point made
by Galen (On Character Traits, 32–​33) and echoed by Balḫī (fear
results both from being “ignorant of the nature (anniyya) of things”
and lacking “experience (tağriba) of the senses”—​one might see
here an invocation of both rational judgments and non-​rational ha-
bituation). Miskawayh does something especially interesting with
the theme of habituation, by repeatedly associating it with the law
(šarīʿa) of Islam:

It is the law that sets the youth on the straight path, habituates
them to admirable actions, and prepares their souls to re-
ceive wisdom, to seek the virtues, and to reach human hap-
piness through sound thought and upright reasoning (qiyās).
(Miskawayh, Refinement, 35)
132 Peter Adamson

Notice again the way that habituation, which reforms the lower soul,
is a first stage that removes obstacles that could hinder the acquisition
of wisdom.27
It should be noted that this process of habituation concerns espe-
cially the desiring soul. The role of the spirit is more complicated.
On the one hand, this aspect of the soul should certainly not be
allowed to dominate. Anger is one of the psychological maladies
discussed in our texts and can obstruct the development of reason.28
On the other hand, as Plato said and is especially emphasized by al-​
Rāzī, one can use the spirit’s sense of indignation against one’s own
desiring soul. He tells a story about a king who is stung by criticism
of his fidgeting:

This man’s rational soul influenced his irascible soul, by means of

rage and haughtiness, so that resolve became vigorous and secure
in his rational soul, such that it exercised a strong influence on him
and became a reminder, making him attentive whenever he started
to become neglectful. Upon my life, the irascible soul was made
solely in order to help reason against the desiring soul. (Al-​R āzī,
Spiritual Medicine, 78)

This is a reminder that the goal of “balance” in the soul is not to

make the lower souls completely inert or ineffective. Rather, we
need only train the lower souls not to obstruct reason. In the case
of the spirit, the well-​trained lower soul can be positive help to
reason.

27 Cf. Refinement, 49, 129. In the latter passage he even says that the best case scenario is being
exposed to the law in childhood and then studying philosophy, and finding it to agree with that to
which one has been “previously habituated.”
28 Miskawayh, Refinement, 196, 205; cf. Balḫī, Benefits, 295 which speaks of waiting for a restful
moment to combat anger with thought, fikr.
 Ar abic Ethical Works 133

Particularism and Bodily Influence

Finally let us consider the second cause of particular ethical traits,

which is the human’s underlying physical state. Al-​Balḫī frequently
invokes “nature” to explain differences between people’s souls, saying
for instance that people may be “by nature (bi-​ṭibāʿihī)” prone to
anger or easily frightened “because of a delicate nature (riqqat al-​ṭabʿ)
and quickly changing soul” (Benefits, 293–​94, 306). A particularly
illuminating passage on this reads:

Each person is not affected by [psychic maladies, aʿrāḍ] to the same

extent, for they differ in terms of which maladies befall them. This
is because each of them takes on [maladies] in accordance with his
bodily mixture (mizāğ), and how strong or weak is his basic compo-
sition. Some are quick to anger, while others come to anger slowly.
Similarly, in some people there is much fear and anxiety about what
is frightful, while others are steadfast and composed. Similarly
what applies to (aḥkām) women and children and those who have
weak natures (ṭabāʾiʿ), is different from what applies to strong men,
with regard to the extent to which each of the [maladies] affects
them. (Al-​Balḫī, Benefits, 271)

The relevance of “bodily mixture” is linked to the fact that we share

ethical dispositions with certain animals (e.g., Benefits, 338, regarding
the trait of sociability). This is probably based on Galen’s consideration
of children and animals at such passages as On Passions of the Soul (ed.
Kühn, 5.38–​40). But more generally the influence of mixture is estab-
lished in Galen’s treatise That the Soul Depends on the Body, which of
course makes a powerful case that ethical traits and other psycholog-
ical states are at least partially caused by bodily states.
Again, Miskawayh finds an opportunity here to harmonize Galen
with Aristotle, since Aristotle famously says that anger is associated
with the boiling of blood around the heart (On the Soul, 403a31).
134 Peter Adamson

Miskawayh repeats this assertion and then remarks, “people differ

in this respect according to bodily mixture,” (Refinement, 193–​94).
Similarly al-​Balḫī says that obsessive thoughts are caused by an excess
of bile (mirra).29 The importance of mixture also explains why climate
is an important influence on character (Miskawayh, Refinement, 47,
175). This may be linked to Hippocratic ideas about climate, but the
main source for this in Arabic was probably Ptolemy,30 as used early
on by al-​K indī.31 Finally, it should be noted that just as the body can
affect the soul, so the soul can affect the body and its mixture. Thus
al-​R āzī remarks that envy causes “prolonged sadness (ḥuzn), worry
(hamm), and obsessive thoughts ( fikar). Upon the incidence of these
symptoms in the soul, [the body] undergoes prolonged sleeplessness
and bad diet, which are followed by poor coloring, bad appearance,
and the disruption of the [humoral] mixture” (Spiritual Medicine, 51).
As al-​Balḫī remarks, “the soul of every living thing is powerfully dis-
posed towards the body in which it resides, and has a harmony with
it” (Benefits, 353).

Conclusion

The upshot of all this is that psychological medicine, just as much as

bodily medicine, must take account of the particular characteristics
of each “patient.” Each of us is born with certain natural tendencies
caused by our bodies, and these tendencies are then modified through
habit (and other factors that affect the mixture itself, like diet). The

29 At Benefits, 344 he mentions an alternative possible cause, namely a demon (šayṭān)—​here one
might think of Christian ascetic literature such as Evagrius, but the idea is also attested in the
ḥadīth. At 345–​46 he again invokes bodily mixture while discussing obsessive thoughts.
30 Tetrabiblos 2.2.
31 See On the Proximate Agent Cause of Generation and Corruption, sec. 7, in Adamson and
Pormann (trans.), The Philosophical Works of al-​Kindī. Al-​K indī here alludes to the Galenic claim
that the states of soul depend on those of the body, showing that he realizes the Galenic theory can
explain the phenomena mentioned by Ptolemy (that climate has an effect on things like hair, as
well as psychological traits).
 Ar abic Ethical Works 135

advice, anecdotes, and arguments gathered in Arabic works like the

ones we have surveyed will not, then, work equally well on everyone.
Someone who really wants to ensure their psychological health should
not only read such books but also seek individual advice tailored to
their needs. This is perhaps why Galen recommends that we call on the
services of a friend to criticize our particular shortcomings.32 Though
this outside perspective can be useful, ultimately all of us must, to
some extent, be our own doctors.33 For this, if for no other reason, if
you want to be happy, you must know yourself.34

32 Passions of the Soul, ed. Kühn, 5.9–​10; cf. al-​R āzī who explicitly refers to Galen on this topic at
Spiritual Medicine, 35, and Miskawayh who also knows Galen’s discussion and points out that an
enemy would be better for this job than a friend (Refinement, 189).
33 Cf. al-​Balḫī’s contrast of external and interior medicine, discussed above.
34 This paper was written with the support of the Leverhulme Trust, which is here gratefully
acknowledged.
Reflection
The R ationa lit y of Medieva l Leechbooks
Richard Scott Nokes
p

The very word “leech” for a medieval physician sounds

romantic, in the way that practices from the past can seem
exotic and alien. I must admit, that even after years of
studying medieval Anglo-​Saxon medical books, the first time
I entered the British Library manuscript room to examine
Bald’s Leechbook, I had the sensation of being involved in
some occult activity, discovering arcane mysteries from
ancient texts. The room was lit with electric lights, not
candles, appointed with computers, not mystical symbols,
and scholarly dress tended toward jackets and ties, not robes
and pointy hats. Yet I couldn’t help feeling as though I were
in some horror movie, in which uttering an incantation
out loud could unleash an unspeakable curse. Of course,
my fantasies were an example of our modern prejudices,
not a representation of the reality of the Middle Ages. Our
romantic ideas about the medievals obscure the truth that
medicine has always largely been a pragmatic affair. While
the Leechbook claims that afflictions in the natural world
occasionally have supernatural causes, the treatment nearly
always privileges the natural.
The Leechbook is actually three different medical texts that have
been bound together into a single manuscript (Royal 12.D.xvii),

136
 Medieval Leechbooks 137

containing hundreds of remedies, transmitted over several

centuries. The first two sections (Leechbook I and II) are commonly
called Bald’s Leechbook, because a colophon in the manuscript lets
us know that “Bald is the owner of this book, which he ordered
Cild to write.” The third book is generally just called Leechbook
III and contains much material duplicating what we find in the
previous two books, suggesting it had a history of independent
transmission before settling into its home in Bald’s Leechbook.
The perennial debate regarding the contents of the Leechbook
and similar medieval texts is to how rational or irrational they
are, and whether they are properly considered magic, medicine,
religion, or some amalgam of all those categories. One of the most
influential works of scholarship on these texts, J. H. G. Grattan
and Charles Singer’s book Anglo-​Saxon Magic and Medicine, marks
this ambiguity in its title.1 Grattan and Singer are not, however,
ambiguous regarding the rationality of these texts, famously
writing:

Surveying the mass of folly and credulity that makes up the Anglo-​
Saxon leechdoms, it may be asked, “Is there any rational element
here? Is the material based on anything that we may reasonably de-
scribe as experience?” The answer to both questions must be, “very
little.”2

At the opposite end of the spectrum is the article, “A Re-​

Assessment of the Efficacy of Anglo-​Saxon Medicine.”3 In an
act of scholarly jujitsu, the authors demolish the assertions by
Godfrid Storms regarding the magical elements of a remedy by

1 J. G. H. Grattan and C. Singer, Anglo-​Saxon Magic and Medicine: Illustrated Specially from the
Semi-​Pagan Text Lacnunga (London: Oxford University Press, 1952).
2 Grattan and Singer, Anglo-​Saxon Magic and Medicine, 92.
3 B. Brennessel, M. Drout, and R. Gravel, “A Reassessment of the Efficacy of Anglo-​Saxon
Medicine,” Anglo-​Saxon England 34 (2005), 183–​95.
138 Richard Scott Nokes

experimentally testing the salve prescribed and demonstrating

that it actually worked.4 Of course, most scholars fall between
these two poles; some considering remedies with incantations as
magical charms, and some considering remedies with exclusively
natural elements as medicine. Still others diminish the distinctions
between magic, medicine, and religion, as Karen Jolly does in
her book Popular Religion in Late Saxon England.5 But all the
debate regarding the rational/​irrational and medicine/​magic
has distracted from the fundamentally pragmatic nature of the
Leechbook. Medicine is, by its very nature, a practical affair dealing
with real human needs, needs that have not really changed in
millennia. Although the treatments for ailments and broken limbs
may have developed over time, the human experience of breaking
a limb today is basically the same as a broken limb 5,000 years
ago . . . or in this case, 1,000 years ago.
Like many other ancient medical manuals, the Leechbooks are
organized in a roughly head-​to-​toe fashion: Leechbook I focusing
on exterior ailments, and Leechbook II focusing on internal
ailments. Some other medical manuals, such as the Old English
Herbarium and Medicina de Quadrupedibus, are organized
according to what we might call the “active ingredient” of the
remedy—​herbal ingredients in the former, and animal ingredients
in the latter. We do not find, say, sections on ailments that are
caused by being elfshot (pierced by the tiny, invisible arrows of
supernatural beings) or by witchcraft. Instead, they are organized
entirely according to their physical elements. Nor is this surprising.
One would presumably seek the help of a leech for a specific
affliction, some particular symptom. When the leech Bald was
looking at a patient, although he might have wondered whether

4 G. Storms, Anglo-​Saxon Magic (Halle: Jijhoff, 1948).

5 K. L. Jolly, Popular Religion in Late Saxon England: Elf Charms in Context (Chapel
Hill: University of North Carolina Press, 1996).
 Medieval Leechbooks 139

the illness was caused by an unbalance of humors, or witches, or

elves, doubtless his primary thought was, “This man is feverish and
vomiting. How can I heal him?” When using any of these books,
the medieval leech was searching for a way to heal the afflicted.
Modern scholars use the Leechbooks differently. We are looking
for a window on the past, and generally more interested in the
ways medieval medical practice differed from modern practice.
As a result we tend to focus on the strange and exotic; scholarship
becomes strongly biased toward novelty. A good example of
this bias is the dozen-​or-​so extant Anglo-​Saxon charm texts.
These texts are widely known and much studied by medieval
scholars, who have been drawn by their magical-​sounding
incantations. In my experience, scholars are often unaware that
any other remedies even existed, let alone that volumes and
volumes of remedies are extant. In no way are these charm texts
representative, in terms of either content or number. Yet they
are the first texts that spring to mind when we hear the word
“leechbook.”
Still, we should not ignore the supernatural elements of medieval
medicine. Although the priorities of the remedies found in the
Leechbooks are pragmatic, behind the practical treatments there is
clearly an understanding that supernatural forces must play some
part in some illnesses. There is a simple reason why the Leechbooks
do not focus on these forces: what, in the end, could be done about
them beyond entreating God for help? Instead, the Leechbooks
focus on what can actually be done by the leech to aid the afflicted.
For that reason, the dichotomy between “rational” medieval
herbal remedies and “irrational” medieval charms and prayers
is a false one. As modern scholars, we remove ourselves from
the very function of these remedies with a set of wildly foolish
anachronistic assumptions: if the leech believed that an illness was
spread by invisible creatures called “elves,” that leech was bound by
irrational superstition. If the leech had only believed that an illness
140 Richard Scott Nokes

was spread by invisible creatures called “microbes,” that leech

would have been rational and wise.
For the medieval leech, focusing on elves would be irrational,
not because belief in elves is superstitious, but because the patient
has come to the leech for a cure. The rational approach is to affect
a cure for the ailment, not to offer the suffering patient a thesis
on the potential causes. So, for example, with the charm “For
Waterelf Disease,” found in Leechbook III, the remedy opens, “If a
man has waterelf disease, then his fingernails will be dark and his
eyes teary and he will look down . . . ” This is then followed by an
herbal remedy (mixed in ale and holy water), and an incantation
for the leech to sing three times. A modern scholar’s focus on elves,
holy water, and incantations cause us to see this as irrational, but
it is entirely rational and pragmatic. After naming the disease, the
remedy immediately lists the symptoms, followed by a cure.
In The Greeks and the Irrational, E. R. Dodds describes an
encounter with a young man who remarks that he is unmoved by
Greek art because “it’s all so terribly rational, if you know what
I mean.”6 By contrast, modern scholars frequently dismiss medieval
science as terribly irrational. Yet the remedies labeled “irrational”
by modern scholars were seen as a bridge between the physical
and supernatural worlds. While the medieval leech certainly
acknowledged the power of supernatural forces, he and his patients
still had to dwell in the natural world. Given this reality, it speaks
poorly of modern scholars that we have so little studied the efficacy
of the remedies in the medieval leechbooks. Instead, we tend to
dismiss them as pseudo-​scientific, because on rare occasions they
blame illnesses on supernatural forces. We miss our opportunity to
cross the bridge offered by these charms.

6 E. R. Dodds, The Greeks and the Irrational (Berkeley: University of California Press, 1951), 1.
 CH A PT ER FI V E

Health in the Renaissance

Guido Giglioni

It will not be out of place, at the beginning of this chapter, to offer a few
introductory remarks on the Latin terminology of health. Although
the centuries between the Middle Ages and the early modern period
saw the increased use of national vernaculars in science, the language
of health remained heavily indebted to the original Latin matrix, all
the more so since during the late Middle Ages and throughout the
Renaissance, Greek and Arabic sources had become available in Latin
translations and led to a wealth of linguistic solutions concerning the
terminology of health. The Latin word salus included the meanings
of “health,” “safety,” and “salvation.” As such, it was a word laden
with medical, political, and religious connotations. For instance,
dwelling on the relationship between health and salvation, Petrarch
(1304–​1374) brought into sharper focus the root of salvation (salutifera
radix) rediscovered through a Platonic meditation on death.1 Pietro

1 E. Carrara (ed.), “Petrarch: Secretum,” in G. Martellotti et al. (eds), Petrarch: Prose

(Milan: Ricciardi, 1955), 30.

141
142 Guido Giglioni

Pomponazzi (1462–​1525), to give another example, underlined the po-

litical sense of sanitas, when in his De immortalitate animae he referred
to the Platonic and Aristotelian view of the statesman as the physician
of the souls, concerned with the right behavior of his people, and not
with their knowledge or culture.2 As for the strictly medical meanings
of salus, sanitas, and valetudo, the latitude of health (discussed later)
was ample, for doctors and laymen were fully aware that one could
have good or bad health, undergo various degrees of chronic dysfunc-
tion, and oscillate between states of valetudinarian and hypochon-
driac impairment.3
In what follows, I examine the principal changes that the idea of
health underwent during the Renaissance (spanning, roughly, from
the second half of the fourteenth century to the beginning of the seven-
teenth). The guiding thread in my analysis of the interrelated concepts
of soundness, safety, and salvation will be provided by the prophy-
lactic framework of the so-​called six non-​naturals (environmental
conditions, nutrition, physical exercise, evacuations, sleeping habits,
and emotions), that is, those factors that, placed at the juncture of both
nature and culture, had been regarded, since antiquity, as capable of
affecting human health in crucial ways. Furthermore, because of their
epistemological and methodological flexibility, the six non-​naturals
have the advantage of bringing to the fore the many intersections be-
tween the physical, social, and political spheres of human experience.
For this reason, Renaissance hygiene can be seen as the ideal vantage
point to investigate the relationships between individual bodies and
the body politic; and the interplay of bodily, mental, and spiritual
conditions in the definition of well-​being; not to mention the many
bio-​ethical questions related to such issues as good life, longevity, and

2 G. Morra (ed.), P. Pomponazzi: Tractatus de immortalitate animae (Bologna: Nanni and

Fiammenghi, 1954), 186–​88.
3 On medical Latin in the early modern period, see G. Giglioni, “Medicine,” in P. Ford, J.
Bloemendal, and C. Fantazzi (eds), Brill’s Encyclopaedia of the Neo-​Latin World (Macropaedia)
(Leiden: Brill, 2014), 679–​90.
 The Renaissance 143

vitality. I refer to a variety of authors and sources, but three names

in particular stand out: Marsilio Ficino (1433–​1499), Alvise Cornaro
(1484–​1566), and Girolamo Cardano (1501–​1576). Ficino, a physi-
cian and a priest known for his recovery and reinterpretation of the
Platonic tradition, also wrote one of the most popular texts of psycho-
somatic prophylaxis in the early modern period. Cornaro, a layman,
was the author of a bestselling guide to healthy life in the Renaissance,
the Discorsi intorno alla vita sobria (Discourses about Sober Life), in
which he argued that everyone could lead a healthy life without the
need to resort to physicians and medicines.4 Cardano, finally, was a
professor of medicine at the universities of Pavia and Bologna and a
renowned practitioner. He wrote an important manual of hygiene, De
sanitate tuenda (How to Preserve One’s Health, 1560), where, as we will
see, he scrutinized the matter of a healthy life (salubritatis materia)
and its natural and cultural implications.

The Historical Background

How Renaissance people perceived the vicissitudes of their health,

both at a learned and a popular level, was marked by a number of signif-
icant variables. Here I mention the new appreciation of Galen’s works,
a remarkable progress in anatomical techniques and discoveries, the
spread of new epidemic diseases, and a distinctively antimedicalizing
attitude among humanist writers.
At the end of the Middle Ages, while commenting on Galen’s
influential definition of medicine from his Ars medica (Medical
Art) as “knowledge of things healthy, unhealthy and which are nei-
ther healthy, nor unhealthy (scientia salubrium, et insalubrium, et
neutrorum),”5 scholastic doctors sparked an intense debate over the

4 In A. Di Benedetto (ed.), Prose di Giovanni della Casa e altri trattatisti cinquecenteschi del
comportamento (Turin: UTET, 1970), 355–​420.
5 K. G. Kühn (ed.), Galen: Claudii Galeni Opera omnia. 20 vols (Leipzig: Knobloch, 1821–​33),
vol. 1, 307–​8.
144 Guido Giglioni

categories of health (salubre), illness (morbosum), and the interme-

diate condition known as “neutrality” (neutrum).6 In the course of the
sixteenth century, especially after the Aldine presses had issued the
1525 Editio princeps of Galen’s works, a more radical and philologically
more sophisticated approach to his oeuvre—​especially to such influ-
ential treatises as Quod animi mores corporis temperamenta sequantur
(The Habits of the Minds Follow the Temperaments of the Body) and
De placitis Hippocratis et Platonis (The Opinions of Hippocrates and
Plato)—​resulted in successive waves of naturalism of a distinctively
medical flavor. The two best known cases are that of the Spanish physi-
cian Juan Huarte de San Juan (c. 1530–​1592), whose Examen de ingenios
para la ciencias (An Appraisal of Mental Skills for the Different Branches
of Knowledge, published originally in 1575 and later reissued in 1594 in
a revised form) provided a thoroughly physicalist understanding of
human life and health; and the Italian philosopher Bernardino Telesio
(1508–​1588), who devoted a large part of his work to formulating a new
concept of natural health and social wholesomeness.
Another aspect of Galen’s medicine that underwent renewed scru-
tiny between the end of the Middle Ages and the Renaissance was his
view of health as a condition defined by the changeable and individual
nature of human beings. During the sixteenth century, university
professors of medicine who were open to both exegetical and anatom-
ical innovation, such as Giambattista da Monte (1498–​1552), Matteo
Corti (1475–​1544), and Girolamo Cardano, debated whether health
was an ideal and timeless norm of perfection against which doctors
were supposed to measure the condition of individual bodies or rather
a pragmatic and flexible criterion, known as “latitude of health”
(sanitatis latitudo), which depended on factors such as age, environ-
ment, diet, and sex. Stressing the clinical and empirical foundations
of medicine, Da Monte, besides editing Galenic texts, promoted

6 T. Joutsivuo, Scholastic Tradition and Humanist Innovation: The Concept of Neutrum in

Renaissance Medicine (Helsinki: Finnish Academy of Science and Letters, 1999).
 The Renaissance 145

anatomical investigations both in Ferrara and Padua. He also

presented the art of restoring health as knowledge of degrees rather
than a science of immutable essences.7
Despite his predominance in the medical panorama of the
Renaissance, Galen was not the only force to cause a reorientation in
ideas and values about human health. Indeed, a series of important
anatomical discoveries accelerated a long-​term shift from a tempera-
mental and humoral consideration of health—​grounded in ideas of
well-​balanced mixtures of humors and cosmological harmonious
correspondences—​ to one based on structures, obstructions, and
tensions. The typically digestive and humoral view of life processes,
marked by varying degrees of slowness and porosity (a porosity that
was deemed to facilitate exchanges between solid, fluid, and airy states
of matter, between physical and mental faculties, and between the
natural and moral orders of life) gradually gave way to a new medical
framework in which life was defined by speed and mechanical mo-
tion: organs were regarded as neatly defined structures that were con-
stantly being filled and emptied through channels and pores, while
mental operations were described in terms of accumulation and re-
lease of tension.
To this intellectual milieu of general Galenic reappraisal, we should
add two more factors: one material, the other intellectual; that is to
say, the spread of new pestilences, and the influence of the humanist
movement. Unknown epidemic diseases, such as syphilis, smallpox,
and sweating sickness, acted as powerful catalysts in the field of public
health and urged policymakers to engage in farsighted sanitary policies,
which in the end led to the birth of the hospital in the modern sense.8

7 On Da Monte’s innovations in clinical medicine, see J. J. Bylebyl, “The School of

Padua: Humanistic Medicine in the Sixteenth Century,” in C. Webster (ed.), Health, Medicine
and Mortality in the Sixteenth Century (Cambridge: Cambridge University Press, 1979), 335–​70.
8 J. Henderson, The Renaissance Hospital: Healing the Body and Healing the Soul (New Haven,
CT: Yale University Press, 2006). On the impact that new diseases had on sanitary strategies
and institutions, see C. Cipolla, Public Health and the Medical Profession in the Renaissance
(Cambridge: Cambridge University Press, 1976); J. Arrizabalaga, J. Henderson, and R. French (eds),
146 Guido Giglioni

Renaissance humanism, on the other hand, exercised a significant in-

fluence on the evolution of medical ideas and practices by bringing
to the fore several ethical issues underpinning contemporary health
plans and by criticizing forms of extreme medicalization. Petrarch, it’s
worth remembering here, had already condemned scholastic doctors
for their reductionist attitude about human health and their attempts
to replace ethical and rhetorical competences with various forms of
medical treatment.9 Moreover, humanist doctors (such as Antonio
Musa Brasavola) and humanists interested in medical topics (such as
Desiderius Erasmus) reinforced the already prevalent assumption that
health was a characteristic trait of individual bodies, immersed in the
life of larger social and political bodies, exposed to the vicissitudes of
historical change.10 Here humanist preoccupations with historicism
and cultural relativism met with contemporary anxieties about the
definition of natural power. This had obvious consequences for how
doctors and laymen undertook the task of protecting and promoting
human health. The account of health as a state “according to nature”
was being increasingly questioned in favor of a broader, more prag-
matic notion of health understood as the condition whereby humans
were not impeded in their activities and aims, in keeping with con-
jectural, pragmatic, and utilitarian views of knowledge. According to
Galen’s standard definition, health consisted in a balanced proportion
between warm, cold, moist, and dry qualities. The best combination

The Great Pox: The French Disease in Renaissance Europe (New Haven, CT: Yale University Press,
1997); R. French and J. Arrizabalaga, “Coping with the French Disease: University Practitioners’
Strategies and Tactics in the Transition from the Fifteenth to the Sixteenth Century,” in R. French
et al. (eds), Medicine from the Black Death to the French Disease (Aldershot: Ashgate, 1998), 248–​87.
9 P. G. Ricci (ed.), Petrarch: Invective contra medicum, in Martellotti et al., Petrarch: Prose, 682–​84.
For the case of a physician dealing with the rhetorical aspects of his profession (Girolamo Cardano),
see G. Giglioni “The Many Rhetorical Personae of an Early Modern Physician: Girolamo Cardano
on Truth and Persuasion,” in S. Pender and N. S. Struever (ed.), Rhetoric and Medicine in Early
Modern Europe (Farnham: Ashgate, 2012), 173–​93.
10 On medicine and humanism, see Bylebyl, “The School of Padua”; V. Nutton, “The Rise of
Medical Humanism: Ferrara, 1464–​1555,” Renaissance Studies 11 (1997), 2–​19; N. G. Siraisi,
History, Medicine, and the Traditions of Renaissance Learning (Ann Arbor: University of Michigan
Press, 2007).
 The Renaissance 147

of these qualities, especially warmth and moisture, resulted in the best

temperament, that is, the most harmonious bodily condition (Galen,
Opera omnia, 6:1–​2; Galen, Hygiene, 5).11 This situation, however,
remained largely hypothetical, for actual temperaments were never
fully balanced in all their qualitative degrees. Moreover, since the in-
evitable formation of superfluous substances and impurities prevented
the body from being fully repaired through food, drink, respiration,
and pulse, a complex system of evacuations and perspirations was
needed to expel all that had not been completely assimilated by the or-
ganism (Galen, Opera omnia, 6:59–​68; Galen, Hygiene, 38–​41). In this
sense, the precarious equilibrium of temperamental and individual
health was crucially related to the various stages of digestion (“con-
coction,” to use the technical term). The delicate interplay of health,
digestion, and evacuations was traditionally associated with the doc-
trine of the so-​called six non-​naturals.
At the end of the fifteenth century, the growth of the print trade
combined with a more diffused level of literacy favored a wider spread
of a particular kind of literature concerned with medical advice.
According to Sandra Cavallo and Tessa Storey, this development and
a number of other crucial factors helped create a more proactive atti-
tude toward the elimination of diseases and the preservation of health.
These factors were the commercialization of new drugs, which more
often than not were manufactured with substances coming from the
East and the Americas; the spread of the Paracelsian view of illness,
which became quite influential during the sixteenth and seventeenth
centuries; and a certain appeal exercised by charlatans and their em-
piric remedies. A “culture of prevention” spread in Renaissance Italy,
where physicians (not only in the courts, but also in urban settings)
were often consulted as advisers in matters of health maintenance
and the prevention of illness. Greater attention to hygiene, both

11 See C. Spon (ed.), G. Cardano: Opera omnia, 10 vols. (Lyon: Jean-​A ntoine Huguetan and Marc-​
Antoine Ravaud 1663. Repr. Stuttgart-​Bad Cannstatt: Frommann, 1966), 6:23b.
148 Guido Giglioni

personal and public, physical and emotional, was being incorporated

into new models of conduct, influenced by more genteel lifestyles,
changes in household management, a diffused interest in how to
employ leisure time, not to mention that in Catholic countries the
post-​Tridentine Church emphasized norms of bodily decorum and
emotional restraint.12 It is a clear sign of the new orientation in health
care that in his book on life De vita libri tres (Three Books on Life),
the fifteenth-​ century philosopher and physician Marsilio Ficino
(1433–​1499) felt the need to include special advice for people living in
cities.13 In De la institutione di tutta la vita de l’ homo nato nobile e in
città libera (The Lifelong Education of a Gentleman Born in a Free City)
published in 1542, Alessandro Piccolomini (1508–​1578) complained
that in the new urban reality human well-​being had been reduced to
a medical and natural philosophical issue, without paying due atten-
tion to the soul and its spiritual needs.14 In his Essayes (published in
1597 and again, in a much enlarged edition, in 1612), Francis Bacon
(1561–​1626) warned that health, both physical and mental, was the
first thing that men of action risked losing: “Certainly, Men in Great
Fortunes, are strangers to themselves, and while they are in the pulse
of businesse, they have no time to tend their Health, either of Body, or
Minde” (Bacon, The Essayes or Counsels, Civill and Morall, 34).

The Six Non-​Naturals

It is evident that, since antiquity, the discourse on health was not

confined only to ways of curing illnesses and restoring the balance

12 S. Cavallo and T. Storey, Healthy Living in Late Renaissance Italy (Oxford: Oxford University
Press, 2013), 4, 7–​9.
13 C. V. Kaske, and J. R. Clark (ed. and trans.), M. Ficino: Three Books on Life (Binghamton,
NY: Center for Medieval and Early Renaissance Studies, 1989), 220.
14 Eugenio Refini, “De la institutione di tutta la vita de l’homo nato nobile e in città libera,” in
Vernacular Aristotelianism in Renaissance Italy Database (VARIDB), https://​vari.warwick.ac.uk/​
items/​show/​4920.
 The Renaissance 149

of lost soundness but also involved ways of preserving a condition of

well-​being, both physical and mental. Starting with Hippocrates, the
art of preserving health was associated with a series of measures con-
cerning prevention, prophylaxis, and hygiene. Preventive measures in-
cluded a broader outlook about the relationship between life and death;
notions of old age and prolongation of life; general considerations of
how human beings should promote vital expansion and ethical ful-
fillment; and, finally, on a broader scale, ways of maintaining the so-
cial and political order. In his treatise on how to preserve one’s health,
Galen had distinguished between two different strategies for dealing
with health: preservation and restoration. In keeping with the same
division, in his De sanitate tuenda (1560), Cardano divided medicine
into two principal parts: “one protects health when this is present;
the other restores it when it is absent.” Health needed to be protected,
Cardano explained, for no single body in nature, however strong and
wholesome, could last long without medical assistance. In Cardano’s
opinion, the part of medicine devoted to prophylaxis and prevention
was more important than the one aiming at recovering lost health. He
thought it was better “not to fall ill for a long time rather than to heal
people that have fallen ill.” The reason was that “those who fall ill do
not know when their disease will end, and, in case they recover their
health, they will not go back to their previous level of wholesomeness
(integritas)” (Cardano, Opera omnia, 6:10–​11).
Since Hippocratic times, and continuing with such seminal texts
as Aristotle’s Parva naturalia and Galen’s De sanitate tuenda, the
overlapping fields of therapy and prevention became populated with
three different kinds of ontological entities: immutable natural prin-
ciples (the “naturals,” κατά φύσιν); pathogenic factors of all sorts
(the “unnaturals,” παρά φύσιν); and various intermediate conditions
that were subject to a limited amount of change and therefore were
considered not completely natural (the “non-​naturals,” οὐ κατά φύσιν
μέν, οὐ μήν ἤδη παρά φύσιν). The medical category of non-​naturals
originated therefore from secular attempts to adjust cultural habits to
150 Guido Giglioni

biological processes (Galen, Opera omnia, 6:27–​28, 57; Galen, Hygiene,

19, 35).15 Besides the seven “naturals” (elements, temperaments,
humors, organs, faculties, actions, and spirits), tradition had gradu-
ally systematized the number of the non-​naturals into six: air, food
and drink, physical exercise, sleep and waking, evacuations, and
emotions. By non-​naturals, doctors referred to those factors—​both
natural and cultural—​that were thought to affect all aspects of human
life. Unlike therapy, which addressed abrupt and exceptional events
(the unnaturals, i.e., illnesses), health regimens centered on ordinary
events of everyday life. It was by using the non-​naturals as a template
that doctors elaborated a set of precautions and devices, largely on an
empirical and practical basis, to maintain relatively stable standards of
a healthy life.
The increasing emphasis placed on variables such as change, con-
tingency, individuality, environment, and habit—​a typical aspect
of Renaissance culture, reinforced by the poignant sense of the past
diffused by the humanists—​confirmed the view that health depended
on the correct administration of the six non-​naturals: where to live,
what to eat and drink, how to regulate the cycle of sleep and waking,
how many hours to devote to exercise and leisure time, how to purge
the body and the mind of physical and emotional pollutants, and fi-
nally how to take advantage of the emotional energy provided by
the passions without suffering mental and physical exhaustion.
Because of their dual status—​natural and cultural—​the six non-​
naturals represented the prophylactic and ecological conditions of an
embodied mind (or ensouled body), situated in a complex environ-
ment and exposed to natural and social constraints at once. Human

15 On the origin and evolution of the “six non-​naturals,” see L. J. Rather, “The ‘Six Things Non-​
Natural’: A Note on the Origins and Fate of a Doctrine and Phrase,” Clio Medica, 3 (1968), 337–​47;
L. García-​Ballester, “On the Origins of the ‘Six Non-​Natural Things,’ in J. Kollesch and D. Nickel
(eds), Galen und das Hellenistiche Erbe (Stuttgart: Steiner, 1993), 105–​15; K. Albala, Eating Right
in the Renaissance (Berkeley: University of California Press, 2002); Cavallo and Storey, Healthy
Living in Late Renaissance Italy.
 The Renaissance 151

beings were regarded as truly cultural-​biological engines, capable of

absorbing energy from the environment (through eating, drinking,
and breathing), of processing that energy through physical and mental
exercise (including sleeping, dreaming, imagining, and feeling), and
of releasing it back into the environment in the form of excretions,
evacuations, and cultural artifacts. For Renaissance human beings
living in a culture of non-​naturals at every social level, food was both
a material and spiritual experience. Moreover, because of the key role
played by the environment, the six non-​naturals underpinned a view
of health that was natural and social at the same time, private and
public. To recapitulate, we can say that by relying on a constant tri-
angulation between the spheres of nature (life), un-​nature (illness),
and non-​nature (health), the art of preserving health took account of
three main variables: the individual, shaped by a specific proportion of
qualities and humors (temperamentum or complexio), in particular by
a definite ratio between innate heat (calor innatus) and original mois-
ture (humidum radicale); the impact that external influences from the
environment, above all air and food, exercised on the individual; and,
finally, the influence of social and cultural factors such as habits, cus-
toms, laws, ethical precepts, religious practices, fashions, and ways of
managing the household economy.
From a more specifically philosophical point of view, the balance
of nature, un-​nature, and non-​nature was predicated on the inter-
play of life and death. Though there is a natural tendency toward
decay and dispersal, living beings had also been described since an-
cient times as driven by an original appetite for self-​preservation that
manifested itself through the biological functions of eating, drinking,
and breathing in and out (the heartbeat was a function of the digestive
system and not of the then-​unknown circulation of the blood; Galen,
Opera omnia, 6:6–​7; Galen, Hygiene, 7). Premodern and early modern
regimens of prophylactic measures can be seen as all-​encompassing
models of socio-​bio-​ethical conduct centered on the functions and
the effects of the digestive system. According to Cardano, to give
152 Guido Giglioni

an example, the part of medicine that dealt with the preservation of

human health had a physical counterpart in the very function of nu-
trition and metabolism, for our bodies are always “in a state of con-
tinual change” (Cardano, Opera omnia, 6:30b). In order for a body to
be able to reconstitute its daily loss of vital matter, Cardano went on,
“sagacious nature” had provided the body with “a faculty of preserva-
tion” whose principal instrument was the very “sensitive” mouth of
the stom­ach (Cardano, Opera omnia, 6:20a).
In writing his own art of preserving health, Cardano was fol-
lowing a well-​trodden path in physiology. The foundations remained
the classical principles of Galenic anatomy before William Harvey
(1578–​1657) discovered that blood circulated incessantly inside the
body at a very high speed. The substance of the living body was warm
and moist. As such it was subject to produce waste that needed to be
constantly replaced through food and drink (alimentum). Sleeping
was the state that was more conducive to digestion (concoctio), and it
was a means of restoring life based on that particular relation of in-
verse proportionality that, in Cardano’s opinion, connected the op-
erations of conscious activity ( facultas animalis) to the unconscious
processes of vegetative life ( facultas vitalis et naturalis). As a result,
when the mind was at rest, the bodily functions grew more active,
and vice versa, when the mind was at its most alert, the vegetative
operations slowed down (Cardano, Opera omnia, 6:21a). Moreover,
a large part of the vital economy of the body rested on the way in
which waste materials were handled by the secretive and excretive
faculties (excrementorum [ut ita dicamus] oeconomia), while illnesses
were caused by accumulation of superfluous matter (Cardano, Opera
omnia, 6:11, 30a). Warmth, finally, had a central role in maintaining
the health of the whole mechanism, especially through the many
exchanges between internal (proprius) and external (ambiens)
heat, exchanges that to a large extent relied on the air as a vehicle
of breathed-​in and breathed-​out substance (Cardano, Opera omnia,
6:31b).
 The Renaissance 153

Considered as a general biological process affecting several parts of

the body at various levels and in different periods, digestion (coctio)
was therefore a central feature in ancient, medieval, and early modern
medicine, in the domains of both physiology and pathology, and
within pathology, in the complementary spheres of physical and
mental illnesses. The same held true of hygiene and prevention, so
much so that the six non-​naturals can be primarily described as ways
of identifying and managing the innumerable operations and variables
affecting the economy of the digestive functions: above all nourish-
ment, drinking, and evacuations, but also motion, thinking, and
socializing. Sleeping, for instance, was closely related to digestion, for
it was during sleep that the most critical phases of concoction designed
to restore the life of the organism were supposed to occur, and so was
moderate exercise, both physical and mental (walking in a garden, for
instance, while admiring the colors and harmonies of the landscape),
for they were operations that facilitated digestion. Likewise, passions
could have both positive and negative consequences on the principal
digestive phases. Diagnoses of melancholy and hypochondria often
suggested disorders that affected the faculties of digestion more than
the nervous system. The environment as a whole, finally, and not
just the breathed air, was perceived in terms of one external force ca-
pable of influencing metabolism in all its stages. Echoing Galen and
Avicenna, Ficino repeatedly stressed the importance of digestion for
a healthy life (digestio vitae radix), not only because undigested or
poorly digested nutritive matter (cruditas) was behind a large number
of illnesses, but also because the seemingly simple act of digesting
food did not stop at the operations performed in the stomach and the
intestines. Since antiquity, digestion had been regarded as a large and
complex vital enterprise, consisting of many stages, called “first diges-
tion” in the stomach, “second digestion” in the liver, third in the veins,
fourth in the various parts of the body, fifth in the left ventricle of
the heart, and sixth in the brain (Ficino, Three Books on Life, 172–​74;
Helmont, Sextuplex digestio alimenti humani). The brain completed
154 Guido Giglioni

the digestive process by elaborating animal spirits, the main tools for
imaginations and thoughts.

Prophylaxis: A Subtle Art of Paradoxes

Early modern physicians were well aware that the best regimen was
the one adjusted to the specific needs of each individual. Prophylactic
norms could not be indifferently applicable to every different situ-
ation. This was yet another reason, unlike the naturals (which, in
keeping with persisting assumptions of Hippocratic and Aristotelian
ontology, were considered to be unmodifiable conditions of biological
development), the six non-​naturals were subject to a certain margin of
manipulation and could be used to ameliorate the physical and mental
condition of individual human beings. Everyone, Cardano argued,
should choose the regimen (victus ratio) that they found appropriate
for themselves, especially those who were not lucky to be healthy and
strong by nature, and therefore needed instructions on how to con-
duct their lives (Cardano, Opera omnia, 6:22b). This was an area where
the six non-​naturals allowed further scope for intervention, that is to
say, the area between nature and technology, on the one hand, and be-
tween nature and habit formation, on the other hand. Alvise Cornaro,
the author of one of the most celebrated guides to healthy living in
the Renaissance, the Discorsi intorno alla vita sobria, never tired of re-
peating that “method” (arte) and “practice” (uso) were forces capable
of curing natural faults (vizi e mancamenti naturali) and mitigating
the pressure of natural determinants (Cornaro, Discorsi intorno alla
vita sobria, 361, 363, 383). In his observations and suggestions, Cornaro
mentioned Galen and was well aware of the tradition of the six non-​
naturals. He recommended a controlled use of food and drink (non
mangiare se non quanto digerisce il mio stomaco con facilità), of sleep
(non impedir i miei sonni ordinarii) and sex (uso del matrimonio), a
careful attention to environmental conditions (non stanziar in mal
aere, non patir dal vento, né dal sole) and to the effects of the passions
 The Renaissance 155

(la malinconia, e l’odio, e le altre perturbazioni dell’animo; gli accidenti

dell’animo; Cornaro, Discorsi intorno alla vita sobria, 363–​64, 376).
Predictably, though, food and drink—​which he called “the two or-
ders of the mouth” (i due ordini della bocca)—​were the most impor-
tant non-​naturals, the one to which all the others were supposed to be
reduced (Cornaro, Discorsi intorno alla vita sobria, 363, 384). Cornaro
died when he was about eighty-​years-​old. The story goes that, suffering
from gout at an early age and fearing he would die of sudden death,
he decided to change his lifestyle drastically and follow a most aus-
tere regimen of food control. A friend of Pietro Bembo, Sebastiano
Serlio, Pietro Aretino, and Sperone Speroni, he recounted his personal
experience in his Discorsi, four tracts published between 1558 and
1565. They praised moderation (sobrietà), which was seen as the “true
medicine for both the soul and the body” (Cornaro, Discorsi intorno
alla vita sobria, 380–​81). The work enjoyed immense success and was
translated into French, German, and English. Cardano mentioned on
many occasions the “little book” that everyone was reading at the time
(qui in omnium manibus est; Cardano, Opera omnia, 6:15b).
Being both individual and holistic, regimens of health required sen-
sible application. During the Renaissance, the art of preserving health
was still seen as a most subtle exercise of judgment, through which
precepts of general knowledge (medicine, but also meteorology, ge-
ography, astrology, physiognomy, ethics, and economy) were applied
to concrete and particular situations. By undergoing a whole range
of adjustments and negotiations, subtlety was mostly required in
addressing various sets of biological polarities (loss and repair, short
and long life, moisture and heat, putrefaction and exsiccation). These
polarities lay at the very foundations of prophylactic and preventive
strategies. In De sanitate tuenda, Galen had described the condition
of health as the result of a precariously balanced relationship between
variables of opposite nature. As mentioned, according to the principles
of his medicine, perfect health could only work as a regulative prin-
ciple, for in real terms perfection remained unachievable. Galen had
156 Guido Giglioni

assumed that any living body was in the end bound to lose its principal
vital constituents, due to the organism’s inability to restore the vital
frame in its entirety and complexity, while an increasing quantity of
excretions (excrementa) and unrecyclable wastes (superfluitates) kept
building up inside the body (Cardano, Opera omnia, 6:30a). Already in
the Middle Ages, a number of physicians interested in the use of chem-
ical remedies had begun to look for ways of overcoming this biological
impasse through the progress of technology (especially in the domain
of chemistry), but it would be only with such militant and confident
advocates of medical progress as Francis Bacon and René Descartes
(1596–​1650) that the indefinite extension of one’s life was presented
as a plausible desideratum, both philosophically and technologically.16
Another polarity affecting the health of human beings was caused by
the air, which was supposed to prey on moisture (consumere humidum)
while extending the life of the individual (producere vitam; Cardano,
Opera omnia, 6:32a). It was not easy to find the right balance between
air, heat, and moisture, given the difficulty of establishing a correct
proportion between the extremes of putrefaction and exsiccation,
firmness and fineness, contraction and relaxation. The always shifting
equilibrium could be maintained by tinkering with the sources of in-
nate heat (calor innatus) and original moisture (humidum radicale).
From this point of view, the easiest way of keeping the balance of heat
and moisture in check was through monitoring the condition of one’s
blood. A constant attention to the quality of blood, for instance, was
essential in Ficino’s health regimen: “Let not the blood be fiery,” he
cautioned the reader of his De vita, “not watery, but airy—​not airy like
a too-​dense air, lest it be too much like water, nor like a very subtle air,
for fear it may easily kindle into fire” (Ficino, Three Books on Life, 177).
The reason why Ficino’s materia medica was particularly rich in spices

16 G. Giglioni, “The Hidden Life of Matter: Techniques for Prolonging Life in the Writings of
Francis Bacon,” in J. R. Solomon and C. Gimelli Martin (eds), Francis Bacon and the Refiguring
of Early Modern Thought: Essays to Commemorate the Advancement of Learning (1605–​2005)
(Aldershot: Ashgate, 2005), 129–​44.
 The Renaissance 157

(aromatica) was because in his eyes these substances contained an ideal

proportion of heat, moisture, and viscosity. As such, they were espe-
cially beneficial for human life (Ficino, Three Books on Life, 192). In
being the biological cornerstones of human health, both physical and
mental, innate heat and original moisture produced opposite effects
that the good physician was able to turn into complementary actions.
While humidity was the material that fueled the activity of heat, heat
was the force that moderated the tendency to putrefaction embedded
in humidity. “We start to dry up as soon as we are born,” said Cardano
at the beginning of his De sanitate tuenda (Cardano, Opera omnia,
6:10). He summed up centuries of medical investigations by stating
that the main aim of a healthy regimen was to prevent excessive in-
ternal moisture from initiating processes of putrefaction and external
sources of heat (calor ambiens) from preying on innate heat (calor
proprius; Cardano, Opera omnia, 6:29b, 31b).
Of the foundational polarities, the most striking of all was perhaps
the one between the length and the healthiness of life (between its
energy and meaning, as it were). It’s certainly no accident that a good
number of physicians and natural philosophers shared the belief that
a long life was not necessarily a healthy life. Cardano explained that
the goal of enjoying good health (ratio valetudinis) often did not coin-
cide with that of living a long life (ratio vitae; Cardano, Opera omnia,
6:12). Bacon, as we will see, despite advocating the need to extend the
limits of human existence, made clear that longevity did not come at
the detriment of pleasure and virtue. Cornaro agreed with many early
modern physicians and philosophers that an unbalanced temperament
(mala or trista complessione) could be transformed into an opportu-
nity for human beings to become more aware of their limitations and
to live a more meaningful life. On the contrary, he considered a sound
temperament (perfetta complessione) at birth to be the main reason be-
hind a poor health (mala condizione) in old age, so much so that they
had to be rightly blamed for that outcome (essi stessi ne sono cagione;
Cornaro, Discorsi intorno alla vita sobria, 360, 369, 382, 397). Huarte
158 Guido Giglioni

de San Juan went so far to argue that, in some circumstances, temper-

amental dysfunctionality could be the starting point for a better life.17
To recapitulate, regimens of health were practical, individual, and
embodied (affecting both individual and social bodies). Being a dis-
cipline that was constantly engaged in finding the correct balance
between sets of interrelated polarities, the art of preserving health
required flexible epistemological canons. Cardano referred to the
expertise concerned with healthy living indifferently as scientia, ars,
and disciplina (Cardano, Opera omnia, 6:15ab). He described the “sci-
ence” of health as a type of knowledge about human bodies (subiecta)
in which substances and situations needed to be constantly evaluated
in order to decide whether they were worth using or avoiding (res
adhibendae et fugiendae), in what ways (modi) and in relation to what
causes (causae; Cardano, Opera omnia, 6:11). It was therefore a kind
of practical knowledge demanding attention to a dizzying amount
of variables (tanta rerum multitudo ac varietas): nutrition, digestion,
quantity and quality of food, the order to be followed in assuming
food, age, sex, passions, geographic regions, and weather (Cardano,
Opera omnia, 6:11–​ 2, 29b–​ 30a). Within such a complex tangle,
Cardano listed seven principal objectives: to preserve one individual’s
specific temperament; to eat the right food; to favor evacuations in
all their forms, from sperm and urine to sweat and tears; to maintain
the organs in their proper condition; to improve the quality of the
surrounding air; to protect the body from all possible sources of “ex-
ternal violence”; and, finally, to take care of all those functions that, as
explained by Aristotle in Parva naturalia, were “common” to both the
body and the soul (Cardano, Opera omnia, 6:30ab). It was precisely at
the intersection of corporeal and mental well-​being that the “science”
of health was confronted with its biggest challenges.

17 G. Serés, (ed.), “J. Huarte de San Juan,” in Examen de ingenios para las ciencias (Madrid: Cátedra,
1989), 174–​82.
 The Renaissance 159

The Health of the Mind

As one of the six non-​naturals, the changeable states of the mind

(its “accidents”) testified to the fact that health (salus understood as
soundness, safety, and salvation) was inextricably natural, spiritual,
and political. Mariano Santo (1488–​1560), a physician from Barletta
(in Apulia), who studied anatomy in Rome and practiced surgery
in Venice and wrote commentaries on Avicenna, wrote a speech de-
voted to the arts of healing in which he defined medicine as a pillar
of human society in that it preserved the bond between the soul and
the body. Santo championed a loosely medicalizing program, with
strongly anti-​Aristotelian tones. It was heavily indebted to that par-
ticular accord between medicine and polity that Plato outlined in
his Timaeus (86b–​88d). Happiness could not simply be regarded as
a property of the soul, as Aristotle argued in the Nicomachean Ethics
(1177a–​1178a); rather, in the true spirit of Galenic medicine, it could
only be a prerogative of embodied souls. Christ himself, added Santo,
had announced his coming into the world as a physician (se medicum
confiteatur) and as God made human (deus humanatus; Santo, Oratio
de laudibus medicinae, 316r). In his commentary on Avicenna’s Canon,
he countered Heinrich Cornelius Agrippa (1486–​1535), who in De
incertitudine et vanitate scientiarum (On the Uncertainty and Vanity
of the Sciences, 1527) had rejected medicine as unreliable learning. In
contrast, Santo embraced the Avicennian consideration of the med-
ical art as a form of all-​inclusive knowledge culminating in the “most
pure” and “most holy” medicine governing “the intellect and the will”
(Santo, Commentaria in Avicennae textum, 4).
In the “Proem” to De vita, Ficino defended the idea that there were
different kinds of medicine, distinguished according to their different
ways of engaging with the physical and the spiritual aspects of human
life. First of all, he differentiated an “Apollonian” therapy, based on
the wise use of herbs and songs, from a “Dionysian” cure, which relied
on wine and a most joyful condition of serenity (securitas laetissima;
160 Guido Giglioni

Ficino, Three Books on Life, 102). Ficino was convinced that the pur-
suit of wisdom required both the health of the body (sanitas corporis),
epitomized by Hippocrates, and the health of the mind (sanitas
mentis), symbolized by Socrates. And yet, seen from the point of view
of “Apollo,” Socrates was, in fact, more effective than Hippocrates,
for the mind remained ontologically superior to the body (Ficino,
Three Books on Life, 160). It was however Christ who, in Ficino’s ac-
count, fulfilled both types of health, physical and spiritual (vera
utriusque sanitas; Ficino, Three Books on Life, 106, 160). Christian re-
ligion combined mental serenity with pious devotion: “as soon as the
mind is purged of all fleshly perturbations through moral discipline
and is directed towards divine truth (i.e., God himself), truth from
the divine mind flows in and productively unfolds the true reasons
of things” (Ficino, Three Books on Life, 163). This was also the reason
why faith and prayers were able to enhance the effects of administered
drugs in the most powerful way (Ficino, Three Books on Life, 202).
Both Santo and Ficino were able to appeal to the medical tradi-
tion, for Galen had already defended the physicians’ ability to con-
tribute to the mental well-​being of humans. In many of his works, he
had described mental health as the province of both medicine and
philosophy. Since the “habit of the mind,” he argued in De sanitate
tuenda, was impaired “by faulty customs in food and drink and exer-
cise and sights and sounds and music,” the “hygienist” (ὁ τὴν ὑγιεινὴν
μετιών) was supposed to be skilled in all these matters and “to mould
the habit of the mind” (Galen, Opera omnia, 6:40; Galen, Hygiene,
26). Moreover, as one of the six non-​naturals, the passions of the soul
(accidentia animi) were universally regarded as a crucial factor among
the many variables affecting human health. Ficino was particularly
concerned with the ways in which emotional imbalances could af-
fect the stability of the psycho-​somatic compound (imaginationis
motus; laboriosus animi corporisque motus; anxietas; ira; solitudo et
maeror; Ficino, Three Books on Life, 168, 172, 188, 211). The old adage
about keeping “a sound mind in a sound body” (mens sana in corpore
 The Renaissance 161

sano) was at the core of his medical philosophy (Ficino, Three Books
on Life, 184).18 The proverb was all the more appropriate when the
lives of philosophers and men of letters were at stake, for the minds
of such people are exposed to all sorts of professional hazards. Ficino
complained that scholars had yet to find their doctor (solus litterarum
studiosis hactenus deest medicus aliquis), for they were prone to neglect
their health; above all, they were particularly heedless of the principal
instrument of their intellectual activities (instrumentum ingenii), that
is, the spiritus, understood in medical terms as the most refined part
of the blood (Ficino, Three Books on Life, 108, 110, 146, 152). To remedy
this situation, Ficino’s directions about the healthy life of the body and
the mind hinged on the natural proximity between spirits, odors, and
air. As the vehicle of sublunary and celestial qualities, air mediated
between bodily spirits and the faculties of the soul; “pure and lumi-
nous air, odours and music” were especially beneficial to the life of the
intellectuals (ingeniosi). While investigating the relationship between
food and the soul, Ficino insisted on the kinship of spiritus and odor.
An odor, he said, is sublimated food: “we call an odour that vapour
into which digested food is subsequently transformed” (Ficino, Three
Books on Life, 223).
We can sum up Ficino’s position on health preservation by saying
that mental soundness consisted for him in a very delicate balance
of humoral components, degrees of temperature, and levels of den-
sity and rarefaction (Ficino, Three Books on Life, 118–​22). Phlegm and
yellow bile were important, but it was the melancholic humor (black
bile) that had the greatest impact on the health of the mind. In De
vita, he compared black bile and the spiritus produced by melancholic

18 On Ficino’s medicine of the mind, see P. O. Kristeller, The Philosophy of Marsilio Ficino
(New York: Columbia University Press, 1943), 351–​401; N. L. Brann, The Debate over the Origin
of Genius during the Italian Renaissance (Leiden: Brill, 2001); M. J. B. Allen, “Life as a Dead
Platonist,” in M. J. B. Allen and V. Rees (eds), Marsilio Ficino: His Theology, His Philosophy, His
Legacy (Leiden: Brill, 2002), 159–​78; G. Giglioni, “Coping with Inner and Outer Demons: Marsilio
Ficino’s Theory of the Imagination,” in Y. Haskell (ed.), Diseases of the Imagination and Imaginary
Disease in the Early Modern Period (Turnhout: Brepols, 2011), 19–​51.
162 Guido Giglioni

reactions occurring in the blood to aqua vitae. As such, they produced

the most refined fuel, the one, that is, belonging to the thinking ac-
tivity, capable of collecting and concentrating the mind (in suum cen-
trum animum colligit; Ficino, Three Books on Life, 120). Excesses in
mental activity could affect one’s health in two ways, following the
well-​known patterns of exsiccation and refrigeration: concentration
was likely to dry up the brain, while the overuse of spirits made the
blood thick and cold (Ficino, Three Books on Life, 114, 134).19
With respect to the six non-​naturals in general, Ficino warned about
three specific “monsters” and how they could impair mental health: sex
(Venereus coitus), excess of food and drink (vini cibique satietas), and
sleep deprivation (ad multam noctem frequentius vigilare; Ficino, Three
Books on Life, 122–​23, 182, 188, 217). He recommended scholars to shun
Saturn, a mythological emblem symbolizing the “secret and too con-
stant pleasure of the contemplative mind,” for in that space of mental
brooding Saturn was deemed to devour “his own children,” that
is, one’s own thoughts (Ficino, Three Books on Life, 213). In this do-
main, Ficino’s dietetic instructions were directed at strengthening the
faculties of the soul, by making the senses more alert, corroborating
memory, refreshing the imagination, and sharpening the mind.
Although, in line with the principles of Galenic psychiatry, Ficino’s
characterization of mental prophylaxis hinged on the notion of mate-
rial temperament (especially black bile, as just noted), he nevertheless
did not downplay the contribution of moral philosophy (disciplinae
moralis instituta) and the extensive benefits that could derive from
relaxing activities and spiritual ways of comforting both the senses
and the imagination:

I advocate the frequent viewing of shining water and of green or red

colour, the haunting of gardens and groves and pleasant walks along

19 On Ficino and melancholy, see the classic R. Klibansky, E. Panofsky and F. Saxl, Saturn and
Melancholy: Studies in the History of Natural Philosophy, Religion and Art (London: Nelson, 1964).
 The Renaissance 163

rivers and through lovely meadows; and I also strongly approve of

horseback riding, driving, and smooth sailing, but above all, of va-
riety, easy occupations, diversified unburdensome business, and the
constant company of agreeable people. (Ficino, Three Books on Life,
135–​37)

To this list he added music, songs, games, moderate laughter, and

devices aimed at recovering memories from one’s childhood (Ficino,
Three Books on Life, 188, 212–​24). Because of the connections they es-
tablished between sensible qualities and mental patterns, synaesthetic
associations were especially appreciated by Ficino. His analysis of the
color green, for instance, remains masterful:

The frequent use of green, since it recreates the spirit of sight, which
is in a way the principal part of the animal spirit, refreshes also the
animal spirit itself. And we will also remember that if the colour
green, which among the colours is the middle grade and the most
tempered, is so good for the animal spirit, much more will those
things which through their qualities are the most temperate will
help the natural and vital spirits and conduce greatly towards our
life. (Ficino, Three Books on Life, 206)

Given the general coordinates of Ficino’s philosophy, the mind’s

sanitas had necessarily a positive effect on the well-​being of the human
beings on two levels, individual and cosmological. From an individual
point of view, the mind was able to secure a condition of sound health
by expanding the scope of self-​knowledge (unusquisque se cognoscat).
This meant that, by acquiring a richer experience of their inner life,
all people were in the position of becoming their own best physicians
(suique ipsius moderator ac medicus esto; Ficino, Three Books on Life,
216). With respect to cosmological life, Ficino’s model of tempera-
mental medicine rested on ideal correspondences between states of
corporeal harmony and their symbolical counterparts more than on
164 Guido Giglioni

relationships between bodily humors and sensible qualities. Heavens,

human bodies, and animal spirits were related to each other because
they were the most “temperate”—​that is, balanced—​things in the uni-
verse. By means of analogical correspondences, the spirit thus became
suited to receive energy and knowledge from celestial things (spiritus
per temperata coelestibus conformatur; Ficino, Three Books on Life,
206). “I advise you to observe what Jupiter the even-​handed taught
Pythagoras and Plato: to keep human life in a certain equal propor-
tion of soul to body and to nourish and augment each of the two with
its own proper foods and exercises” (Ficino, Three Books on Life, 212).
For all these reasons, Ficino’s guidelines for preserving health
provided an original synthesis of cosmological, theurgic, and reli-
gious teachings, unified by the need to achieve a stable condition
of mental soundness. Likewise, the immensely popular Discorsi
by Cornaro owed part of their success to the way in which the
Venetian nobleman combined medical advice, ethical directions,
and religious devotion. He described his “pious” medicine (santa
medicina) as a lifestyle in which the soul was allowed to dwell in a
good body (buona stanza nel corpo), in peaceful harmony with the
humors, the senses, and the appetites (Cornaro, Discorsi intorno
alla vita sobria, 380). He stated that he was able to enjoy “two
lives at the same time,” the earthly one through the senses (con
l’affetto), and the heavenly one through the intellect (col pensiero;
Cornaro, Discorsi intorno alla vita sobria, 400). For Cornaro,
a frugal life invigorated both a healthy brain and a serene mind
(un cervello purgato and alte e belle considerazioni delle cose divine;
Cornaro, Discorsi intorno alla vita sobria, 372–​73). He reiterated
the commonsense assumption that everyone was able to cure him-
self in the best manner (l’uomo non può essere medico perfetto di
altri, fuor che di sé solo) by highlighting the irreducibly individual
character of human health, seen as a unique combination of qual-
ities, temperaments, and faculties (Cornaro, Discorsi intorno alla
vita sobria, 368).
 The Renaissance 165

Other Renaissance authors followed a different route to defend

the legitimacy of mental health. Rather than blaming the senses
and the appetites, authors such as Telesio and Bacon warned against
assigning too conspicuous a role to the sphere of the intellect in one’s
cognitive and ethical life. Their philosophical programs entailed a
momentous rehabilitation of the senses—​from sense perception
(discernment) to good sense (judgment). Telesio, it should be said,
acknowledged that not everything in the mind could be reduced to
the senses, for that part of the soul whose functions developed from
the seed (educta e semine) was in fact the material substratum onto
which God had directly and immediately grafted an individual and
immaterial soul. It was on this basis that Telesio managed to dif-
ferentiate between the souls of nonhuman and human animals.
The former were mere corporeal spiritus, the latter, specific “forms”
imprinted by God on the corporeal spiritus. In the work he wrote
to rebut Galen’s division of the faculties of the soul, entitled Quod
animal universum ab unica animae substantia gubernatur (The
Living Being as a Whole Is Governed by the One Substance of the
Soul), Telesio argued that the spiritus was able to perform all the bi-
ological and cognitive functions but not to account for some higher
tendencies of a moral and religious order (such as self-​sacrifice and
disinterested acts of altruism), which transcended the level of purely
biological self-​preservation (Telesio, Quod animal universum, 188;
Telesio, De somno libellus, 380).
Telesio was aware that the great majority of doctors, both the ones
belonging to the traditional camp and the follower of new trends, shared
the view that a change in bodily conditions, induced through a careful
use of diet, drugs, and a variety of material stimulations, could affect
the state of the mind. More complex, however, was the question con-
cerning the type of mental operations that were able to alter the body.
Telesio’s solution to this problem—​a bold solution indeed—​derived
from his original views about the soul. In his opinion, every living
being, including man, was governed by one sentient entity. Regardless
166 Guido Giglioni

of whether people called it anima, universitas, or substantia, the un-

derlying meaning remained the same, that is, the most rarefied and ac-
tive part of the vital fluid, the spiritus. In De rerum natura (published
in three different versions in 1565, 1570, and 1586), he described the
spiritus as a continuum of pneumatic energy, diffused in every part of
nature and in each single organism, capable of perceiving and reacting
to all the stimuli received from the outside. Telesio labeled this spir-
ituous core as a “fully perceptive spirit” (spiritus omnino omniscius),
that is to say, a material substance that at any time was aware of its
surrounding reality down to the last detail. He thus viewed the soul as
a collective pneumatic organization capable of connecting the knowl­
edge that pertained to spiritus as a whole (universitas spiritus) and the
knowledge coming from local and peripheral aggregations of spiritus
to the functioning of the organs and each bodily part. Being in charge
of the vital organization of the body, the spiritus was also able to enact
the best conduct of life (ratio vivendi; Telesio, De rerum natura, 3:348,
352; Telesio, Quod animal universum, 215–​16).
This model had important consequences in relation to notions of
physical health, physical pleasure, and the physiological processes
underlying the activity of knowledge. Given the all-​pervasive ac-
tivity of the fully sentient—​omniscius, in fact—​spiritus, Telesio
intertwined very closely cognitive operations, physiological
processes, and feelings of pain and pleasure. In doing so, he tied
perception, pleasure, and happiness together, for it was through sen-
tient reactions that the primordial forces of nature—​heat and cold—​
could immediately probe and sense any advantage or harm coming
from external things. These unmediated perceptions were always
accompanied by feelings of pleasure or pain. Pleasure and pain, in
turn, were acts of knowledge. Laughter, for instance, was described
by Telesio as a motion that signaled the extent to which spiritus
was taken “by the greatest desire to preserve itself and at the same
time to draw pleasure from it” (Telesio, Quod animal universum,
214). Given the pneumatic dimensions of Telesio’s prophylaxis, it
 The Renaissance 167

is easy to understand why air was for him the most important non-​
natural, for the spiritus inside the body of living beings constantly
interacted with the spiritus outside them, that is, air (Telesio, Quod
animal universum, 196). It was certainly no accident that Telesio
had written a short treatise dealing with the effects of the atmos-
phere on human health, De iis quae in aere fiunt et de terraemotibus
(On Atmospheric Phenomena and Earthquakes).20
To a certain extent, Bacon shared Telesio’s central argument in
De rerum natura that the health of the mind depended crucially on
the health of the senses. Bacon’s medicine of the mind, as we will
see in the next section, implied a rediscovery of the unadulterated
life of the senses, and through the senses, of the innermost appeti-
tive life pervading the whole body of nature. As would also happen
with René Descartes (see the chapter by Gideon Manning in this
volume), Bacon thought that the notion of health had to be dramat-
ically reinterpreted by exploring the nature of matter and life along
radically and experimentally new lines. In his Historia vitae et mortis
(1623), he rejected the foundations of traditional and institutional
medicine (turba medicorum), that is, the already mentioned notions of
original moisture (humor radicalis) and natural heat (naturalis calor),
in favor of a view of vital phenomena seen as processes that could be
perpetually repaired and restored (Bacon, The Instauratio Magna, pt.
3, 144). Distancing himself from Ficino’s and Cornaro’s advice, Bacon
thought that the mind was not the cure, but a substance in desperate
need of a cure, for left to its own devices—​mainly, imaginations and

20 On Telesio’s views on nature, self-​preservation and health, see N. Badaloni, “Sulla costruzione
e la conservazione della vita in Bernardino Telesio (1509–​1588),” Studi Storici, 30/​1 (1989), 25–​42;
M. Mulsow, Frühneuzeitliche Selbsterhaltung: Telesio und die Naturphilosophie der Renaissance
(Tübingen: Niemeyer, 1998); G. Giglioni “Spirito e coscienza nella medicina di Bernardino Telesio,”
in G. Ernst and R. M. Calcaterra (eds), “Virtù ascosta e negletta”: La Calabria nella modernità
(Milan: Angeli, 2011), 154–​68; “Introduzione,” in G. Giglioni (ed.), Bernardino Telesio: De rerum
natura iuxta propria principia libri IX (Rome: Carocci, 2013), xi–​x xxii; Giglioni, “Medicine.”
168 Guido Giglioni

passions—​the mind would be trapped in a world of phantasms (idola)

and lose touch with reality (nature).21

Conclusion: Long Life, Healthy Life,

Meaningful Life

Another development concerning the art of preserving health that

gathered particular momentum during the early modern period was
the almost obsessive attention with which physicians, philosophers,
and divines focused on the complex interplay of vitality, longevity,
and lifestyle. Galen had already demonstrated that, in order for
human beings to enjoy good health, they needed to watch carefully
the way in which they aged, in addition to control the evacuation of
excrements and the replacement of wastes (Galen, Opera omnia, 6:8–​
9; Galen, Hygiene, 9–​10). Ficino referred to a Chaldean precept (regula
Chaldaeorum) intimating that humans slowly cleansed extraneous
humors (peregrinos humores imbibitos corpori expurgare gradatim) to
recover their lost youth (Ficino, Three Books on Life, 218). By and large,
growing old was a key variable in any health regimen, for while death
could not be avoided, it could be deferred. As stated by Cardano,
all living bodies had a natural tendency to last and postpone decay
(Cardano, Opera omnia, 6:30b). Accordingly, and following a long tra-
dition, he divided the art of prophylaxis by referring to two different
aims: preservation of good health (ad servandam bonam valetudinem)
and prolongation of life (ad producendam vitam; Cardano, Opera
omnia, 6:12).22
As explained at the beginning of this chapter, all the operators in the
field of “health protection” (sanitas tuenda) described the functions of

21 On Bacon’s idea of “medicining the mind” and its legacy in the seventeenth century, see G.
Giglioni, “Medicine of the Mind in Early Modern Philosophy,” in J. Sellars (ed.), The Routledge
Handbook of the Stoic Tradition (London: Routledge, 2016), 189–​203.
22 On aging in the Renaissance, see C. Skenazi, Aging Gracefully in the Renaissance: Stories of
Later Life from Petrarch to Montaigne (Leiden: Brill, 2013).
 The Renaissance 169

life in terms of natural heat, and, to be effective, they all agreed that
heat required a constant supply of energy, a “primordial” or “radical”
source of moisture (the humidum radicale). The medical tradition
had described this fuel in terms of an oily (pinguis) and airy (aerius)
moisture. Summing up the way in which Aristotle had explained the
processes of life and death in the Parva naturalia (464b–​467a; 478b),
Ficino reminded his readers that death could derive from either “reso-
lution” (resolutio) or “suffocation” (suffocatio), respectively depending
on whether the natural fuel was lacking or the heat was quenched by an
excess of fluids or putrefaction (Ficino, Three Books on Life, 168, 216).
In discussing the natural sources of death, Galen too had emphasized
the role of exsiccation. While growth relied on a balanced relationship
of moisture and dryness, old age was determined by a slow but unstop-
pable (and in the end deadly) increase of dryness (Galen, Opera omnia,
6: 4–​6; Galen, Hygiene, 7).
As argued by Cornaro in his Discorsi, to look at aging as a process
that could be gradually delayed was tantamount to perceiving the final
term of one’s life as the painless outcome of a natural and slow con-
sumption of vital moisture (bella e desirabil morte è quella che ci dà la
natura per via di risoluzione; Cornaro, Discorsi intorno alla vita sobria,
379, 383). A “good” death was therefore evidence of a “good” life, ex-
tended through a long series of ethically meaningful acts. As pointed
out, Cornaro’s approach to a healthy life was based on few simple
precautions centered on common sense and moral commitments, such
as pursuing order and virtue (la virtù dell’ordine), applying oneself to
routine tasks (la forza dell’uso), establishing good habits (l’uso negli
uomini col tempo si converte in natura), and practicing a frugal life-
style (la natura si contenta di poco; Cornaro, Discorsi intorno alla vita
sobria, 357, 361, 366, 371). The best antidote to avoid an early death, he
stated, consisted in “a sober and orderly life,” premised on a relent-
less exercise of virtue (Cornaro, Discorsi intorno alla vita sobria, 360).
He recounted how nothing had better kept him away from the grip of
death than the “great order” he had followed for many years. Cornaro
170 Guido Giglioni

believed in the power of virtue to impart structure and purpose to

one’s mortal life, for “it is impossible in nature that he who leads an
orderly and continent life may fall ill or die of unnatural death before
his time comes” (Cornaro, Discorsi intorno alla vita sobria, 367, 398).
Moral and religious issues, therefore, played a key role in Cornaro’s
account of healthy longevity. Significantly, he identified three specific
“vices”—​or better three “cruel monsters”—​which more than any-
thing else could hamper the course of human life: social conformism
(l’adulazione e le cerimonie), the spreading of heterodox views in reli-
gion (il viver secondo l’opinione Luterana), and succumbing to the em-
pire of bodily appetites (crapula). These “monsters” had adulterated,
respectively, “the honesty of civic life, the religion of the soul and the
health of the body.” Cornaro’s principal aim behind his treatises was
to defeat the third “monster.” In his diagnosis, crapula, that is, de-
bauchery and intemperance, derived from gluttony (vizio della gola),
which in turn was the symptom of a distorted use of the sense faculties
(senso and appetito, or vivere secondo il senso; Cornaro, Discorsi intorno
alla vita sobria, 358, 362). He was particularly concerned with three
desires: sex (desiderio della concupiscenza), glory (desiderio degli onori),
and wealth (desiderio della roba). More than any other appetite, they
could expose human life to serious mortal dangers (Cornaro, Discorsi
intorno alla vita sobria, 373). The solution lay in a life modeled on the
ideals of natural simplicity (la semplicità della natura), moderation (la
santa continenza), and reason (la divina ragione), achieved by following
an extremely frugal diet in which people were advised to eat only the
amount of food that was strictly necessary and thus easily digestible.
Most of all, they needed to mistrust taste as a reliable indicator of
nourishing and healthy food (quello che sa buono, nutrisce e giova) and
rather embrace that piece of practical advice which suggested always
to stop eating before one felt full (non saziarsi di cibi è uno studio di
sanità), for any surplus of food would inevitably be converted into pec-
cant humors (tristi umori; Cornaro, Discorsi intorno alla vita sobria,
359, 362–​63, 383–​86).
 The Renaissance 171

Cornaro described in glowing terms long life as a good life: not a vita
morta, but a vita viva (Cornaro, Discorsi intorno alla vita sobria, 374,
378). He looked at nutrition as the foundation of long-​lasting order,
at both an individual level and a social level. Other authors preferred
to stress the power that virtue and thinking had in prolonging life.
Ficino, for instance, agreed with many philosophers and physicians
since antiquity that a long life depended on a prudent use of judg-
ment (prudentis iudicii perspicacia; Ficino, Three Books on Life, 166).
Cardano, too, listed health among the crowning achievements in a long
and prosperous life, full of wisdom and intellectual accomplishments,
in which death was expected to arrive in the most natural of ways,
“without pain” (Cardano, Opera omnia, 6:15b). In this respect, the art
of preserving health had clear ethical overtones:

We are led astray by the abundance and variety of things, for in our
greedy attraction for flavours we are all driven to titillate our palate,
without paying attention to any difference, not the ones concerning
the surrounding air and physical exercise, nor the ones regarding
the other six non-​naturals, where we look for opportunities to be
healthy (salubritatis materia). The result is that the course of our
life is short and precarious. And this happens not because it is
something that is inherently determined by nature (as some like
to think), but because it is procured as a result of our mistakes.
(Cardano, Opera omnia, 6:11)

As noted, the time-​honored doctrine of the six non-​naturals combined

a strong faith in the prophylactic effects of prudent action with close
attention to the power of natural constraints. There was an evident rec-
ognition that human “art” could play a significant role in changing the
conditions of one’s life. Within this framework, ethical prescriptions
were seen as capable of preserving and improving human health.
Unassisted by the art of prevention, human beings were bound to lead
a disorderly, indeed deranged, life (inordinate, imo insane), breathing
172 Guido Giglioni

polluted air (aër pravus), in the grip of “sorrows, anxieties, insomnia,

sex and purposeless exertions,” prone to excessive eating and drinking,
at the mercy of time and chance, and finally dying a death that was
“unnatural,” “unexpected,” “violent,” or “due to illness” (Cardano,
Opera omnia, 6:11).
And yet long life was not necessarily synonymous with happy
and meaningful life. Precisely because control over the biological
conditionings of one’s existence implied the social and ethical use of
the non-​naturals, a desire to postpone the end of one’s life had always
to be accompanied by a parallel desire to make the right decisions. If
in some circumstances life was shortened by bad habits and dietary
preferences, which would dissipate the reserve of natural heat, dissolve
the vital moisture and dry up the spirits, in other cases a short life lived
with intensity could add meaning and vitality precisely by accelerating
the course of the principal vital processes. This means that the pur-
suit of happiness could sometimes be at odds with the attempt to
live a long life. Indeed, more often than not, a sickly life lasted longer
than a healthy one. Valetudinarianism was certainly not the symptom
of a happy existence, and yet it led its devotees to a long life. Ficino
noticed how weak and frail people, who obsessively took care of their
lives, were capable of living longer than healthy but imprudent people
(Ficino, Three Books on Life, 166).
Cardano was therefore right in pointing out that means of assistance
for a sound life (auxilia salubritatis) were not the same as those that
lead to a long life (auxilia longitudinis vitae; Cardano, Opera omnia,
6:32a). In the end, whatever doubts one might have had about the best
relationship between long life and good life, the fact remained that
a long life risked re-​enacting Tithonus’s predicament, the situation
symbolized by a human awarded with the divine gift of immortality
but without eternal youth. If it was true that, since time immemo-
rial, the long life of the biblical patriarchs and pious anchorites had
been taken as a proof that longevity, moral perfection, and emotional
contentment were all parts of one comprehensive understanding of
 The Renaissance 173

healthy life, a renewed sense of natural order and spiritual immanence

induced more than one thinker to question the contribution to happi-
ness provided by physical and spiritual maceration (Cornaro, Discorsi
intorno alla vita sobria, 402). Bacon insisted on keeping “healthy life”
and “long life” as separate categories: people could increase the level
of activity and nimbleness in their spirits and in so doing shorten the
course of their life, or conversely, they could prolong life, and thus
damage their health. Given the complexity of the question and the su-
periority of the active over the contemplative life, in his Historia vitae
et mortis Bacon went so far to deny that physical health could be taken
as normative: “The duties of life are more important than life itself ”
(Bacon, The Instauratio Magna, pt. 3, 240).23 His main preoccupa-
tion concerned the question of how to live a healthy and long life that
was also worth living. In his program for the reformation of human
learning, this was one of the reasons behind his decision to link the
idea of physical health to the complementary ones of methodical
soundness (medicining of the mind) and religious salvation (salus).24

23 See also Spon, Cardano: Opera omnia, 6:15a.

24 Research leading to this chapter was supported by the ERC Grant 241125 MOM.
Reflection
Ea r ly Moder n A natom y a nd
the Hum a n Sk eleton
Anita Guerrini
p

The Roman physician Galen wrote in his instruction manual

On Anatomical Procedures: “As poles to tents and walls to
houses, so are bones to living creatures.” In his short treatise
On Bones for Beginners he added that bones were the “hardest
and driest parts of the living body and, as one might say, the
earthiest. . . . All else depends on or is attached to them.”
Therefore knowledge of the skeleton must precede any
other exploration of the body.1 They were the beginning of
anatomical knowledge and the conclusion of the process of
dissection.
The human skeleton has had multiple meanings in
history: medical, scientific, and symbolic. These perceptions
have shifted over time and place, and as anatomical study rose to
prominence in early modern Europe, they continued to coexist.
Between the sixteenth and the mid-​eighteenth centuries, a
critical juncture in the history of anatomy, the skeleton became
an object of scientific regard while retaining long-​held symbolic

1 C. Singer (trans.), Galen: On Anatomical Procedures (Oxford: Oxford University Press, 1956), 2,
5; C. Singer, “Galen’s Elementary Course on Bones,” Proceedings of the Royal Society of Medicine 45
(1952): 767–​76, at 768. This is a translation of Galen’s De ossibus ad tirones.

174
 Early Modern Anatomy and the Human Skeleton 175

and emotional connotations as symbols of death and as relics.2

The skull held particular significance: to anatomists, it held the
brain and therefore the senses, and to Christians it was the seat of
the soul.
The skeleton first became a focus of rational study with the
ancient Greeks; Aristotle described the bones of “blooded” (i.e.,
vertebrate) animals in History of Animals.3 By the time Galen
wrote 500 years later, knowledge of the skeleton was a customary
aspect of medical education. But when dissection ceased after the
fall of Rome, skeletons ceased to be scientific objects for several
centuries, while retaining their symbolic resonance. Skeletons
had appeared in frescoes and mosaics at Pompeii as reminders of
mortality, and Christian iconography adopted this symbolism.
Images of the “Dance of Death” in which skeletons danced with
the living emerged with the plagues of the fourteenth century, and
the figure of the transi, or decomposing corpse, adorned tombs
from the late fourteenth century into the seventeenth.4
The first printed image of the human skeleton was a “Dance of
Death” in the Nuremberg Chronicle of 1493 (plate 3).5
The first printed anatomical representation of the skeleton also
dated from 1493, indicating its reemergence as a scientific object.6
Skeletons, complete and in parts, were prominent in the illustrated
textbooks of anatomy that began to appear in the sixteenth
century, which often employed familiar tropes of mortality.

2 On the definition of “scientific object,” see L. Daston, “Introduction: The Coming into Being
of Scientific Objects,” in L. Daston (ed.), Biographies of Scientific Objects (Chicago: University of
Chicago Press, 2000), 1–​14.
3 A. L. Peck (trans.), Aristotle: History of Animals, vol. 1 (Cambridge: Harvard University Press,
1965), 516a8–​516b31.
4 H. Weaver (trans.), Philippe Ariès: The Hour of our Death (New York: Alfred A. Knopf, 1981),
113–​16; K. Cohen, Metamorphosis of a Death Symbol: The Transi Tomb in the Late Middle Ages and
the Renaissance (Berkeley: University of California Press, 1973).
5 Weaver, Ariès, Hour of our Death, 116–​18; R. Saban, “Les premières représentations anatomiques
des squelettes humain imprimées en Alsace au XVe siècle,” 113e Congrès nationale des sociétés
savantes 1988, Questions de l’ histoire de la médecine (1991), 27–​46, at 29; J. de Vauzelles, Les
simulachres et historiées faces de la mort, autant élégamment pourtraictes, que artificiellement
imaginées (Lyon: Soubz l’eseu de Coloigne, 1538).
6 Saban, “Premières représentations anatomiques,” 30–​32.
176 Anita Guerrini

Berengario da Carpi in 1523 showed a skeleton standing over an

open sarcophagus, while a skeleton held an hourglass in Felix
Platter’s textbook sixty years later. Into the eighteenth century,
anatomists employed these symbols and others such as winding
sheets and scythes, much like the artistic convention known as the
“vanitas” genre (plate 4). The title page of a 1615 book on bones by
the Leiden anatomist Pieter Pauw (1564–​1617) featured skeletons
engaged in a dance of death.7
The order of dissection in these textbooks most often began
with the skeleton, as Galen had advised, even though it logically
would appear last and not first, a product of dissection rather than
its origin. André du Laurens (1558–​1609) explained this practice
in Galenic terms in his often reprinted 1593 text: the bones were
the most similar of the parts of the body, being made all of one
substance; they were the most dry and earthy (following the
cosmic order); they gave form to the rest of the body. Bones also
provided exceptionally good evidence of the divine plan of the
body.8 In practice, this meant that the anatomy theater required
an assembled skeleton before any dissection took place, and by
the end of the seventeenth century, several manuals detailed the
construction of a skeleton.
The first works wholly devoted to osteology, the science of the
bones, appeared in the sixteenth century. In 1556 a corrected Latin
translation of Galen’s De ossibus ad tirones appeared, edited by
the renowned Paris anatomist Jacques Dubois, known as Sylvius
(1478–​1555). Dubois noted in his preface that although Galen had
used monkey skeletons, now human bones could be examined.9
The preliminary matter of the much-​reprinted Alphabet anatomic
of the Montpellier surgeon Barthélémy Cabrol (1529–​1603)

7 Primitiae anatomicae de humani corporis ossibus (Leiden: Iusti a Colster, 1615).

8 P. Pauw, A. du Laurens: Historia anatomia humani corporis (Paris: Excudebat Iametus Mettayer
and Marcus Ourry, 1600), 50–​51, 65–​87.
9 J. Dubois [Sylvius, pseud.], Iacobi Sylvii . . . Commentarius in Claudij Galeni de Ossibus ad Tyrones
libellum, erroribus quamplurimis tam Graecis quàm Latinis ab eodem purgatum (Paris: Petrum
Drouart, 1556), 3–​4 .
 Early Modern Anatomy and the Human Skeleton 177

included a sonnet to Cabrol and his skill in uncovering the

skeleton, comparing the body to a house with the skeleton as the
foundation. Cabrol listed “ostéologie” on his title page among the
subjects he treated, possibly the first use of that word in French.
Expanding on the architectural metaphor, he stated that the
skeleton sustains the body “as pillars do a house.” His work was not
illustrated, but the 1633 Dutch translation by Vopiscus Fortunatus
Plemp included an engraving of Pauw’s Leiden anatomy theater
with a skeleton presiding.10
Bones also held increasing interest to those concerned with
human and animal generation and development. The 1573 essay on
the development of the bones of the fetus by Volcher Coiter (1534–​
1576) was only the first of several treatises on this topic, and his
anatomical tables published the previous year had included the first
scientific illustration of a fetal skeleton.11 Fetal skeletons continued
to be a focus of interest: Coiter’s work was reprinted in 1659, and
Amsterdam anatomist Frederik Ruysch (1638–​1731) employed
them in anatomical dioramas on “vanitas” themes, enacting small
but heartfelt dramas on the theme of death.12 William Hunter
(1718–​1783) noted that a complete fetal or infant skeleton was
highly prized.13
Yet because they were hidden from view, bones served in this
period as imperfect markers of health. While abnormalities of
bone structure and development were widely documented—​
particularly within the genre of the “monstrous”—​what are now

10 B. Cabrol, Alphabet anatomic (Tournon: C. Michel and G. Linocier, 1594), “Au dit Sieur Cabrol
sur son livre des os. Sonnet,” 5. In ARTFL’s Dictionnaires d’autrefois the term “osteology” only
appears in 1762. B. Cabrol, Ontleeding des menschelycken lichaems. Eertijts in’t Latijn beschreven
door Bartholmaeus Cabrolius (Amsterdam: Cornelis van Breugel voor Hendrick Laurentsz, 1633).
11 V. Coiter, Externarum et internarum principalium humani corporis partium tabulae
(Nuremberg: Gerlatzenus, 1572).
12 F. Ruysch, Thesaurus anatomicus, in Opera Omnia, 4 vols. (Amsterdam: Jansson-​Waesberg,
1720–​33).
13 W. Hunter, Lecture notes 1775–​76 fol. 257, Library, Royal College of Surgeons of London.
178 Anita Guerrini

recognized as bone diseases attracted little medical attention. The

hunched back of certain forms of tuberculosis was considered
to be congenital before Percivall Pott (1714–​1788) recognized
its connection to tubercular infection. Rickets and other effects
on the bones and joints, because of vitamin deficiency, were
recognized, but their causes were unknown; and treatments, when
they existed, were ineffective. Skilled surgeons could set simple
fractures and dislocations, but compound fractures, because of the
dangers of infection, often resulted in amputation.
According to the renowned Paris surgeon Pierre Dionis (1643–​
1718), the most common surgical operation for illnesses of the head
was trepanation: cutting out a piece of the skull. In ancient times,
it had been used to treat a variety of ailments, including headaches,
but by the late seventeenth century, it was used mainly in cases of
head trauma and particularly skull fracture, and also, although
rarely, in cases of hydrocephalus.14 Trepanation was performed
with a circular, hand-​cranked drill on a patient who (unlike in
most surgical operations of the time) was often unconscious;
indeed, Dionis believed that loss of consciousness as a result of a
blow or a fall always required trepanation. The anatomical and
spiritual significance of the skull made this a particularly fraught
operation, and Dionis spent several pages in his surgical textbook
detailing the procedure and how to determine if it was necessary.15
By the end of the seventeenth century, the term “osteology” was
well established in a number of European languages, as was the
study of bones, including the comparative study of human and
animal bones. When a new edition of the massive compendium
Bibliotheca anatomica (first published in 1685) appeared in 1711,
almost the entire first volume consisted of works on the bones,
with citations from a dozen authors, most of them dating from

14 P. Dionis, Cours de chirurgie (Paris: Chez la Veuve d’Houry, 1708), 349.

15 Dionis, Cours de chirurgie, 335–​64.
 Early Modern Anatomy and the Human Skeleton 179

after 1650. The Paris anatomist Joseph-​Guichard Duverney (1648–​

1730) gave a separate course on the topic beginning in the 1680s.
Works on osteology multiplied into the eighteenth century; at least
twenty appeared between 1650 and 1750. Nonetheless, although
its identity as a scientific object was now firmly established, the
skeleton retained its symbolic and emotional resonance. When
the many charnel-​houses in Paris began to be cleared in the late
eighteenth century and their bones transferred to the empty
quarries below the city, the bones were carefully arranged to form
an aesthetically pleasing and emotionally resonant façade of arm
and leg bones and skulls (see plate 5). The lintel above the entrance
to these catacombs read “Arrête! C’est ici l’Empire de la Mort”
(Stop! Here is the empire of death).16

16 P. Koudounaris, The Empire of Death (New York: Thames and Hudson, 2011), 132–​33.
 CH A PTER SI X

Health in the Early Modern

Philosophical Tradition
Gideon Manning

It shows great prudence and virtue. . . not cowardliness and fearfulness, to set store by
one’s health.
​B artolomeo Paschetti, Del conserver la sanità (1603)1

Introduction

The early modern period, which in this chapter refers to the seven-
teenth century, is of particular importance in charting the terrain
covered in this book as a whole.2 Though this is the period covering
the so-​called “scientific revolution,” it does not represent a complete
break with the past. Far from it, for no less than in earlier periods,

1 Cited in S. Cavallo and T. Storey, Healthy Living in Late Renaissance Italy (Oxford: Oxford
University Press, 2013), 277.
2 T. M. Lennon, “Bayle and Late Seventeenth Century Thought,” in J. P. Wright and P. Potter
(eds), Psyche and Soma: Physicians and Metaphysicians on the Mind-​Body Problem From Antiquity
to Enlightenment (Oxford: Oxford University Press, 2000), 197–​216, uses the analogies of navi-
gation and topography to good effect in discussing mind-​body dualism, and I follow his lead to
discuss the concept of health.

180
 The Early Modern Philosophical Tr adition 181

seventeenth-​century philosophers aspired to the good life and, as in

earlier periods, the idea of the good life was linked to tranquility, hap-
piness, and virtue, all of which were conceived through the medical
idiom of health.3 Additionally, a healthy body was generally thought
to facilitate a healthy mind, and even if it was possible to exercise
enough discipline of mind to assure a good life independent of one’s
bodily states, the advantages offered by a healthy mind were often
thought to include a healthy body. In other words, ancient wisdom
was still very much alive in the early modern period.
Taking a closer look at the medical topography where the concept
of health is most at home, there are landmarks in the early modern pe-
riod that look surprisingly familiar, that is to say, contemporary. There
was, for example, a thriving genre of vernacular medical writing that
details what measures can be taken at home, such as Philibert Guibert’s
L’Apothicaire du médecin charitable (1625), as well as numerous gen­
eral medical self-​help guides, including Bartolomeo Paschetti’s Del
conserver la sanità (1603) and Thomas Tryon’s The Way to Health, Long
Life and Happiness (1697), the latter of which even advocates a vege-
tarian diet. Moreover, the consolidation and expansion of anatomical
investigation, as well as the lasting innovations and discoveries of a
cadre of “great doctors,” such as Santorio Santorio, William Harvey,
Gasparo Aselli, Thomas Willis, Thomas Sydenham, and Marcello
Malpighi, all took place in the seventeenth century with long-​term
consequences for the concept of health. There are also several medical
firsts that stand as the entry point to what today are densely populated
lands, including the first extended study of population demography
in John Graunt’s Natural and Political Observations . . . upon the Bills

3 For an account of what made early modern life worth living, see K. Thomas, Ends of Life: Roads
to Fulfillment in Early Modern England (Oxford: Oxford University Press, 2009). A philosophical
introduction to the early modern good life can be found in J. Cottingham, Philosophy and the Good
Life (Cambridge: Cambridge University Press, 1998), whereas M. L. Jones, The Good Life in the
Scientific Revolution: Descartes, Pascal, Leibniz and the Cultivation of Virtue (Chicago: University
of Chicago Press, 2006) offers a presentation of the good life tied specifically to early modern
science.
182 Gideon Manning

of Mortality (1662), which analyzed recorded causes of death in dif-

ferent English locales, and the first human blood transfusions, which
occurred almost simultaneously in the late 1660s at Britain’s Royal
Society and France’s Académie des Sciences.4
There are equally familiar landmarks in the philosophical and sci-
entific landscape of the time, though historians have rarely discussed
how the concept of health relates to this terrain. Easily recognized are
philosophers like René Descartes, Pierre Gassendi, Thomas Hobbes,
Baruch Spinoza, John Locke, Nicholas Malebranche, and Gottfried
Wilhelm Leibniz, all of whom sought to replace or supplement the phil-
osophical teaching of “the Schools” with an alternative more in keeping
with the “new science” developed by figures such as Francis Bacon, Galileo
Galilee, Descartes, Jan Baptiste van Helmont, Robert Boyle, Robert
Hooke, Christian Huygens, Leibniz, and Isaac Newton. Together, early
modern philosophy and science precipitated a crisis about the nature of
substance, space, causation, motion, force, and the laws of nature, all of
which was bundled in a rhetoric of innovation that continues to inform
our scientific ideals.
All these facts are well known, but the reason early modern philos-
ophy is of particular importance to the history of the concept of health
is because the landmarks just referred to are often blamed for med-
icine having lost its way. This is especially true of the contributions
made by Descartes. For example, the neurologist Antonio Damasio
believes Descartes neglects the “psychological consequences of
diseases of the body proper . . . [and the] body-​proper effects of psycho-
logical conflict.”5 Mark Sullivan notes the consensus that “the source
of medicine’s ills is . . . René Descartes,” and Kay Toombs explains

4 Any good survey of early modern medicine will discuss the figures and topics mentioned above.
See, e.g., A. Wear, “Medicine in Early Modern Europe,” in L. I. Conrad et al. (eds), The Western
Medical Tradition: 800 BC to AD 1800 (Cambridge: Cambridge University Press, 1995), 215–​362.
5 A. Damasio, Descartes’ Error: Emotion, Reason and the Human Brain (New York: Avon Books,
1995), 251.
 The Early Modern Philosophical Tr adition 183

that Descartes’s “paradigm is incomplete.”6 Put simply, though with

a bit more detail, Descartes’s famous dualism between mind and
body and his causally monistic view of life, where living things are
presented in the common yet purely material terms of machines and
their dispositions, set the agenda for much of the seventeenth century
and have had disastrous consequences in the form of an impersonal
scientific medicine ever since.7 Thus, to the extent that we have run
aground in modern medicine and in contemporary thinking about
health, the early modern period stands out as the period during which
we took a wrong turn, thanks largely to Descartes.
Such accusations obscure the many ways in which medicine and the
multiple meanings of “health” and “healthy living” influenced the early
modern philosophical tradition, and vice versa. Yet Descartes does pro-
vide an excellent vantage point for surveying the concept of health
within the early modern philosophical tradition. For one, he is an ex-
ample of a philosopher with an account of the “medicine of the mind”
directed not just at the avoidance of error but also the general Stoic
ideal of tranquility, happiness, and controlling the passions; and he re-
peatedly claims an interest in the “medicine of the body,” going so far
to offer advice and even record his own remedies. Additionally, and this
much his contemporary critics get right, Descartes’s influence was pro-
found and nearly immediate, so much so that by focusing on Descartes
and the Cartesian aftermath, we can glimpse how seventeenth-​century
physicians and philosophers struggled with the implications of the
“new science” and the appropriate way to understand the relationship

6 M. Sullivan, “In What Sense Is Contemporary Medicine Dualistic?” Culture, Medicine and
Psychiatry 10/​4 (1986), 331; and S. K. Toombs, “Illness and the Paradigm of Lived Body,” Theoretical
Medicine 9/​2 (1988), 201; respectively.
7 T. M. Brown, “Descartes, Dualism, and Psychosomatic medicine,” in W. F. Bynum et al.
(eds), The Anatomy of Madness: Essays in the History of Psychiatry, vol. 1 (New York: Tavistock,
1985), 40–​62, rejects the conclusion that Descartes is the source of these and related errors. Cf. I.
Switankowsky, “Dualism and Its Importance for Medicine,” Theoretical Medicine 21 (2000), 567–​
80. Perhaps the most interesting question to ask here is why this fiction persists or how it arose; the
answers are not at all obvious.
184 Gideon Manning

between mind and body when our health is at stake. For this reason
Descartes, and a handful of medical Cartesians, will serve as the pri-
mary focus of this chapter.
The next section of this chapter contains a series of reminders about
the concept of health relevant to the early modern period. Here the
goal is to survey the broader landscape of the seventeenth century and
the context in which Descartes’s work belongs, where it is just one part
of a larger whole. In the third section of the chapter, the emphasis will
be on resurrecting a more accurate account of Descartes’s relation-
ship with medicine and the concept of health. This section identifies
Descartes’s three forms of medical advice: biomechanic, psychoso-
matic, and naturaopathic.8 In addition, it will highlight a conceptual
difficulty Descartes recognized; namely, a dispositional or functional
account of health—​we are healthy when we function normally—​
cannot be justified outside of references to our lived and embodied
experience as composites of mind and body. The concluding section
traces several interpretative choices made by medical Cartesians repre-
sentative of the last half of the seventeenth century—​Henricus Regius,
Jacques Rohault, Johannes De Raey, Johannes Clauberg, Friedrich
Gottfried Barbeck, and Tobias Andreae—​who, in their effort to rec-
oncile medical practice with dualism and mechanism, did not always
agree with one another about what therapeutic strategies to adopt.9

8 I have borrowed the first two labels from D. Des Chene, “Life and Health in Descartes and
After,” in S. Gaukroger et al. (eds), Descartes’ Natural Philosophy (New York: Routledge, 2002),
723–​35, and the third from S. Voss, “Descartes: Heart and Soul,” in Wright and Potter, Psyche and
Soma, 173–​96.
9 These figures were first called to my attention in the groundbreaking scholarship of T. Verbeek,
Descartes and the Dutch: Early Receptions to Cartesian Philosophy, 1637–​1650 (Carbondale: Southern
Illinois University Press, 1992); Verbeek, “Tradition and Novelty: Descartes and some Cartesians,”
in T. Sorell (ed.), The Rise of Modern Philosophy: The Tension Between the New and Traditional
Philosophies from Machiavelli to Leibniz (Oxford: Clarendon, 1993), 167–​75; and F. Trevisani,
Descartes in Germania: La ricezione del Cartesianesimo nella Facolta filosofica e medica di Duisburg
(1652–​1703) (Milano: F. Angeli, 1992); expanded in Trevisani, Descartes in Deutschland: Die
Rezeption des Cartesianismus in den Hochschulen Nordwestdeutschlands (Wien: LIT, 2011). For
English-​language readers, portions of Descartes in Germania are summarized in Des Chene,
“Life and Health,” and J. E. H. Smith, “Heat, Action, Perception: Models of Living Beings
 The Early Modern Philosophical Tr adition 185

Finding and Defining Health

Defining health in the early modern period is not especially easy.

Sometimes it is understood as the absence of pain or disease, as a kind
of symptom-​free existence. At other times, it is conceived as a balance
of traditional humors or an ordering of the chemical elements of the
body. And at still other times it is described as a robustness of function
in the face of external pressures.10 Health can be mechanically defined
or chemically defined, or it may not be defined at all. By analogy to
the concept of a healthy body, the healthy mind is in turn conceived
as free from error or vice, well ordered, spiritually pure, or resolute in
the pursuit of truth and virtue, or, again, may not be defined at all. In
fact, during the seventeenth century, health’s companion concept of
disease appears far more often precisely because there were so many
ways one could be sick, and it was sickness and its discomforts more
than health that required attention and treatment.11

in German Medical Cartesianism,” in M. Dobre and T. Nyden (eds), Cartesian Empiricisms

(Dordrecht: Springer, 2013), 105–​24.
10 This second positive conception of health—​not as a balance but as the ability to resist environ-
mental insults—​fi nds expression in the philosophical project of Baruch Spinoza, who links conatus
(“appetite” or “striving”) with the essence of finite things. A. Gabbey speculates that Spinoza’s
conatus may derive, at least in part, from the medical tradition: see “Spinoza’s Natural Science and
Methodology,” in D. Garrett (ed.), The Cambridge Companion to Spinoza (Cambridge: Cambridge
University Press, 1996), 168. Spinoza’s views of finitude, human vulnerability, and health are
discussed in A. Schmitter, “Responses to Vulnerability: Medicine, Politics and the Body in
Descartes and Spinoza,” in S. Pender and N. S. Struever (eds), Rhetoric and Medicine in Early
Modern Europe (Surrey: Ashgate, 2012), 141–​71. For Spinoza’s connection to medicine and the med-
ical tradition more generally, see W. Aron, “Baruch Spinoza and Medicine,” The Hebrew Medical
Journal 2 (1963), 255–​82. I thank Raphael Krut-​Landau for helpful discussions of Spinoza’s views.
11 Helen King has observed that it “is much easier to talk about disease than health” because
disease comes in many forms and is invariably noticed, whereas health “lives in the shadow
of disease” often only coming to our attention when it is gone: H. King, Health in Antiquity
(London: Routledge, 2005), 3. King’s observation applies as much in the early modern period as
to the classical period. Citing but one example, Montaigne asks rhetorically, “How much more
beautiful health seems to me after the illness” when “the beautiful light of health” returns: D. M.
Frame (trans.), Montaigne: The Complete Works: Essays, Travel Journal, Letters (New York: Knopf,
2003), 1021; cited in M. Schoenfeldt, “Aesthetics and Anesthetics: The Art of Pain Management in
Early Modern England,” in J. F. van Dijkhuizen and K. A. E. Enenkel (eds), The Sense of Suffering
Constructions of Physical Pain in Early Modern Culture (Leiden: Brill, 2009), 26.
186 Gideon Manning

At a time when malnutrition in all its forms was common, and poor
sanitation and hygiene were the norm, diseases and infections were
spread rapidly in the early modern period, especially among the poor
and urban masses.12 Chronic diseases were also a fact of early modern
life, ranging from persistent skin diseases of all kinds, to dysentery,
gout and kidney stones. Epidemics of plague also continued to affect
Europe throughout the seventeenth century, with unfathomably hor-
rible outbreaks in Naples in 1656, when more than 300,000 of a city
of 500,000 died, and in London in 1665, the plague to which we owe
Daniel Defoe’s gripping History of a Plague Year (1720). Taking these
facts together, it is hardly a surprise that early modern patients did
not have great confidence that medicine could heal them or that anx-
iety about loss of health was a constant theme that occupied medical
writers, poets, dramatists, and visual artists throughout the seven-
teenth century.
Equally unsurprising, references to health and disease have a promi-
nent role in surviving diaries and early modern correspondence, where
discussion in a letter could easily turn to personal health or the health
of family and friends.13 This included dramatic first-​person accounts
of pain and even anguish and loss, and equally obvious efforts at objec-
tive description, sometimes even by patients, of crippling discomfort.
It mattered, of course, whether one’s correspondent was a physician or
healer, and whether the author or recipient of the letter was a woman

12 Public health efforts became especially efficacious in the eighteenth century (see Tom Broman’s
contribution in the present volume). For the prehistory of modern public health, see the early
chapters of D. Porter, Health, Civilization, and the State: A History of Public Health from Ancient to
Modern Times (London: Routledge, 1999). For the existence of health boards that exercised broad
powers in the early modern world, see C. Cipolla, Public Health and the Medical Profession in the
Renaissance (Cambridge: Cambridge University Press, 1976), which also demonstrates that urban
planning from the late medieval period did, in fact, lead to an increased focus on sanitation and
clean air to maintain healthy living conditions.
13 For discussion of physicians as part of the Republic of Letters, and not simply answering med-
ical queries from patients, see H. Steinke, and M. Stuber, “Medical Correspondence in Early
Modern Europe. An Introduction,” Gesnerus 61 (2004), 139–​60 and the references they pro-
vide; for a slightly earlier period, see N. Siraisi, Communities of Learned Experience (Baltimore
MD: Johns Hopkins Press, 2013).
 The Early Modern Philosophical Tr adition 187

or a man, but, in all these cases, references to health and disease were
common.14
The correspondence of the philosopher Lady Anne Conway, and
those in her circle, is an especially clear example of how health and
disease enter early modern letter writing. From her teens until her
death at the age of forty-​eight, Conway suffered debilitating attacks of
pain. In her own letters, she referred to her “afflictions,” but, as Sarah
Hutton has noted, Conway tended to present herself as resolved to
endure, exposing little of her true suffering. The correspondence of her
family presents a different picture. In 1658, Conway experienced acute
and prolonged pain for more than seven weeks. At the time, her hus-
band Lord Conway wrote to his brother-​in-​law George Rawdon, “her
sighs, and grones come so deep from her, that I am terrifyed to come
neere her.”15
Conway’s correspondence with her mentor and confidant, the
Cambridge philosopher Henry More, shows his personal concern for
Conway’s health, but also his efforts to find a cure for her physical and
psychological suffering. Securing Conway’s health, in other words, was
a significant topic of More’s correspondence with her, and the health
he wished for her was the absence of pain. It was More, for example,
who arranged for the famous physician Francis Mercury van Helmont
(son of Jan Baptiste van Helmont) to attend to her. It was also More

14 The wealth of scholarship concerning woman and their indispensable role in early modern
medicine from the household to the anatomical theater continues to grow. For several exem-
plary recent studies, see K. Park, Secrets of Woman: Gender, Generation, and the Origins of
Human Dissection (Brooklyn: Zone Books, 2006); E. Leong, “Making Medicine in the Early
Modern Household,” Bulletin of the History of Medicine 82 (2008), 145–​68; A. Rankin, Panaceia’s
Daughters: Noblewomen as Healers in Early Modern Germany (Chicago: University of Chicago
Press, 2013); and M. DiMeo, “‘Such a Sister Became Such a Brother’: Lady Ranelagh’s Influence
on Robert Boyle,” Intellectual History Review 25 (2015), 21–​36. O. Weisser, Ill Composed: Sickness,
Gender, and Belief in Early Modern England (New Haven, CT: Yale University Press, 2016) is an
eye-​opening account of the role gender plays in the experience of illness.
15 Lord Conway to Major Rawdon, August 17, 1658; cited in S. Hutton, “Making Sense of
Pain: Valentine Greatrakes, Henry Stubbe and Anne Conway,” in L. Jardine and G. Manning (eds),
Testimonies: States of Mind and States of the Body in the Early Modern Period (Dordrecht: Springer,
forthcoming).
188 Gideon Manning

who put her in touch with Frederik Clodius, who nearly poisoned
Conway using the then popular chemical medicine of mercury.16
More’s own medicine for Conway was psychosomatic. It amounted
to the (sadly common) advice offered to anyone who suffered chronic
pain. More counseled “patience and fortitude, the reading of spiritual
guides . . . and strengthening [Conway’s] mind with philosophy and
religion.”17 There was obviously more than a hint of piety and mo-
rality in this advice. Elsewhere More wrote, “the Diseases of the Body
are, for the most part, from the Vices of the Mind,” believing that “a
purifi’d Mind goes a great way to the purging and purifying of the
Body” so much so that “there is no Remedy so powerful . . . as a se-
vere application of Virtue and Piety.”18 Consistent with this, More’s
advice to Conway was medicine for the mind and not an intervention
in the body, at least not directly. At most it was a medicine meant to
affect Conway’s experience of her body, and only secondarily would
this change of mind affect her body.
While one of Conway’s physicians, van Helmont, thought that
many diseases resulted from the mind’s disordered passions, and so
could be treated directly in the way More advised, this was not clearly
More’s view nor the view of most other physicians or philosophers
at the time, although they certainly did believe that the mind af-
fected the body, and vice versa.19 Conway would eventually reject the

16 Mercury was a common chemical medicine, especially popular as a cure for “the pox” or “French
disease,” as it was known outside of France, which appears to have been a virulent form of syphilis.
17 Hutton, “Making Sense of Pain.” For more on Conway’s life and the Platonic character of
her philosophy, see S. Hutton, Anne Conway: A Woman Philosopher (Cambridge: Cambridge
University Press, 2004); and C. Mercer, “Platonism in Early Modern Natural Philosophy: The
Case of Leibniz and Conway,” in C. Horn and J. Wilberding (eds), Neoplatonic Natural Philosophy
(Oxford: Oxford University Press, 2012), 103–​26.
18 H. More, An Account of Virtue, or, Dr. Henry More’s Abridgment of Morals Put into English
(London: Printed for Benj. Tooke, 1690), 147–​48; cited in Hutton “Making Sense of Pain.”
19 For more on Van Helmont, see G. B. Sherrer, “Philalgia in Warwickshire: F. M. van Helmont’s
Anatomy of Pain Applied to Lady Anne Conway,” Studies in the Renaissance 5 (1958), 196–​206;
S. Hutton, “Of Physic and Philosophy: Anne Conway, Francis Mercury van Helmont and
Seventeenth-​Century Medicine,” in A. Cunningham and O. Grell (eds), Religio Medici: Medicine
and Religion in Seventeenth-​Century England (Surrey: Aldershot, 1996), 218–​46; Hutton, Anne
Conway, 140–​55. One of Descartes’s followers, Tobias Andreae seems to share a similar view to
 The Early Modern Philosophical Tr adition 189

consolations of philosophy, in the end experiencing the terrible indif-

ference of family and friends that those with chronic disease still find
today after long years of suffering.
It would compound the injustice of Conway’s illness to propose it
as the key to understanding her life and work. Yet her life, and her
philosophy’s strong rejection of dualism between mind and body,
reminds us that medicine and medical care in the early modern period
was the most obvious real-​world test of a philosopher’s or scientist’s
beliefs about the natural world. Did they know enough to secure their
own health and longevity or the health and longevity of others? This
question was not out of place in the early modern period. Indeed,
philosophers and scientists alike were not just consumers in the med-
ical marketplace, as Conway was in her efforts to cure her pain. They
doctored themselves and their acquaintances, as More tried to do for
Conway, and they frequently saw themselves as contributing to the ad-
vancement of medical care of both the mind and body.
And this reminds us of something else. Early modern philosophy
was as much a way of life, with practical implications actively pursued
and explicitly advertised, as it had been in earlier times.20 In the
seventeenth-​century English context, for example, speculative and
experimental science served as a means to both correct the mind’s
defects and secure its perfection. This image of the medicine of the
mind derives from a number of sources, but two traditions enjoying
newfound vitality in the sixteenth century are especially important,
namely Stoicism and the Christian emphasis on our fallen state.21

van Helmont’s (on which see the conclusion of this chapter), but even though others can be found
expressing similar views, we should not necessarily infer that they viewed the mind as the source of
all disease or that a change of mind could cure all the body’s diseases.
20 For accounts of early modern philosophy as a way of life, see the references in note 3; S.
Corneanu, Regimens of the Mind: Boyle, Locke, and the Early Modern Cultura Animi Tradition
(Chicago: University of Chicago Press, 2011); and the essays in C. Condren et al. (eds), The
Philosopher in Early Modern Europe: The Nature of a Contested Identity (Cambridge: Cambridge
University Press, 2006).
21 Stoic influence on early modern philosophical thought is discussed in the essays collected in
J. Miller and B. Inwood (eds), Hellenistic and Early Modern Philosophy (Cambridge: Cambridge
190 Gideon Manning

While the immediate religious and moral value of engaging in phi-

losophy or science was being declared, their indirect advantages were
also being cited. It was believed that the new science, as a science of the
natural world, would eventually reveal many secrets, including secrets
about the human body. An improved medicine of the body would
follow this newfound knowledge and enable further cultivation of
the mind once freed from the body’s daily and sometimes painful
distractions. Ultimately, this cycle would lead to the realization of
goods like happiness and tranquility during our earthly lives.
Along with such optimism came the belief that a new method for
avoiding errors and discovering truths was required if we were to
achieve these goals. As early modern philosophy came to be associ-
ated with these new methods, it was the latter (the method), as a form
of education and cultivation, either in the guise of a traditional logic,
a logic of invention, or a method of interpretation, that took on the
role of a “medicine of the mind.” Francis Bacon is an important case
in point. In the first instance, he describes his moral philosophy as
a “medicining of the minde” in the Advancement of Learning (1605),
something he reiterated in his later De Augmentis scientiarum (1623).22
“Medicining of the body,” wrote Bacon, it is appropriate “first to know
the diuers Complexions and constitutions, secondlye the diseases,
and lastlye the Cures.” And so too “in medicining of the Minde, after
knowledge of the diuers Characters of mens natures, it foloweth in

University Press, 2003). For the Stoic background to the early modern medicine of the mind in par-
ticular, see Guido Giglioni’s chapter in the present volume, as well as his “Medicine for the Mind
in Early Modern Philosophy,” in J. Sellars (ed.), The Routledge Handbook of the Stoic Tradition
(London: Routledge, 2016), 189–​203; D. Jalobeanu, “Francis Bacon and Justus Lipsius: Natural
Philosophy, Natural Theology and the Stoic Discipline of the Mind,” in J. Papy and H. Hirai
(eds), Justus Lipsius and Natural Philosophy (Bruxelles: Wetteren Universal Press, 2007),
107–​21; and Corneanu, Regimens of the Mind. The significance of religion to early modern sci-
ence would be hard to overstate. For entry into this unsurprisingly large body of literature that
includes discussion of original sin, see P. Harrison, The Fall of Man and the Foundations of Science
(Cambridge: Cambridge University Press, 2007).
22 I thank Soranna Corneau for correspondence about Bacon’s medicine of the mind. Any
misunderstandings are my own. For more on Bacon see Guido Giglioni’s chapter in the present
volume.
 The Early Modern Philosophical Tr adition 191

order to know the diseases and infirmity[i]‌es of the mind, which ar

no other then [sic] the perturbations and distempers of the affec-​tions
[sic].”23
The precise details of Bacon’s early medicine of the mind are not
easily summarized. Its goal is to teach virtue by curing us of the
distempers and passions that distract our intellect. Whether the med-
icine of the mind alone can deliver us to a virtuous life is ambiguous;
it looks more like a preparation, a ground clearing for the diligence
and continuous labor needed to achieve virtue. Still, the Stoic rhetoric
Bacon adopts represents the best state of the soul (virtue) by analogy to
the ideal state of the body, namely health.24 The analogy even extends
to discussing vice, which Bacon presents as comparable to the diseases
of the body. Each of these diseases is a disturbance, the former of the
healthy mind, the latter of the healthy body, and each can be avoided
or corrected with the appropriate regimen, either a medicine for the
mind or a medicine of the body.25
Bacon goes on to extend much of the same language from his moral
philosophy to describe his cure for our false beliefs, that is, his method
in natural philosophy. Bacon’s response to error required long-​term
care and an effort to fight what he identified first in the Advancement
of Learning and later in the New Organon (1620) as the obstacles
to human reasoning: the “Idols” or “Illusions” of the Tribe, Cave,
Marketplace, and Theatre.26 The first of these impediments, the Idols

23 M. Kiernan (ed.), The Oxford Francis Bacon, vol. 4 (Oxford: Oxford University Press,
2000), 149.
24 Similarly, in De Augmentis the good of the mind is presented as analogous to the good of the
body consisting in “health” (absence of perturbations), “beauty” and “strength”: J. Speeding, R.
Ellis, and D. Heath (eds), The Works of Francis Bacon, 15 vols. (London: Longman, 1860), 5:30.
25 Other self-​styled reformers in the seventeenth century, including the German university pro-
fessor and Calvinist minister Johann Heinrich Alsted, would describe philosophy, and not method
per se, as “a universal medicine . . . by means of which the diseases which the mind suffers in knowing
things, words, and modes can be removed”; cited and translated in H. Hotson, Johann Heinrich
Alsted 1588–​1638: Between Renaissance, Reformation, and Universal Reform (Oxford: Clarendon
Press, 2000), 73.
26 L. Jardine, and M. Silberthorne (eds), Francis Bacon: The New Organon (Cambridge: Cambridge
University Press, 2000), 40 (I.34).
192 Gideon Manning

of the Tribe, include limitations owing to human nature in general,

such as the limitations of sense experience. The second, Idols of the
Cave, are more personalized limitations of mind and body, including
those errors that result from individual prejudices, habits, or styles
of reasoning. Idols of the Marketplace derive from our common lan-
guage, which does not reliably distinguish phenomena. Finally, Idols
of the Theatre are like fictional worlds built using systems of philos-
ophy and traditional (though inadequate) rules of demonstration.
In the New Organon these four sources of error are described as
being in need of a “remedy,” a word Bacon uses repeatedly throughout
the text.27 It is his view that conducting experiments will ameliorate
the errors of the senses, and in his more polemical moments he declares
that the Idols of the Cave and Marketplace “can be eliminated” while
those of the Theatre can “in no way” be eliminated unless a new
method is introduced into philosophy.28 We must “indict [the Idols],”
Bacon says, “and . . . expose and condemn the mind’s insidious force.”
Exposing and restraining the mind is necessary “in case after the de-
struction of the old, new shoots of error should grow and multiply
from the poor structure of the mind itself.” This is precisely why con-
stant vigilance is needed, to avoid the return of error and to keep the
mind well ordered. Bacon’s constructive proposal is to “fix and estab-
lish for ever the truth that the intellect can make no judgement except
by induction in its legitimate form.”29 And this is precisely the remedy
or medicine the New Organon will provide us. It delivers a method
that limits the mind to the proper form of induction.

27 Additional examples of medical language in the New Organon include referring to the method
Bacon advocates as offering “true helps” (vera auxilia) (I.9); “treatment and cure” (remedium &
medicinam) (I.94); “ministration” (ministramus) and “regulation” (regimus) (I.126).
28 Jardine and Silberthorne, Bacon: The New Organon, 19.
29 Jardine and Silberthorne, Bacon: The New Organon, 19. See also I.68 where Bacon declares the
Idols “must be rejected and renounced and the mind totally liberated and cleansed of them, so that
there will be only one entrance into the kingdom of man, which is based upon the sciences” (56).
 The Early Modern Philosophical Tr adition 193

But if Bacon was optimistic about the cures available in the early
years of the seventeenth century, others were less so later in the cen-
tury. Leibniz, who thought he might successfully reconcile the
Catholic Church with Protestantism, so himself far more an opti-
mist than most, would lament in 1670: “we are ignorant of the med-
icine of bodies and of minds.”30 And Henry More, whom we met
earlier, identified a “disease incurable,” namely, atheism, or “perfect
Scepticisme.” A “thing rather to be pitied or laught at,” thought More,
“then seriously opposed.”31 Pursuing the analogy between the med-
icine of the mind and the medicine of the body just a bit further,
More’s “disease incurable” reminds us that there is a limit to what the
medicine of the mind could cure or even ameliorate, just as there were
diseases of the body that had no remedy.
The aim of this section has been to show that there are many lands
where the concept of health can be found. It is present in what we
today would characterize as philosophical and medical texts, but it is
also a part of social and religious ritual and constituted, in part, by the
spaces in which we live. It is in literature and art, and religion, but also
relevant to economic and political events effecting tens of thousands.
In other words, were this an entire volume about the early modern
period, all these contexts would deserve attention, and this diversity
should not be forgotten in spite of the narrow focus required here.

Descartes and His Medical Philosophy

Nearly everything mentioned about health and the medicine of the

mind and body in the previous section applies to Descartes. His

30 L. E. Loemker (ed. and trans.), Philosophical Papers and Letters: A Selection (Dordrecht: D.
Reidel, 1969), 132. For the view of Leibniz as an optimist and “conciliatory eclectic,” see C.
Mercer, Leibniz’s Metaphysics: Its Origins and Development (Cambridge: Cambridge University
Press, 2001).
31 A. Gabbey, “ ‘A Disease Incurable’: Scepticism and the Cambridge Platonists,” in R. H. Popkin
and A. J. Vanderjagt (eds), Scepticism and Irreligion in the Seventeenth and Eighteenth Centuries
(Leiden: Brill, 1993), 89.
194 Gideon Manning

correspondence is replete with medical discussion, and he freely offers

advice to his correspondents about their health or his desire to cure
them of their ailments.32 Descartes also developed his own remedies,
one of which, for constipation, Leibniz thought enough of to have
transcribed and preserved in its only surviving copy.33 Uniquely
among the standard bearers of early modern philosophy, Descartes
was also offered a position on the medical faculty at a major European
university.34 Indeed, so central were the notions of health and disease
to his projects that in 1637, in the concluding section of the Discourse
on Method, he wrote of a commitment “to devote the rest of [his] life
to nothing other than trying to acquire some knowledge of nature
from which we may derive rules in medicine which are more reliable
than those we have had up till now” (Writings, 1:43).35
In this section, we will proceed to examine, first, Descartes’s com-
mitment to medicine and his therapeutic view of philosophy. Next
we will consider evidence of his interest in the medicine of the body.
Finally, after considering the relationship between the medicine of the
body and the medicine of the mind, we will identify the three forms of
therapeutic advice present in his correspondence. In spite of his many
innovations, Descartes’s medical advice remained quite traditional;
this mix of innovation and tradition is a persistent mark of the early
modern concept of health.

32 The first volume of Descartes’s correspondence published in 1657 came with a subheading
indicating that “les plus belles Questions de la Morale, Physique, Medecine, & des Mathematiques”
were discussed in the volume.
33 The recipe is cited and translated in J. E. H. Smith, “Early Modern Medical Eudaimonism,” in
P. Distelzweig et al. (eds), Early Modern Medicine and Natural Philosophy (Dordrecht: Springer,
2015), 325–​41, at 325–​26.
34 For discussion of the University of Bologna’s efforts to hire Descartes, see G. Manning,
“Descartes and the Bologna Affair,” British Journal for the History of Science 47 (2014), 1–​13.
35 Descartes’s work is cited in the text using the now standard Cambridge translations of J.
Cottingham et al., Descartes’ Philosophical Writings, 3 vols (Cambridge: Cambridge University
Press, 1985–​1991), hereafter abbreviated Writings.
 The Early Modern Philosophical Tr adition 195

Medicine for the Mind

The position Descartes takes in his first publication, the Discourse,

involves more than a commitment to preserving the health of the body
or even learning how to reclaim it once lost, both common goals de-
fining a physician’s activities. Just prior to the passage quoted earlier,
Descartes elaborates his motivation. “Even the mind depends so much
on the temperament and disposition of the bodily organs that if it is
possible to find some means of making men in general wiser and more
skillful than they have been up to now, I believe we must look for it in
medicine” (Writings, 1:43). For Descartes, medicine of the body is the
key to our moral and intellectual improvement. Elsewhere in the same
work, he wrote, “we might free ourselves from innumerable diseases,
both of the body and of the mind, and perhaps even from the infirmity
of old age, if we had sufficient knowledge of their causes and of all the
remedies that nature has provided” (Writings, 1:143).
It would be a mistake to dismiss Descartes’s sentiment from the
Discourse. In 1645 Descartes wrote to the Marquis of Newcastle,
“the preservation of health has always been the principal end of my
studies.” Two years later, in the French letter preface to the Principles
of Philosophy, the principal benefit of philosophy—​which includes not
just metaphysics but also natural philosophy, the two disciplines with
which Descartes is most often identified—​is said to “depend on those
parts of it which can only be learnt last of all”; namely, medicine, me-
chanics, and morals. In the tree of knowledge from the same preface,
Descartes informs us that the roots of knowledge are metaphysics, the
trunk physics, and the three branches, where the fruit is to be found,
are medicine, mechanics, and morals.36 Thus, in spite of our image of
Descartes as primarily a physicist and metaphysician, there is ample
evidence that he located the value of his project neither in metaphysics

36 For earlier uses of “the tree of knowledge,” see R. Ariew, “Descartes and the Tree of Knowledge,”
Synthèse 92 (1992), 101–​16.
196 Gideon Manning

nor even physics, but in philosophy’s ability to deliver what is good

for human beings, whether the instrumental goods of mechanics, the
natural good of health, or the highest good of morals. In other words,
Descartes understood the value of philosophy in terms of the life it
could deliver and, specifically, as the means to a better life that in-
cluded greater health than previously possible.
In providing guidance on how to live, including how to improve our
knowledge, Descartes often resorted to the language of therapeutics
and medicine, just as we saw Bacon doing in the previous section.
Among his earliest extent writings, for example, likely from 1619 to
1622, Descartes declared, “I use the term ‘vice’ to refer to the diseases
of the mind, which are not so easy to recognize as diseases of the body.
This is because we have frequently experienced sound bodily health,
but have never known true health of the mind” (Writings, 1:3). If this
is not a full embrace of the traditions discussed in the early chapters of
this volume, Descartes is certainly helping himself to the compelling
rhetoric of health to describe the imperfect state of our knowledge and
our minds.
Twenty years later, in what today is his most famous work, the
Meditations on First Philosophy (1641), Descartes would again resort
to the language of health and disease to defend his project. Against
Hobbes’s criticism that he had said nothing new when raising skeptical
doubts in Meditation One—​for example, perhaps I am dreaming? per-
haps there is an evil deceiver?—​Descartes replied: “I was not looking
for praise when I set out these arguments; but I think I could not have
left them out, any more than a medical writer can leave out the de-
scription of a disease when he wants to explain how it can be cured”
(Writings, 2:121). Descartes’s philosophy was a cure, but the question
that remains unanswered in the reply to Hobbes is, a cure for what? In
the Meditations, the answer would seem to be skeptical doubt, but this
would confuse just one symptom for the true disease. What we must
cure are our false beliefs more generally, and these, Descartes tells us,
result from the prejudice of relying on the senses as a guide to truth,
 The Early Modern Philosophical Tr adition 197

itself a by-​product of being born into the world as children who must
rely on our senses to survive.37
Conceiving Descartes’s philosophy as a therapy tied to overcoming
our false beliefs and the overreliance on the senses is also encouraged
by the topic of his earliest book-​length philosophical manuscript: the
Rules for the Direction of the Mind. This is a difficult work—​made more
difficult by a newly discovered manuscript in 2011—​but the Rules of
the late 1620s has as its goal “to direct the mind with a view to forming
true and sound judgments about whatever comes before it” (Writings,
1:9). Among the benefits of the “universal wisdom” Descartes sought
to cultivate, he included an “intellect” that could “show his will what
decision it ought to make in each of life’s contingencies” (Writings,
1:10). From judgment, to universal wisdom, to the cultivation of the
intellect, in the Rules philosophy equipped us to attain “the comforts
of life . . . [and] the pleasure to be gained from contemplating the truth,
which is practically the only happiness in this life that is complete and
untroubled by pain” (Writings, 1:10, see also 1:179).
As we saw in the case of the later Discourse and Principles, the theme
of guiding the mind to knowledge and virtue, and ultimately hap-
piness, is not just to be found in Descartes’s unpublished work. It is
hinted at on many occasions over a lifetime of writing. Its fullest ex-
pression comes late, however, when he is called upon to address the
concerns of Princess Elisabeth of Bohemia and, subsequently, in
his Passions of the Soul (1649). To Elisabeth he wrote: “True philos-
ophy . . . teaches that even amidst the saddest disasters and most bitter
pains we can always be content, provided that we know how to use our
reason” (Writings, 3:272). The cultivation of the mind, in other words,

37 There are, of course, many different interpretations of the Meditations, but for an elaboration
of the interpretation I follow here, including one in which childhood is presented as the source of
our errors, see D. Garber, “Semel in vita: The Scientific Background to Descartes’ Meditations,”
in A. O. Rorty (ed.), Essays on Descartes’ Meditations (Berkeley: University of California Press,
1986), 81–​116; S. Menn, Descartes and Augustine (Cambridge: Cambridge University Press,
2002); and G. Hatfield, Routledge Philosophy Guidebook to Descartes and the Meditations
(London: Routledge, 2002).
198 Gideon Manning

is the key to happiness, and with adequate effort virtue and happiness
are attainable in this life. Though Descartes would go on to write in
the final article of the Passions, “it is on the passions alone that all the
good and evil of this life depends,” what the medicine of the mind
can offer, consistent with his letters to Elisabeth, is a contentment im-
mune to the passions and our bodily condition.

Medicine for the Body

We will return to Descartes’s medical advice, but before this we

should document another of the currents that flows into Descartes’s
correspondence. It is his interest in theoretical medicine—​anatomy
and what we would now call physiology. These are the capstones of
Descartes’s natural philosophy or physics and the basis for his scien-
tific medicine.
Roughly at the time when he abandoned the Rules, in a letter
from December 1629 to his friend and intellectual ally in Paris,
Marin Mersenne, Descartes announced that he had begun “to study
anatomy.” Early the next year, Descartes made his interest in both
theoretical and practical medicine more explicit, and at the same
time declared it more central to his ongoing work. Writing again to
Mersenne, Descartes expressed regret in January 1630 that Mersenne
was experiencing an outbreak of an acute skin disease. “Please look
after yourself,” Descartes wrote his friend, “at least until I know
whether it is possible to discover a system of medicine which is founded
on infallible demonstrations, which is what I am investigating at pre-
sent.” Shortly afterward, in April 1630, Descartes similarly indicated
how medicine, and by implication medicine’s central notion of health,
consumed his time:

I am now studying chemistry and anatomy simultaneously; every

day I learn something that I cannot find in any book. I wish I had
already started to research into diseases and their remedies, so that
 The Early Modern Philosophical Tr adition 199

I could find some cure for your erysipelas, which I am sorry has
troubled you for such a long time. (Writings, 3:21)

For Descartes these are among the earliest indications he was taking
an active interest in the medicine of the body, and one of the few
instances in which he cites chemical medicine among his interests.
Regrettably, any reconstruction of Descartes’s activities during this
period, due to gaps in the historical record, must be inferred from a
limited number of surviving letters along with the ultimate fruit born
from his research later in the 1630s. We do know that The World, a
work occupying Descartes from 1630 to 1633, was initially conceived
as a contribution to meteorology, portions of which appeared among
the essays accompanying the Discourse in 1637. But we also know
that Descartes repeatedly expanded the scope of The World between
1630 and 1633, so much so that what survives today as The World and
the Treatise on Man were meant to be two parts of a single work of
physics. And finally, we know that the content of the Treatise on Man
presupposes and incorporates extensive knowledge of anatomy and
physiology, preliminary studies to a medicine of the body. Evidence
for Descartes’s interest in the medicine of the body appears repeat-
edly throughout his subsequent publications and correspondence, the
latter of which includes exchanges with physicians, such as Vopiscus
Fortunatus Plempius, a professor of medicine in Amsterdam and later
Leuven, and those, like Princess Elisabeth of Bohemia, who welcomed
Descartes’s medical advice.
To recall the terrain we have mapped so far, we have discovered in
Descartes a diverse medicine of the mind meant to cure us of errors,
aid us in gaining true beliefs, equip us to make true judgments, and
even provide for happiness and contentment. We have also found a
medicine of the body in Descartes, one aimed at curing diseases
and preserving health through greater knowledge in physics, es-
pecially through anatomy and physiology. We do not yet know the
relationship between these two medicines. It would seem that the
200 Gideon Manning

medicine of the mind as a cure to error and a method of invention is

a prerequisite to a medicine for the body for Descartes. That is, the
medicine of the mind cultivates the intellect and it is through the in-
tellect that we attain a better physics and, ultimately, a better physi-
ology and medicine. Yet lurking here is a tension within Descartes’s
project. Do we need a medicine of the mind for an effective medicine
of the body, or can the latter develop on its own, in which case the art
of medicine might not need the science of physics. And how are we to
understand the health of the body? This is not merely a question about
how physicians might define health but, more fundamentally, whether
the physics that comes on the heels of the medicine of the mind has
the resources to differentiate between something that is healthy as op-
posed to diseased. In the next subsection, I consider the prospects for
the concept of health, after which, I present Descartes’s three thera-
peutic strategies. Although Descartes did not see any obvious tension
between his medicine of the mind and his medicine of the body, we
will have a chance to consider whether there is a tension between the
biomechanics that develops from his medicine of the mind and his
other therapeutic strategies in the conclusion to the paper, when we
look at the reception of Descartes’s medicine.

Medicine and Metaphysics

The pivotal passage relating Descartes’s most fundamental meta-

physical commitments about the natural world to health occurs in
Meditation Six, where he emphasizes the natures we must cite when
referring to artificial and natural kinds. He specifically tells us what
is involved in imagining bodies suffering from, in his words, “errors of
nature” (Writings, 2:58–​59). The passage is long, but it is too important
not to quote at length:

Yet it is not unusual to go wrong even in cases where nature does

urge us toward something. Those who are ill, for example, may
 The Early Modern Philosophical Tr adition 201

desire food or drink that will shortly afterwards turn out to be bad
for them. Perhaps it may be said that they go wrong because their
nature is disordered, but this does not remove the difficulty. . . .
A clock constructed with wheels and weights observes all the laws
of its nature just as closely when it is badly made and tells the wrong
time as when it completely fulfils the wishes of the clockmaker. In
the same way, I might consider the body of a man as a kind of ma-
chine equipped with and made up of bones, nerves, muscles, veins,
blood and skin in such a way that, even if there were no mind in it, it
would still perform all the same movements as it now does in those
cases where movement is not under the control of the will or, conse-
quently, of the mind. I can easily see that if such a body suffers from
dropsy, for example, and is affected by the dryness of the throat
which normally provides in the mind the sensation of thirst, the
resulting condition of the nerves and other parts will dispose the
body to take a drink, with the result that the disease will be aggra-
vated. Yet this is just as natural as the body’s being stimulated by a
similar dryness of the throat to take a drink when there is no such
illness and the drink is beneficial. Admittedly, when I consider the
purpose of the clock, I may say that it is departing from its nature
when it does not tell the right time; and similarly when I consider
the mechanism of the human body, I may think that, in relation to
the movements which normally occur in it, it too is deviating from
its nature if the throat is dry at a time when drinking is not bene-
ficial to its continued health. . . . As I have just used it, “nature” is
simply a label which depends on my thought; it is quite extraneous
to the things to which it is applied, and depends simply on my com-
parison between the idea of a sick man and a badly-​made clock, and
the idea of a healthy man and a well-​made clock. But by “nature” in
the other sense I understand something which is really to be found
in the things themselves; in this sense, therefore, the term contains
something of the truth. When we say, then, with respect to the body
suffering from dropsy, that is has a disordered nature because it has
202 Gideon Manning

a dry throat and yet does not need drink, the term “nature” is here
used merely as an extrinsic denomination [denominatio extrinseca].
However, with respect to the composite, that is, the mind united
with this body, what is involved is not a mere label, but a true error
of nature, namely that it is thirsty at a time when drink is going to
cause it harm. (Writings, 2:58–​59; modified)

One way in which to understand Descartes here would begin by

noting that there are cases of illness in which we desire something that
will, in fact, lead to great harm. If we genuinely desire something when
it is not good for us, the background worry for Descartes is that God
would be deceiving us by giving us a “nature” susceptible to such errors;
God would be responsible for our misperception. But, Descartes asks,
what is it for us to have a nature in this sense? Consistent with his
remarks from the Treatise on Man and Discourse, in Meditation Six
Descartes initially uses “nature” to signify the bodies that are defined
by their size, shape, and state of motion. To this extent our nature is no
different than the nature of those things studied in physics or natural
philosophy. In other words, our bodies, like the rest of the bodies in
the world, are extended and necessarily obey the laws of nature along
with the other general constraints appropriate to extended things.
In Meditation Six, Descartes extrapolates from this insight to the
rest of the physical world. Thus, from the point of view of Descartes’s
physics, the human body and the animal body, and really all bodies,
are alike just machines with dispositions to act. In terms of mechanical
analysis, the desire for harmful food or drink is the result of a disposi-
tion or state of motion coupled with the laws of nature, just as any other
physical phenomenon will be. There simply is no normative or evalu-
ative judgment that can be made which calls the process of a human
body or machine causing its own demise unnatural. As Descartes
concludes, there is no room for straightforward characterizations
of health and illness given the resources of dispositions and laws of
 The Early Modern Philosophical Tr adition 203

nature alone; there is nothing that can be disordered in violation of

its nature.
Even so, it seems undeniable that living things get sick, age, and
eventually die. It is as true of the world we experience as anything we
might claim to know.38 Put another way, pain hurts, and so too, in a
slightly different way, does the loss of vitality. If these are not caused
by deviations from our healthy states or subjective experiences of such
deviations, then what are they, and how should they be understood?
Contrary to how it may at first appear from Meditation Six, Descartes
believes that the language of function and malfunction appropriate to
his mechanical physiology and pathology, especially where medicine
is concerned, is more than either a figment of our imagination or, in
contemporary language, a sophisticated account of biological function
plus species-​specific statistical normality.39
Scholars disagree about how to interpret what Descartes says next
in Meditation Six, but it seems clear that for animals, the human
body, and even clocks, assigning them a nature that justifies talking
as though they are supposed to be like something, or supposed to do
something, is to assign them a nature that they do not have from the
standpoint of physics. It is to use “nature,” Descartes says, as an “ex-
trinsic denomination.”40

38 G. Hatfield, “Animals,” in J. Broughton and J. Carriero (eds), Companion to Descartes

(Oxford: Blackwell, 2008), 404–​25, emphasizes this fact and makes good use of it when discussing
the ontological status of our bodies in Descartes’ physics. It is also a fact that speaks strongly
against eliminative readings of Descartes’s conception of life.
39 See C. Boorse, “Health as a Theoretical Concept,” Philosophy of Science 44 (1977), 542–​73
for a defense of the view that health involves a value-​free statement of biological function plus
statistical normality. As I suggest above, Boorse’s position is close to the view Descartes presents
but ultimately rejects in Meditation Six. Boorse has defended his view, although understandably
not against Descartes, in Boorse, “A Rebuttal on Health,” in J. M. Humber and R. F. Almeder
(eds), What Is Disease? (Totowa: Humana Press, 1997), 1–​134; and Boorse, “A Second Rebuttal on
Health,” The Journal of Medicine and Philosophy 39 (2014), 683–​724. For more on Boorse’s view
and its critics see Elselijn Kingma’s contribution in the present volume.
40 Alternatively, in adopting this technical terminology Descartes may be indicating that the
right way to understand our judgment that some objects are broken and others are in working
order, or that animals are healthy or unhealthy, would follow accounts of the so-​called secondary
qualities. This claim does not enter my discussion here, but it may signal a neglected approach to
204 Gideon Manning

I have argued elsewhere that the proper interpretation of Meditation

Six, at this critical juncture in the text, hinges on this technical and
antiquated term.41 In citing an “extrinsic denomination,” Descartes
is acknowledging that it is not a mistake to speak about a clock, an
animal, or the human body as malfunctioning or being in error; our
talk of a “nature” or of “health” is not arbitrary or simply imposed
without justification. Instead, we are simply relying on a relation or
analogy that exists between the clock, animal, or human body, and
something else. A very different example will help illustrate these two
points. When we refer to a healthy salad, “healthy” would be an ex-
trinsic denomination. This does not mean we are incorrect to claim
that a salad is healthy, it is just that salads are healthy because they are
a cause of (related to) health in human beings.
The point we have reached in our survey of Descartes is this: ac-
cording to the privileged reality described by his physics, the human
body and the animal body are extrinsically denominated with a nature
because, taken by themselves, they lack an individual nature; in the
mechanical world there are no normative ideals but only necessities
controlling the way a body’s dispositions produce effects. Nevertheless,
as in the case of a clock, when the clock is related to our intentions, this
relation justifies our saying that the clock is for telling the time, and
relative to our purposes is a good or a bad clock. In itself, of course, the
clock is a complex bit of matter disposed to move in fixed patterns.42
Following Descartes’s account, the next step is to realize that what has

the issues of teleology and function in nonhuman living things that have become a focus of recent
scholarship (see references in note 42).
41 G. Manning, “Descartes’ Health Machines and the Human Exception,” in D. Garber and S.
Roux (eds), The Mechanization of Natural Philosophy (Dordrecht: Springer, 2013), 237–​62.
42 There is a question of whether even this is so according to the strictures of Descartes’s meta-
physics and, if it is, whether one might accept teleology and derive an account of function from the
dispositional unities that exist in the world. For discussion with a negative conclusion, see D. Des
Chene, Spirits and Clocks: Machine and Organism in Descartes (Ithaca, NY: Cornell University
Press, 2001), 125ff. For a more optimistic conclusion, see L. Shapiro, “The Health of the Body
Machine? Or Seventeenth-​Century Mechanism and the Concept of Health,” Perspectives on
Science 11 (2003), 421–​42; D. J. Brown, “Cartesian Functional Analysis,” Australiasian Journal of
Philosophy 90 (2012), 75–​92; and K. Detlefson, “Descartes on the Theory of Life and Methodology
 The Early Modern Philosophical Tr adition 205

just been said about a clock is true of animals and the human body. In
relation to our purposes, or perhaps some other touchstone, as I ex-
plain below, we can make normative judgments about a thing’s nature
and our healthy states.
Beyond the purposes we might have for our bodies when thought of
as instruments, in our case—​when we understand ourselves to be more
than our mechanical bodies, but a union between mind and body—​
there exists an individual nature not otherwise found in the Cartesian
world. Descartes clearly believed that there are things about ourselves
we do not choose. When the union’s natural and intrinsic tendencies are
frustrated, we have a case of what he calls in Medication Six a “true error
of nature.” In still other words, our nature is intrinsically denominated,
and our embodied existence as human beings, as combinations of minds
and bodies, serves as the touchstone for normative judgments about our
healthy states. It specifically introduces the need for a body that can sup-
port union with the mind while minimally interfering with the mind’s
operations. The idea is that health and illness can be defined relative to
the purpose of extending the existence of the union and the mind’s pro-
ductive activity while the union exists.43 In all of Descartes’s writing,
Meditation Six appears to be the only place where he explicitly and
thoughtfully endorsed attaching normative claims to bodies without
the need to utilize an extrinsic denomination.44
Indeed, elsewhere in the Meditations and his correspondence,
Descartes emphasizes how our experience of pain and pleasure mark
our relation to our bodies and how it is bodily sensation, and not dis-
embodied reflection on our minds or bodies alone, that is our route

in the Life Sciences,” in P. Distelzweig et al. (eds), Early Modern Medicine and Natural Philosophy,
141–​72.
43 As I understand her, this is also the view presented A. Simmons, “Sensible Ends: Latent
Teleology in Descartes’ Account of Sensation,” Journal of the History of Philosophy 39 (2001), 49–​75.
44 Scholars have not reached a consensus on this issue. Though my sympathies lie closer to Des
Chene, Spirits and Clocks, alternatives can be found in Voss, “Descartes: Heart and Soul”; Shapiro,
“The Health of the Body Machine”; Hatfield, “Animals”; Brown, “Cartesian Functional Analysis”;
and Detlefson, “Descartes on the Theory of Life.”
206 Gideon Manning

to understanding ourselves as a compound of mind and body. This

does likely imply for Descartes that there is something about our
earthly existence that cannot be fully known, and the sorts of “clear
and distinct” cognitions he otherwise prized in knowledge of mind
and of body are not available in the case of the compound of the two.
Nevertheless, the point is that in spite of a long tradition portraying
Descartes as denying the lived embodied experience of a human
being, his position seems to be quite the opposite. For him, the human
being, the composite of mind and body, plays a fundamental role in
grounding even the health of the human body. Descartes is so invested
in the role bodily sensations play in guiding us to preserve our health
that he writes: “The best system [of the body] that could be devised
[by God] is that it should produce the one sensation which, of all pos-
sible sensations, is most especially and most frequently conducive to
the preservation of the healthy man. And experience shows that the
sensations which nature has given us are all of this kind” (Writings,
2:60–​61).
The initial challenge Descartes identifies in Meditation Six, of
characterizing health in terms of errors or malfunctions—​deviations
from our nature—​is still with us today, and there is not yet agreement
on how to meet it. For his part, however, once having staked out a
position in Meditation Six, Descartes does not appear to look back
(and it is interesting to note that the long passage from Meditation Six
does not figure prominently among his disciples or later reception).
To the contrary, Descartes provided medical advice to his friends and
correspondents as though the concept of health was easily or obviously
defined, in spite of the apparent tension between his metaphysical de-
piction of bodies as merely extended and the fundamental place of the
human being in his medical philosophy.45

45 Voss, “Descartes: Heart and Soul,” reads the evidence slightly differently here. “To define the
body’s health in terms of the human being’s welfare is to go against [the] grain” of Descartes’s
 The Early Modern Philosophical Tr adition 207

Descartes’s Medical Therapies

Descartes’s interests in theoretical and practical medicine come to-

gether, as well as his interests in the medicine of the mind, in his cor-
respondence with the exiled Princess Elisabeth.46 Descartes has his
hands full in these letters on nearly every subject that Elisabeth raises,
but our purposes can be served if we focus on Elisabeth’s “indisposition
in the stomach,” which is a topic of their correspondence in July 1644.
Assuming the role of a corresponding physician, he writes “the remedies
which Your Highness has chosen, diet and exercise, are in my opinion
the best of all.” With this, Descartes endorses a very traditional view of
medical intervention: you cure the body by controlling a subgroup of
the non-​naturals, in this case what you eat and how much you move.
Yet, tellingly, Descartes also qualified this endorsement. Intervening
through direct control of the body was best, “leaving aside those
[remedies] pertaining to the soul.” The medicine of the mind or
soul, by which Descartes means the same thing here, was relevant
because he had

no doubt that the soul has great power over the body, as is shown
by the great bodily changes produced by anger, fear and the other
passions . . . I know no thought more proper for preserving health
than a strong conviction and firm belief that the architecture of
our bodies is so thoroughly sound that when we are well we cannot
easily fall ill except through extraordinary excess or infectious air
or some other external cause, while when we are ill we can easily

metaphysical commitments and “the evidence is that Descartes abandons the attempt” (189; see
also Shapiro, “The Health of the Body” for the same conclusion). The evidence Voss cites is largely
Descartes’s silence on the issue, but I hesitate to equate silence with outright rejection.
46 For more extensive accounts of the medical content of Descartes’s correspondence with
Elisabeth see S. Mills, “The Challenging Patient: Descartes and Princess Elisabeth on the
Preservation of Health,” Journal of Early Modern Studies 2 (2013), 101–​22; and the extensive edito-
rial notes in L. Shapiro (ed. and trans.), The Correspondence between Princess Elisabeth of Bohemia
and René Descartes (Chicago: University of Chicago Press, 2007).
208 Gideon Manning

recover by the unaided force of nature, especially when we are still

young. (Writings, 3:237)

All three of Descartes’s therapeutic strategies for regaining physical

health are on display and work in tandem with one another in the 1644
correspondence with Elisabeth. First, Descartes advises Elisabeth to
attend to what she eats and how much she exercises. Though it is not
explicit in the letter, this unremarkable advice is based on an entirely
different etiology for Descartes than for other physicians. It reduces to
a form of mechanical therapy or, as I labeled it earlier, biomechanics.
In the example above, Descartes does not advise exercise because of
an imbalance in the traditional four humors, but because exercise
will facilitate circulation; thinning of the blood; and possibly even
modulating the heat in the heart, which plays a central role in all phys-
iological functions.47 Biomechanics is also implicated in the two fur-
ther therapeutic strategies Descartes endorses, as we are about to see,
though it is not itself the most effective therapy on Descartes’s view.48

47 In the Description of the Human Body (1649) Descartes writes, “it is so important to know the
true cause of the heart’s movement that without such knowledge it is impossible to know anything
which relates to the theory of medicine. For all the other functions of the animal are dependent on
this, as will be clearly seen in what follows” (Writings, 1:319).
48 Tad Schmaltz notes that though “Descartes sometimes suggests that therapeutic treatments re-
quire only our ordinary experience, and thus need not involve an investigation of the physiological
details, for the most part his medicine presupposes a special form of ‘biomechanics’ ”: T. Schmaltz,
Early Modern Cartesianisms: Dutch and French Constructions (Oxford: Oxford University Press,
2016), 228–​29. Schmaltz also finds that the art of medicine is “distinct in kind” from Descartes’s
biomechanical medicine (265). The relation between the art of medicine and the science of med-
icine on which the art is supposedly based according to both scholastics and Descartes is a com-
plicated one. So far as I understand Schmaltz, however, I disagree with his assessment. It is worth
noting that the medical advice Descartes offered was quite traditional and, as we are about to see,
his psychosomatic medicine also presupposes the mind can affect the biomechanics of the body,
something it admittedly does without knowledge of the physiological details. To me this suggests
that psychosomatic medicine exploits biomechanics and is not wholly distinct from it. Further,
the fact that Descartes’s naturopathic medicine offers a direct route to an individualized thera-
peutic intervention (as such it allows for an informed rejection of a physician’s recommendation)
does not mean that the biomechanical science Descartes envisions would (ultimately) recommend
a different medicine for the body than the one recommended by his naturopathic medicine. These
two medicines would ultimately agree about the proper intervention; it is simply that the patient’s
 The Early Modern Philosophical Tr adition 209

The additional complementary therapies recommended in the corre-

spondence with Elisabeth are psychosomatic and naturopathic medicine.
Let us take each of these in turn. We saw above that Elisabeth is advised
by Descartes to think about how persistent and self-​sustaining her body
is, and this thought, this reassuring and happy thought, will serve as a
kind of hygiene preventing illness except in “extraordinary” cases. Later
in the correspondence to Elisabeth, from May or June of 1645, Descartes
further elaborates the power of the mind and especially the imagination
on our bodies. He cites two hypothetical men. The first man’s thoughts
make him physically sick, while the other’s preserve and heal his body.
Specifically, the first man has “every reason to be happy” but spends all
his time “in the consideration of sad and pitiful objects.” This “by itself,”
writes Descartes, “would be enough gradually to constrict his heart and
make him sigh in such a way that the circulation of his blood would be
delayed and slowed down” (Writings, 3:250). Linking the mind’s thoughts
to the body, as Descartes unquestionably does here, his biomechanical
view of the body reemerges. For the “grosser parts of his blood, sticking
together, could easily block the spleen, by getting caught and stopping in
its pores.” Alternatively, “the more rarefied parts, being continually agi-
tated, could affect his lungs and cause a cough which in time could be very
dangerous” (Writings, 3:250). The real message to Elisabeth is not about
biomechanics and physiology, however, but about psychosomatic medi-
cine: the wrong thoughts can make us physically ill.
In the second hypothetical case, Descartes asks Elisabeth to consider
a man with little reason to be happy due to life’s misfortunes. But this
man, as opposed to the one before, spends his “time in the consideration
of objects which could furnish contentment and joy,” including, presum-
ably, that earlier mentioned “conviction and firm belief that the archi-
tecture of [his body] . . . is sound.” Descartes maintains that this second
man’s happier thoughts “would be capable of restoring him to health,

individual body is best known to the patient herself. This is precisely why Descartes can recom-
mend that the patient be her own physician.
210 Gideon Manning

even if his spleen and lungs were already in a poor condition because
of the bad condition of the blood caused by sadness” (Writings, 3:250).
Descartes only adds that coupling psychosomatic therapy with “medical
remedies to thin out the part of the blood causing the obstructions,”
which is to say traditional medicine informed by his biomechanical view
of the body, would be the most effective approach. Once again, if we
look beyond the proximate physical causes Descartes cites, the lesson for
Elisabeth is about psychosomatic medicine: the right thoughts can pre-
serve our bodies and even regain our health.49
While acting as a corresponding physician for Elisabeth, Descartes
advises her to direct her mind toward ideas that will bring her
joy. Initially citing the advantages of a medicine of the body, he
acknowledges “the waters of Spa are very good,” but “above all if
Your Highness while taking them observes the customary recom-
mendation of doctors, and frees her mind from all sad thoughts” she
could maximize chances of recovery.50 Indeed, in this way, using the
biomechanical therapy indicated by her condition plus psychosomatic
medicine, Descartes believes she “will recover perfect health.” In ad-
dition, and repeating a sentiment from the Discourse some eight years
earlier, he reminds her that bodily health “is the foundation of all the
other goods of this life” (Writings, 3:250).
Descartes’s medical views presented in the 1644 and 1645 corre-
spondence with Elisabeth are repeated the following year, in October
or November 1646. Again writing to Elisabeth about the advantages
of psychosomatic medicine, Descartes points out that “bodily health

49 In presenting this Stoic-​inspired idea of resisting life’s circumstances, whatever they may be,
Descartes’s second hypothetical man turns out to be Descartes himself: “I take the further liberty
of adding that I found by experience in my own case that the remedy I have just suggested cured an
illness almost exactly similar, and perhaps even more dangerous” than Elisabeth’s own (Writings,
3:250).
50 Descartes finishes his recommendation by advising Elisabeth to “even [refrain] from all se-
rious meditations on scientific subjects.” This added suggestion is not simply a remark informed by
Elisabeth’s gender. It is also something to which Descartes appeared committed in his own life (see
the discussion in Garber, “Semel in vita” and the references to Descartes’s work there).
 The Early Modern Philosophical Tr adition 211

and the presence of agreeable objects greatly aid the mind by chasing
from it all the passions which partake of sadness and making way
for those which partake of joy.” Moreover, “when the mind is full of
joy, this helps greatly to cause the body to enjoy better health and to
make the objects which are present appear more agreeable” (Writings,
3:296). There are many additional passages in the correspondence with
Elisabeth, but also in the later Passions, where Descartes reiterates
these and similar claims.51 We will see in the next section, how-
ever, that Descartes’s psychosomatic medicine was not uniformly
embraced by his followers. Indeed, the perceived tension between his
biomechanical and psychosomatic medicine during the years after his
death has contributed to the image of Descartes as an enemy to mind-​
body medicine. But before moving to his reception, we must discuss
his third therapeutic strategy.
Descartes’s naturopathic medicine also surfaces in his July 1644
letter to Elisabeth with which this subsection began. Recall that he
told Elisabeth the “unaided force of nature” recovers our health when
it is lost. Descartes’s claim here is not obviously consistent with his
well-​known rejection of teleological explanation in physics (Writings,
2:38–​39). But even so, Descartes unquestionably supports the idea
that bodies can resist external causes that would otherwise change

51 The topic of the passions assumes a more prominent role in the final years of Descartes’s life and
deserves much fuller treatment than I have provided here. For entry into the discussion, see the
essays collected in B. Williston and A. Gombay (eds), Passion and Virtue in Descartes (Amherst,
MA: Humanity Books, 2003). Still, at least two things are worth noting. First, Descartes does
not pursue the topic of the passions as a moral philosopher but only as a “natural philosopher”
(Writings, 1:327). Second, Descartes’s view of the passions includes a partial or qualified endorse-
ment. Specifically, the passions are good insofar as they promote the body’s health, understood,
I believe, in terms of the preservation of the body, and they can even provide us with happiness
understood in terms of our bodily states. However, even this notion derives from a prior com-
mitment to the human being as a compound of mind and body, which (on my account) is the real
measure of the body’s health. The relevant questions for Descartes always become (1) is the body fit
to support union with the mind, and (2) is it obstructing the mind’s activities to the least possible
extent? These two goals are not always realized together, but the key idea is that the body’s preser-
vation, though a point Descartes often emphasizes and though a precondition for the preservation
of the union and the freeing of the intellect from our embodied distractions, is merely a means to
answering yes to questions (1) and (2) and is valued accordingly.
212 Gideon Manning

their present state and that bodies even return to a state of health of
their own accord. As he explained in a conversation recorded by Frans
Burman: even “when we are ill, nature still remains the same . . . and
makes light of any obstacles in her way, provided we obey her.”
Accordingly, physicians ought to “allow people the food and drink
they frequently desire when they are ill . . . [because in] such cases na-
ture herself works to effect her own recovery; with her perfect internal
awareness of herself, she knows better than the doctor who is on the
outside” (Writings, 3:354). In other words, physicians should be less in-
trusive or, better, should help their patients do as their patient’s na-
ture dictates because the patient knows the particularities of her case
best. Indeed, the privileged insight of a patient into her own care is
emphasized by Descartes when he cites Tiberius Caesar: “No one who
has reached the age of thirty should need a doctor, since at that age he
is quite able to know for himself through experience what is good or
bad for him, and so be his own doctor” (Writings, 3:354).52
What we find in the correspondence with Elisabeth is that
Descartes’s advice fell into three categories: manipulate the tradi-
tional non-​naturals, entertain happy thoughts, and let our natures
guide us. In the 1644 correspondence, Descartes advises we pursue
all three therapeutic strategies together, intervening in the body and
in the mind, but also encouraging Elisabeth to use her knowledge of
herself to take the lead in how to proceed. The potential tension be-
tween these three forms of medical advice will be a topic below, as will
the lasting impression that only the biomechanical strategy is strictly
Cartesian.

52 This idea that the patient was best suited to understand her own complaints and guide her own
care was unique neither to Descartes nor Tiberius, nor a principled stand against trained physicians.
For a brief discussion of self-​management of medicine in the early modern period, see R. Porter,
Disease, Medicine and Society in England, 1550–​1860 (Cambridge: Cambridge University Press,
1992), 17–​26. This provides yet another reason to be cautious before concluding that Descartes’s
threefold strategy in therapeutics is internally inconsistent.
 The Early Modern Philosophical Tr adition 213

Cartesian Physicians

We have already seen that it is incorrect to identify Descartes as just

a metaphysician or a mechanical scientist, and so it will be little sur-
prise that his early influence was strongest in medical circles, where
his views were taught and his ideas disseminated to younger gener-
ations who would themselves go on to enliven Europe’s salons and
scientific societies throughout the remainder of the seventeenth cen-
tury.53 Instrumental in shaping the medical reception of Descartes
were physicians such as Henricus Regius, Johannes De Raey, Tobias
Andreae, and Friedrich Gottfried Barbeck, as well as textbook writers
like Johannes Clauberg and Jacques Rohault. Like us, however, they
had to confront the ambiguities and potential inconsistencies among
Descartes’s texts.54 In fact, many of the initial reactions to Descartes
accepted one or more features of his system while rejecting others.55 As
we are about to see, this last observation applies equally to Descartes’s

53 See P. Mouy, Le développement de la physique cartésienne (Paris: Vrin, 1934), 73–​85; and, more
recently, A. H. Munt, “The Impact of Dutch Cartesian Medical Reformers in Early Enlightenment
German Culture (1680–​1720)” (PhD diss., University College London, London, 2005); and
Schmaltz, Early Modern Cartesianisms. Although his focus is on the history of physics, John
Heilbron identifies the significant role of a “cadre of physicians” early in Descartes’ reception: “Was
There a Scientific Revolution?,” in J. Z. Buchwald and R. Fox (eds), The Oxford Handbook of the
History of Physics (Oxford: Oxford University Press, 2013), 7–​24 (15ff). These works notwith-
standing, historians of philosophy have by and large ignored the insight, explicitly provided by
Gary Hatfield, that Descartes’s physics includes what we think of today as biology and aspects of
medicine. See, e.g., G. Hatfield, “Descartes’ Metaphysical Physics by Daniel Garber; Kant and the
Exact Sciences by Michael Friedman,” Synthese 106 (1996), 113–​38.
54 The choices made by Descartes’s followers erase some of the complexity in Descartes’s position
and often introduce distortions. This is not to suggest that a “pure Descartes” can be discovered; we
should not seek such a thing as our goal. As Geneviève Rodis-​L ewis puts it, we “cannot of course go
back in time,” but we should try to avoid “the distortions of the Cartesian system which arise when
one examines it from the perspective of the systems that succeeded it—​systems which diverged very
considerably from the source of their initial inspiration”: “Descartes and the Unity of the Human
Being,” in J. Cottingham (ed.), Descartes (Oxford: Oxford University Press, 1998), 197–​210, at 198.
55 Des Chene claims the “ambiguous legacy of Descartes is reflected in the attitudes of his
successors” (“Life and Health,” 733). However true this may be, it should not reflect on Descartes,
who saw no tension between his three therapeutic strategies. He believed they complemented one
another, as the correspondence with Elisabeth suggests. The idea that the three strategies point in
different directions, and so contribute to an ambiguous legacy, is (I believe) itself a by-​product of
the interpretative choices of his successors, along with political and institutional constraints un-
known to Descartes.
214 Gideon Manning

medicine and his therapeutic strategies, not all of which survived to-
gether among seventeenth-​century Cartesians.
Recall that Descartes allows a “true error of nature” only in the
human case, as when we are thirsty at a time that “drink is going to
cause us harm.” This links the concept of bodily health to what is
intrinsically good for the union of mind and body, but Descartes’s
definition of health remains mostly “programmatic,” linking what
is good for the body to what is good for the union but without
specifying what is good for the union beside bare survival and the
body’s minimal interference with the mind.56 To be sure, Descartes
does offer specific medical advice but his advice easily fits with estab-
lished medical traditions. The exception is the etiological justification
for medical intervention deriving from Descartes’s mechanical view
of the body and the scientific medicine his physiology is meant to sup-
port. So, while his biomechanical therapy is distinctive, its originality
lies in the supporting theory and not the theoretically informed prac-
tice itself. The same combination of tradition and innovation, and
the same gaps between innovative physiology and innovative prac-
tice, appear among Descartes’s followers when they express views
about the concept of health. In some cases, they emphasize one of
Descartes’s therapeutic strategies as opposed to the others, and, in at
least one case, they separate medicine from Descartes’ philosophy,
emphasizing that medicine is an art, not a science, and so only a na-
turopathic therapy will be viable.
To appreciate the medical landscape of the early Cartesians, take,
as a first example, advocates of Descartes’s medical science and his
biomechanical therapeutics, the pair of Henricus Regius and Jacques

56 Voss, “Descartes: Heart and Soul,” 188–​89. Efforts to fill in some of the details in Descartes’s
position beyond what I say here include L. Shapiro, “Descartes on Human Nature and the
Human Good,” in C. Fraenkel, D. Perinetti, and J. E. H. Smith (eds), The Rationalists: Between
Tradition and Innovation (Dordrecht: Springer, 2011), 13–​26; and Smith, “Early Modern Medical
Eudaimonism.”
 The Early Modern Philosophical Tr adition 215

Rohault.57 Rohault, the younger of the two, includes an entire chapter

titled “Of Sickness and Health” in his Cartesian textbook, the Treatise
on Physics (1671).58 In this work, Rohault defined health as “a partic-
ular Disposition of the Body whereby it is enabled readily to perform
all the Duties belonging to it.” What exactly these “Duties” are re-
mains unspecified. But interestingly, this definition is all about the
body, not the mind or the union of mind and body, and the very same
definition was offered thirty years earlier by Descartes’s most promi-
nent medical follower, Regius. In Regius’s Physiology or the Knowledge
of Health (1641), a collection of disputations written with Descartes’s
help, health is defined as the “disposition of the parts of the human
body such that it is able to perform its proper actions.”59 In Regius’s
later Fundamentals of Physics (1646) the earlier definition extends be-
yond human beings to animals in general: “health is the disposition of
the parts of the animal body such that it is able to perform its proper
actions.”60 His emphasis on dispositions continued the following year
in the Fundamentals of Medicine (1647) where he explains that the
“true form of illness . . . is a depraved disposition of the parts of the
body.”61 Although it is hardly unexpected that Descartes’s physiolog-
ical views led some of his followers to characterize health in terms of

57 There are similarities between the two beyond their treatment of health. For example, Rohault
choose to present Descartes’s physics without his metaphysics, a perspective consistent with
Regius’s earlier efforts; and Rohault advocated an explicit melding of Descartes’s physics with
experimentation, which was a hallmark of Regius’s earlier work as well. To my knowledge these
similarities are not well explored.
58 All translations of the Traité de physique come from J. Clarke (trans.), Rohault’s System of
Natural Philosophy, Illustrated with Dr S. Clarke’s Notes, Taken Mostly out of Sir Isaac Newton’s
Philosophy. With Additions, 2 vols. (London: Printed for James, John and Paul Knapton, 1723),
pt. 4, chap. 25.
59 Sanitas est dispositio partium humani corporis actionibus recte perficiendis apta: H. Regius,
Physiologia, sive Cognitio sanitatis (Vltraiecti: Ex Officinâ AEgidii Roman, Academiae
Typographi, 1641), I.I.I; reproduced in E.-​J. Bos, “The Correspondence between Descartes and
Henricus Regius” (Ph.D. diss., Utrecht University, Utrecht, 2002), 199.
60 Sanitas est dispositio partium corporis animalis, actionibus rectè perficiendis apta: H. Regius,
Fundamenta physices (Amstelodami: Ludovicum Elzevirium, 1646), 154).
61 Cum enim morbus sit partium dispositio, nullam materiam habet. Forma vero morbis,
quae, est dispositionis partium pravitas, est ipse morbus: H. Regius, Fundamenta medica
216 Gideon Manning

the body’s actions and dispositions—​Regius lists among the body’s

actions: motion, sensation, sleep, appetites, pulse, and respiration—​
neither Regius nor Rohault follow Descartes in relating the body’s
“Duties” or “proper actions” to what is good for the union, and so by
reference to something over and above the body itself.
Still, Regius and Rohault do elaborate on Descartes’s medical science
and his biomechanical therapy. As Rohault explains, “Two Things gen-
erally go to this [healthy] Disposition; namely, a fit Construction of the
Parts, and a just Temperature of them.” This is entirely consistent with
viewing the body as a machine as Descartes’s physiology surely does. The
emphasis on the temperature of the parts is also noteworthy, though en-
tirely traditional in associating the question of temperature with health.
But here too it seems likely Regius served as Rohault’s model, and not
Descartes himself. In Regius’s 1641 disputations, he also separates two
elements of health: “the right temperature (bona temperies)” and “proper
conformation of the parts (apta partium conformatio).”62 He goes on to
explain, “the right temperature” is not a question of the body’s primitive
qualities but the “position, figure, quantity and motion or rest of insen-
sible particles, causing harmony of actions in the sensible parts.”63
These physiological views are extended by Rohault to account for
the diseases affecting the parts and the temperature of the body. “All
Distempers are generally owning to the ill Regulation of our Lives, ei-
ther from too much or too little Sleep, too much or too little Exercise,
&c. Sometimes they are caused by Things without, and very often by

(Ultrajecti: Theodorum Ackersdycium, 1647), 27. For discussion of this definition of illness, see
T. P. Gariepy, Mechanism without Metaphysics: Henricus Regius and the Establishment of Cartesian
Medicine (PhD. diss., Yale University, 1990), 216ff.
62 Sanitatis partes duae sunt, bona temperies et apta partium conformatio: Physiologia, I.I.14;
reproduced in Bos, The Correspondence, 201. Regius would use the same language in the
Fundamentals of Physics, 159, the Fundamentals of medicine, 3, and again in the subsequent expanded
edition of the Fundamentals of physics: H. Regius, Philosophia naturalis (Amstelodami: Ludovicum
Elzevirium, 1654), 236.
63 Idcirco bona temperies à nobis definitur: situs, figura, quantitas, et motus vel quies particularum
insensibilium partes sensibiles constituentium, actionibus perficiendis conveniens: Physiologia, I.I.14;
reproduced in Bos, The Correspondence, 202.
 The Early Modern Philosophical Tr adition 217

Abuse of Food; that is, by our intemperance in eating and drinking;

which is so much the more injurious to us, because it affects us in-
wardly.”64 Remarkably, just as Rohault embraces the biomechanical
implications of Descartes’s physics for medical theory, he offers very
traditional advice tied to the regulation of the non-​naturals. This is yet
another instance of the theme I mentioned earlier in connection with
Descartes himself, where we found a melding of philosophical innova-
tion with traditional forms of therapy.
Among Descartes’s followers, this melding of innovation and tra-
dition sometimes favored one side of the synthesis over the other, as
in the case of Johannes De Raey (1622–​1702), the third Cartesian we
will consider. De Raey had been Regius’s student at Utrecht and later
became a professor of philosophy at Leiden, where he also lectured on
medicine, before becoming a member of the Amsterdam Athenaeum.
His evolution from a strong believer in Descartes’s scientific medicine
and the biomechanics it engendered to a skeptic about the very idea of a
scientific medicine, Cartesian or otherwise, is well documented.65 But
it would be wrong to suggest De Raey broke entirely with Descartes.
While De Raey certainly rejected biomechanics as the basis for med-
ical practice, it is also the case that he endorsed naturopathic therapy.
The shift in De Raey’s thinking appears to have occurred after an en-
counter with the Leiden physician Franciscus de la Boë (Sylvius), who
had suggested, “in medicine as in physics what is known truly is known
only by experience.”66 De Raey did not approve of the extension of
such a claim to physics, which he assigned to philosophy. Instead, De
Raey believed medicine had its own “foundation and subject” and this

64 Clarke, Rohault’s System of Natural Philosophy, 187–​8.

65 See especially Verbeek, “Tradition and Novelty,” 167–​96, and the recent discussion in Schmaltz,
Early Modern Cartesianisms, 264 ff.
66 . . . tam in Physica quam in Medicina id omne quod vere scitur, sola experientia sciri: J. De Raey,
Cogitata de interpretatione (Amstelædami: Henricum Wetstenium, 1692), 659; cited and translated
in Schmalz, Early Modern Cartesianisms, 266. This claim appeared in an October 1680 letter De
Raey wrote to another Cartesian, Christopher Wittichius (mentioned below), later reprinted in
the Cogitata.
218 Gideon Manning

insulated philosophy from any overlap with medical epistemology.67

While it is certainly not a view we might expect to find in a Cartesian,
according to De Raey it was essential that “one should not philoso-
phize outside of philosophy” and accordingly “medicine . . . [has] never
been or can ever be a part of philosophy.”68
De Raey’s shift reorients him away from Descartes’s biomechanics
and the dispositional accounts of health he would have learned from
Regius and toward un-​theorized tenets of medical practice, especially
faith in the body’s ability to recover and the individuals’ capacity to
heal themselves. No other possibility presents itself if, following De
Raey, we must accept that philosophy does not affect medicine. As
Tad Schmaltz explains, De Raey’s “conception of medicine as an art
can be understood in terms of the notion in Descartes of a médicin
de soi-​méme.”69 In other words, De Raey excises all but Descartes’s na-
turopathic medicine, embracing the implication that each of us has a
privileged knowledge of our bodies and that we need not look beyond
ourselves to philosophy for effective medicine. We each know when
we are healthy, in other words, and we know what to do about it when
we are not.
Along with representatives of Descartes’s biomechanical and natur-
opathic medicine, there were other Cartesians in the late seventeenth
century who emphasized the virtues of psychosomatic medicine. If
we move east from Paris, where Rohault was active, passing through
the Netherlands, which was the home of Regius and De Raey, and
into early modern Germany, we discover a diverse Cartesianism with

67 Ita longius progressus, imprimis perspicue intellexi, atque non uno loco & temper Claris verbis
dixi & scripsi olim, Medicinam, Jurisprudentiam, Theologiam, in communi omnium hominum
intellectu habere fundamentum & subjectum suum, verum hoc partier dici non debere de Philosophia,
cuius pars Physica est, quam à Medicina distinguimus: De Raey, Cogitata, 660; cited and translated
in Schmatlz, Early Modern Cartesianisms, 265.
68 Praecipuus Philosophiae fructus est ac debet esse quod nos doceat, haec duo potissumum: Unum,
Extra phiosophiam philosophandum non esse; Alterum, quod hinc sequitur, Medicinam artesque
mechanisas, neque suisse hactenus, neque unquam posse esse, philosophiae huc usque promotae
partem: De Raey, Cogitata, 654; cited and translated in Verbeek, “Tradition and Novelty,” 194.
69 Schmaltz, Early Modern Cartesianisms, 265.
 The Early Modern Philosophical Tr adition 219

both biomechanical and psychosomatic medicine clearly represented.

Cartesianism was taught at Jena, Marburg, Leipzig, Wittenberg, and
Frankfurt on the Oder, though even among these universities it was
the gymnasium at Duisberg that stands out. Founded in 1654, the
Cartesians Johann Clauberg and Christopher Wittichius were active
at Duisberg from the start. Its medical faculty would later include
Theodor Craanen, Tobias Andreae, and Friedrich Gottfried Barbeck,
making it one of the only medical institutions in Europe where
Cartesianism was continuously and openly taught for five decades. Yet
in spite of this continuity, Duisberg’s Cartesians did not always agree
with one another and were often willing to point out the limitations
of the other therapeutic strategies they did not prefer. For example,
Clauberg, who had been a student of De Raey’s, was a proponent of
Descartes’s medicine of the mind. For Clauberg, this medicine was as-
sociated with logic and curing prejudices through, first and foremost,
an appreciation of the distinction between mind and body.70 Clauberg
was also committed to Descartes’s vision of a mechanical physiology
and the need to perform experimental and observational work in order
to discover medicines for the body.71 Barbeck, like Clauberg, was a be-
liever in biomechanics. And he would explicitly discuss the physician’s
need to understand the body’s actions and the internal (mechanical)
sources of its motion.72

70 Et praecipua causa infinitarum confusionum & densissimarum tenebrarum in Physica &

Medicina fuit hactenus, quod neque solius mentis proprietates sola mente seorsim considerant,
sed quia perpetuo adhaerent sensibus & mentem cum corpore confundunt: J. Clauberg, Notae
in Cartesii Principia, in J. T. Schalbruch (ed.), J. Clauberg: Opera Omnia Philosophica, 2 vols.
(Amstelodami: Ianssonio-​Waesbergii, Boom, à Someren, and Goethals, 1691), 1:lxvi; cited in
Trevisani, Descartes in Deutschland, 94. For discussion of Clauberg’s logic in English, see A.
Strazzoni, “A Logic to End Controversies: The Genesis of Clauberg’s Logica Vetus et Nova,” Journal
of Early Modern Studies 2 (2013), 123–​49.
71 Medicina quodcunque boni habuit non ex illis, quae in Scholis Physicis frequentabantur . . . ; sed
potius ab experientia & observatione: Clauberg, Disputationes, I, 11; cited in Trevisani, Descartes in
Deutschland, 83.
72 [F]acilius construi potest definitio generalis vitis corporeis omnibus conveniens, nimirum quod sit
actio proveniens ex certa corporis organisatione seu structura & transftuxu alicujus fluidi ex interna
& propria causa moti proveniens: Barbeck, Disputatio medica de vita, sec. 7; cited in Trevisani,
220 Gideon Manning

Different from Clauberg and Barbeck, Andreae saw the special

value of psychosomatic medicine. Not to be confused with his
cousin of the same name, who had been a teacher of Clauberg’s,
Andreae’s student years at Duisberg included a medical dissertation
touching on the causes of epilepsy. In this work, he showed aware-
ness of Descartes’s prioritization of the union between mind and
body. He seemed especially taken by a passage from Meditation Six
where Descartes explains that “the part of the brain that immedi-
ately affects the mind produces just one corresponding sensation”
and that this correspondence, owing to the union, is part of the
“best system that could be devised” because it produces “the one
sensation which, of all possible sensations, is most especially and
most frequently conducive to the preservation of the healthy man”
(Writings, 2:60). For Andreae, this meant that when we are healthy
similar thoughts are associated with similar bodily motions, and
similar bodily motions correspond to similar thoughts.73 In the
case of epilepsy, this has the unfortunate implication that fear of
an epileptic seizure can cause an attack. The solution, which is not
foolproof, is to seek to control our passions by, among other things,
focusing on intellectual pleasures.74 This advice could have come
straight from Descartes’s letters to Elisabeth.
Indeed, part of the message to extract from this account of
Descartes’s reception is that it was his medical advice that his
followers pursued, even if they were willing to follow one strategy
more than others. Germany would continue to serve as the home
for some of the most interesting responses to Descartes’s medicine

Descartes in Deutschland, 146. For discussion of Barbeck in English, see Des Chene, “Health and
Life,” 733–​34 and Smith, “Heat, Action, Perception,” 118–​19.
73 Ita enim Natura nos formavit, ut similibus cogitationibus similes motus corporei, similibusque
spirituum motibus similes cogitationes respondeant: T. Andreae, Disputatio philosophica inauguralis
explicans naturam & phaenomena cometarum (Duisburg, 1659), sec. 20; cited in Trevisani,
Descartes in Deutschland, 102.
74 See Trevisani, Descartes in Deutschland, 103, on whose analysis I rely, as well as the more gen­
eral discussion in Des Chene, “Health and Life,” 733; and Smith, “Heat, Action, Perception,” 116.
 The Early Modern Philosophical Tr adition 221

and his preferred medical advice, where the ever more explicit sides
of Descartes’s medicine gained lives of their own both inside and
outside the universities. Eventually, the links to Descartes began to
fray, though never entirely in the case of biomechanics and its ma-
terialist implications. Due to the traditional character of so much
of Descartes’s medical advice, however, it would be hard to claim
that the psychosomatic and naturopathic medicine he championed
was as distinctively his own. We might speculate that it is for this
reason that Descartes is so often vilified for the excesses of a sci-
entific and impersonal medicine but rarely credited with the other
therapeutic strategies he endorsed and led others to support. Be that
as it may, it must also be remembered that the Cartesian story con-
tinued through other equally complex and innovative figures whose
medical interests have only recently begun to receive the attention
they deserve. Leibniz, for example, who would offer his own reno-
vation of tradition, and Enrenfried Walther von Tschirnhaus, the
only early modern figure to have written, so far as I am aware, a
work with the title Medicine of the Mind and Body (1686),75 were
both students of German Cartesianism and deserve a place on the
map this chapter has attempted to reveal.76

75 For Leibniz, see J. E. H. Smith, Divine Machines: Leibniz and the Life Sciences (Princeton,
NJ: Princeton University Press, 2011); and especially Smith, “Heat, Action, Perception.”
Tschirnhaus remains a figure relatively unknown outside of his correspondence with Spinoza.
A valuable exception in English is J. Adler, “The Education of Ehrenfried Walther von Tschirnhaus
(1651–​1708),” Journal of Medical Biography 23 (2015), 27–​35.
76 I am deeply indebted to Cynthia Klestinec and especially Peter Adamson who read and
commented on many drafts of this paper with great generosity, wisdom, and patience.
 CH A PTER SEV EN

Health in the Eighteenth Century

Tom Broman

In many respects, to speak of “health” is to speak of an absence, to

place a label on something for which there is no clear concept. Take,
for example, the essay “Concepts of Health and Disease” in the re-
cently published volume on philosophy of medicine in the Handbook
of the Philosophy of Science. The essay begins, unsurprisingly, by linking
“health” with “normality,” and then using normality as a standard
for determining whether a given physical or behavioral condition
warrants designation as an illness or disorder that requires therapeutic
intervention.1 No doubt there is good reason to approach health from
this point of view. After all, if there is no condition that can be de-
termined, either subjectively or instrumentally, as lying beyond the
boundaries of normal function—​as a pain, for example, or an unusual

1 C. Boorse, “Concepts of Health and Disease,” in F. Gifford (ed.), Philosophy of Medicine

(Amsterdam: Elsevier, 2010), 1–​52. Boorse has long been a champion of the idea that normality is
best understood as a statistical concept, although the essay considers a broad range of concepts of
health, some of which, at least, recognize potential drawbacks to treating it from a negative point
of view. See further Elselijn Kingma’s chapter in the present volume.

222
 The Eighteenth Century 223

reading for some metabolic product—​then it makes sense to call the

person “healthy.”
The problem of how to describe health other than as an absence of
pathological indicators does not just arise with statistically inflected
measures of normality. To the contrary, our uncertain grasp on the
concept of health is the product of three entrenched ways of conceiving
the human body, all of which pertain to our understanding of health,
but none of which address it directly. The first tradition can be called
the “anatomical-​morphological” or “physiological” tradition and has
its origins in writings such as Aristotle’s Parts of Animals and Galen’s
Usefulness of the Parts, as well as the heaps of works that have followed
their template. This is a view of the body that assesses the functions
of living beings, with an eye toward cataloguing and explaining those
functions. The gradual transfer of attention from gross anatomy and
organs to cells to molecular biology has not fundamentally altered the
basic explanatory thrust of this tradition. However, to describe the
body’s functions from this point of view is not the same as describing
what it means to be healthy.
A second originally independent “pathological” tradition dealt di-
rectly with disease as a phenomenon to be interpreted semiotically and
countered therapeutically. One can observe this orientation in many
Hippocratic writings, such as the Epidemics and Regimen in Acute
Diseases. Conspicuously, this view of the body did not depend directly
on comprehension of physiological function, although it would be in-
correct to say that ancient writers overlooked any possible relationship
between function and illness as a deviation from normal function. The
Hippocratic Places in Man clearly suggests otherwise, although the
way it links a discussion of anatomy to an account of various fluxes in
the body is not very consistent. In short, while various ancient writers
did link pathology to physiology, such efforts did not express a belief
in a necessary connection between the two.
Over time, of course, a more intimate association between physi-
ology and pathology did develop, as Georges Canguilhem described
224 Tom Broman

in his famous 1943 doctoral thesis, Essay on the Normal and the
Pathological. For Canguilhem, the redefinition of pathological states
as quantifiable deviations of “more or less” from physiological norms,
which he attributed to the work of Auguste Comte and, above all, the
nineteenth-​century physiologist Claude Bernard, was not an entirely
happy development, because it downplayed the subjective experience
of illness. If physiological knowledge can be extracted from the path-
ological states of one organ or another, he insisted, that can only be
because of the prior clinical reality of someone having suffered a sick-
ness.2 Thus illness as a condition that befalls individuals necessarily
precedes any possibility of analyzing the relationship between physi-
ology and pathology.
Even for Canguilhem, an insistence on illness as a distinct state of
being did not translate into a similar emphasis on what it means to
be healthy, although he did not overlook it entirely. In Canguilhem’s
language, life could be described as a “normative” process, a dynamic
interplay between organism and environment by means of which
the norms that define healthy function are constantly defined and
redefined.3 Put another way, when healthy, living things exhibit what
could be called an adaptive responsiveness whereby they adjust their
body’s functions to their variable surroundings. A hibernating bear
displays far lower levels of metabolic activity than an active one, but
the bear plainly is not ill. Instead it exhibits an altered state of “norma-
tivity” and thus is healthy by Canguilhem’s definition.
The third tradition of writing to emerge from the ancient world, di-
etetics, or hygiene, is probably the one that brings us closest to a clearly
articulated concept of health. In its rich evocation of what came later
to be called the “non-​naturals,” dietetic advice on food, drink, exercise,
and living environment presented a glimpse into what Greek writers,

2 C. R. Fawcett and R. S. Cohen (trans.), Georges Canguilhem: The Normal and the Pathological
(New York: Zone Books, 1991), 88.
3 Fawcett and Cohen, Canguilhem: The Normal and the Pathological, 126–​27.
 The Eighteenth Century 225

ranging from the Pythagoreans to Galen, considered the good life. Yet
in this respect too, “health” was characterized neutrally as a balance
between humors that was appropriate for a given person, without fur-
ther specification of what is meant by the term.4
If we now turn to some eighteenth-​century writings, we can see
how the meaning of “health” easily slips between the three different
senses of the body just presented. In Herman Boerhaave’s Institutiones
medicae, the most widely used medical textbook of the era, the body’s
overall physiology is introduced by means of mechanical metaphors, as
in the following well-​known passage:

The solid parts are either membranous pipes, or vessels including

the fluids; or else instruments made up of these, and more solid
fibers, so formed and connected, that each of them is capable of per-
forming a particular action by the structure, whenever they shall
be put into motion we find some of them resemble pillars, props,
cross-​beams, fences, coverings, some like axes, wedges, levers, and
pulleys; others like cords, presses, or bellows; and others again like
sieves, strainers, pipes, conduits, and receivers; and the faculty of
performing various motions by these instruments, is called their
function; which are all performed by mechanical laws, and by them
only are intelligible.5

Similarly, the body’s fluids perform their functions “agreeable to the

laws or principles of Hygrostatics, Hygraulics, and Mechanics.”6

4 L. Edelstein, “The Dietetics of Antiquity,” in O. Temkin and C. L. Temkin (eds), Ancient

Medicine: Selected Papers of Ludwig Edelstein (Baltimore, MD: Johns Hopkins University Press,
1967), 303–​16; F. Steger, “Antike Diätetik—​L ebensweise und Medizin,” NTM Zeitschrift für
Geschichte der Wissenschaften, Technik und Medizin 12 (2004), 146–​60.
5 H. Boerhaave, Institutiones medicae (Leiden: Severinus, 1730), sec. 40, 12–​13. The translation is
taken from Dr. Boerhaave’s Academical Lectures on the Theory of Physick 6 vols. (London: W. Innys,
1742–​46), 1:81.
6 Boerhaave, Institutiones medicae, sec. 41, 85. In choosing the terms “hygrostatics” and
“hygraulics” in preference to the more familiar “hydrostatics” and “hydraulics,” Boerhaave
226 Tom Broman

As useful as they might have been for understanding, or at least

analogizing, the body’s physiology, Boerhaave’s mechanical metaphors
were not well suited for accounting for the specific qualities of living
beings, such as “life” itself. In a section describing the causes of life
and health that are present in a body—​and let us note that Boerhaave
separated the two conditions—​he remarked with reference to knowl­
edge of causes that “so long as the heart continues its motion, so long
does life remain; but whenever the organ ceases to move, life itself also
ceases to be; the motion of the heart is therefore the cause of life.”7
Meanwhile, Boerhaave described life as “the condition of the several
solid and fluid parts of the body, which is absolutely necessary to main-
tain that mutual commerce between that and the mind to a certain
degree, so as to be not perfectly removed beyond the power of being
restored again.” Recognizing perhaps that this was not the most pel-
lucid definition imaginable, he added that “life cannot be defined
well till its physiology, or [the] nature and principles of action have
been first considered; for it is the sum and aggregate of all the actions
performed in the human body.”8
The meaning of “health” in the Institutiones was similarly com-
plicated. The text opens by presenting a basic definition of health as
the performance of “the several actions of the human body with ease,
pleasure, and a certain constancy.”9 We should take note of the sub-
jective criterion in this statement. Being healthy is feeling healthy—​at
least, in part. From that point, the Institutiones made repeated and
numerous references to “health,” but offered no further specification
of its meaning until Boerhaave turned to the section on “Pathologia.”

expressed his intention to speak not just about water but also about fluids more generally. See sec.
41, notes 9 and 10, 87–​88.
7 Boerhaave, Institutiones medicae, sec. 43, note 2, 92.
8 Boerhaave, Institutiones medicae, sec. 42, note 1, 90–​91.
9 Boerhaave, Institutiones medicae, sec. 1, 2. The subjective component of health is reinforced in
sec. 33, note 1, 77, where the “sum or aggregate of all the actions resulting from the structure of
the several parts” is designated “life” and the ease and comfort of those actions is called “health.”
 The Eighteenth Century 227

There he presented a summary of the main points previously set out in

the lengthy section on physiology, reiterating a threefold division of
living functions into the vital, the natural, and the animal. This cat-
egorical division of functions was conventional, indeed ancient, in its
roots. Vital functions refer to those that are essential to the mainte-
nance of life, such as breathing and the heartbeat, along with the “se-
cretory action of the cerebellum,” while natural functions pertain to
processes such as nutrition, growth, and reproduction. Finally, animal
functions are designated as “those by which the human understanding
conceives Ideas agreeable to the corporeal action with which they are
united.”10 At this point, Boerhaave reintroduced the idea of health,
using much the same language as before, but this time without any
suggestion of feelings of ease or comfort. As described in the section
on pathology, health was “that faculty of the body, in which all parts
are duly enabled to perform their respective offices with perfection.”11
Considering that the Institutiones and other textbooks were written
for aspiring physicians whose work would largely consist of the diag-
nosis and treatment of illness, perhaps it is only to be expected they de-
voted little attention to exploring heath, a condition that leaves them
with little to do, apart from offering hygienic advice. Even if we grant
this objection, however, other more or less contemporary definitions
of health displayed similar points of view. The Cyclopedia published
by Edward Chambers in 1728 defined health in a brief entry in two
ways, first in terms of the body’s constituent parts as “a due tempera-
ment, or constitution, of the several parts whereof an animal is com-
posed, both in respect of quantity and quality.” Second, it addressed
health functionally as “that state of the body, wherein it is fitted to dis-
charge the natural functions perfectly, easily, and durably.”12 Another

10 Boerhaave, Institutiones medicae, sec. 695, 255–​56.

11 Boerhaave, Institutiones medicae, sec. 695, 256.
12 E. Chambers, Cyclopædia: or, an Universal Dictionary of Arts and Sciences, 2 vols. (London: W.
Strahan et al., 1728); the entries “Health” and “Healthiness” are in volume 1.
228 Tom Broman

encyclopedia from the early eighteenth century, Johann Heinrich

Zedler’s Grosses vollständiges Universal-​Lexicon aller Wissenschaften
und Künste, which began appearing in 1732 and eventually reached
sixty-​four volumes plus four supplements, offered a more expansive
and moralistic view. In the tenth volume (1735), “Gesundheit” was
presented with two meanings. The first one offered the conventional
definition as “that condition of the human body, in which all its unin-
jured parts can carry out their natural functions without hindrance.”13
But then the Universal-​Lexikon added a second, less typical defini-
tion: “One attributes health to human understanding (Verstand) if
it finds itself able to distinguish the true from the false, and moves
the will to dispose its actions accordingly.” The reason for considering
health as pertaining both to mind and body immediately became clear
as the article added that “natural health consists of a fitting balance be-
tween the mutually interactive forces of the soul and the body.”14 The
article then described health as a gift bestowed upon humans by God
and condemned as sinful the failure to preserve it through attentive
regulation of the non-​naturals.15
One last example from the encyclopedic literature can be cited
here, the article on “Santé” in the Encyclopédie of Denis Diderot,
authored by Arnulphe d’Aumont, a graduate of the medical faculty

13 “Einmahl ist es ein solcher Zustand des menschlichen Leibes, in welchem derselbe an allen
seinen Theilen unverletzt seine natürlichen Verrichtungen ungehindert ausüben kann.” The syn-
tactical positioning of “unverletzt” makes its precise meaning unclear, and the translation offered
here is merely one possible rendering. J. H. Zedler, Grosses vollständiges Universal-​Lexicon der
Wissenschafften und Künste, 64 vols. (Halle: J. H. Zedler, 1732–​50), 10: col. 1334.
14 Zedler, Grosses vollständiges Universal-​lexicon der Wissenschafften und Künste.
15 Zedler, Grosses vollständiges Universal-​Lexicon der Wissenschafften und Künste, 10: cols. 1335–​
36. Articles in Zedler’s Universal-​Lexikon were not attributed to individual authors, and citations
in the article offer no clear clue as to the author’s intellectual allegiances. Only two recent authors
are referred to: Friedrich Hoffmann and Michael Alberti, both professors of medicine at the
University of Halle. But since Hoffmann is usually thought of as a mechanist, while Alberti was
one of the most prominent German followers of Georg Ernst Stahl’s animist physiology, their
pairing in this article is not very indicative, apart perhaps from suggesting the author’s connection
with Halle.
 The Eighteenth Century 229

at the University of Montpellier.16 D’Aumont opened by declaring

that health was “the most perfect state of life,” and then specified
health as a “natural accord, the reasonable arrangement of the living
body’s parts from which it follows that the exercise of all its functions
happens in a lasting manner, with all the ease and freedom and in all
of the extension of which each organ is susceptible, according to its
purpose, and relative to the actual situation, to the different needs of
age, sex, the temperament of the individual person, and the climate in
which the person lives.”17 The “ease and freedom” in this description of
healthy organs refers not only to their physiological function but also
to the feelings of well-​being enjoyed by the healthy person: “Thus it is
by the ease with which one feels the exercise of the body’s and soul’s
functions; by the satisfaction that one has for his physical and moral
existence; by the fitness [convenance] and constancy of this exercise; by
the testimony which one renders of this feeling, and the connection of
these effects that one knows that one is living as healthy and perfect a
life as possible.”18
The individuality of health received repeated emphasis in the article.
“Health does not consist of a precise point of perfection common to
everyone,” d’Aumont declared at one point, and then he delivered an
exhortation on the centrality of regulating the non-​naturals as the best
means to maintain health. Just as with health, the proper balance to
be maintained with the non-​naturals could only be comprehended

16 The article was unsigned and its attribution is somewhat contested. According to Victoria
Meyer, the author was Louis de Jaucourt, a student of Boerhaave’s who authored a considerable
number of articles for the Encyclopédie, including several on medical topics. See “Health,” available
in the online The Encyclopedia of Diderot & d’Alembert Collaborative Translation Project. However,
W. Coleman attributed the article to d’Aumont in his “Health and Hygiene in the Encyclopédie: A
Medical Doctrine for the Bourgeoisie,” Journal of the History of Medicine and Allied Sciences
29 (1974), 399–​421, and this attribution has been supported by Elizabeth Williams in personal
communication with the author. On d’Aumont’s role in the Encyclopédie, see E. A. Williams, A
Cultural History of Medical Vitalism in Enlightenment Montpellier (Burlington, VT: Ashgate,
2003), esp. 121–​23.
17 Jaucourt, “Health.”
18 Jaucourt, “Health.”
230 Tom Broman

individually, with all the complexities that differences in age, sex, oc-
cupation, temperament, and other factors brought into consideration.
The article did not go into specifics; rather it referred the reader to
other articles in the Encyclopédie on “Régime” and “Non-​naturelles,
choses,” both of which were signed articles by d’Aumont, along with
the entry on “Hygiene,” which was unsigned, but which he may also
have written.19
So much for direct definitions of health. Other examples could be
added to these, but the range of meanings would not be broadened ap-
preciably. So instead of pursuing this path further, it will be more fruitful
to approach the idea of health indirectly by examining other important
concepts that were closely associated with it during the 1700s. In the rest
of this chapter I will focus on two such concepts: sensibility and public
health. As we shall see, each of these introduced significant novelties to
the understanding of health during the period.

Sensibility and Health

To talk about “sensibility” in the eighteenth century as if it were a

single concept would restrict the range of its applicability far too nar-
rowly. Instead, it would be far more accurate to describe it as a set of
associated concepts, or, as Henry Martyn Lloyd suggests, as a discur-
sive formation—​arguably the most characteristic such formation of
the period.20 At the most general level, sensibility denotes the ability

19 As claimed by Coleman, “Health and Hygiene in the Encyclopédie,” 402.

20 If ever something deserved to be labeled a discursive formation, according to Foucault’s def-
inition in The Archaeology of Knowledge, then sensibility surely qualifies. See H. M. Lloyd, “The
Discourse of Sensibility: The Knowing Body in the Enlightenment,” in H. M. Lloyd (ed.), The
Discourse of Sensibility: The Knowing Body in the Enlightenment (New York: Springer, 2013),
1–​23, at 2–​3. There are an enormous number of studies of sensibility, many of which focus more
or less exclusively on its use in literature. For two excellent studies that range widely over litera-
ture, science, and moral philosophy, see G. J. Barker-​Benfield, The Culture of Sensibility: Sex and
Society in Eighteenth-​Century Britain (Chicago: University of Chicago Press, 1992); and J. Mullan,
Sentiment and Sociability: The Language of Feeling in the Eighteenth Century (Oxford: Clarendon
Press, 1988). For a similarly wide-​ranging and well-​crafted study that does the same for France but
 The Eighteenth Century 231

of an individual to perceive and respond to stimuli, and the study of

these responses became the preoccupation of novelists and dramatists,
as well as moral philosophers and physicians. Its use in medical writing
was usually accompanied by a more or less explicit renunciation of
mechanistic models of the body, such as Boerhaave’s. Sensibility, by
contrast, was offered as a uniquely vital function that could not be
redeployed in mechanistic language.21
Sensibility possessed three distinct yet closely related meanings.
First, it referred in an epistemological frame to the sources of human
knowledge in sensory experience. As is well known, eighteenth-​century
philosophy was dominated by empiricist theories of knowledge in
the writings of John Locke, David Hume, and the Abbé Condillac,
and for them sensibility denoted the mind’s receptiveness to external
stimuli.22 The empirical sources of knowledge also connected sensi-
bility to its second meaning—​the basis for our judgments of right and
wrong. In contrast to systems of ethics that depended on particular
doctrines of revealed religion or on a deduction from a consideration
of human nature in the abstract, eighteenth-​century moralists such
as Hume, Adam Smith, Denis Diderot, and Jean-​Jacques Rousseau
claimed that moral sensibility is a product of our day-​to-​day inter-
course with other people. This experience, coupled with our ability to

with greater emphasis on medicine, see A. Vila, Enlightenment and Pathology: Sensibility in the
Literature and Medicine of Eighteenth-​Century France (Baltimore, MD: Johns Hopkins University
Press, 1998).
21 See P. H. Reill, Vitalizing Nature in the Enlightenment (Berkeley: University of California
Press, 2005). More narrowly focused on Scottish developments but more wide-​ranging in its
consideration of the intellectual currents that informed sensibility is C. Packham, Eighteenth-​
Century Vitalism: Bodies, Culture, Politics (Houndsmills: Palgrave Macmillan, 2012); on vitalism
at the University of Montpellier, which was one of its leading centers, see Williams, Medical
Vitalism. Although from its title one might suppose that sensibility plays a major role in Stephen
Gaukroger’s recent synthetic historical account, S. Gaukroger, The Collapse of Mechanism and the
Rise of Sensibility (Oxford: Clarendon Press, 2010), it is subordinate to the author’s stated aim of
charting the rise of natural science as a model for all cognitive claims in the modern world. To this
end sensibility is mobilized as evidence of the spreading influence of natural science.
22 Lloyd, “The Discourse of Sensibility,” 7–​8.
232 Tom Broman

share the feelings of others via sympathy educates the sensibility, and
by means of this this process we formulate our ideas of morality.
For these writers, to claim that moral judgments should be tempered
by social intercourse represented an effort to place ethics on a solid
scientific basis. This theme was sounded by Hume in his Treatise of
Human Nature (1739), where he rejected as “metaphysical reasonings”
any philosophy that attempted to derive human nature deductively
from first principles. Instead, Hume asserted that “careful and exact
experiments” would furnish the foundation of his examination of
human nature.23
An explicit experimental basis (in our contemporary meaning) for
sensibility emerged from the research of the Göttingen medical pro-
fessor Albrecht von Haller, and this provides us with the third meaning
of sensibility. The aim of Haller’s experiments was to determine which
vital forces are present in different parts of the body. He identified two
such forces, the first of which was irritability, associated anatomically
with muscle tissue. In his experiments, Haller could observe irrita-
bility directly, by poking a tissue with a needle or applying alcohol or
a caustic chemical and then watching it contract. However sensibility,
the other vital force identified by Haller, proved a more difficult phe-
nomenon to observe. “I call that a sensible part of the human body,”
Haller wrote in his Dissertation on the Sensible and Irritable Parts of
Animals (1752), “which upon being touched transmits the impression
of it to the soul; and in brutes, in whom the existence of a soul is not
so clear, I call those parts sensible, the irritation of which occasions
evident signs of pain and disquiet in the animal.” Haller localized
this effect in nervous tissues while denying that sensibility occurred

23 Hume, Treatise of Human Nature (1739), xvii. For his purposes, Hume’s use of “experiment” here
is nicely ambiguous. In the 1730s, Hume’s readers would have understood the word in the context
of the experimental approach to natural philosophy promoted by Royal Society luminaries from
the seventeenth century such as Robert Boyle and Robert Hooke, and, of course, Isaac Newton.
On the other hand, Hume plainly did not perform experiments of that kind in his study of human
nature, and thus his use of the term also called upon its older classical meaning as experimenta, the
fruits of experience. On this point, see Gaukroger, The Collapse of Mechanism, 450–​51.
 The Eighteenth Century 233

anywhere else. But the method of his experiments in the two cases
was strikingly different: whereas Haller could observe irritability in
contractions that were the immediate result of his experimental inter-
vention, sensibility could only be observed indirectly, requiring that
the effects of his interventions come to the animal’s (or his own, or his
students’) consciousness for their expression.
In the context of how sensibility served as a link between the or-
ganic and the mental and moral spheres of human life, such an in-
direct description of its effects would make sense to Haller and his
contemporaries. But the lack of equivalence between irritability and
sensibility as empirically demonstrable properties of living matter also
exposed Haller to criticism regarding their supposed independence
from one another. His most committed opponent was the Edinburgh
physician Robert Whytt, whose own experimental work had suggested
the presence of what he described as a “sentient principle” that resided
in the nerves and was distributed throughout the body. It was this
principle, Whytt maintained, that perceived external stimuli and then
prompted the muscles to respond. Thus what appeared to Haller as an
independent force of irritability in muscles was, according to Whytt,
actually a force that was secondary and subordinate to sensibility.24
These interpretive difficulties notwithstanding, what made Haller’s
experiments compelling to his contemporaries was that they illus-
trated how sensibility sits at the intersection of three key domains
of human life. We think, we move, we act: sensibility negotiated the
transition between these domains and knit them together. An illus-
trative example of how sensibility functioned in this capacity can be
seen in Denis Diderot’s Lettre sur les aveugles (1749). Diderot claimed
that blind people, by virtue of their lack of sensible contact with the
outside world, were given to a highly abstract form of reasoning that

24 R. K. French, Robert Whytt, the Soul, and Medicine (London: Wellcome Institute for the
History of Medicine, 1969), esp. 63–​76. On the larger ramifications of the controversy over irrita-
bility and sensibility, see Reill, Vitalizing Nature, 128–​31.
234 Tom Broman

made them excel at endeavors such as mathematics. At the same time,

however, their sensory deprivation prevented blind people from de-
veloping their sensibility to an adequate degree, and this would hand-
icap their attempts to forge social bonds with others. To be sure, a
blind person could communicate via language. But lacking the rich-
ness of sensory experience that most people have, so Diderot claimed,
the blind person would lack those feelings that attend human social
interactions, specifically those feelings of sympathy mediated by our
sensibility.25
Although the cultivation of sensibility was linked to a healthy
human life, it also posed a significant risk because excessive levels of
sensibility made one susceptible to moral decadence, as Rousseau acer-
bically and notoriously pointed out in his first and second Discourses.
Moreover, the dangers arising from excessive sensibility also made
individuals susceptible to the vapors and other kinds of nervous ex-
haustion. Nowhere was this connection made more explicit than in
the writings of Samuel Auguste Tissot, the most popular writer on
moral and physical hygiene during the entire eighteenth century. Like
Rousseau a native of Switzerland, Tissot shared his compatriot’s alarm
at the decadence and self-​indulgence of the wealthier classes, and in
his writings he delivered a caustic scolding that, if the numbers of
translations and reprints of his writings are any indication, captured
the anxieties of his readers, even if it did little to force them to change
their lifestyles.
An example of Tissot’s attitude toward moral decay in concert with
physical illness can be found in the Essay on the Illnesses of Fashionable
People (1770). Tissot opened the essay with some general considerations

25 D. Diderot, “Lettre sur les aveugles, à l’usage de ceux qui voient,” in Oeuvres de Denis Diderot,
tome I (Paris: J. L. J. Brière, 1821), 283–​382. See 286, where Diderot claims that the blind lack a sense
for beauty. On the lack of sensibility more generally, see 297–​98. Evidently, Diderot discounted
the role of the other senses in educating the sensibility. For a discussion of Diderot’s Lettre, see J.
Riskin, Science in the Age of Sensibility: The Sentimental Empiricists of the French Enlightenment
(Chicago: University of Chicago Press, 2002), 52–​59.
 The Eighteenth Century 235

of what makes someone healthy. Alongside the standard criteria of

regularity and ease of vital functions, he also noted that the healthy
person was not likely to be affected by routine and unavoidable
alterations in the state of the non-​naturals.26 Against this condition of
perfect health Tissot contrasted that of someone with a “delicate” con-
stitution, whose health may be good at any one moment, but whose
grasp on health was ever threatened by changing circumstances. Such
people, he continued, are hardly ever well, without being able to deter-
mine a precise cause of their suffering.
Tissot next turned his attention to the causes of good health, of
which he named three. The first was strong fibers, which gives the
proper tone to muscles and blood vessels and maintains the regu-
larity of “animal functions.” The second cause was good perspiration,
which, because it is the most general of the body’s evacuations is also
the most important. The third cause was “firm nerves” that are not
too sensible to impressions and “don’t disorder the whole frame for a
trifling cause.”27 Such disorders, he added, are common in people who
have weak nerves and too great a degree of sensibility. With respect to
the question of who enjoys the best health, Tissot declared that rural
laborers were in the best position to do so. Not surprisingly, the coun-
terpoint to the healthy routines of the sturdy peasant came in the form
of the dissipative pursuits of the idle rich, “who, to defeat the insup-
portable tediousness of a life disagreeably inactive, attempt to kill time
by pleasure.”28
This stereotypical contrast between the hearty rural laborer and
the overly delicate bourgeois allowed Tissot to specify the different
ways that each group interacted with the non-​naturals. With re-
spect to food and drink, for example, the peasant eats “the coarsest

26 Note the correspondence with Canguilhelm’s discussion of health as adaptive responsiveness,

discussed earlier in this chapter.
27 S. A. Tissot, “Essai sur les maladies des gens du monde,” in Oeuvres de Monsieur Tissot, vol. 4
(Lausanne: François Grasset, 1784), 22–​23. Translations mine.
28 Tissot, “Essai sur les maladies des gens du monde,” 26.
236 Tom Broman

bread,” buttermilk, “vegetables, and those commonly the least savory,”

and very little butchered meat. By contrast, the wealthy bourgeois
consumes “the juiciest meats, the most highly flavored game, the most
delicate fishes stewed in the richest wines, and rendered still more in-
flammatory by the addition of aromatic spices,” and so on.29 Similar
contrasts were offered throughout the rest of Tissot’s discussion of the
non-​naturals, making it plain that what he was aiming for was not
merely a reform of the hygienic practices of the wealthier and more
educated classes, rather a more thorough social critique.
The attack on the over-​refinement of sensibility in modern society
achieved its apotheosis in L’onanisme, Tissot’s notorious discourse on
masturbation, which unsurprisingly became his most famous work
as well—​translated, reissued, and pirated for decades after its appear-
ance in 1760. In the subject of masturbation, Tissot seemingly found
the perfect vehicle for his analysis. Accordingly, he filled the book
with case studies of nervous exhaustion and other physical ailments
to which those who practice “self-​abuse” are subject, the stories so ar-
ranged as to lead the reader on a titillating path toward a crescendo of
moral depravity. This summit was represented by the story of a young
clockmaker who began indulging himself as a boy and who, by his
early twenties, had so exhausted himself that he was unable to control
his vital functions and could do nothing other than lie in his own ex-
crement.30 With the aid of such lurid narratives, Tissot could tap a rich
vein of moral outrage, diagnosing an epidemic of self-​abuse that other
writers fell over each other to exploit. One of the earliest such efforts,
the article on “Mansturpation” for the Encyclopédie in 1765, was in
large measure plagiarized from Tissot; many others would follow.31
Although from these examples it might seem that the hygiene and
pathology of sensibility was almost exclusively a French obsession,

29 Tissot, “Essai sur les maladies des gens du monde,” 28.

30 S. A. Tissot, L’onanisme, in Oeuvres, vol. 1, 33–​6.
31 For discussion of the article from the Encyclopédie, see Williams, Medical Vitalism, 228.
 The Eighteenth Century 237

such was not the case. To be sure, Rousseau’s powerful presence in

French letters as both social critic and epitome of the homme sensi-
tive made French writers especially responsive to its significance. But
English-​language writers could claim a share of the discussion as well,
and many of them published their work decades before Rousseau and
Tissot appeared on the scene. We have already mentioned Hume’s
writing in the context of linking epistemology and ethics via senti-
ment. For their part, English physicians preceded Tissot in diagnosing
an epidemic of diseases stemming from overindulgence and nervous
exhaustion. Richard Blackmore, the personal physician to Queen
Anne, published his Treatise on the Spleen and Vapors in 1726, and it
was followed by an even more successful guide to health and ill health,
The English Malady, by George Cheyne, a physician whose practice
was located in Bath, but who was consulted by the learned and the
powerful far and wide.
Finally, it deserves mentioning that the language of sensibility was
highly gendered. Men certainly possessed sensibility, but women
overflowed with it, to such an extent that women’s heightened ca-
pacity for sensibility made them moral exemplars and beacons of sym-
pathy. Best-​sellers such as Samuel Richardon’s Pamela (1740) played
on such notions in telling the story of a servant girl whose steadfast
virtue in resisting the advances of her rakish aristocratic master and
suitor succeeds in converting him into a good man. But alongside
these tributes to feminine virtue and sympathy came a view of femi-
nine bodies as vessels far too weak to contain the torrents of sensitive
energy coursing through them. And of course contemporaries, usually
males, criticized women’s self-​indulgent pursuit of leisure for making
things worse. Already in 1711, the Earl of Shaftsbury found himself
called upon to denounce one such leisure activity, reading novels, for
its affect on girls, writing how “tender virgins, losing their natural soft-
ness, assume the tragic passion, of which they are highly susceptible.”32

32 Quoted in Barker-​Benfield, The Culture of Sensibility, 119.

238 Tom Broman

Shaftesbury made this prescient observation, it should be noted, years

before the novel-​reading craze had properly begun. By century’s end,
political reformers, such as Mary Wollstonecraft, could turn such sen-
timental wallowing into a call for the reform of women’s education in
her Vindication of the Rights of Woman (1792), and shortly afterward
Jane Austen satirized the attitude in her novel Sense and Sensibility
(1811).
Heightened sensibility manifested itself not only in women’s weepy
attachment to novels and other behaviors but also in their bodies.
The age-​old women’s disease of hysteria was reinscribed as a dis-
order of nervous excess, while the French physician François Boissier
de Sauvages accounted for chlorosis as a distinctly female affliction
because of women’s heightened emotional sensitivity. When men
succumbed to various forms of burning passion, according to Tissot,
they began to resemble women physiologically, succumbing to “mel-
ancholic anorexia” that manifested in symptoms such as erotomania.
The pathological feminization of men through overly excited sensi-
bility, as Elizabeth Williams points out, was a dominant theme of the
French medical literature in the last third of the century, but it was
certainly not uniquely French.33
By the latter decades of the century, the gendering of women’s bodies
in terms of their heightened sensibility had hardened into a model of
physiological uniqueness. Pierre Roussel’s Système physique et moral
de la femme (1775) described women’s bodies as entirely configured
around the essential task of reproduction. Roussel described the fe-
male reproductive organs—​womb, Fallopian tubes, and ovaries—​as
centers of extraordinary sensibility that subjugate the rest of the body,
becoming “the dominant center of movement and action.” This greater
share of sensibility made women unsuitable for physically demanding

33 Williams, Medical Vitalism, 234–​35. On the longer history of chlorosis, see H. King, The Disease
of Virgins: Green Sickness, Chlorosis and the Problems of Puberty (London: Routledge, 2004).
 The Eighteenth Century 239

tasks such as brisk walking or horseback riding, as well as for the intel-
lectually demanding pursuit of scholarship and research.34
Thus sensibility was framed in the eighteenth-​century as a highly
sensitive register of the intersection between health and morality.
While providing the indispensable foundation for social life in general
and the cultivation of an appropriate ethos of behavior in society, when
developed too far sensibility also opened the door to degradations
and abuses that threatened both physical health and moral standing.
Moreover, when inscribed physiologically onto women’s bodies, sensi-
bility served as a flexible device for describing the contrasting visions
of women’s nature promoted by their male counterparts. On the
one hand, their supposed possession of heightened sensibility made
women exemplars of virtue, a point exploited repeatedly in literature.
On the other hand, the same wellsprings of sensibility placed women
in danger of becoming slaves to their passions, thirsting after self-​
indulgence in a deepening spiral of degradation and ultimately in ill
health.

Health as a Public Good

The other important concept that gives us purchase on concepts of

health in the eighteenth century was the idea of health as a collective
social good, a direct antecedent of our contemporary concept of “public
health.” In some respects, to identify the origins of public health in
the 1700s might appear doubly dubious. The roots of public health ar-
guably go back well before 1700, at least as far back as late medieval
efforts to combat the bubonic plague. Already in the fifteenth century,
the responses undertaken by municipal and princely governments to
repeated onslaughts of the bubonic plague suggest a clear concern for
health in a collective sense and an attempt to institute measures to

34 Williams, Medical Vitalism, 244–​45. Vila, Enlightenment and Pathology, 243–​55, describes the
broader literary and cultural context for Roussel’s ideas.
240 Tom Broman

preserve it.35 Although such initiatives were far from insignificant in

the longer history of public health, those medieval and early modern
efforts tended to be episodic in nature, relapsing into quiescence when
the latest outbreak of plague receded. The most significant applications
and developments of what we recognize as public health occurred in
the nineteenth century to combat the appalling problems of urbani-
zation and epidemic disease that became so prominent at that time.
Yet the eighteenth century did introduce some novelties to public
health that would figure significantly in later developments. One such
novelty was based on the concept of political arithmetic—​the new sci-
ence of political arithmetic formulated by John Graunt and William
Petty in the late seventeenth century. Graunt, a London tradesman
with little formal education and no official standing in England’s sci-
entific elite, published his Natural and Political Observations Made
upon the Bills of Mortality in 1662. The timing of the publication was
significant. In the aftermath of the Civil War and the subsequent res-
toration of the English monarchy in 1660, Graunt sought to use tables
of mathematical data about London’s population to document the
city’s stability as a vehicle to promote the prosperity of the country.
The source used by Graunt for constructing his tables were the London
bills of mortality first published in the fifteenth century as a way of
providing an early warning of plague outbreaks. Graunt’s enthusiasm
for the quantification of population for administrative and economic
ends was shared by William Petty, a physician and charter member
of the Royal Society when it was founded in 1660. A member of the
medical staff in Oliver Cromwell’s army in Ireland in 1652, Petty was
charged with conducting a survey of the island, the first ever. Thus
when Graunt’s Natural and Political Observations appeared in 1662,

35 See A. G. Carmichael, Plague and the Poor in Renaissance Florence (Cambridge: Cambridge
University Press, 1986); and J. Henderson, “The Black Death in Florence: Medical and Communal
Responses,” in S. Bassett (ed.), Death in Towns: Urban Responses to the Dying and the Dead, 100–​
1600 (Leicester: Leicester University Press, 1992), 136–​50.
 The Eighteenth Century 241

Petty held a favorable position to see its potential, and he applied sim-
ilar techniques to an analysis of Dublin bills of mortality.36
While the inspiration for assessing the national population lay in
the seventeenth century, the economic benefits of having a growing
population became a favorite topic in the eighteenth century; namely,
in the political economic writings of David Hume and Adam Smith in
the United Kingdom; Anne-​Robert-​Jacques Turgot (1727–​1781) and
Pierre Samuel du Pont de Nemours (1739–​1817) in France; and Johann
Heinrich Gottlob von Justi (1717–​1771) and Joseph von Sonnenfels
(1733–​1817) in Prussia and Austria, respectively. Insofar as these
writers prompted rulers and government ministers to look to trade
and to the vitality of their domestic economies, and not merely to their
treasuries, as a measure of wealth, the health of the productive forces
in those economies became a matter of national concern.37
The responses to this interest in population and the support of ec-
onomic vitality took different forms in different places. In Great
Britain, it manifested itself in part as attempts to understand the spread
of epidemics and the promotion of inoculation against smallpox.
Inoculation—​the introduction of pus from smallpox pustules into
healthy people as a preventive measure against the disease—​had long
been practiced in areas as diverse as China, the Ottoman Empire,
even in Wales, but its acceptance in learned medicine was virtually
nonexistent before the early 1700s. Two accounts of the practice by
Italian physicians living in Ottoman Constantinople were presented
to the Royal Society in 1713 and 1714 but failed to ignite much interest
in the technique. A more sustained interest came from the accounts

36 On the origins of political arithmetic, see J. C. Riley, Population Thought in the Age of the
Demographic Revolution (Durham: Carolina Academic Press, 1985); and A. A. Rusnock, Vital
Accounts: Quantifying Health and Population in Eighteenth-​ Century England and France
(Cambridge: Cambridge University Press, 2002).
37 As is well known, Michel Foucault famously coined the now-​ubiquitous term “biopower” to
describe this intersection of governance with the disciplining of bodies as a cornerstone of modern
public health. On the reception of the concept of biopower, see R. Cooter and C. Stein, “Cracking
Biopower,” History of the Human Sciences 23/​2 (2010), 109–​28.
242 Tom Broman

of inoculation communicated by Mary Wortley Montagu, the wife

of the British ambassador to the Ottoman court in 1717 while resi-
dent in Istanbul. Upon her return home, Montagu, who had been a
victim of smallpox as a child, had her daughter inoculated in 1721, and
the next year she was one among several advocates who succeeded in
persuading Caroline, the wife of the future George II, to have their
two daughters inoculated against the disease.38
The publicity attending the successful treatment of the two young
princesses gave inoculation a considerable boost among the British
public, but it remained controversial for a number of reasons. In the
first place, physicians encountered ethical problems in deliberately
giving their patients a disease, a clear violation of the Hippocratic
dictum of “first do no harm.” Moreover, the purported benefits of
inoculation ran counter to the individualistic thrust of humoralist
thinking, which emphasized adaptation by individuals to local
environments. Even granting that inoculation might have some pro-
tective value in foreign lands such as Turkey, skeptics asked what proof
could be offered that the same would hold in the United Kingdom,
with its different climate acting on temperamentally different British
bodies. The marshaling of such environmentalist perspectives in med-
ical thinking, which were clearly derived from Airs, Water, Places,
offers powerful evidence of their enduring persuasiveness.39
Such objections were met by the mathematically inclined physicians
John Arbuthnot and James Jurin, who used quantitative measures of
the population similar to those pioneered by John Graunt to argue

38 The reception of Montagu’s news about inoculation and subsequent royal patronage of the
technique is described in G. Miller, The Adoption of Inoculation for Smallpox in England and
France (Philadelphia: University of Pennsylvania Press, 1957), 70–​100.
39 On this line of thinking, see most recently J. Golinski, British Weather and the Climate of
Enlightenment (Chicago: University of Chicago Press, 2010), 140–​50. Like Riley, Golinski believes
that the eighteenth century experienced a “Hippocratic revival,” Golinski, British Weather, 140,
although it is not evident what supposedly was undergoing revival. Clearly many of the same
doctrines about bodies and climate were present in sixteenth-​and seventeenth-​century writing as
well. See A. Wear, “Place, Health, and Disease: The Airs, Waters, Places Tradition in Early Modern
England and North America,” Journal of Medieval and Early Modern Studies 38 (2008), 443–​65.
 The Eighteenth Century 243

for the overall value of inoculation. Arbuthnot satisfied himself with

attempting to measure the overall cost to the population of mortality
resulting from smallpox. Jurin attempted to argue a different and more
complicated point, an assessment of the comparative risks to an indi-
vidual from inoculation versus a naturally occurring case of smallpox.
Jurin’s number made the case that inoculation was the safer alterna-
tive, and his results were widely appealed to throughout the eight-
eenth century by advocates of the practice. Yet resistance continued,
in part because although Jurin’s calculations quantified a measure of
risk to the individual, they could not adequately account for the risk
to the population from the artificial inducement of cases of smallpox
resulting from inoculation. In the absence of a more widespread ap-
preciation by the reading public of what it meant to talk about risk as
a collective phenomenon, Jurin’s arguments could only succeed to a
limited extent.
In France, meanwhile, the organization of public health to promote
population growth took a number of different forms. One such initi-
ative involved the organization of defenses and quarantine measures
against epidemic diseases. The outbreak of bubonic plague in the vi-
cinity of Marseilles in 1720—​the last such appearance of the disease
in western Europe—​saw the government mobilize the army to erect a
massive quarantine operation that effectively prevented the epidemic
from spreading beyond Provence. The utility of a well-​administered
quarantine was not lost on France’s neighbors, nor, indeed, on
the French government itself. The British Parliament replaced the
Quarantine Act of 1710 with a more stringent version in 1721, while
in France the lessons learned in Provence provided a blueprint for
combatting an economically serious wave of cattle epidemics during
the century.40

40 L. Brockliss and C. Jones, The Medical World of Early Modern France (Oxford: Oxford
University Press, 1997), 350–​54 and 744–​45. For Great Britain, see M. DeLacy, The Germ of an
244 Tom Broman

Population growth also underlay initiatives begun in France and

elsewhere to improve delivery of health care by physicians and other
healers. In 1759, the French government awarded a royal warrant to
Angélique-​Marguerite Le Boursier du Coudray, a midwife who had
practiced for a number of years in Paris. Coudray undertook a lengthy
tour of various regions in France, offering courses in midwifery to
local women. To judge by contemporary accounts, the courses were
both well attended and successful in raising the standards of practice.
By the time of Coudray’s retirement from teaching in 1783, she was
said to have trained some 5,000 women as midwives. The efforts to
improve the practice of midwifery in France were matched by similar
efforts to increase the skills of surgeons, male accoucheurs, and others
who might attend women during birth.41 In the Holy Roman Empire,
meanwhile, a number of principalities passed medical ordinances
that, among other things, subjected midwives, apothecaries, and
other healers to more stringent training requirements and recurrent
inspections of their practices. Even if in many cases those enhanced
requirements did little more than steer additional income in the di-
rection of town doctors (Stadtphysici) and medical faculties tasked
with enforcing the ordinances and receiving fees for inspections and
training courses, at a minimum they expressed a desire to improve the
level of care provided to the public.42
The cameralist impulses that drove these health reforms, supported
by the conviction that well-​ designed administrative regimes
could promote the commonweal and enrich the ruler’s treasury,

Idea: Contagionism, Religion, and Society in Britain, 1660–​1730 (Houndmills, UK: Palgrave
Macmillan, 2016), 157–​58.
41 Brockliss and Jones, Medical World of Early Modern France, 740–​42. In England, man-​
midwives largely replaced female midwives during the eighteenth century, a move that was par-
tially justified on the basis of the men’s supposedly superior training and skill. See A. Wilson, The
Making of Man-​Midwifery: Childbirth in England, 1660–​1770 (Cambridge: Harvard University
Press, 1995).
42 T. H. Broman, The Transformation of German Academic Medicine, 1750–​ 1820
(Cambridge: Cambridge University Press, 1996), 42–​72.
 The Eighteenth Century 245

received their fullest expression in Johann Peter Frank’s System einer

vollständigen medicinischen Polizey (A Complete System of Medical
Policy), a sprawling six-​volume treatise that began appearing in 1779
and was eventually completed in 1817. In Frank’s expansive view of
cameralist administration, nearly everything was fair game: He urged
that marriages between younger men and older women be legally
discouraged, because the man’s seed would be wasted on a barren
woman; he called on Catholic principalities to discourage young men
and young women from entering convents and monasteries, again on
the grounds that their valuable reproductive potential was going to
waste; and he advocated dramatic improvements in orphanages and
birthing facilities available to pregnant women. Beyond policies aimed
at increasing the population directly, Frank also presented a host of
suggestions for regulating the quality of food, building safer and more
salubrious housing, cleaning streets, and much, much more.
Unsurprisingly, no government stepped forward to embrace Frank’s
vision for medical police in its gargantuan totality, although much of
what he proposed represented initiatives undertaken piecemeal in a
number of places.43 Instead, his work merits our attention for another
reason. The System and related writings present clear evidence of what
was fast becoming a widely accepted realization that the population’s
heath had become an ongoing concern for governments at all levels.
Whereas in previous centuries, health magistracies and other regula-
tory apparatuses had been periodically resuscitated during outbreaks
of bubonic plague and other epidemics, by the eighteenth century,
governments thought about public health in the context of economic
vitality. That connection would provide the foundation for many of
the major developments in public health after 1800.

43 For example, R. Porter describes a number of initiatives undertaken in eighteenth century

London in “Cleaning Up the Great Wen: Public Health in Eighteenth-​Century London,” Medical
History, suppl. no. 11 (1991), 61–​75.
Reflection
Pictur es of Hea lth?
Ludmilla Jordanova
p

It is common enough to hear someone described as a

“picture of health,” a compliment, possibly tinged with
gendered assumptions, that hints at contentment and bonny
appearance. The phrase has been used as a title for books on
subjects such as sickness and inequality, advice for young
girls, and health propaganda. “Picture of health” sounds
straightforward, but once probed, it reveals many of the
complexities of the concept “health.” What does “health”
look like, especially if it is an ideal, a notion that tends to
be future directed? Is it more than the absence of obvious
illness? How does it vary from one person to another? How is
it related to changing aesthetic ideals?
We have difficulty picturing “health,” perhaps precisely because
the notion expresses some kind of ideal, a state to be desired and
aspired to—​an absence more than a presence. Arguably, pictorial
traditions have been more eloquent, vivid, and confident when it
comes to negatives compared to positives. “Health” is, however,
rendered visible in the context of other personified abstractions,
which often take the form of a female figure. In the present day,
it is alluded to in many forms of visual culture, such as images of
fitness that derive equally from the sport and beauty industries.
“Health,” we might say, is a particularly treacherous keyword; the

246
 Pictures of Health? 247

visual expressions of which invite close scrutiny. Both its cognates,

such as cleanliness, goodness, and purity, and its opposites,
including disfigurement and monstrosity, help us understand its
elusive richness.
Simple gestures and expressions can effectively convey extreme
pain and suffering. Distorted bodies can be used to ridicule and
criticize, as in cartoons. Although there is considerable cultural
and historical variation in these matters, untutored audiences
can, through their somatic understanding, recognize another
person who is not well or experiencing anguish. In Christian
traditions there have been many opportunities for exploring
how the absence of “health” can be rendered visible, in images of
martyrdom and crucifixion, for instance. We currently possess
a vast visual repertoire, deeply indebted to photojournalism,
that represents sickness, injury, and suffering, both physical and
mental. However, it is more difficult to depict the presence of
health, which is an elusive abstraction. What would this look
like—​a newborn infant, a young child, or a breastfeeding mother?
These examples suggest some generic attributes of health, which
are associated not just with life but also with future promise. In
the case of older people, since the manifestations of health vary
markedly from one individual to another, it is difficult to imagine
what a picture of health would look like. Then at particular times
and places there are ideals, which may lead to a general preference
for a plump baby, or a skinnier one, a tanned body or perhaps a
pale one, women with flat stomachs or protruding ones, and so
on. Although there is rarely consensus on such matters, there are
dominating norms, which can be traced in a range of artifacts
from paintings to advertising, and from book illustrations to toys.
Evidently, then, health never stands alone but is bound up with
other concepts, values, and trends. The visual arts have portrayed
ideals, but the attractions of representing the absence of health
seem to have been greater. While my evidence is impressionistic,
248 Ludmilla Jordanova

this is a claim that would be worth pursuing. My hypothesis is

that for artists, and for their audiences, the visual relish of illness,
disability, disfigurement has been considerable, allowing a range
of moralizing commentaries to be constructed that are relatively
easy to decipher. Traditions of the nude, of depicting physical
beauty have certainly been significant, but they did not necessarily
invite viewers to contemplate “health” in particular. By contrast,
depictions of its absence, especially in settings where there is an
extensive written culture promoting healthful practices, could
prompt such contemplation. The image of a sickly child could
prompt reflection on the parenting practices most likely to produce
a healthy one, for example. William Hogarth’s well-​known series
Marriage à la Mode (ca.1743; plate 6) provides a graphic account
of descent into ill health. Indeed the deterioration of health or
death is the end point of a number of his moral series. There are no
comparable suites of pictures that tell a wholly positive story—​that
would have been far too bland, I suspect, to command interest.
It seems clear that notions of health, hygiene, fitness, and
cleanliness are variable, even if they are widely desired. It can be no
coincidence that, over many hundreds of years, people have turned
repeatedly to idealized figures to express them, to presiding gods
and goddesses, and to stylized representations. Personifications
are useful because they make explicit notions that people at
the time took for granted. In reflecting on the visualization of
abstract ideas, I have often turned to George Richardson’s 1779
Iconologia (plate 7).1 Relatively small prints depict a vast array on
concepts, including health—​a short commentary is provided for
each idea. Richardson’s account of “health,” which is shown as
an attractive, mature woman, is fuller than many others. “She”

1 G. Richardson, Iconology: or, a Collection of Emblematical Figures, Containing Four Hundred

and Twenty-​Four Remarkable Subjects, Moral and Instructive; in Which Are Displayed the Beauty
of Virtue and Deformity of Vice (London: Printed for the author by G. Scott, 1779).
 Pictures of Health? 249

also comes up in relation to “Goodness,” who “is represented

by the figure of a very beautiful and comely woman, dressed in
white robes. . . . She is represented beautiful and comely to express
health and contentment.” The image itself is, predictably enough,
rather bland, while the connections among physical and moral
goodness, virtue, health, and happiness are perfectly explicit in
the text. Richardson treatment of health drew upon centuries of
personifying and worshipping health. The images are “classical”
in somewhat unspecific ways, in showing simple, flowing gowns,
for example. Another example is the golden globe held by Health,
which “signifies that health is the most precious treasure of
human life.” This idea that health is necessary for the other parts
of life to be enjoyed was familiar in ancient Greece, with the
worship of Hygieia, the daughter and assistant of Asklepios, who
represented the preservation of health and the curing of sickness.
So Hygieia helps her father, the son of Apollo, and presides over
the continuing state of good health. Images of her on vases and in
stone are indeed pictures of health.
The existence of representations of Hygieia suggests the wish to
have something graspable to represent an idea that is so elusive.
Images of deities facilitate worship. Worship invites mediating
objects of veneration. What the classical evidence suggests is the
force of an idea—​health or hygiene—​can be visualized as a woman,
whose figure can carry a multitude of ideas about the desirability
of human well-​being. There is plenty of evidence to suggest that
personifications of health have also had strategic value in more
recent times.
These examples of ideas of health taking simple feminine
forms support my point about the difficulties of visualizing
“health.” Visual analysis of health propaganda hints at similar
conclusions. Words and images work together to reinforce
simplified notions, which link exercise, or good food, or routine
cleanliness with health. The promise of health if only certain
250 Ludmilla Jordanova

practices are routinely performed indicates a future directed,

even utopian, orientation. Onto such basic imagery we can
project a deep desire for health, which may be imagined with
vivid intensity but remains in the realms of fantasy. Visual
representations suggest ways of thinking about health and its
history that respect its complex characteristics.
 CH A PTER EIGHT

Freud and the Concept

of Mental Health
Jim Hopkins

Freud and his successors have often described the aim of psychoanal-
ysis in terms of three goals: resolving or mitigating patients’ emotional
conflicts; strengthening patients’ sense of or relation to reality; and
enabling patients better to love and to work. Freud’s therapy thus
linked mental health with the ability to form affectionate, nurturing,
and cooperative relationships and to gain satisfaction from purposeful
efforts to alter conditions in reality; and these with a realistic and
unconflicted attitude toward oneself, toward one’s own motives, and
toward other people and the world generally.
These aspects of health are connected by Freud’s overarching
hypotheses about the “alienation from reality” that he took to be con-
stitutive of mental disorder. This alienation, Freud held, was to be seen
both in psychiatric symptoms, like hallucinations and delusions, and
in the more ordinary, but nonetheless debilitating, failures in under-
standing and feeling—​self-​defeating misconstructions of their own

251
252 Jim Hopkins

motives, projects, and relationships with others—​that created the

difficulties in loving and working (or more generally the difficulties in
living) that led people to seek psychoanalysis. In this sense, his therapy
can be seen as an extension of the Delphic injunction to know oneself.1

Alienation, Phantasy, and Memory

Freud regarded this alienation as a form of natural shielding, or de-

fense, by means of which the brain (or mind) protected itself against
harsh internal realities of emotional frustration, psychic conflict, and
pain, or causes of unpleasure more generally.2 These are internally re-
lated: conflict produces frustration, frustration produces anger, and
both conflicts and frustrations are inevitable in our attempts to satisfy
needs and desires. He formulated preliminary ideas about conflict and
defense early in his psychiatric career. Finding contemporary physical
treatments for mental disorder useless, he followed the example of his
senior colleague Joseph Breuer, who told him of a patient, now called
Anna O., who had been diagnosed with hysteria. She and Breuer had
so thoroughly investigated the occurrence of her symptoms in the

1 This essay builds on previous work of mine, including “Psychoanalysis Representation and
Neuroscience: The Freudian Unconscious and the Bayesian Brain,” in A. Fotopolu, D. Pfaff,
and M. A. Conway (eds), From the Couch to the Lab: Psychoanalysis, Neuroscience and Cognitive
Psychology in Dialogue (Oxford: Oxford University Press, 2012), 230–​65, on psychoanalysis and
Bayesian neuroscience; “Understanding and Healing: Psychiatry and Psychoanalysis in the Era
of Neuroscience,” in K. W. M. Fulford et al. (eds), The Oxford Handbook of the Philosophy of
Psychiatry (Oxford: Oxford University Press, 2013), 1264–​92, on psychoanalysis and psychiatry;
“The Significance of Consilience: Psychoanalysis, Attachment, Neuroscience, and Evolution,”
in S. Boag et al. (eds), Psychoanalysis and Philosophy of Mind: Unconscious Mentality in the 21st
Century (London: Karnac Books, 2015), 47–​136, on psychoanalysis, evolution, attachment, and
neuroscience; “Free Energy and Virtual Reality in Neuroscience and Psychoanalysis,” Frontiers in
Psychology 7 (2016), art. 922, which coordinates some important recent work in neuroscience on
dreaming and mental disorder with the discussion here.
2 Freud regarded psychical conflict as a pivotal concept for understanding mental disorder, and he
used unpleasure for a range of homeostatic and emotional sufferings and discomforts, as exemplified
by those attending the sensory initialization of birth. For information on italicized psychoanalytic
terms, see J. Laplanche and J.-​B . Pontalis, The Language of Psychoanalysis, trans. D. Nicholson-​
Smith (London: W. W. Norton, 1973); for neuroscientific terms such as homeostasis below see
neuroscience.uth.tmc.edu.
 Freud and Mental Health 253

context of their occurrence that, as Breuer said, “her life had became
known to me to an extent to which one person’s life is seldom known
to another” (Works 2: 21–​2).3
In this relationship of full disclosure doctor and patient found to-
gether that her symptoms expressed forms of fictive experience or
belief—​ now psychoanalytically described as phantasy—​related to
emotionally significant events she had apparently forgotten. Moreover,
her symptoms eased when she remembered these events and expressed
the emotions connected with them.4 For example, for a time, and
despite “tormenting thirst,” she refused to drink. She pushed away
water like “someone suffering from hydrophobia” (Works 2:34), as if
drinking itself had become disgusting or dangerous. Under hypnosis
she remembered remaining silent despite great disgust, when a com-
panion let a little dog (“horrid creature”) drink from her glass. After
expressing her outrage and disgust, she was able again to drink again
without difficulty.
In this case the patient’s phantasy—​a delusory conviction that there
was something about drinking plain water that made it disgusting or
dangerous—​had apparently stemmed from a memory she was uncon-
scious of, in the sense that that it was inaccessible to awareness, under-
standing, and reason. Accordingly, Breuer and Freud focused on the
memories in which Anna O.’s phantasies were rooted, as opposed to
the phantasies themselves. Hence, they hypothesized that their hys-
terical patients suffered, not from engrossment in phantasy, but from
memories of events they have found traumatic, and so had banished
them from consciousness and thought by repression. Insofar as these
memories could be made conscious, the symptoms could be relieved.

3 References to Freud are to J. Strachey (ed.), The Standard Edition of the Complete Psychological
Works of Sigmund Freud, 24 vols. (London: Hogarth Press, 1957). Cited by volume and page
number.
4 Toward the end of the last century, Breuer’s treatment of Anna O., like much else to do with
Freud, was the subject of much uninformed historical discussion. This is clarified in R. Skues,
Sigmund Freud and the History of Anna O. (Houndmills, UK: Palgrave Macmillan, 2006), in
which Breuer’s modest, but apparently genuine, therapeutic success can be discerned.
254 Jim Hopkins

Freud was soon to revise the assumptions about memory and phan-
tasy embodied in this theory. Before doing so, however, he pressed his
patients for memories connected with their symptoms, and he was able
to trace a range of disorders back through childhood to origins that
apparently lay in infancy. Although this risked conflating the roles of
memory and phantasy, these researches were nonetheless pioneering
and valuable. They can now be seen to accord with more recent work
in psychopathology indicating that many disorders do indeed have an
early developmental history, and with research in attachment and de-
velopmental psychology indicating that basic patterns in emotion and
conflict—​for example, those that give rise to secure as opposed to dis-
organized attachment—​are initially achieved in the first months of
postnatal life.5

The Interpretation of Dreams and

the Conception of Free Energy Neuroscience

Freud’s radical revisions began when he started to analyze his own and
his patients’ dreams. This required engaging in the process of free asso-
ciation, in which patients described the rapidly changing contents of
their own conscious states of mind in as much detail as possible and
without omission or censorship. This enabled Freud to learn as much
about his patients’ experiences, memories, thoughts, and feelings as
they were able to put into words and to extend this understanding by
observing how their expressions in analysis were related to one another,

5 Current journals related to this topic include Child Development, Attachment and Development;
Development and Psychopathology; and The Journal of Child Psychology and Psychiatry. On early
attachment see B. Beebe and F. Lachman, The Origins of Attachment: Infant Research and Adult
Treatment (New York: Routledge, 2014). For a psychoanalytic case history focusing on the inter-
generational transmission of trauma see V. Volkan, A Nazi Legacy: Depositing, Transgenerational
Transmission, Dissociation, and Remembering Through Action (London: Karnac Books, 2015); and
for related empirical hypotheses as to the mechanisms involved see C. Cohen et al. “The Lasting
Impact of Early-​Life Adversity on Individuals and Their Descendants: Potential Mechanisms and
Hope for Intervention,” Genes, Brains, and Behavior 15/​1 (2016), 155–​68.
 Freud and Mental Health 255

to their dreams and symptoms, and to their actions in life outside their
sessions. This radical mode of self-​disclosure—​and the range of data
it provided—​was unprecedented in previous psychological research
and even now remains without parallel in any other discipline. Hence,
although other forms of investigation of the emotional functions of
dreaming increasingly acknowledge the evidential importance of the
dreamer’s associations,6 none so thoroughly takes them into account.
Freud’s first love in research had been the study of the nervous
system, in which he had shown unusual distinction.7 As his new
sources of data led to new hypotheses, he initially tried to formu-
late them in a new approach to neuroscience, in a “psychology for
neurologists,” later published as the Project for a Scientific Psychology.
Here he observed “the pathological mechanisms which are revealed in
the most careful analysis in the psychoneuroses bear the greatest simi-
larity to dream-​processes” (Works 1:336). Both dreams and symptoms,
as he now saw, served the common function of protecting the con-
scious self or “ego” from otherwise distressing or disruptive arousals
of conflicting emotions. They did so, moreover, in the same way: via
the creation of fictive experiences and beliefs, forms of phantasy that
entailed an “alienation from reality” that masked and pacified (or in
neuroscientific terms inhibited) aspects of emotion and conflict.
Freud’s new approach to neuroscience envisaged the nervous system
as operating to minimize free energy, a conception he apparently de-
veloped on the basis of Helmholtz’s account of the thermodynamic
energy in a system that was available for conversion into work. Freud
thought of this energy as introduced into the nervous system by sen-
sory impingement, both external (as in visual, auditory, or tactile

6 J. Malinowski and C. Horton, “Metaphor and Hyperassociativity: The Imagination Mechanisms

behind Emotion Assimilation in Sleep and Dreaming,” Frontiers in Psychology: Psychopathology 6
(2015), art. 1132.
7 While Freud was a medical student, he was invited by the celebrated physiologist Ernest Bruke
to conduct research in his laboratory. Prior to practicing as a psychiatrist, Freud had published well
over 100 papers in neurology, as well as monographs on disorders of movement and childhood ce-
rebral palsy that established him as a leading expert in these fields.
256 Jim Hopkins

perception) and internal (as in proprioception and interoception). The

most important source was the constant and inescapable flow of “en-
dogenous (interoceptive) stimuli” (Works 1:297) that reflected the
“peremptory demands of the internal needs.” These inputs created a
“demand for work” on the part of the nervous system, to produce the
“specific actions” in the external world that would satisfy the needs
and thereby minimize the energy introduced by their arousal.
Thus the “scream” of the helpless infant was also her first commu-
nication of urgent need, expressing the demand for work that others
had to perform on her behalf if she was to survive in order to learn to
do so herself (Works 1:318). The first mental process by which the in-
fant accomplished this was the innate primary process that generated
phantasies—​fictive dreamlike beliefs and experiences—​that helped
mitigate frustration and pain while promoting learning. Just as a
hungry and distressed infant finds comfort and relief in the experi-
ence of being held and nursed by her mother, so an infant could also
(temporarily) secure a degree of comfort by engaging in a dreamlike
phantasy of such experience. Such phantasies could shield the in-
fant from “the first great anxiety state” generated by the sensory as-
sault that occurred with birth, and later from “the infantile anxiety of
longing—​the anxiety due to separation from the protecting mother”
(Works 19:58).
This could in turn promote learning, as Freud illustrated by an
example in which a nursing infant used the pacifying “wishful ca-
thexis” provided by phantasy to “experiment” by turning her head
in such a way as to secure the nipple. But this mode of learning re-
quired the infant to forgo the immediate relief provided by wishful
phantasy to focus on the “indications of reality” available in percep-
tion (Works 1:328–​29, 356). Thus against the background of the regula-
tion of pleasure and unpleasure by the primary process, the secondary
processes introduced the infant—​cry by cry, feed by feed, excretion by
excretion—​to the harsh realities of the world into which she has been
born, as well as to her resources for coping with them.
 Freud and Mental Health 257

Whereas the fictive satisfactions provided by phantasy are instanta-

neous, those obtained in accord with the reality principle require tol-
erance of frustration and delay. But these real satisfactions are essential
for the maintenance of life, are deeper and more lasting, and are there-
fore more effective in minimizing free energy, than those provided
by phantasy. Hence, the infant’s waking image of the world, as con-
stantly registered and re-​registered in memory, steadily diverges from
its dreamlike beginnings. As development proceeds the secondary
processes increasingly inhibit, overlay, and supplant the primary pro-
cess in waking life, so that finally it operates without realistic con-
straint only in the processing of memory and emotion during sleep.
Waking and dreaming consciousness contribute to the minimiza-
tion of free energy in distinct ways. In waking life, sense-​perception
arouses emotions and desires, and these drive thought and action
so that the desires are satisfied and the emotions pacified and the
free energy introduced with their arousal is minimized. In sleep, by
contrast, arousals of emotion are prompted by memory rather than
perception, and these, and the associated free energy, are pacified
by the fictive satisfactions of dreaming. Still, if memories of partic-
ularly traumatic events or conflicts are aroused during sleep, this
may cause a dream experience of anxiety or terror for which no
pacifying solution can be devised, as in the nightmares that are part
of post-​traumatic stress disorder. In such cases, the minimization
of free energy requires inhibition of the primary process and a re-
turn to waking consciousness and thought. Alternatively, powerful
conflicts and frustrations rooted in early experience can be aroused
in waking life. In this case, particularly in individuals who already
rely excessively on engrossment in phantasy for the regulation of
their emotions, the primary process may again become dominant in
waking consciousness, producing the fictive beliefs and experiences
constitutive of mental disorders.
Thus on Freud’s account, a main part of mental health consists
in coordinating the primary and secondary processes, or again in
258 Jim Hopkins

coordinating phantasy with reality-​oriented thought. As we will

briefly consider below, phantasy and imagination are instrumental in
imbuing real activities with emotional significance derived from the
past; but the balance between mental health and disorder turns on
the achievement of real as opposed to phantasied satisfactions. Health
is shown in the appropriate ordering of the emotional significance of
relationships and projects, and this requires bearing frustration suffi-
ciently over the course of development to be able to replace phantasy
by thought.

The Priority of Phantasy

In Freud’s account, the primary process is “in the apparatus from the
first” (Works 5;603) and so prior to memory. As Freud saw, this entailed
that the possibility of tracing the history of his patients’ conflicts via
memory was severely limited. As well as being established to replace
phantasy, memory was apparently the product of a continual recon-
struction, in which memories were re-​formed as they were re-​aroused.
Thus as Freud described in “Screen Memories” (Works 3), what might
seem to be emotionally significant memories from childhood may
turn out on analysis to be interwoven with distorting phantasies.
Something similar held within the therapeutic process itself, in which
Freud’s patients could clearly be seen to develop phantasies about him
as their therapist that replicated those about their parents in their
memories, dreams, and symptoms.
Freud described this as transference. It enabled him to triangu-
late among his patients’ dreams, symptoms, apparent memories, and
experiences of transference in therapy to gain a fuller sense both of
their phantasies and of the remembered events that had given rise to
them. Nonetheless, the relation between apparent or seeming memory
and genuinely veridical memory remained to be determined in each
individual case. Hence as Freud later said, “the phantasies possess
psychical in contrast to material reality, and we gradually learn to
 Freud and Mental Health 259

understand that in the world of the neuroses it is psychical reality that

is of the decisive kind” (Works 16:368).

Identification and Projection

In addition, Freud and his successors came to understand phan-

tasy as including two families of mechanisms that we can describe
as identification and projection. These are mechanisms of devel-
opment as well as defense, and they are related to individual and
group cooperation and conflict. Freud described identification as
“the assimilation of one ego to another” (Works 22:63), and he took
this to include at least three developments. The first was the basic
assimilation of attitudes and other dispositions from those around
us by which we initially articulate our selves and characters. An
example might be the way some 60–​70 percent of infants come to
share basic emotional dispositions (as shown in categories of attach-
ment) with their mothers by the end of the first year. The second
was the assimilation of abilities and skills in personal learning,
such as infants’ acquisition of language. The third, facilitated by
the first two, was the assimilation of attitudes and stances in em-
pathy, sympathy, and other socially coordinating emotions that
distinguish members of cooperating ingroups, of which the family
is the first example.
Projection, by contrast, represents and creates difference. Whereas
identification often involves the assimilation of admired or desired
characteristics, projection often involves the imaginary relocation of
morally condemned or unwanted characteristics from the self onto
others. Thus where identification often creates an image of a good
self in relation to a good other or others (a good us), projection often
creates an image of a good self in relation to a bad other or others (a
bad them). Identification thus mediates relations of amity in coopera-
tive ingroups, while projection mediates relations of competition and
hostility with members of outgroups. The two mechanisms coordinate
260 Jim Hopkins

in creating and maintaining the many forms of ingroup cooperation

for outgroup competition and conflict characteristic of human sociality.8
The development of identification and projection thus begins in the
family. In early infancy emotions such as rage, fear, and distress at sep-
aration are directed at the mother, so that these “negative” emotions
serve as honest signals of urgent need. The first good us is that of the
mother nursing the child; and this entails the exclusion of others
(father and siblings) from this relationship. Early projection creates
images of both parents as liable to punish aggression within the family
with retaliatory moralistic cruelty, so that infants learn to inhibit ag-
gression partly by identifying with these “earliest parental imagos”
(Works 22:50). 9 In this they create the harshly self-​critical part of the
self that Freud called the superego or ego ideal, which comes to the fore
in depression and suicide, and some of whose manifestations we will
consider below. Projection then shifts the locus of anger and fear away
from the parents and outside the family as the infant comes to repre-
sent the mother as enduring, unique, and irreplaceable.
This is shown by the angry protests at separation from their mothers
that infants begin to show at about eight months, and the fear of
strangers (particularly those with beards) that arises at the same time.
This indicates the establishing of the overall structure of ingroup-​
outgroup relations, as captured by the well-​known proverb:

Myself against my brother

My brother and I against the family
My family against the clan
All of us against the foreigner.

8 See: J. Hopkins, “Evolution, Emotion, and Conflict,” in M. Chung and C. Feltham (eds),
Psychoanalytic Knowledge (Houndmills, UK: Palgrave Macmillan, 2003), 132–​56, and J. Hopkins,
“Conscience and Conflict: Darwin, Freud, and the Origins of Human Aggression,” in D. Evans
and P. Cruse (eds), Emotion, Evolution, and Rationality (Oxford: Oxford University Press, 2004),
225–​48.
9 Freud uses the Latin term imago (image) for mental representations.
 Freud and Mental Health 261

Such structures place each individual in series of groups, groups of

groups, and so forth, up to the level of competing coalitions of nations.
The cohesion of cooperating ingroups is based on identification, often
with an idealized leader or creed that acquires the role of superego to
the group, and so facilitates the projection of bad qualities into rival
groups (Works 18:69–​143). For this reason, although the mechanisms
of identification and projection are continually in operation, some
of their clearest manifestations are visible in group competition
and conflict. Obvious examples would be the idealization of Hitler
and the denigrating projections onto the Jews that were part of the
unifying ideology of the Nazis, or again the denigrating projections
onto Muslims that foster current anti-​Muslim hostility, the idealiza-
tion of particular versions of Islam and denigrating projections onto
“unbelievers” that foster Islamic terrorism, the denigrating projections
into available immigrant minorities that have become part of the
electoral politics of most democracies, and so on ad finem nostrum.
Members of groups with such common good and bad objects feel uni-
fied by identification and purified by projection and are consequently
able to show hostility to their rivals that is justified by common ideals.

Conflict, Dreams, and Symptoms

In what follows I will illustrate some of Freud’s basic ideas with simple
examples, which I have elsewhere discussed in more neuroscientific
terms.10 Let us start with core case of the secondary processes (percep-
tion, desire, belief, action) in reducing free energy by satisfying a desire
based on sensory signals of need. In general, we can represent desires
in sentential form, that is, as desires that P, where “P” is replaced by a
sentence specifying the content of the desire. Thus an agent’s desire to
drink can be more specified as her desire that she get a drink. When an

10 J. Hopkins, “Free Energy and Virtual Reality in Neuroscience and Psychoanalysis,” Frontiers in
Psychology: Cognitive Science 7 (2016), art. 922.
262 Jim Hopkins

agent acts successfully on this desire this will bring about the situation
P (that she gets a drink) that satisfies the desire; and this in turn will
cause a perceptual experience of desire-​satisfaction (here, the experi-
ence of drinking water and slaking thirst).
Such an experience serves to pacify the desire whose satisfaction it
registers, freeing the agent for work on further desires and the biolog-
ical imperatives that underlie them. This is the general pattern of the
secondary processes, operating in accord with the reality principle to
minimize free energy by ensuring the satisfaction of desire and need.
This is schematized in the following diagram:

Agent’s Action that Experience of Pacification

interoceptively satisfies desire satisfaction that (termination) of
generated desire pacifies desire desire with
P [A drinks] and inhibits inhibition of
A desires sensory signals sensory signals
P [I drink] causing it that caused it.

A experiences, A’s desire for

believes P pacified
P [I drink]

This also illustrates how the operation of the neural mechanisms re-
lated to need and desire are reflected in commonsense psychology. We
describe desires in terms of the actions they will produce if acted on, so
that the description of a desire tacitly predicts its effect on the agent’s
behavior. Also, we tacitly understand how emotions and desires are re-
lated to perceptual experiences that will pacify them. Such experiences
of satisfaction go beyond individual desires to inhibit, at least tempo-
rarily, the drives or emotions in which they originate. In the right
circumstances an experience of eating or drinking (or nursing) can
terminate not only hunger and thirst but also the fear of starving
or dying, as that of a single breath can end the panic of apparently
impending suffocation, or a yearned-​for look or touch can end the pain
of separation, exclusion, or social isolation. Even a minimum of satis-
faction can go a long way. Such satisfactions are particularly important
 Freud and Mental Health 263

to the newborn, for whom obtaining physical and emotional care is a

continual matter of thriving or failing.
The discovery that prompted the developments in Freud’s thinking
discussed above was that dreams also used experiences of satisfaction
to inhibit sensory signals and pacify drives, emotions, and desires.
Thus—​continuing the simple example above—​he reported that when
he had eaten anchovies or some other salty food, he was liable to dream
that he was drinking cool, delicious water. After having this dream, he
would wake, find himself thirsty, and get a drink. In waking from such
a dream, we intuitively regard them as caused by, and representing the
satisfaction of, desires familiar from waking life.
This natural conclusion is based on a tacit comparison of the desire
we feel on waking with the experience of the dream. The desire is to
drink, and the dream is of drinking; so the dream is the dreamt fictive
experience of satisfaction of the desire. In light of this, the dream-​ex-
perience seems best understood as caused by the desire and—​since it
has apparently been doing so prior to waking—​as serving to pacify
the desire, if only temporarily, so that sleep and dreaming can con-
tinue. These fictive pacifying experiences both mask and mitigate con-
flict—​in this case as between nocturnal arousals of drive, emotion,
desire or feeling on the one hand, and the wish to sleep, or again the
mechanisms that operate to continue the biological functions of sleep
and dreaming on the other. We can represent their role as follows:

Sleeping agent’s Dreaming agent’s Temporary pacification

incipient desire to believed fictive of desire allowing
drink, in conflict with experience of satisfaction sleep and dreaming,
mechanisms preserving (drinking) that both with which desire is in
sleep pacifies and masks the conflict, to continue.
desire
A desires P A’s desire for
A experiences, P pacified.
believes P

This is a simple example of the structure Freud discovered in dreams,

which he thought played a particularly important role in easing the
264 Jim Hopkins

infant into the sensory initialization of birth. Two things in partic-

ular are worth noting. First, even this simple dream is similar to the
kind of hallucination or delusion characteristic of mental disorder. In
responding to the onset of thirst with a dream of drinking, a dreamer
instantly obscures both internal and external reality: the reality of her
own state of mind, and her engagement with the extra-​mental world.
Her real state of mind is that she has an incipient and growing desire
(need) for water; but this is overlaid and masked—​and so, as in repres-
sion, rendered unavailable to consciousness—​by the fictive experience
of satisfying a desire that in fact remains unfulfilled. The dreamer is
so divorced from her own needs, wants, and real situation that if she
remained shielded in this way she would die. This, in miniature, is
the situation of someone suffering from a psychotic hallucination or
delusion. So even this simple dream illustrates what Freud means by
speaking of “alienation from reality.”
Second, it seems that the dream process, like that of the pacifica-
tion achieved in real action, operates by temporarily eliminating or
reducing such parameters of motivation as desire and emotion. Just
as the experience of a real drink eliminates the thirst and desire to
drink, so (albeit temporarily) does the fictive experience of drinking
in a dream. In the case of such emotions as anger and guilt, this reduc-
tion or elimination of desire or emotion is particularly important. For
this let us consider another relatively simple dream, reported by the
neuroscience blogger Neurocritic, who had recently suffered an injury
to his leg, in a recent discussion of the suppression of pain in rapid-​eye-​
movement (REM) dreaming.11

Yesterday morning, I had a terrible nightmare in which my real life

leg pain was projected onto someone else in an exceptionally grue-
some way. I was driving along an unknown neighborhood street

11 neurocritic.blogspot.co.uk/​2011/​09/​neurophysiology-​of-​pain-​during-​rem.html.
 Freud and Mental Health 265

when suddenly a man . . . had fallen under my car and had both his
legs amputated from being run over. . . . The gravely injured man
was still alive . . . I was absolutely horrified. All I could do was say
“oh my god oh my god oh my god” over and over. . . . It was an awful
nightmare, and in the dream I was quite traumatized by the entire
experience.

This dream has the same wish-​fulfilling form as diagrammed above,

except that in this case the phantasy has further consequences for
the dreamer. As Neurocritic says, this dream illustrates projection,
involving the imaginary relocation of some aspect of the self in an-
other person. While often the imaginary relocation is used to increase
self-​esteem or diminish guilt, in this case the projection was of pain
and was realized by imagining causing terrible pain in someone else,
which in turn made the dreamer himself feel anxious and guilty. So
this dream could also exemplify the mechanism that Freud’s successor
Melanie Klein described as projective identification, in which the psy-
chic relocation in the projection is imagined as occurring via bodily
activities.

Examples from One of Freud’s Case Histories

The emotional conflicts with which Freud was concerned were of

two related kinds. The first was conflict between love and hate (or
positive and negative emotion more generally) for a single person.
The second, based on this, was conflict between parts or aspects
of the self, for example those involving the self-​critical and self-​
punishing superego. The relations between such conflict, the pri-
mary process, and mental disorder are displayed in a case history that
predated Freud’s formulation of his ideas about the superego, and
from which some of his session-​by-​session notes survive. The patient,
known as the Rat Man (hereafter R) suffered from what Freud called
266 Jim Hopkins

an obsessional neurosis, nowadays described as obsessive-​compulsive

disorder (OCD).
As R told Freud in the consultation before his analysis began, his
main compulsive ideas concerned “a fear that something bad might
happen to two people he loved very much,” his father and a lady he
venerated and hoped to marry. Also, he suffered impulses “to do some
injury to the lady” and to harm himself. The impulses to harm his lady
did not occur when she was with him, but when she went away. Thus
when she went to visit her grandmother, and would not agree for him
to join them, he had felt “commanded” to cut his own throat. As he
went to fetch his razor as if to do so, however, it occurred to him that
things were not so simple: he must kill the old woman instead. At this
he had fallen down in horror (Works 10:260).
Freud understood this episode in a way that was close to common
sense but also made use of his distinctive hypotheses. In commonsense
terms, R was frustrated and pained by his lady leaving him alone. He
first directed his anger at himself and then at the old woman the
lady had left him to visit. But also—​and here is the characteristically
Freudian part of the account—​R was so alienated from the reality of
his own emotions he was unaware of his separation distress, the anger
it caused, and of their suddenness and force. Thus, he had “an uncon-
scious fit of rage” (188), which he experienced, in accordance with the
mechanism of projection, as something coming from outside, in the
form of a command to cut his own throat.
This provides a clear example of the second kind of conflict described
above, the direction of anger or hatred by a part of the self against the
self. In this case, the directing part was the agency internal to R that
commanded him, as if from outside, to cut his own throat in response
to the aversive emotions he was feeling. The first kind of conflict,
that of love and hate directed at the same individual, was also clear
in R’s main compulsive symptom, the fear that “something bad might
happen” to the lady and father he loved.
 Freud and Mental Health 267

This was expressed in his repeated compulsive imagining—​as in a

waking nightmare—​that his beloved father or venerated lady were
being subjected to a terrible torture, in which hungry rats ate their way
into the anus of the victim, causing an agonizing death. Imagining
this, particularly in the case of his father, made R guilty, anxious, and
depressed, even though he knew that his father was beyond harm since
he had been dead for years. He constantly sought to forestall or pre-
vent it by performing the actions or rituals that were the symptoms of
his OCD. These included undertaking meaningless but onerous tasks
or uttering various preventive formulae, sometimes with the insertion
of “without rats” (291).
Despite R’s genuine affection for both his father and his lady, one
might reasonably think that his repeatedly imagining them being
tortured in this way was an expression of hostility toward them. Freud
understood these imaginings—​like the “commands” he received to
kill the old lady or to cut his own throat—​as stemming from uncon-
scious rage, harbored, in the case of his father, from early childhood.
This was confirmed in his analysis both by transformations of his un-
conscious rage into conscious expressions of rage, and by his recovering
both his anger and his fear toward his father in early childhood, and
in subsequent episodes in which his anger had been expressed. He
realized that when he was angry with people he often “wished the rats
on them” and that he had long harbored such rat-​wishing rage against
his father.
Thus R’s symptom had a pattern that we can illustrate as similar to
those above:

R’s unconscious R’s conscious Temporary pacification

impulsive conflicted but fictive experience of R’s unconscious
angry wish that of satisfaction rage by the fictive
his father be in imagining and experience that masks
tortured by the rats. believing that and mitigates his
his father was conflict but also
being tortured causes anxiety
by the rats. and depression.
268 Jim Hopkins

An Example from Post-​Freudian Psychoanalysis

Finally, let us consider some delusions described by Elyn Saks in her

account of her descent into schizophrenia.12 She entered a psychi-
atric hospital in a savagely self-​critical depression, in which she kept
repeating, “I am a piece of shit and I deserve to die.” Such self-​hating
internal conflict is a mark of the rage against the self that characterizes
“introjective” depression,13 which Freud described in terms of the su-
perego, as seen in the examples from R above. When antidepressants
gave Saks some relief, she told her doctor that she felt less angry and
remarked on “how much rage I had felt, directed mostly at myself.”
Later, however, her self-​reproaches returned in force, and her in-
creasingly unbearable depression altered only when she began to im-
agine herself “receiving commands” from “shapeless powerful beings
that controlled me with thoughts (not voices) that had been placed in
my head.” These commanded, for example, “Walk through the tunnels
and repent. Now lie down and don’t move. You are evil.” She was also
commanded to injure herself, which she did by burning herself with
cigarette lighters, electric heaters, or boiling water, so that finally she
spent most of her time “alone in the music room or in the bathroom,
burning my body, or moaning and rocking, holding myself as protec-
tion from unseen forces that might harm me.”14
These delusions also fit the generalizations diagrammed in the fig-
ures so far. They served to mitigate the conflict of Saks’s self-​punishing
depression, by replacing it with an imaginary relationship in which the
self-​punishing part of herself was projected, as in Neurocritic’s dream,
into imaginary punishing others. Thus, while greatly simplified, we
can represent Saks’s development of paranoid symptoms parallel to the
simple dream and symptom diagrammed earlier.

12 E. Saks, The Center Cannot Hold: My Journey Through Madness (New York: Hyperion, 2008).
13 S. Blatt, Experiences of Depression (Washington, DC: APA Press, 2004).
14 Saks, The Center Cannot Hold, 84–​86.
 Freud and Mental Health 269

Saks directs rage Saks externalizes (projects) Saks’ rage against herself
against herself, her internal conflict and desire to be punished
and desires that by imagining/phantasizing are temporarily pacified
she be punished. that she is controlled by this alienation from
by shapeless powerful reality, which however,
beings who command leaves her isolated,
the punishments of deluded, and miserable.
burning that she inflicts,
thus yielding an experience
of satisfaction that
temporally pacifies her rage.

This kind of transition from depressive to paranoid functioning

has often been discussed in psychoanalysis,15 and it is usually said to
involve the projection and fragmentation of the superego. This goes
back to Freud’s account of how, in schizophrenia, “the voices, as well
as the undefined multitude [of critical presences embodied in the su-
perego] are brought into the foreground again by the disease” so that
the sufferer’s harshly critical conscience “confronts him in a regressive
form as a hostile influence from without” (Works 14:96). Thus once
her delusions set in, as Saks says, “the commanding influence” respon-
sible for her self-​directed moralistic cruelty “came from within my
own head, but was not mine. It was someone else commanding me.”16
In such a case, while the reduction in internal conflict may relieve
the unbearable internal hostility and depressive pain that can cause su-
icide, it also marks a deeper alienation from reality, and a deeper failure
of self-​regulation than the depression it relieves. Saks’s self-​critical fac-
ulty was already punishing her dysfunctionally, for some imagined
or phantasied transgression.17 Projecting this part of herself into the
“shapeless powerful beings” of her delusions was a further step from

15 See for example D. Bell, “Who Is Killing What or Whom? Some Notes on the Internal
Phenomenology of Suicide,” in S. Briggs, A. Lemma, and W. Crouch (eds), Relating to Self Harm
and Suicide: Psychoanalytic Perspectives on Practice, Theory and Prevention (London: Routledge,
2008), 38–​45, and in the same volume J. T. Maltsberger, “Self Break-​up and the Descent into
Suicide,” 38–​44.
16 Saks, The Center Cannot Hold, 85.
17 Cf. her phantasies of killing babies, as discussed in Hopkins, “Understanding and Healing.”
270 Jim Hopkins

reality. This is why the projective externalization constitutes a deeper

regulatory failure; why Freud describes it as regressive in the quotation
above; and why such paranoia involves a deeper alienation from reality
than depression, even though a main risk in schizophrenia is suicide in
the depressive phases in which the subject is attempting to re-​establish
internal regulatory control.
Freud remarked that R’s relief from his OCD was related to his
recognizing himself in the invading rats of his phantasy; and we can
now see that this symptom, like Saks’s delusions or Neurocritic’s
dream, effected an imaginary relocation (projection) of an enraged
(and biting) part of himself in another. The oscillation between de-
pression and mania in bipolar disorder (BPD) shows a related mech-
anism, in which attempts to maintain internal but overly depressive
regulatory control give way to delusions in which, for example, the sub-
ject imagines himself accomplishing or expecting wonderful things.
(An important difference between Saks’s paranoid solution to de-
pressive conflict and the manic one is that the superego is fragmented
and projected by the delusions constituting the former but only mas-
sively inhibited by the delusions of excellence constituting the latter.)
A third conflict-​reducing response is the inhibition of the generation
of purposive action itself, as seen in the response to separation distress
in infant animals.18

Symbolism and the Cognitive

Regulation of Emotion

Since the body-​invading rats of the phantasy that was R’s main
symptom also represented R’s own biting rage, we can also see this as

18 D. F. Watt and J. Panksepp, “Depression: An Evolutionarily Conserved Mechanism to

Terminate Separation Distress? A Review of Aminergic, Peptidergic, and Neural Network
Perspectives,” Neuropsychoanalysis 11/​1 (2009), 7–​51.
 Freud and Mental Health 271

an example of Freudian symbolism.19 The forming of this particular

symbol seemed traceable to R seeing what he took to be a large rat in
the graveyard where his father was buried and imagining the creature
had been eating his father’s corpse (Works 10:297). A comparable ex-
ample of symbol-​formation could be seen in R’s transference phantasy
of Freud’s mother dead, with R’s two Japanese swords stuck through
her breast, and the lower part of her body, and especially her genitals,
eaten up by Freud and his children (282–​83).
The swords were a military souvenir that hung in R’s bedroom, and
he had previously named them “marriage” and “copulation” (267).
Here he used this established symbolic relation to create a phan-
tasy of a phallic and oral attack on the nurturing and reproductive
capacities of the maternal breast and genitals, as well as the projection
onto Freud and his children of the primitive oral rage and greed that
he often symbolized in his phantasies about the rats. We can now see
such symbolism as instantiating psychodynamic forms of what cog-
nitive scientists have described as conceptual metaphor.20 Thus as R’s
symptoms and phantasies indicate, such symbol formation, clearly
rooted in bodily activities and processes, is a form of enactive embodied
cognition, and one that plays a significant role in the processing of
emotion.
Freud described this symbol formation as enabling the sublimation
of the drives, that is, the diversion of affect from basic bodily processes
(e.g., those of biting and oral incorporation, or again genital aggression,
as seen in R’s case) to those to which the symbolization imparted emo-
tional significance (e.g., activities with swords). Later analysts, such as
Melanie Klein, came to regard this as central to the development of
the ego, so that, for example, the lack of symbolic play and inhibition

19 A. Petocz, Freud, Psychoanalysis, and Symbolism (Cambridge: Cambridge University

Press, 1999).
20 See J. Hopkins “Psychoanalysis, Metaphor, and the Concept of Mind,” in M. P. Levine (ed.),
The Analytic Freud: Philosophy and Psychoanalysis (London: Routledge, 2000), 11–​35.
272 Jim Hopkins

of interests found in some autistic individuals were explainable by

failures in this basic process. Hence, as discussed by Malinowski and
Horton,21 such symbolic but cognitive work seems a particularly im-
portant part of processing emotion in dreams.

Psychoanalysis and Recent Work

in Development and Neuroscience

We saw that Freud initially cast the basic ideas of psychoanalysis in

terms of an account of neuroscience in which the brain operated to
minimize free energy. This bears a striking resemblance to the new
paradigm for neuroscience advanced over the last decade by Karl
Friston and his colleagues under the free energy principle.22 They rep-
resent the brain as operating to minimize variational free energy, an
information-​ theoretic analogue of Helmholtz’s conception. This
implies, consistently with both Helmholtz and Freud, that the brain
naturally embodies a model of the causes of the impingements on its
own sensory receptors and uses this to minimize its own errors in
predicting them.
This conception of free energy as prediction error makes it possible
to solve one of the great epistemic problems of neuroscience (and ar-
guably of philosophy more generally); namely, how brains (or per-
sons) can ensure the correctness of their representations or model of
the world on the basis of information internal to the nervous system.
It has attracted widespread interest in the sciences of the mind, in-
cluding recent philosophically informed books.23 Owing to the use of
the concept of free energy, the account of the brain that emerges has
the same overall structure as that given by Freud.

21 Malinowski and Horton, “Metaphor and Hyperassociativity.”

22 For more detail, see Hopkins, “Free Energy and Virtual Reality.”
23 A. Clark, Surfing Uncertainty: Prediction, Action, and the Embodied Mind (Oxford: Oxford
University Press, 2016); J. Howhy, The Predictive Mind (Oxford: Oxford University Press, 2013).
 Freud and Mental Health 273

In both accounts free energy enters the nervous system via sensory
impingement, with “endogenous [interoceptive] stimuli” as a partic-
ularly important source. As in Freud these inputs reflect “the major
needs,” or biological imperatives, so in Friston they predict departures
from a continuously recalculated overall homeostatic (or allostatic)
equilibrium, in which free energy is minimized.24 As Freud speaks
of these inputs as creating a “demand for work” to produce “specific
actions,” so Friston speaks of “an imperative to minimize prediction
error” via the “kinematic trajectories” involved in action.25 In both ac-
counts the process of minimization requires the brain to embody a
representation or model of the world, including the agent’s body (in
Freud the “bodily ego”); and for both this requirement is initially met
by the innate generation of a prior virtual (or phantasy) version of re-
ality, which will subsequently be modified by experience.
During the trimester prior to birth, infants spend most of their
time in a state resembling later REM sleep and dreaming, and their fa-
cial expressions indicate both positive (laughter-​related) and negative
(cry-​related) emotions.26 Accordingly, Hobson, Hong, and Friston hy-
pothesize that the brain is “genetically endowed with an innate vir-
tual reality generator” whose working “is most clearly revealed in rapid
eye movement sleep dreaming.”27 We are “born with a virtual reality
model” of what we will subsequently discover to be the causes of sen-
sory impingement, and this model is “entrained by sensory prediction
errors” to become “a generative or predictive model of the world.”

24 G. Puzzlio et al., “Active Inference, Homeosatis Regulation, and Adaptive Behavioural

Control,” Progress in Neurobiology 134 (2015), 17–​35.
25 K. Friston, “Prediction, Perception and Agency,” International Journal of Psychophysiology 83
(2012), 248–​52.
26 V. Schöpf et al., “The Relationship between Eye Movement and Vision Develops before Birth,”
Frontiers in Human Neuroscience 8 (2014), 775; N. Reissland et al., “Do Facial Expressions Develop
before Birth?” PLoS ONE 6/​8 (2011), e24081; N. Reissland, B. Francis, and J. Mason, “Can Healthy
Fetuses Show Facial Expressions of ‘Pain’ or ‘Distress’?” PLoS ONE 8/​6 (2013), e65530.
27 A. Hobson, C. Hong, and K. Friston, “Virtual Reality and Consciousness Inference in
Dreaming,” Frontiers in Psychology: Cognitive Science 5 (2014), art. 1133.
274 Jim Hopkins

The operation of this “virtual reality generator” thus almost exactly

parallels that of Freud’s primary process, or post-​Freudian accounts
of innate infantile phantasy. Like the primary process/​phantasy, it is
an innate precursor of dreaming that serves for the minimization of
free energy from birth and paves the way for perceptual learning, the
establishing of memory, and free-​energy minimizing action. Freud
described these latter as the secondary processes, and Friston describes
them in terms of active inference. Hence on both accounts, the role of
innate phantasy/​virtual reality at birth is supplanted during waking
by the reality-​oriented processes and the actions they inform, so that
the primary process/​virtual reality generator come to operate without
sensory constraint only in the sensory attenuation and bodily paralysis
of dreaming.
As Friston and his colleagues remark, “if the brain is a generative
model of the world, then much of it must be occupied with modelling
other people.”28 This suggests that the generative model of the infant
should coincide with the “internal working models” of self and other
as studied in the development of the emotional bonds that constitute
attachment. Indeed, postnatal active inference—​and hence the fun-
damental shift from virtual reality to generative model—​seems to
be driven by the subcortical “prototype emotion systems” limned by
Panksepp.29 These play the role in contemporary affective neurosci-
ence that Freud assigned to the drives. Watt and Panksepp describe
the systems as “sitting over homeostasis proper (hunger, thirst, tem-
perature regulation, pain, etc.)” and “giv[ing] rise to attachment,”
which in turn serves as “the massive regulatory-​lynchpin system of the

28 K. Friston et al., “Computational Psychiatry: The Brain as a Phantastic Organ,” The Lancet
Psychiatry 1/​2 (2014), 148–​58, at 151.
29 J. Panksepp, Affective Neuroscience (Oxford: Oxford University Press, 1998). See also
L. Bivens and J. Panksepp, The Archaeology of Mind: Neuroevolutionary Origins of Human
Emotions (New York: Norton, 2013); and A. Damasio and G. B. Carvalho, “The Nature of
Feelings: Evolutionary and Neurobiological Origins,” Nature Reviews Neuroscience 14 (2013),
143–​52.
 Freud and Mental Health 275

human brain” exercising “primary influence over the prototype sys-

tems below.”30
As this indicates, from the turn of the century there has been in
increasing consilience among the findings of psychoanalysis, attach-
ment and other forms of developmental psychology, and affective
and cognitive neuroscience.31 The free energy paradigm seems ideally
fitted to serve as a framework for consolidating these results. Hence,
Alan Hobson, for four decades the most persistent and zealous
neuroscientific critic of Freud, has produced two books applying
the notion of a virtual reality generator/​generative model in support
of what he has recently described as Freud’s “visionary” conclusions
linking dreaming and psychopathology.32 In this, as Hobson says, he
“takes up the Project for a Scientific Psychology exactly where Freud left
it in 1895.”33 But of course Freudian and post-​Freudian developments
of the ideas in Freud’s Project should also be taken into account, as well
as the specific notion of computational complexity that Friston relates
to dreaming.

The Complexity Theory of Dreaming

and Mental Disorder

In Friston’s framework, the minimization of free energy is effected

via the maximization of the predictive accuracy of the brain’s model
together with the minimization of its computational complexity.
Complexity is measured by the number of hypotheses (parameters)
engaged in predicting a range of data and the extent to which they
require modification during this engagement. Hence in his accounts,

30 Watt and Panksepp, “Depression.”

31 See Hopkins, “The Significance of Consilience.”
32 A. Hobson, Ego Damage and Repair: Towards a Psychodynamic Neurology (London: Karnac,
2014); A. Hobson, Psychodynamic Neurology: Dreams, Consciousness, and Virtual Reality
(New York: Taylor and Francis, 2015).
33 Hobson, Psychodynamic Neurology, 5.
276 Jim Hopkins

the brain tends to maximize accuracy while also increasing com-

plexity (by introducing and altering hypotheses or parameters) during
waking, and then to reduce complexity during sleep, by means that in-
clude synaptic pruning during slow wave sleep (SWS) and dreaming/​
virtual reality in REM.
Friston’s notion of complexity is conceptually related to the psycho-
analytic and psychiatric notions of emotional conflict and trauma and
hence to key notions in Freud’s account of dreaming and mental disorder.
Emotional conflict consists in the activation of emotions that produce
inconsistent kinematic trajectories, and these perforce require reduction
or elimination for coherent behavior. Again, the alterations that consti-
tute complexity can be regarded as measuring the load of learning that
sensory impingement places on the model in waking life.
The most important part of this, moreover, can be described as affec-
tive or emotional learning, as required for the computation of behavior
(“kinematic trajectories”) in relation to others. In this case, the load of
learning indexed by complexity becomes the load of emotional learning
or adjustment that the experience of relating to others places on the
brain’s model.34 Experiences are rightly regarded as traumatic when, as
in PTSD or BPD, the emotional adjustments (complexity, conflict) re-
quired for integrating them into thought and action are greater than the
brain can manage.35
Taking Friston’s conception of complexity in these Freudian terms
enables us fully to integrate psychoanalytic findings about the role of
conflict and trauma in dreaming and disorder into the new free energy
paradigm. This yields what Chris Mathys has called “the complexity

34 Cf. the notion of affective load in R. Levin and T. Nielsen, “Nightmares, Bad Dreams, and
Emotion Dysregulation,” Current Directions in Psychological Science 18/​2 (2009), 84–​88.
35 M. Enlow et al., “Mother–​ Infant Attachment and the Intergenerational Transmission
of Posttraumatic Stress Disorder,” Development and Psychopathology 26/​1 (2014), 41–​65; D.
Mosquera, A. Gonzalez, and A. Leeds, “Early Experience, Structural Dissociation, and Emotional
Dysregulation in Borderline Personality Disorder: The Role of Insecure and Disorganized
Attachment,” Borderline Personality Disorder and Emotion Dysregulation 1/​1 (2014), art. 15, 1–​8.
 Freud and Mental Health 277

theory” of dreaming and mental disorder: as I have argued elsewhere,36

the theory that the conflicts and trauma that Freud thought expressed
in the virtual realities of dreaming and mental disorder should be seen
as forms of neurocomputational complexity, and that mental disorder
is the product of such complexity, together with the mechanisms—​
phantasy/​virtual reality at the level of the mind and synaptic pruning
at the level of the brain—​that have evolved to reduce it.
Such an account enables us to provide operational descriptions of
the reduction of complexity in terms of psychoanalytic accounts of
dreaming and mental disorder such as sketched above. Also it is nearly a
consequence of the basic account of complexity that informs the work of
Hobson et al.37 If the accumulation of complexity in waking is so serious
a problem for the brain that it requires processes of complexity reduction
in sleep, then it would seem to follow that inadequacies or malfunctions
in these processes—​like prolonged sleep deprivation itself—​might foster
potentially damaging accretions of complexity that show as a waking
mental disorder. In addition, just as the mechanisms of inflammation
that have evolved to protect the body from injury can themselves cause
bodily disorders, so the mechanisms that have evolved to reduce emo-
tional complexity in sleep might cause disorders of the brain and mind
in waking. This latter hypothesis enables us to integrate psychoanalysis
and neuroscience with a range of observations about the correlation of
disturbances in sleep with waking forms of disorder. If this updated and
thoroughly testable integration of psychoanalytic and neuroscientific
hypotheses proves correct, it may lead to advances in the understanding
of the causes of mental disorder, both mental and physical, and as these
operate both in waking and in sleep and dreaming.

36 Hopkins, “Free Energy and Virtual Reality.”

37 Hobson, Hong, and Friston, “Virtual Reality and Consciousness.”
278 Jim Hopkins

This would fit with current approaches to mental disorder as

involving “harmful dysfunction,” explicable in evolutionary terms.38
Here, although the dysfunction would concern the reduction of com-
plexity, the reduction itself would be required by the complexities
involved in the management of aggression in our uniquely group-​
cooperative and lethally group-​competitive species, as well as emotions
rooted in the triangle of parental investment, parent-​offspring, and
sexual conflict.39 Our susceptibility to emotional conflict, trauma, and
mental disorder, as well as our pervasive recourse to forms of conflict-​
relieving virtual reality, has deep evolutionary roots, particular to our
uniquely complex and emotionally conflicted species.

Freud and the Philosophical

and Scientific Traditions

Freud’s investigations of symptoms and dreams yield an overall ac-

count of psychological development that encompasses normal life
and work as well as mental health and disorder. In framing these
ideas, Freud both reaffirmed an ancient understanding of dreaming
and disorder and reformulated it in scientific terms. The Socrates of
the Platonic dialogues had argued that human beings have “a wild
beast within us,” whose emotions and desires may be expressed in the
committing in dreams of “every conceivable folly or crime—​not ex-
cepting incest or any other unnatural union, or parricide.” Like Freud,
Socrates held that such desires can be “controlled by law and reason,

38 J. Wakefield, “Taking Disorder Seriously: A Critique of Psychiatric Criteria for Mental

Disorders from the Harmful-​D ysfunction Perspective,” in T. Millon, R. F. Krueger, and E.
Simonsen (eds), Contemporary Directions in Psychopathology: Scientific Foundations of the DSM-​
V and ICD-​11 (New York: Guilford Press, 2010), 275–​302; and J. Wakefield and J. C. Baer, “The
Cognitivization of Psychoanalysis: Toward an Integration of Psychodynamic and Cognitive
Theories,” in W. Bordon (ed.), Reshaping Theory in Contemporary Social Work: Toward a Critical
Pluralism in Clinical Practice (New York: Columbia University Press, 2010), 51–​80. For discussion,
see Elselijn Kingma’s chapter in the present volume.
39 Hopkins, “The Significance of Consilience.”
 Freud and Mental Health 279

and the better desires prevail over them.” But in some persons—​such
as the “tyrannical man,” whose development is described in the ninth
book of Plato’s Republic—​they become the main principles of action.
Later Descartes, among others, compared dreams with delusions, and
Kant argued that “the deranged person” was “a dreamer in waking.”40
Freud’s work provides a culmination to this line of thought.
Socrates’s incestuous, parricidal, and potentially tyrannical “wild
beast within us” is the unconscious but continually active residue of
the powerful, impulsive, and unregulated emotions of early infancy,
as these are expressed in dreams, psychoanalytic transference, and
the symptoms of mental disorder. Thus Freud explained to R that the
conflicts of his disorder had both arisen and been rendered uncon-
scious in his infancy. The part of him that harbored these distressing
emotions “was the infantile”:

That part of the self which had become separated off from it in
infancy, which had not shared the later stages of its develop-
ment, and which had in consequence become repressed. It was the
derivatives of this repressed unconscious that were responsible for
the involuntary thoughts which constituted his illness. (Works
10:177–​78)

Freud also decisively advanced another of Plato’s aims: that of un-

derstanding the relation between harmony and discord in the in-
dividual and in society. Plato’s overall aim in the Republic was to
understand the virtue of justice as involving a kind of psycholog-
ical harmony in the individual that corresponded to, and could best
flourish in, the social harmony of a just society. For him discord in
the individual was both causally and conceptually linked to discord

40 H. Wilson (trans.), “Essay on the Maladies of the Head,” in P. Guyer and H. Wood, The
Cambridge Edition of the Works of Immanuel Kant in Translation: Anthropology, History, and
Education (Cambridge: Cambridge University Press, 2007), 71.
280 Jim Hopkins

in society. A similar understanding appears in Freudian group psy-

chology, in which identification and projection link individuals and
their frustrations and conflicts both to the ingroups with whom they
cooperate and the outgroups with whom they engage in competi-
tion and conflict. Thus the same mechanisms that render us liable to
group-​on-​g roup destructiveness in war, and helpless even in peace to
curb the group competition for resources that threatens to destroy
our environment, are also those that render the management of in-
dividual aggression so fraught with conflict to leave us vulnerable to
mental disorder.
Also, and again like Freud, Plato’s Socrates seems to have taken the
aim of knowing the self to encompass knowing the nature and scope of
such unconscious emotions and desires. In wanting to know himself,
Socrates said, he wanted to know whether he was “a beast more com-
plicated and savage than Typhon, or a tamer, simpler animal.”41 He
was expressing his sense of the potentially radical nature of his inner
divisions and the extremities of his own rage and other emotions, as
well as the possible burial of these things beneath the part of himself
that seemed gentle and simple. Typhon was “complicated” because he
had a hundred different heads, and his fury led him to attack Zeus, the
king of the gods. His punishment, like that of the Titans, was to be
buried beneath Mount Etna so that his rage was hidden and expressed
only in occasional volcanic eruptions.
This too approaches a Freudian view of the self, and a Freudian un-
derstanding of mental disorder as rooted, like that of R above, in rage
and aggression that escapes self-​knowledge. Freud was to use the same
image as Socrates for the unconscious mind, comparing the wishes
that give rise to dreams and symptoms to the Titans buried at Etna.
Investigating and integrating these hidden but still furious aspects
of the self, and thereby rendering them more rational and gentle, is

41 Phaedrus 230a, translation from J. M. Cooper (ed.), Plato: Complete Works

(Indianapolis: Hackett, 1997).
 Freud and Mental Health 281

the main task of psychoanalysis. Freud thus integrated this Platonic

image of the self into a theory of the mind that radically extended
the commonsense psychology of emotion, desire, and belief that we
share with Socrates and fused this extension with a new form of neu-
roscience and developmental psychology. The scientific cogency of his
results may only now be gaining full recognition.
Reflection
Portr a it of the Hea lth y A rtist
Glenn Adamson
p

What does a healthy artist look like? Perhaps artists

themselves are not the ones to tell us. Oftentimes, it’s true,
they have presented themselves as respectable and entirely
well-​adjusted, suited, or smocked, standing at the easel with
palette in hand. But the more indelible images left to us by
art history, particularly since the onset of Romanticism in the
nineteenth century, are more vivid and less peaceful of mind.
Take, for example, Theodore Géricault, an early nineteenth-​
century painter who defined the Romantic sensibility both
in his work and life. In one of his earliest works, Géricault
showed himself slouched in a chair with a skull perched
on the shelf above him. The pictorial analogy between his
own youthful, handsome visage and the death’s head was
clear: the artist was haunted by his own eventual demise. In
1824, shortly after completing a series of sensitive portrayals
of “monomanics” (the inhabitants of asylums), which form
a visual canon of mental disturbance, he would make good
on the prediction of his early self-​portrait, showing himself
hollow-​eyed and ghoulish, a dying man, as indeed he was.
Géricault was soon to pass away at the age of thirty-​two of
tuberculosis.

282
 Portr ait of the Healthy Artist 283

Two decades later, Gustav Courbet painted himself in equally

dire straits. Two self-​portraits show him respectively as wounded
and raving mad. In L’Homme Blessé, he lies back languidly,
blood spilling over his shirt, regarding us with sensual calm as
his life ebbs away. (The painting had originally featured a female
companion and an unhurt Courbet, but when his affair with her
ended, he adapted it into this more theatrical image.) A related
work, Le Déséspère (the Desperate Man), shows the painter
clawing at his own loosely flowing hair. Tightly cropped as if in
a photograph, he stares out of the picture like a man possessed
(plate 8).
Both Géricault and Courbet deployed the imagery of mental
disturbance as an emblem of the Romantic temperament. They
presented themselves as fired by an imagination that burned so
intensely it hurt. From this metaphorical approach it is only a
short step to the all-​too-​real mental illness of Vincent Van Gogh.
The self-​portraits he made shortly before he took his own life,
alternately startled and mournful, stand for all time as the symbol
of the artist as a disturbed genius. By this time in his life, he had
become like one of those asylum dwellers shown by Géricault. Yet
he was producing some of the greatest (and most self-​aware) works
ever painted. With his bandaged head and swirls of paint emerging
from his pipe, he showed himself as both fragile and potent, the
embodiment of the artist who cannot contain the force of his own
creativity.
The uncomfortable question posed by Van Gogh’s art is,
ultimately, a philosophical one. If he had not been so troubled, it
seems reasonable to conclude, he would also have been unable to
create images of such originality. This makes his talent seem like
a symptom, as much as a gift. Perhaps we should ask ourselves: is
it ethically suspect to take aesthetic pleasure in the condition of a
man like this? What do we make of a situation in which art and
health seem at odds?
284 Glenn Adamson

These questions relate in an interesting way to the concept of

“moral luck,” a term popularized by Thomas Nagel and Bernard
Williams in the late 1970s. Their goal was to think in a new
way about an old philosophical problem, that is, the dilemma
that arises from the uncertain relationship between actions and
consequences. The problem is at root a simple one. Imagine two
people committing the same unwise action, for example, dropping
a hammer off a high balcony. In one case, the hammer clatters
harmlessly to the pavement. In the second case, however, it hits
a child and kills him. The first person will simply have lost his
hammer; the second will likely go to jail.
In practical terms, it is impossible for society to hold people
accountable for their actions, regardless of their effects—​who
would keep track of all those falling hammers? In philosophical
terms, matters are no less difficult. We must first consider the
relation between action and intention. In our example, did persons
A and B mean to drop the hammer, or did it get bumped off the
ledge accidentally? And then there is the inherent messiness of
intention itself, which may not be clear to someone committing
a given action, much less those observing it. Taking these various
factors into account, Nagel and Williams concluded, it seems that
we do inhabit a world involving moral luck—​“a significant aspect
of what someone does depends on factors beyond his control,
yet we continue to treat him in that respect as an object of moral
judgment.”1
This line of thinking has an interesting parallel in thinking
about the case of Van Gogh, and art’s relation to health in general.
In his work on moral luck, Williams used the example of Paul
Gauguin, Van Gogh’s friend and rival. By all accounts, Gauguin
was a nasty piece of work. He abandoned his wife and children to

1 T. Nagel, Mortal Questions (Cambridge: Cambridge University Press, 1979), 59. See also B.
Williams, Moral Luck (Cambridge: Cambridge University Press, 1981).
 Portr ait of the Healthy Artist 285

pursue his art. His stay with Van Gogh in Arles, during which he
proved to be selfish and abusive, helped push poor Vincent over the
edge. His later relations with Tahitian women struck people at the
time as sexually indecent, and many since as a cardinal instance of
colonialist exploitation and exoticism. Despite this track record,
Gauguin’s name is venerated rather than despised because he
created artworks that were both gorgeous and highly original.
Moral luck was on his side.2
Van Gogh’s case is the mirror image of Gauguin’s, placing us
as viewers in a position that involves the opposite quandary. If
we might feel uneasy appreciating Gauguin’s work because of his
unpleasantness, we might feel equally uncertain about appreciating
Van Gogh’s expressive genius, because it derived in part from his ill
health. Gauguin was a perpetrator, and Van Gogh a victim. But the
result is to this extent the same: a disturbing dissonance between
our ethical and aesthetic response. To enjoy the works they created
without qualms, we feel that we need to sweep aside what we know
of their biography, the lives that led to the work we see before us.
Nor is Van Gogh’s a unique case. The stereotype that underlies
the popular cult of the bohemian artist is of an individual driven
by passion, often self-​destructively so, and certainly unable to
find a congenial place within the bourgeois social order. (Émile
Zola created the classic text of the genre in his 1886 novel The
Masterpiece, whose main character, the painter Claude Lantier,
eventually hangs himself in his studio.) In more recent years, the
canon of art history has been expanded to include individuals
who are far more mentally ill than Van Gogh was. They have been
embraced as masters of so-​called outsider or visionary art, or in
French Art Brut. The first artist to be celebrated in this way was
Adolf Wölffli, a Swiss man who had been the victim of abuse as

2 See A. Gopnik, “Van Gogh’s Ear,” The New Yorker, January 4, 2010.
286 Glenn Adamson

a child and spent his adult life in an asylum in Bern. Wölffli’s

artworks, and those of other artists whose biographies paralleled
his (such as Henry Darger, Martín Ramírez, and Down syndrome
sufferer Judith Scott), are appreciated for their intensity, often
taking the form of repetitive marks that suggest a mental state
of relentless obsession. Advocates of these artists argue that their
value lies precisely in showing us the beauty and originality of
supposedly “abnormal” minds.3 The implication is that we should
accept mental illness (whether it leads to great art or not) simply as
a form of difference and not as a condition to be treated.
Matters are still more complex when we consider the fact that
if artists are themselves aware of these dynamics, they can also
manipulate them. That was the case with Courbet, who adopted
the pose of a madman for dramatic effect. It was also true of
Bada Shanren, an “unorthodox” painter and poet who lived in
seventeenth-​century China. One of the distinctive features of
the history of Chinese ink painting is that unorthodoxy is itself a
tradition. By Shanren’s time, there had already been many literati
(scholar-​artists) who withdrew from society, living as hermits in
natural surroundings. This brought them away from court life, and
indeed, this role was often adopted purposefully to escape political
conflict.
Shanren would have been aware of the long tradition of such
supposed eccentrics, and he seems to have played on it as a way
to build his own fascinating reputation, though period sources
suggest that he had at least one genuine nervous breakdown. This
makes his enthusiastic splashes and stabbing, cursory, sideways
brushstrokes difficult to evaluate. They were certainly a dramatic
departure from precedent. But was he innovating on purpose
or because he could not help it? Either way, it seems, there is a

3 C. J. Morris, Judith Scott: Bound and Unbound (Brooklyn: Brooklyn Museum of Art, 2014).
 Portr ait of the Healthy Artist 287

quandary for the viewer of his work. If he was genuinely mentally

unstable, then we are again venerating his symptoms. If not, then
we might feel there is something inauthentic, even cynical, in
his work.
The uncertainty is heightened still further if we shift
from the mental to the physical domain. What if an artist
cannot see very well? Surely that would reduce the quality of
their work. Yet consider the Venetian master Titian or the
impressionist Claude Monet, both of whom created their most
revolutionary and effective works late in life. Both suffered
from significant loss of eyesight in their older years; they even
painted with extra-​long brush handles, so that they could
stand farther away from their canvases. In both Titian’s and
Monet’s late works, there is an approximate quality, a lack of
focus. The paintings were made by men with poor eyesight
and trembling hands, but they are all the more evocative and
lush as a result.
The conceptual artist Robert Morris has staged an even more
extreme situation in a series of drawings entitled Blind Time.
The first of these were executed in 1973 by the artist himself,
blindfolded and carrying out a series of predetermined regular
marks in graphite. Three years later he recruited a woman
(identified only as A. A.), who had been blind from birth, to
continue the series. Working to his verbal instructions, she
made a set of drawings that she was of course unable to see. If we
enjoy them—​as well we might, given their atmospheric quality
and the poignant story behind their making—​does that mean
that we are in some sense enjoying her disability? Or conversely,
that we are rejecting the idea that her blindness is a disability,
that she is simply “differently abled”? Morris’s collaboration
with A. A. returns us to the parallel with moral luck, in that
her drawings cannot in any normal sense be considered the
direct result of her own intention. If we appreciate them, can we
288 Glenn Adamson

even say that we are valuing her creativity? Or are we not rather
appreciating blindness itself, and the compositional freedom that
results from it?
I began this short Reflection by posing the question, “What
does a healthy artist look like?” We have touched on artworks
made by the mentally ill, the aged, and the blind. In none of these
cases does the artistic quality of the work seem to have suffered
as a consequence. Are we to conclude that health and aesthetics
simply operate independently from one another—​that there is
no correlation between the two? No. In each case, the condition
that would typically be considered a malady proves not only to
be compatible with the realization of the work but also to be
fundamental to its character. This points to a key trait of artists.
They always work within constraints, and these boundaries of
practice are not a negative factor in art but rather the source of
creative friction. Think of the four sides of a painting, or the
particular qualities of materials such as clay, stone, or plaster.
Artists invariably encounter such limiting factors for their own
creativity—​format, materiality, scale, and many others—​and make
something of them. From the artistic perspective, health is just
another of these constraints.
Viewed from this point of view, the health of artists takes on a
different aspect. What is debilitating in other walks of life proves
to be a spur to creativity. More than this, for if art is one of the
purest expressions of our human experience, then perhaps its
most important boundaries are those of human experience itself,
the limits of the body and mind, which is exactly where illness
carries us. When art shows what it is to suffer a condition that
we conventionally label as madness, disease, or disability—​and
when we, in turn, take aesthetic pleasure in its doing so—​we are
recognizing that art and sickness are both a part of life. The one,
considered properly, may help us accept the other.
 CH A PTER NI NE

Contemporary Accounts of Health

Elselijn Kingma

Much of the contemporary philosophical discussion about health and

disease finds its origins in the 1960s and 1970s, which saw a period of
great controversy surrounding psychiatry. So-​called anti-​psychiatrists
argued that psychiatry was not a legitimate medical discipline but a
“mere tool of social control”: acting to affirm, enforce, and police cer-
tain social and evaluative norms.1 The revision of the “bible of psychi-
atric classification” in the early 1970s, the Diagnostic and Statistical
Manual (DSM)-​II, formed the stage for a heated social and profes-
sional discussion about homosexuality:2 Should this be included as a
disease in the new version of the DSM—​as it has been previously—​or
not? A very active gay lobby pushed the latter point, but psychiatrists
were divided on the issue. In the discussion amongst them, two

1 See e.g. T. S. Szasz, “The Myth of Mental Illness,” American Psychologist 15 (1960), 113–​18; T.
S. Szasz, The Myth of Mental Illness (London: Paladin, 1972); R. D. Laing, The Divided Self
(London: Tavistock, 1959); and R. Howard (trans.), Michel Foucault: Madness and Civilisation: A
History of Insanity in the Age of Reason (London: Tavistock, 1961).
2 R. Bayer, Homosexuality and American Psychiatry: The Politics of Diagnosis (Princeton,
NJ: Princeton University Press, 1987).

289
290 Elselijn Kingma

competing positions on the definition of health and disease became

apparent. The first proposed a value-​free account of health and disease
that embodied a vision of health as normal biological function. On this
view—​assuming that the sole biological function of sexual behavior
is the production of direct biological offspring—​homosexuality was
thought to be a disease. The second and opposing position embodied
a clinical focus: diseases are things that bother patients that prompt
them to seek help and alleviation. On this value-​laden view of health
and disease, homosexuality would only be a disease if it was experi-
enced as a problem by the person who “suffered” from it.
In the DSM debate, the gay protesters and the proponents of the
second, clinical definition of health and disease won. In the final,
1974 revision of the DSM-​II, homosexuality was replaced by the
much weaker “sexual orientation disorder.” In the DSM-​III (1980),
only “ego-​dystonic homosexuality”—​for example, homosexuality that
was experienced by the “sufferer” as a problem—​was listed. That edi-
tion of the DSM was also the first to provide an explicit definition of
mental disorder (preceded by many caveats) as a “clinically significant
behavioral or psychological syndrome.” This clinical definition of dis­
ease has persisted unchanged into subsequent versions of the DSM. In
the philosophical literature, however, the debate on defining health
and disease would continue, and the clinical and value-​free positions
on defining mental disorder would crystallize into two opposing
positions on health and disease: naturalism and normativism.3

3 D. Murphy, “Concepts of Disease and Health,” in E. N. Zalta (ed.), The Stanford Encyclopedia
of Philosophy, 2009, following P. Kitcher, The Lives to Come: The Genetic Revolution and Human
Possibilities (New York: Touchstone, 1996), contrasts “objectivism” and “constructivism.” Note
that in this debate “disease” or “disorder” is meant to be inclusive, denoting not just what we or-
dinarily call disease but any condition that is a departure from health (including, e.g., trauma,
disability, etc.). See, e.g., C. Boorse, “On the Distinction between Disease and Illness,” Philosophy
and Public Affairs 5 (1975), 49–​68; C. Boorse, “A Rebuttal on Health,” in J. M. Humber and R.
F. Almeder (eds), What Is Disease? (Totowa, NJ: Humana Press, 1997), 1–​134; and R. Cooper,
“Disease,” Studies in History and Philosophy of Biological and Biomedical Sciences 33 (2002), 263–​82.
I shall stick with that convention.
 Contempor ary Accounts of Health 291

Naturalism

Naturalism is the view that health and disease are objective, empir-
ical, or value-​free concepts.4 The central idea is that we could read the
distinction between health and disease directly off the natural world,
without having to appeal to the values that these states hold for us.
Thus, proponents would hold, just as we can say that a dog, rabbit, or
tree has a disease without having to appeal to the value that such a con-
dition holds for either us, the dog, or the tree, so we should be able to
say when a human has a disease without having to appeal to the value
that condition holds for that human or for humanity.

The Descriptivity Problem

The central problem for any naturalistic account of health and disease
is this: both working eyes and nonworking eyes are eyes. Both appear
in nature. And both obey natural laws. How, then, does the natu-
ralist about health and disease distinguish—​as she should—​healthy,
working eyes from unhealthy nonworking ones? And specifically, how
does she do that without leaving the descriptive realm?

4 Naturalists include M. Ananth, In Defense of an Evolutionary Concept of Health: Nature,

Norms and Human Biology (Aldershot: Ashgate, 2008); Boorse, “On the Distinction between
Disease and Illness,” 49–​68; C. Boorse, “What a Theory of Mental Health Should Be,” Journal
for the Theory of Social Behaviour 6 (1976), 61–​84; C. Boorse, “Health as a Theoretical Concept,”
Philosophy of Science 44 (1977), 542–​73; C. Boorse, “Concepts of Health,” in D. van de Veer, and
T. Regan (eds), Health Care Ethics: An Introduction (Philadelphia: Temple University Press, 1987),
359–​93; Boorse, “A Rebuttal on Health”; C. Boorse, “Concepts of Health,” in F. Gifford (ed.),
Philosophy of Medicine (Oxford: Elsevier, 2011), 13–​64; C. Boorse, “Replies to my Critics,” The
Journal of Medicine and Philosophy 39 (2014), 648–​82; J. Garson and G. Piccinini, “Functions Must
Be Performed at Appropriate Rates in Appropriate Situations,” British Journal for the Philosophy
of Science 65 (2014), 1–​20; D. Hausman, “Is an Overdose of Paracetamol Bad for One’s Health?”
British Journal for the Philosophy of Science 62 (2011), 657–​68; D. Hausman, “Health, Naturalism
and Functional Efficiency,” Philosophy of Science 79 (2012), 519–​41; L. R. Kass, “Regarding the
End of Medicine and the Pursuit of Health,” The Public Interest 40 (1975), 11–​42; R. Kendell,
“The Concept of Disease and Its Implications for Psychiatry,” British Journal of Psychiatry 127
(1975), 305–​15; J. G. Scadding, “Health and Disease: What Can Medicine Do for Philosophy?”
Journal of Medical Ethics 14 (1988); 118–​24; J. G. Scadding, “The Semantic Problem of Psychiatry,”
Psychological Medicine 20 (1990), 243–​48; T. Schramme, “A Qualified Defence of a Naturalist
Theory of Health,” Medicine, Health Care, and Philosophy 10 (2007), 11–​17; and Szasz, “The Myth
of Mental Illness,” 113–​18.
292 Elselijn Kingma

One could think of this as a problem of natural normativity,5 for

instance: How do we arrive at natural norms for eyes? But I am reluc-
tant to use that terminology because it seems to carry a whiff of value-​
ladenness—​of “ought”—​about it. The central aim of the naturalistic
project is precisely to avoid such value-​ladenness. It is to state a descrip-
tive norm, from which no ought follows, not even weakly. This kind
of “norm” could thus never establish whether Fido should be able to
wag his tail, only that there is a non-​ought-​carrying tail-​wagging norm
that Fido does or does not comply with. No “ought” follows. I shall
therefore not call this the “normativity problem” but the “descriptivity
problem.”
As foreshadowed by early anti-​psychiatrists and in the context of the
DSM debate,6 the naturalist’s strategy for tackling the descriptivity
problem has been to appeal to notions of biological function and dys-
function. In the literature on philosophy of biology there are two
dominant proposals for analyzing biological function. Accordingly,
two closely related but subtly different naturalistic accounts of disease
have been proposed: a statistical account by Christopher Boorse and
an etiological one by Jerome Wakefield.

Disease as Dysfunction

Christopher Boorse employs a so-​called causal role account of func-

tion to define health and disease, where functions are the causal
contributions made by traits to the organism’s goals: survival and

5 P. S. Davies, Norms of Nature (Cambridge, MA: MIT Press, 2001), employs this terminology.
6 Szasz (see above, n. 1) defined a disorder as a dysfunction or lesion at a structural, cellular, or
molecular level. He then submitted that no such lesion is present in so-​called mental disorders;
therefore these aren’t disorders but mere problems in living. Later naturalists, by contrast, argued
that such conditions do present such dysfunctions or lesions, though not at the level of the brain but
the mind (“The Myth of Mental Illness,” 113–​18). E.g., Boorse, “What a Theory of Mental Health
Should Be,” 61–​84; D. Papineau, “Mental Disorder, Illness and Biological Dysfunction,” in A.
Griffiths (ed.), Philosophy, Psychology and Psychiatry (Cambridge: Cambridge University Press,
1994), 73–​82.
 Contempor ary Accounts of Health 293

reproduction.7 The heart, for example, makes a causal contribution to the

organism’s survival and reproduction by pumping blood. This is therefore
its function. Boorse then offers a statistical solution to the descriptivity
problem: normal functions—​a.k.a. health—​are those contributions to
survival and reproduction that are statistically typical. This appeal to
statistics is meant to distinguish normal functions, first, from accidental
functions. An accidental function is a causal contribution to survival
and reproduction that is not a biological function, as when my heart
contributes to my survival by making noises or emitting a weak electrical
current that allows a search and rescue team to find me after an earth-
quake. Second, it distinguishes normal, healthy function from subnormal
function: a damaged heart that may still pump blood well enough to keep
me alive but not well enough to be healthy or normal. Subnormal function
and other departures from statistically normal function are dysfunctions,
and hence departures from health on Boorse’s account.
The alternative account of biological function and health, employed
by Wakefield, solves the descriptivity problem in a historical fashion.8

7 C. Boorse, “On the Distinction between Disease and Illness,” 49–​68; C. Boorse, “Wright on
Functions,” Philosophical Review 85 (1976), 70–​86; see further the references in note 4 above.
Causal role accounts of function are also known as “Cummins Functions” (R. Cummins,
“Functional Analysis,” The Journal of Philosophy 72 (1975), 741–​65).
8 J. C. Wakefield, “Disorder as Harmful Dysfunction: A Conceptual Critique of DSM-​I II-​R’s
Definition of Mental Disorder,” Psychological Review 99 (1992), 232–​47; J. C. Wakefield, “The
Concept of Medical Disorder: On the Boundary between Biological Facts and Social Values,”
American Psychologist 47 (1992), 373–​88; J. C. Wakefield, “Dysfunction as a Value-​Free Concept: A
Reply to Sadler and Agich,” Philosophy, Psychiatry and Psychology 2 (1995), 233–​46; J. C. Wakefield,
“Evolutionary versus Prototype Analyses of the Concept of Disorder,” Journal of Abnormal
Psychology 108 (1999), 374–​99; J. C. Wakefield, “Mental Disorder as a Black Box Essentialist
Concept,” Journal of Abnormal Psychology 108 (1999), 465–​72; J. C. Wakefield, “Spandrels,
Vestigial Organs, and Such: Reply to Murphy and Woolfolk’s ‘The Harmful Dysfunction Analysis
of Mental Disorder,’” Philosophy, Psychiatry and Psychology 7 (2000), 253–​69. The etiological
account of function is developed and defended in detail by K. Neander, “Functions as Selected
Effects: The Conceptual Analyst’s Defense,” Philosophy of Science 58 (1991), 168–​84; K. Neander,
“The Teleological Notion of ‘Function,’” Australasian Journal of Philosophy 69 (1991), 454–​68; and
R. G. Millikan, Language, Truth and Other Biological Categories (Cambridge, MA: MIT Press,
1984); R. Millikan, “In Defense of Proper Functions,” Philosophy of Science 56 (1989), 288–​302.
Wakefield is often not considered a naturalist because he maintains that only harmful dysfunction
is a disorder. That seems to me an unhelpful way of classifying the debate: he sufficiently resembles
naturalists to be classified as such because he defines disease in part as biological dysfunction. See
E. Kingma, “Health and Disease: Social Constructivism as a Combination of Naturalism and
294 Elselijn Kingma

On this view, functions of traits are the effects that explain why traits
were naturally selected.9 Thus the pumping effect of my heart is its
function because the pumping effect of hearts explains the differential
reproductive success of my ancestors and hence my present existence.
The difference between these accounts is subtle but not irrelevant.
Consider the turtle’s flippers.10 These (or so the story goes) were selected
for their current shape and form because of their ability to propel
turtles in water. But turtles now also employ their flippers for the useful
purposes of digging nest-​holes and burying eggs. According to Boorse’s
account, the function of turtle flippers is swimming, digging, and
burying—​because all of these contribute to survival and reproduction
of the turtle. Wakefield, by contrast, must argue that flippers’ function
is only their etiological function, that is, the effect for which they were
selected: swimming. Whether they also dig and bury is neither here nor
there. The upshot of this is that if we could imagine a flipper that retained
its swimming ability but lost its burying and digging ability (for example
because a mutation in its muscle fibers means it overheats when exercised
outside the water), then this flipper would be disordered according to
Boorse but not Wakefield.11
This example immediately illustrates what I and others have claimed
is a key problem for Wakefield: it appears that our bodies, and especially
our minds, perform many functions that they were never selected to
perform. Right now, for example, I am writing and reading a foreign
language, typing, sitting on a chair, manipulating abstract symbols,

Normativism,” in H. Carel and R. Cooper (eds), Health, Illness and Disease: Philosophical Essays
(Durham, NC: Acumen, 2012).
9 Neander, “Functions as Selected Effects,” 168–​84; and Neander, “The Teleological Notion of
‘Function,’ ” 454–​68; Millikan, Language, Truth and Other Biological Categories; and Millikan,
“In Defense of Proper Functions,” 288–​302.
10 M. Perlman, “The Modern Philosophical Resurrection of Teleology,” The Monist 87
(2004), 3–​51.
11 Whether a Wakefield-​t ype of account truly fails to account for digging being a function is a
matter of dispute that hinges in part on the role of maintenance selection. See, e.g., P. Godfrey-​
Smith, “A Modern History Theory of Functions,” Noûs 28 (1994), 344–​62.
 Contempor ary Accounts of Health 295

and so on. None of these functions, arguably, were ones that my

mind or body was selected to perform, even though performing them
must—​like the flipper’s digging ability—​at least in part rely on other,
selected, functional mechanisms. It thus appears that Wakefield’s
account can only ever single out a subset of the many things we do
with our bodies and minds as subject to health and disease judgments.
Other performances—​such as the flipper’s digging—​simply fall out-
side the realm of health and disease altogether. This does not square
well with modern medicine that, when push comes to shove, is inter-
ested in what our bodies do for us now, not in the performance of
body parts that drove their selection. As the turtle’s flipper illustrates,
selection and useful function can come apart. But modern medicine
(if it were to be interested in turtles) would surely want to consider the
digging-​disabled turtle ill. I therefore favor Boorse’s account.12

The Biostatistical Theory and Its Critics

So, does Boorse’s biostatistical theory (hereafter BST) of health map

onto our intuitions and succeed in solving the descriptivity problem?
Since its inception, nearly forty years ago, BST has been seen as the
most viable naturalistic candidate and, as such, has been subjected
to a staggering array of criticisms. Broadly speaking these criticisms
are of three kinds. One set of criticisms contends that BST fails to
map onto our intuitions about particular conditions and must thus be
discarded.13 A second set, which perhaps aren’t really criticisms, but
friendly improvements, propose amendments or alternative versions

12 E. Kingma, “Naturalist Accounts of Disorder,” in K. W. M. Fulford et al. (eds), Oxford Handbook

of Philosophy and Psychiatry (Oxford: Oxford University Press, 2013). See also D. Murphy and R.
L. Woolfolk, “The Harmful Dysfunction Analysis of Mental Disorder,” Philosophy, Psychiatry and
Psychology 7 (2000), 241–​52; and D. Murphy and R. L. Woolfolk, “Conceptual Analysis versus
Scientific Understanding: An Assessment of Wakefield’s Folk Psychiatry,” Philosophy, Psychiatry
and Psychology 7 (2000), 271–​93.
13 Boorse, “A Rebuttal on Health,” painstakingly documents and responds to these criticisms; and
he does so again to more recent ones in Boorse, “Concepts of Health,” 13–​64, and Boorse, “Replies
to my Critics,” 648–​82.
296 Elselijn Kingma

of Boorse’s account, which are meant to preserve its spirit of natu-

ralism.14 This is often done in response to a third set, which contends
that BST is not value-​free.
One version of the latter criticism focuses on Boorse’s use of refer-
ence classes. These reference classes—​age, sex, and (perhaps) race—​are
groups that ground statistical abstraction; what is healthy is not what
is normal per se, but what is statistically normal for a reference class.
This move is necessary because statistical normality alone is too crude
to define normal function: normal toddlers would be thoroughly dys-
functional if we compared them with what is normal in the whole
population. But what justification can Boorse give for employing the
reference classes he uses? If, as the criticism maintains, Boorse’s is to be
a value-​free account of health, then his use of reference classes needs to
be justified. Boorse needs to explain why it is acceptable to treat people
with a Y chromosome as a separate reference class for the purposes of
defining normal testosterone levels but not people who are blind as a
separate reference class for the purposes of defining normal vision. The
answer can’t—​on pain of circularity—​be that being male is normal
and healthy, but that being blind or deaf is not. But Boorse has not
provided another answer.15 This puts pressure on the idea that, in his
use of reference classes, Boorse captures natural rather than social or
evaluative norms.
BST faces a similar problem when it comes to environments.
Physiological functions are very varied, specific, and fine-​grained—​
often operating within a very narrow and situation-​specific norm: clot-
ting factors and blood platelets must clot blood when there is a bleed
or damage to the blood vessel. But they must not clot when there

14 E.g., Garson and Piccinini, “Functions Must Be Performed at Appropriate Rates in Appropriate
Situations,” 1–​20; Hausman, “Is an Overdose of Paracetamol Bad for One’s Health?” 657–​68;
Hausman, “Health, Naturalism and Functional Efficiency,” Philosophy of Science 79 (2012), 519–​41;
P. Schwartz, “Defining Dysfunction: Natural Selection, Design, and Drawing a Line,” Philosophy
of Science 74 (2007), 364–​85.
15 E. Kingma, “What Is It to Be Healthy?” Analysis 67 (2007), 128–​33.
 Contempor ary Accounts of Health 297

isn’t such damage. Statistically normal function must therefore be

defined as what is normal relative to a particular environment or sit-
uational demand. But that raises a challenge similar to that of refer-
ence classes: Why are sunshine, sleeping in the sand, sprinting, and
sex normal situations or environments, in which the statistically typ-
ical function is healthy, but Paracetamol overdose, poliovirus expo-
sure, and a pneumococcal infection not situations or environments in
which the statistically normal function is healthy? Again, the answer
can’t, on pain of circularity, be that the former set of environments is
normal or healthy, and the latter unhealthy.16

Naturalism and Value

Whether or not BST can survive such criticisms, questions about

values cannot be ignored. Even the staunchest naturalists acknowl-
edge that a naturalist account of health is at best a theoretical notion,
which will have to be supplemented with value judgments insofar as it
is employed in an actual social or policy context.17 It is because certain
functions are also disvaluable that they become appropriate for med-
ical treatment and/​or social security. If naturalist accounts of health
were never brought in contact with values, they could not be relevant
to policy at all. So whether values form part of our best naturalist ac-
counts or are merely added to it when theoretical accounts of health
and disease meet practice, they matter. It is therefore to questions of
value that we shall now turn.

16 E. Kingma, “Paracetamol, Poison and Polio: Why Boorse’s Account of Function Fails to
Distinguish Health and Disease,” British Journal for the Philosophy of Science 61 (2010), 241–​64.
See Hausman, “Is an Overdose of Paracetamol Bad for One’s Health?” 657–​68; and Garson and
Piccinini, “Functions Must Be Performed at Appropriate Rates in Appropriate Situations,” 1–​20,
for a response; E. Kingma, “Situational Disease and Dispositional Function,” British Journal for
the Philosophy of Science 67/​2 (2015), 391–​404, responds to Hausman.
17 See, e.g., Boorse, “On the Distinction between Disease and Illness,” 54–​55 and 60; “Health as a
Theoretical Concept,” 544; “A Rebuttal on Health,” 11, 12–​13, 55, and 95–​99.
298 Elselijn Kingma

Two Questions for Normativism

Normativists believe that health and disease are value-​laden concepts.

But although the vast majority of commentators seem to hold a version
of this view, normativist accounts have not received anything like the
amount of attention or detailed scrutiny that naturalist proposals have
received. In this section I aim to partially rectify that, as well as consider
why this is the case.
When we consider normativism about health and disease, a first
thing to note is that this label unites an extraordinarily diverse group
of views.18 What these positions share is the view that health and
dis­ease are in some sense value-​laden. But how values come into the
dis­ease concepts, what (those) values are, and how health and disease
should be defined, are questions on which normativists are anything
but unified.
We might depict this state of the literature as one where there is a
small, dense, and homogenous core in the middle, which represents

18 Normativists include G. J. Agich, “Disease and Value: A Rejection of the Value-​Neutrality

Thesis,” Theoretical Medicine 4 (1983), 27–​41; K. D. Clouser, C. M. Culver, and B. Gert, “Malady
a New Treatment of Disease,” The Hastings Center Report 11 (1981), 29–​37; K. D. Clouser, C.
M. Culver, and B. Gert, “Malady,” in J. M. Humber and R. F. Almeder (eds), What Is Disease?
(Totowa, NJ: Humana Press, 1997); Cooper, “Disease,” 263–​ 82; R. Cooper, Classifying
Madness: A Philosophical Examination of the Diagnostic and Statistical Manual of Mental
Disorders (Dordrecht: Springer, 2005); H. T. Engelhardt, “Ideology and Etiology,” Journal
of Medical Philosophy 1 (1976), 256–​68; K. W. M. Fulford, Moral Theory and Medical Practice
(Cambridge: Cambridge University Press, 1989); W. Goosens, “Values, Health and Medicine,”
Philosophy of Science 47 (1980), 100–​15; J. Margolis, “The Concept of Disease,” Journal of Medicine
and Philosophy 1 (1976), 238–​55; L. Kopelman, “On Disease: Theories of Disease and the Ascription
of Disease: Comments on ʻThe Concepts of Health and Disease,ʼ” in H. T. Engelhardt and S. F.
Spicker (eds), Evaluation and Explanation in the Biomedical Sciences (Dordrecht: Reidel, 1975),
143–​50; L. Nordenfelt, On the Nature of Health: An Action-​Theoretic Approach (Dordrecht: Reidel,
1987); L. Nordenfelt, Quality of Life, Health and Happiness (Aldershot: Ashgate, 1993); L.
Nordenfelt, Health, Science and Ordinary Language (Amsterdam: Rodopi, 2001); L. Nordenfelt,
“The Concepts of Health and Illness Revisited,” Medicine, Health Care, and Philosophy 10 (2007),
5–​10; L. Nordenfelt, “Establishing a Middle-​R ange Position in the Theory of Health: A Reply to
my Critics,” Medicine, Health Care, and Philosophy 10 (2007), 29–​32; L. Reznek, The Nature of
Disease (London: Routledge, 1987); and C. Whitbeck, “Four Basic Concepts of Medical Science,”
PSA: Proceedings of the Biennial Meeting of the Philosophy of Science Association 1 (1978), 210–​22.
 Contempor ary Accounts of Health 299

naturalism.19 Around this densely compact naturalist core float many

normativist positions, which are widely dispersed in all directions and
appear to share or agree on almost nothing—​except that they all reject
naturalism.
In this kind of situation one would expect a sizeable literature on
the relative merits of different normativist proposals: we should see
normativists jockeying with each other to establish which normativist
account is the best, as well as competing with naturalists to establish
whether naturalism or normativism is right. But perhaps one of the most
surprising features of the literature on health and disease is that former
type of engagement is almost entirely lacking; normativists don’t engage
with one another. Consider, for example, Cooper who structures her
paper, first, by discussing and rejecting naturalism, and, second, by de-
veloping her own alternative normativist account.20 What she does not
do is consider other main normativist accounts: she does not point out
why they are unsatisfactory or defend why her account is superior or even
needed. It is almost as if other normativists don’t exist.21 This is not a par-
ticular criticism of Cooper; it is typical of the normativist literature that
nearly always proceeds by first criticizing Boorse—​who has become the
referential point of departure—​before positing a normativist alternative.
The upshot of this is twofold. First, the relationship of different
normativist accounts to each other is, at best, unclear. In the picture
I just sketched, the “points” that represent normativist accounts are
not in any way related or structured; it is not clear whether they are
similar or dissimilar and whether they could be placed on—​say—​
axes that would structure the option space. Second, normativist ac-
counts have not had the benefit of scrutiny and critical engagement.

19 For—​a lthough, as we saw, naturalists can subtly differ on how they interpret dysfunction—​they
are otherwise in very close agreement both on what it means to give a value-​free account of disease
and on what that value-​free account consists in: biological dysfunction.
20 Cooper, “Disease.”
21 Though Cooper criticizes Aristotelian views in a separate paper: R. Cooper, “Aristotelian
Accounts of Disease—​W hat Are They Good For?” Philosophical Papers 36 (2007), 427–​42.
300 Elselijn Kingma

For whatever one may think of naturalists’ success in responding to

their many challengers, it is fair to say that the resulting dialogues have
improved the debate, forcing a clarification and sometimes improve-
ment of positions, making sure that there is now a relative consensus
on the strengths and weaknesses of naturalism; how naturalist claims
are to be interpreted; and the implications of the different accounts.
Normativist accounts, in contrast, are virtually untested territory.
Why do normativists not engage with one another? One reason
may be that people simply have not realized that normativist ac-
counts are so heterogeneous. Or perhaps they simply don’t feel confi-
dent that normativism is attractive enough to warrant debates within
normativism, rather than in defense of normativism. A third possibility
is that because naturalism is widely seen as desirable, though prob-
ably false, the burden of proof seems (subtly) to fall on the naturalist,
with normativism appearing as the default view. The outcome is that
naturalism is defended by positing accounts that are then defended
and criticized, resulting in their being well described and well tested,
whereas normativism is defended by criticizing naturalism, rather
than by a positive defense—​which requires a clear articulation—​of
any particular refined version of a normativist account.
Whichever explanation is correct—​and I think all have some
merit—​they do clearly indicate that normativism is not very easily,
and perhaps should not at all be, discussed as one single position. But
I have no space in this chapter to compare and contrast normativist
accounts or consider them one by one in great detail. What I will do
instead is posit two general questions that I think any normativist ac-
count has to face, which I hope will stimulate a more mature debate
between, and resulting refinement of, different normativist positions.
These questions concern the circumscription problem, and the rela-
tion between values, health, and disease.
 Contempor ary Accounts of Health 301

The Circumscription Problem

The circumscription problem is the problem of giving good criteria

that delineate, amongst all bad conditions—​domestic disagreements,
bad days at work, economic downturns, miserable weather, and flat
tires—​only those bad conditions that are also diseases (which none of
the above are). This is an important question for any normativist ac-
count because value-​laden definitions of disease nearly always overgen-
eralize. For any normativist account’s central evaluative criterion there
will always be many more conditions than diseases alone that will meet
it. To illustrate this, and also by way of introduction to the different
substantial normativist accounts on offer, I shall briefly discuss how
each fares with respect to the circumscription problem. I contend that,
at first sight, no single one performs very well.
First, consider Clouser, Culver, and Gert, who define disease as a
condition, not caused by a rational belief or desire, that incurs or sig-
nificantly increases the risk of incurring a harm or evil.22 A “harm
or evil” is to be interpreted liberally, to include limits to freedom or
pain. Thus a broken leg is a disease because it limits your freedom and
causes pain, but running in a marathon is not a disease because, even
though it is very painful, it is due to a rational desire. This account,
however, is far too inclusive. Bodily conditions that limit freedom or
cause pain but that are not due to a rational belief or desire include
many that we would not want to consider diseases. The need to sleep
and go to the bathroom, for example, limit your freedom, but they are
not diseases.23 In a similar vein, the possession of ovaries and a womb
puts you at significant risk of pain, discomfort, and limitations on
your freedom in the form of menstruation—​but nonetheless it is not a

22 Clouser, Culver, and Gert, “Malady a New Treatment of Disease,” 29–​37; Clouser, Culver, and
Gert, “Malady,” in Humber and Almeder.
23 See also M. Martin, “Malady and Menopause,” Journal of Medicine and Philosophy 10 (1985),
329–​37 and Boorse, “A Rebuttal on Health,” 43–​4 . Note that although sleep may be rationally
desired, the need for sleep is not due to a rational desire (in the way that, for example, blisters in the
pursuit of a new garden hedge are).
302 Elselijn Kingma

disease. The same holds for being male, which limits one’s freedom to
produce milk for one’s own children.
A second account by Whitbeck suffers from a similar problem. She
defines diseases as conditions that people want to prevent because they
interfere with the bearer’s capacity to do things people commonly
wish and expect to be able to do.24 This is also too inclusive. Normal
hair growth on legs, faces, and armpits, for example, is a physical pro-
cess that many treat or prevent because it interferes with a culturally
common desire to appear hairless in certain places. It is therefore a
disease on Whitbeck’s account.
Nordenfelt defines diseases as second-​order inabilities to reach vital
goals.25 Vital goals, in his view, are the goals that are jointly necessary
and sufficient to achieve minimal happiness. Second-​order abilities are
abilities to gain first-​order abilities. Thus, a first-​order ability is, say,
playing the violin (which I cannot do). A second-​order ability is the
capacity to learn to play the violin if appropriate training is provided
(my possession of which, given my age, is starting to look implausible).
This account, too, seems hopelessly over-​inclusive. First, consider that
someone may have vital goals that constitute “expensive preferences”
or that are highly ambitious. For such a person, conditions that we do
not ordinarily consider diseases—​such as lacking the ability to achieve
amazing athletic or artistic prowess, or financial success, would be-
come diseases.26 Second, there are many conditions that would signif-
icantly impact most people’s second-​order abilities to reach vital goals,
yet we still do not ordinarily think of them as diseases. These include,
for example, the lack of social or financial resources.

24 Whitbeck, “Four Basic Concepts of Medical Science,” 210–​22.

25 Nordenfelt, On the Nature of Health; Nordenfelt, Quality of Life, Health and Happiness;
Nordenfelt, Health, Science and Ordinary Language; Nordenfelt, “The Concepts of Health and
Illness Revisited,” 5–​10; Nordenfelt, “Establishing a Middle-​R ange Position in the Theory of
Health,” 29–​32.
26 Schramme, “A Qualified Defence of a Naturalist Theory of Health,” 11–​17.
 Contempor ary Accounts of Health 303

It therefore seems that neither Whitbeck nor Clouser, Culver, and

Gert, nor Nordenfelt have a convincing solution to the circumscrip-
tion problem. Or, if they bite the bullet, then their accounts of disease
are extremely revisionary—​to the point of being thoroughly counter-
intuitive. And that requires substantial defense in its own right.
A fourth group of “normative” accounts is neo-​Aristotelian.27 I put
“normative” in scare quotes, because the thinking that supports these
accounts denies a distinction between facts and values and so might
reject their characterization as normative. Simply put, Aristotelian
accounts suppose there is a natural norm for all biological entities
that governs how humans and other biological entities ought to be.
These norms are grounded in the kind of thing an entity is. Thus,
bees are colony-​living pollen collectors. A “good” bee is therefore
one that is good at living in the colony and good at collecting pollen.
These natural norms apply to both what we might think of as our so-
matic realm—​that we should have two arms, ten fingers, and a well-​
functioning liver, for example—​as well as our mental lives and the way
we should live: they provide an account of our flourishing. According
to neo-​Aristotelian accounts of health, health is Aristotelian normal
function.
In response to these accounts one might once again argue that
these accounts are over-​inclusive. Cooper, for example, argues that
neo-​Aristotelians face a problem because they can’t distinguish be-
tween vices and diseases: both impair flourishing. 28 As we saw in pre-
vious chapters of this volume, that is exactly in line with what earlier
Aristotelians wanted to say: vices are diseases of the soul.29 Nonetheless
it does not map onto present discussions about disease, which are

27 P. Foot, Natural Goodness (Oxford: Clarendon Press, 2001); C. Megone, “Aristotle’s Function
Argument and the Concept of Mental Illness,” Philosophy, Psychiatry and Psychology 5 (1998), 187–​
201; Megone, “Mental Illness, Human Function and Values,” Philosophy, Psychiatry and Psychology
7 (2000), 45–​65.
28 Cooper, “Aristotelian Accounts of Disease?,” 427–​42.
29 See the contributions of James Allen and Peter Adamson in the present volume.
304 Elselijn Kingma

precisely concerned with separating diseases from vices, bad choices,

and bad personal traits—​think, for example, of the insanity defense
in court or the discussion of homosexuality and psychiatry that this
chapter started with.30 This account, too, is highly revisionary.
A fifth account of disease is offered by Cooper, who defines diseases
as conditions that are (1) bad for the sufferer; (2) unlucky/​abnormal
(which serves to exclude ordinary conditions such as hair growth); and
(3) are deemed within the remit of the medical profession.31 Although
this account also suffers from inclusivity—​unwanted pregnancies, for
example, are a disease on her account32—​I think it is the best performer
amongst contenders on the circumscription problem. Nonetheless
I think the method by which Cooper achieves this success undermines
it. After limiting conditions to those that are (1) bad and (2) unlucky/​
abnormal, the main job of solving the circumscription problem is
performed by the third criterion: whether society considers these
conditions within the remit of the medical profession. But that seems
unsatisfactory. First, if we appeal to an account of disease in the hope
that it would help us decide what conditions fall within the medical
profession—​as many commentators, including Cooper,33 do—​then
this is hopelessly circular and unhelpful. It cannot explicate; it can
merely track. Second, it makes diseases prone to vary with a societies’
perception of the condition and of what medicine might do.34
In short, in the present overview we have seen not just quite how di-
verse normativist accounts are, but also that a serious problem for pretty

30 I don’t mean to suggest that homosexuality is bad (I don’t think it is); merely that, historically,
when people agree on their disvaluation of homosexuality, they must still tackle the question of
whether it is a disease or some other kind of trait.
31 Cooper’s account is very similar to that offered by Reznek, The Nature of Disease. The difference
between Cooper and Reznek is that Cooper gives an anthropological account of medical treat-
ment, whereas Reznek defines it in terms of surgical and pharmacological interventions. The former
is more convincing; think of recreational opiate use or doping in sport (Cooper, “Disease,” 278).
32 Cooper, “Disease,” 278–​79, acknowledges and defends this commitment.
33 See, e.g., R. Cooper and C. Megone, “Introduction,” Philosophical Papers 36 (2007), 339–​41.
34 I provide more detail in E. Kingma, “Cooper on Disease” (unpublished).
 Contempor ary Accounts of Health 305

much all normativist accounts is piecing together the non-​evaluative

components of their account in such a way as to convincingly solve the
circumscription problem—​for any evaluative component, it seems, is
over-​inclusive by nature.

How Do Health, Disease, and Value Relate?

The second important challenge for normativism is that they tell

us something substantive about values beyond the general, not-​
particularly-​informative and highly-​open-​to-​different-​interpretations
claim that health and disease are in some sense value-​laden. This chal-
lenge is particularly interesting if, like me, you are convinced that even
supposedly naturalist accounts include evaluative components. This
challenge comprises at least the following two questions: First, how
are health and disease value-​laden, or how do evaluative considerations
enter into accounts of health and disease? Second, what are these
values, and how do they need to be understood?
As the accounts discussed above illustrate, there are different ways
in which values appear in accounts of definitions of health and disease,
and this source of variation is not something that has received a lot of
attention. Without claiming to be exhaustive, let me review some of
the options. First, an evaluative criterion such as “bad” or “harmful”
can appear as one of the criteria that a condition must meet to be a dis­
ease. This is how normativism is most widely understood.35 But here is
a different way in which concepts might be evaluative: health and dis­
ease could be so-​called thick concepts, where the negative evaluation is
not separable as one of the criteria but inextricably intertwined with a
descriptive content.36 I think this is an interesting possibility, but not
one that seems to have been explored.37 A third option is to make health

35 See, e.g., Cooper, “Disease,” 263–​82; and Reznek, The Nature of Disease.
36 See S. Kirchin (ed.), Thick Concepts (Oxford: Oxford University Press, 2013).
37 But see J. L. Nelson, “Health and Disease as ‘Thick’ Concepts in Ecosystemic Contexts,”
Environmental Values 4 (1995), 311–​22, for an exception.
306 Elselijn Kingma

and disease derivative of some evaluative notion—​as Nordenfelt does

in this case of vital goals.38 Fourth, one might fully equate (or reduce)
health and disease to an evaluative criterion—​as neo-​Aristotelians do
in the case of flourishing. Fifth—​as we saw in the form of objections to
Boorse—​accounts may be value-​laden if the reasons for selecting and
employing particular descriptive concepts in particular roles is or was
motivated by evaluative considerations.39 Whether this latter version
is still in opposition to naturalism is, I think, not obvious.
It appears, then, that there are many ways for concepts to be value-​
laden. Surely one important task for normativists—​and one way in
which the literature as a whole could make considerable progress—​is
to get very clear on how values enter health and disease concepts. Some
normativists are clear about this, as we saw in the above accounts, but
many (as will be clear in a moment) aren’t.
A second question that normativists should answer takes us into
ethics proper. It is what the relevant values involved in health and dis­
ease concepts are, and how they should be understood. Once again
there is a wide scope for variety here; we can distinguish several dif-
ferent proposals in the accounts already discussed. Contrast, for ex-
ample, the neo-​Aristotelians’ proposal that refers to an impairment of
flourishing with Whitbeck’s idea that the relevant evaluative criterion
is an impairment of common wishes and expectations. These are very
different. A much wider range of variation emerges if we also consider
the things that normativists who fall short of offering a full account of
health and disease say about values. Compare, for example: (1) a condi-
tion is a disease if and only if it is bad for you;40 (2) to label something

38 See also Clouser, Culver and Gert, “Malady a New Treatment of Disease,” 29–​37; and Clouser,
Culver, and Gert, “Malady,” in Humber and Almeder; Whitbeck, “Four Basic Concepts of
Medical Science,” 210–​22.
39 Kingma, “What Is It to Be Healthy?,” 128–​33; Kingma, “Health and Disease.”
40 Clouser, Culver and Gert, “Malady a New Treatment of Disease,” 29–​37; and “Malady”;
Cooper, “Disease,” 263–​82; and Reznek, The Nature of Disease; Wakefield, “Disorder as Harmful
Dysfunction,” 232–​47; J. C. Wakefield, “The Concept of Medical Disorder,” 373–​88; and to some
extent Goosens, “Values, Health and Medicine,” 100–​15.
 Contempor ary Accounts of Health 307

a disease is to express disapproval of the condition;41 (3) our concepts

of health and disease are grounded in nonnaturalistic concerns, such
as pain, discomfort, and disability;42 (4) health and disease are relative
to subjective goals, values, and desires;43 (5) to label something a dis­
ease is to commit to an obligation to treat it;44 and (6) health and dis­
ease are relative to social expectations.45 All these claims are professed
by normativists—​but they are quite different. They do not just vary
on the first question—​how values appear in definitions of health and
disease—​but also on the second one: what those values are and how
they are to be interpreted. Such variation is not, of course, a problem in
itself; ethicists also hold very different views on what values are. Thus
this might be taken to indicate that normativists simply hold different
and quite sophisticated ethical views. For example, the claim that to
label something a disease is to express disapproval of the condition
might sound like a non-​cognivist approach, whereas the claim that
to label something a disease is to commit to treatment might sound
like prescriptivism, while the claim that disease is relative to subjective

41 For example H. T. Engelhardt, “The Concepts of Health and Disease,” in H. T. Engelhardt

and S. F. Spicker (eds), Evaluation and Explanation in the Biomedical Sciences (Dordrecht: Reidel,
1975), 127 and 137; Margolis, “The Concept of Disease,” 242; and Nordenfelt, “The Concepts of
Health and Illness Revisited”; Whitbeck, “Four Basic Concepts of Medical Science,” 210–​22,
disagrees.
42 Cooper, “Disease,” 263–​ 82; Engelhardt, “The Concepts of Health and Disease,” 127;
Engelhardt, “Ideology and Etiology,” 262, Goosens, “Values, Health and Medicine”; Margolis, “The
Concept of Disease,” 242; and Nordenfelt, “The Concepts of Health and Illness Revisited,” 5–​10.
43 Nordenfelt, On the Nature of Health; Nordenfelt, Health, Science and Ordinary Language, and
“The Concepts of Health and Illness Revisited”; Engelhardt, “Ideology and Etiology,” 256–​68;
Whitbeck, “Four Basic Concepts of Medical Science,” 210–​22; and, depending on the account
of badness that she adopts, Cooper, “Disease,” 263–​82. Goosens, “Values, Health and Medicine,”
denies this claim.
44 Engelhardt, “The Concepts of Health and Disease,” 127, 137; R. L. Spitzer and J. Endicott,
“Medical and Mental Disorder: Proposed Definition and Criteria,” in R. L. Spitzer and D. F.
Klein (eds), Critical Issues in Psychiatric Diagnosis (New York: Raven Press, 1978), 18; and possibly
Cooper, “Disease.” But Goosens, “Values, Health and Medicine”; Kopelman, “On Disease”; and
Whitbeck, “Four Basic Concepts of Medical Science,” disagree.
45 Engelhardt, “Ideology and Etiology,” 265; L. S. King, “What Is Disease?” Philosophy of Science
21 (1954), 193–​203; Margolis, “The Concept of Disease,” 247; and Whitbeck, “Four Basic Concepts
of Medical Science”; Kopelman, “On Disease,” disagrees.
308 Elselijn Kingma

goals might be a version of moral naturalism. Nonetheless, I caution

against reading normativists in this way. Most normativists profess
the above claims indiscriminately and in often inconsistent ways;46 so-
phisticated ethical positions cannot be readily applied to most forms
of normativism.47 It would be helpful, however, if normativists did de-
velop such clearer and more sophisticated views. For the unanalyzed
claim “health is something that is (essentially) good, and disease is
something that is (essentially) bad”—​or, worse, “Boorse is wrong”—​is
simply not good enough as an analysis of the relations among health,
disease, and value. Our understanding of health and disease would
be better served if less time was spent arguing whether naturalism or
normativism was right, and more time was spent on how normativists
get things right. This is not just a point that is relevant to normativism;
it is also important if naturalists are right. For, as I argued, values are at
the very least crucially implicated in the translation of theoretical, nat-
uralist accounts to applied medical, social, and political domains; but
they are probably also implicated in the nature of dysfunction, even
according to naturalism.
Here is an additional reason why it is important to be clear about the
exact role and understanding of values in any particular normativist
position. An often-​heard worry about normativism is that it would
lead to social and historical relativism.48 To illustrate this point people
often refer to past “diagnoses” that we now consider not only to be
mistaken but also to indicate—​or so it is argued—​an illegitimate
intrusion of problematic social and evaluative judgment on disease.
Examples include masturbation (sexual morale); hysteria (sexism and
sexual morality); “drapetomania,” which supposedly was the dis­
ease suffered by slaves who ran away from their master (racism); and

46 Though there are exceptions, e.g., Cooper, “Disease,” 263–​82; Foot, Natural Goodness, and
Fulford, Moral Theory and Medical Practice.
47 See J. Simons, “Beyond Naturalism and Normativism: Reconceiving the ‘Disease’ Debate,”
Philosophical Papers 36 (2007), 343–​70, for a similar conclusion.
48 See, e.g., Boorse, “Concepts of Health,” 13–​64.
 Contempor ary Accounts of Health 309

the locking away of political dissidents in psychiatric institutions.49

Normativists, it is thought, can’t avoid such worries because they con-
done an account of health and disease that is determined by contin-
gent and contemporary value judgments.
But whether any specific normativist account must be subject to this
worry is by no means a foregone conclusion. It depends on the specific
account of values it adopts. To contrast two examples, it seems that
Whitbeck, who defines disease by reference to what people commonly
wish and expect to be able to do, is committed to at least some forms
of cultural and historical relativism. For common wishes and expec-
tations vary substantially with time and place. But neo-​Aristotelian
accounts, for example, seem explicitly committed to a view of health
and human flourishing that is grounded in what humans are. Such
an account, depending on how precisely it is to be cashed out, may
not be subject to social and historical relativism; surely a successful
neo-​Aristotelian account would not condone that drapetomania and
political dissidence are diseases.

Health, Well-​Being, and the Good Life

The original debate between naturalism and normativism was cen-

trally concerned with the question whether health and disease were—​
on the one hand, and as naturalists argued—​objective, value-​free, and
empirical concepts that can then feed into value-​driven personal, med-
ical, and political decision-​making processes; or—​on the other hand—​
whether they are already, and thoroughly, value-​driven. I have cast
doubt on this supposed opposition: these options aren’t necessarily
mutually exclusive, and there aren’t single, homogeneous options to be
contrasted on both sides. Yet it is not surprising that this “opposition”

49 See, e.g., H. T. Engelhardt, “The Disease of Masturbation: Values and the Concept of Disease,”
Bulletin of the History of Medicine 48 (1974), 234–​48; Boorse, “Concepts of Health,” gives more
examples.
310 Elselijn Kingma

has received much attention and has seemed difficult to resolve. For,
I shall now suggest, the two positions map onto two prominent so-
cial criticisms of medicine that pull in different directions. These
criticisms focus on the relationships among medicine, health policy,
and what we may broadly call “the pursuit of the good life.”

The Cessation of Paternalism and the Rise of Informed Consent

The first of these criticisms has stressed the need to deemphasize

the medical focus on the “good life.” This criticism has at least two
components. One, which we have discussed, relates to the anti-​
psychiatrists’ worry that medicine should not impose or take an im-
plicit stance on what the good life is. For this is far too likely to result in
psychiatry’s reinforcing a set of questionable social norms. Medicine
does and should stick to “the facts.”
But there is a similar drive that has nothing to do with psychiatry.
In very general terms, the second half of the twentieth century has
seen a well-​documented change in the health-​care professional’s role
away from paternalism—​and thus away from judging what is best for
the patient—​toward an (idealized) model of medical decision-​making
in which the doctor merely provides information and leaves it up to
the patient to judge what is best. This move is not so much motivated
by worries about the implicit enforcing of social norms, but by a more
general—​and perhaps liberalist—​resistance to and distrust of au-
thority: a recognition of legitimate value-​pluralism on the one hand,
and an emphasis on personal autonomy on the other. The doctor, we
think, may know what is “best” in terms of medical knowledge, but
she does not know what is, all else being equal, best for you. Given that
people do and should be able to develop very different conception of
the good, only you are the judge of that. And even if the doctor does
know what is best for you, we now think that it is still your right to
make your own decisions—​and decide otherwise. For that falls under
the legitimate exercise of your autonomy.
 Contempor ary Accounts of Health 311

This approach, however, requires that the doctor is able to refrain

from value-​judgment and restricts her pronouncements—​much more
narrowly—​to the “facts at hand.” These facts can then feed into an eval-
uation, a supported or shared decision-​making process, and eventually
a normative judgment by the patient. But this type of expectation of
our health-​care system practically demands naturalism: it requires a
medical language, and medical concepts, that are “fact-​focused” and
distinct, if not divorced, from questions about value. On this kind
of view, medicine is there for the former, not the latter. We have at
least two kind of social demands, then, that broadly speaking push
in a “naturalist” direction: in a direction that divorces medical, fact-​
based judgments from subjective, evaluative non-​medical judgments.
It is hardly surprising, then, that naturalism has received such prom-
inence and seemed so appealing in the forty years since Boorse’s first
publication.

Focus on Well-​Being, Not Function!

Yet in the same period, we have also seen a movement that pushes in
the opposite direction. That is, the persistent complaint that modern
medicine is too focused on reductive, biomedical considerations and is
not sufficiently attuned to the good; it is not focused on what is impor-
tant to us. Again, this criticism appears in many forms. A prominent
one is the disability critique that has complained, loudly and justly,
that a medical model aiming to restore them to the biomedically
normal functioning, rather than to a position in which they can best
do the things important to them, is not good health care.50 In response
we have, thankfully, generally abandoned attempts to biomedically
normalize people with disabilities. We no longer attempt to teach
the paralyzed to walk painfully and for short distances on crutches,

50 See, e.g., R. Amundson, “Against Normal Function,” Studies in History and Philosophy of
Biological and Biomedical Sciences 31 (2000), 33–​53.
312 Elselijn Kingma

teach the deaf to speak and lip-​read, or teach left-​handed people to

write with their right hands. Instead we favor wheelchairs, ramps, sign
language, and left-​handed tools that are much better ways of helping
people with these disabilities/​different abilities to do the important
things able-​bodied people do with ease: move, communicate, and
open cans.
But we can find versions of this criticism in many places. One ex-
ample is the criticism that medicine, especially medical research, is too
bent on output parameters that may be “objective” or easily measur-
able but are not relevant to patients. Examples are physiological meas-
ures of pain or lung capacity rather than subjective pain experience or
the ability to do the things that need doing. We can probably view the
attraction of “holistic” medicine, “personalized” medicine, and per-
haps even certain complementary and alternative treatments in a sim-
ilar vein. Finally there has been a general move, especially at the end of
life, to considering quality rather than quantity of life of utmost im-
portance. This, too, embodies the idea that health-​care professionals
should not focus on (curing) diseases, prolonging life, or promoting
some objective notion of health—​but that they should try to better
things for people and strive for them to have a good life.
This second kind of push, then, seems to pull away from naturalist
accounts of disease. Or, at the least, it would say that the naturalist
account of disease or health is not very relevant to health care; it is not
what medicine should strive for.
I suggest, then, that the debate between naturalism and normativism
exists in the context of two important social movements and critiques
of medicine that pull in opposite directions. The one wishes to divorce
medicine from any value-​judgments, making doctors the providers
of informative facts only and leaving patients as the evaluative
interpreters and action guiders. This is the exact and naive model of
naturalism about health and disease: an objective, value-​free judg-
ment of health or disease that then feeds into an evaluative decision
or application. The other movement criticizes medicine for focusing
 Contempor ary Accounts of Health 313

on notions of health and disease that are too divorced from what really
matters to us; medicine has lost sight of, and should return to, the pro-
motion of values and the good life.
This social context not only mirrors the supposed naturalist/​
normativist opposition, but it also encounters the same problems
that I previously argued are encountered by these two positions. For
just as normativism suffers from expanding the category of diseases
beyond all recognition unless it satisfactorily solves the circumscrip-
tion problem, so the push for a health-​care system more focused on
the good life runs the risk of not being recognizable as health care
anymore—​for example, deciding to fund family cruises rather than
chemotherapy for the terminally ill because that is what, in fact, will
promote well-​being. On the other hand, a health-​care system focused
on a narrow, naturalist account of disease is perhaps too much at risk
of forgetting what really matters—​well-​being. Just like naturalism, it
risks no longer being relevant to us. The more naturalized an account
becomes, the weaker its connection to well-​being will be.
It is all the more important, then, to ask what the right kind of
connection between health and well-​being should be, in light of the
difficulties that face both normativists and naturalist accounts and in
light of these two social criticisms.

The Relation between Health and Well-​Being

One way one might answer that question is by taking the second type
of criticism very seriously, and, as a result, start to equate “health” with
“well-​being.” This is exactly what the World Health Organization
(WHO) proposed when it famously and aspirationally defined health
as “a state of complete physical, mental and social well-​being.”51 But
that strikes me as the wrong way to respond.

51 Preamble to the constitution of the WHO as adopted by the International Health Conference,
New York, June 19–​22, 1946; signed on July 22, 1946 by the representatives of sixty-​one states
(Official Records of the WHO, no. 2, p. 100) and entered into force on April 7, 1948.
314 Elselijn Kingma

There are many ways in which one might find this definition prob-
lematic, but I want to focus on two related ones. First, if health simply
is well-​being, then what is the point of having the concept of health?
Surely merely having well-​being (or health, but not both!) is enough?
Second, and more substantially, equating health and well-​being makes
it impossible for us to rationally sacrifice our health in the pursuit of
other goods or forms of well-​being. So, for example, whilst I am still
able to sacrifice my health to selflessly benefit others—​by throwing
myself in front of a car to save a child, or by donating a kidney to a
stranger, for example—​it would be logically impossible self-​interestedly
to sacrifice my health to pursue other aspects of my well-​being. This
means that were I to decide—​say—​to become unfit, overweight, sed-
entary, and overtired in the pursuit of my art, my philosophy, or some
of my other worldly or spiritual projects that I believe constitute the
good life for me, then either I am mistaken about what contributes to
my well-​being, or I don’t sacrifice my health. Similarly if I regularly
consume too much alcohol or binge on less-​than-​healthy food in the
pursuit of a fun evening out, or decide to move to a city with worse
air quality—​which will worsen my asthma—​in the pursuit of a better
paid and more fulfilling job, I either don’t sacrifice my health, or I am
mistaken about these decisions’ enhancing my well-​being. But at least
on the face of it, it seems plausible that we can, and do, often sacrifice
our health in the pursuit of other things that are important to us. It
also seems patronizing and distinctly implausible to think that all we
should strive for in life is health.
Now the defender of the “health as well-​being” approach might
respond in two ways. First, they might say I am stuck in too much
of an un-​aspirational idea of health; if health genuinely is well-​being
then I do not sacrifice my health in the pursuit of a fulfilling job or
fun evening out. Instead I sacrifice something on the physical dimen-
sion of health in the pursuit of its other dimensions: social and mental
well-​being. A different line of response concedes the other horn of
the dilemma: I am mistaken in my assessment of well-​being. Thus,
 Contempor ary Accounts of Health 315

the defender might say, in setting up these examples I confuse well-​

being with things that I value or desire; it is perfectly possible for me
to sacrifice my well-​being in pursuit of something I value, like world
peace, the safety of my children, or a political goal. And this would
create a similar dilemma. Thus, I might value my job in the city, but
this simply leads to a conflict between my desires and my well-​being/​
health, which are best served by staying in the country and would be
compromised if I pursued city life.
Such responses are possible but hardly convincing. The first just
serves to highlight quite how revisionary this concept of health as
well-​being is. Imagine responding to one’s doctor, who counsels to
cut down on smoking and take more exercise, as follows: “No, doc,
I thought about it, and according to the WHO smoking is good for my
health.” That makes little sense. What does make sense is to say: “No,
doc, taking everything else into consideration, that just isn’t best for
me.” This connects to the first point: there is a good reason we have
two concepts, one for health and one for well-​being.
Of course, this boils down to the now familiar point that the
attempted equation between health and well-​being runs into serious
circumscription problems, even if we take a sophisticated and objec-
tive stance of what well-​being is. It also shows that at least our ordi-
nary understanding of health is one that very clearly does not map
onto well-​being but leaves a clear gap between the two. This leads me
to think that we can at least take one firm step forward in an investi-
gation of the relationship between health, disease and value: health is
not well-​being. It is only of instrumental value—​or, if one has an ex-
pansive view of intrinsically valuable things, it is only one out of very
many things that are intrinsically valuable.
Is such a firm separation between health and well-​being com-
patible with the kind of social criticisms that push in the direction
of well-​being? Yes. Consider the “disability” critique. One does not
need to equate health with well-​being to recognize that ramps and
wheelchairs are the best way to help someone who can’t walk. Indeed,
316 Elselijn Kingma

such an argument may even be better supported by an instrumental

view of health. Precisely because health is only of instrumental value,
what matters to people is not their health, but what health (ordinarily)
allows people to do: the ability to get around. And so the best way to
help them is to improve that ability. One might, in fact, consider it a
particular advantage of the instrumental view of health that it retains
the ability simultaneously to recognize that a person who suffers paral-
ysis does not have perfect, or even normal, health—​which puts them
within the scope of our health-​care system—​and that moving them in
the direction of restoring their health—​or some other kind of physical
or functional “normality”—​is not what matters. What matters is the
restoration of what they see as important.
Furthermore, one need not define health as well-​being if one is to
criticize an overly reductive approach to medicine. The problem with
focusing on measurable physiological parameters of pain or lung
function—​rather than experienced pain or breathlessness—​is related
to the problem of measuring what can be measured, rather than meas-
uring what needs to be measured. It is not a problem of defining dis­
ease as dysfunction: pain and breathlessness still indicate what can be
deemed a biological dysfunction, but at a higher or less reductive level.
Finally, an emphasis on quality over quantity of life is certainly
compatible with viewing health as instrumental, perhaps even more
so than an equation of health and well-​being. Again, it allows us to
recognize someone’s illness, and that what really matters is not health
or length of life but well-​being.
What the instrumental view does particularly well, because it avoids
the circumscription problem, is to provide a notion of disease that
might still serve as some guide as to whom a health-​care system should
concern itself with, and what kind of conditions it should seek to re-
lieve.52 How it best relieves those conditions should—​of course—​be

52 Which is a main reason why people seek an account of health and disease in the first place. See,
e.g., Cooper and Megone, “Introduction,” 339–​41.
 Contempor ary Accounts of Health 317

guided by what matters: well-​being, not health (which is only instru-

mental to it).
The view that health and disease are only instrumental to well-​being
does not, of course, commit to a “retreat” into some supposedly value-​
free concept of health and disease. As I have indicated, I am highly
suspicious of both the desirability and likelihood of arriving at such
a concept. Health is not well-​being, but neither is health value-​free.
Health sits at an intermediate position: it has enough descriptive con-
tent to avoid the circumscription problem and play some guiding role
in apportioning health care, but it also has enough evaluative content
to be normatively relevant. I have indicated that the important and in-
teresting work is in uncovering the right combination of the two, and
I have indicated multiple ways in which values can be combined with
other, more descriptive factors.
This chapter started by discussing the controversy surrounding
psychiatry in the 1960s and 1970s. Those controversies have waxed
and waned but have never really gone away. They do not, how-
ever, form the main contemporary focus for an interest in health
and disease. Controversies in psychiatry have been surpassed by a
contemporary focus on global health inequalities, the just distri-
bution of health-​care resources, and the rising costs of health care
in the western world, as well as the (related) expansion of an in-
terest in life-​style diseases and responsibility in health and—​in
philosophy—​a focus on enhancement debates. In these contexts,
somatic medicine is, squarely, the focus. Difficult questions about
psychiatry, concerning the relation between body and mind and
the merging of the social and the biological, may increasingly be
avoided by concentrating on the somatic level. But questions about
naturalism, normativism, and social norms were never specific to
psychiatry. They affect all of medicine and, as I have argued, mirror
the social framework within which medicine operates. To make
progress in these debates, we need to ask not whether values play
a role but how they do so, and which values are important. As a
318 Elselijn Kingma

small step in that investigation, I have argued that health cannot

be equated with well-​being but is instrumental to it. Investigating
these questions further is important because in the context of
allocating scarce resources between many needy people on a global
scale, questions about the relation between health and value are un-
likely to diminish in either importance or controversy.
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 Index of Terms

Academic skepticism 78, 93 biological 152

Académie des Sciences 182 emotional 160
acupuncture 28–​9 of human life 164
afterlife 65, 73, 81 of humors. See humors, balance of
alchemy, inner (neidan) 37, 41 mental 258
alienation 251–​2, 255, 264, 269–​70 of nature 151, 155, 229
Anna O. 252–​3 of soul 15, 130, 132
anxiety 21, 100, 113, 133, 186, 257, 267 biomechanics 200, 208–​10, 217–​19, 221
infantile 256 biostatistical theory 295–​7
Apollo 160, 249 bipolar disorder (BPD) 270
Art Brut 285 bloodletting (medical) 60, 80, 208
Asklepios 249 brain fever 60
ataraxia 91 breath cultivation 12, 37. See also qi
Ayurveda 1 British Royal Society 182
Buddhism 35
Baijia school 9
balance 15, 44–​6, 48, 53, 62, 64–​6, 69, Cambridge Platonism 187. See also
108–​11, 115, 120, 130, 147, 149, 158, 164 More, Henry
of air 156–​7 cauterization 80

353
354 Index of Terms

celestial 34, 161, 164 incurable 193

Celestial Masters movement (Tianshi naturalism’s view on 291–​3, 312–​13
Dao) 34 normativism’s view on 298, 301–​3
chi. See qi psychological consequences of 182
Christ 159–​60 skin 198
Christianity 65, 247 theodicy of 34
cleanliness. See hygiene waterelf 140
clinic 38–​9 divination 9, 25–​6, 30
clinical 144, 224, 290 drapetomania 308
clinician 39, 57 dream 21, 64, 151, 196, 252, 254–​8,
corpse 175, 271 261–​5, 272–​8
Cromwell, Oliver 240 Neurocritic’s 268, 270
Cynics 45, 79 drug 49, 52–​3, 63, 118, 147, 160, 165

Dao 13, 40 ego ideal. See superego

Daoism 8, 16, 20, 22, 36–​7 elephantiasis 89–​90
Ge Hong 36 elf 139–​40
Shangqing 36 eudaimonia 114
Daoyin 18, 33 eukrasia 46
death 7, 17, 21, 81, 122, 130, 168 evil 76, 198, 301
head 282 exhaustion 60
dance of 175 mental 150
empire of 179 nervous 234, 236–​7
good 169 physical 150
natural 171 exsiccation 155–​6, 162, 169
unnatural 170, 172
depression 260, 267–​70 fangshi 9
despondency 62, 68 fear 32, 62–​3, 68, 121, 131–​3, 207, 220,
destiny 31, 33–​7, 41 260, 266–​7
diagnosis 27, 88, 113, 237, 308 of death 78, 127, 130, 155, 262
diet 5, 9, 15, 23, 27, 29, 35, 37, 68, 80, 109,
144, 165, 172, 207 God 139, 159, 160, 165, 202, 206, 228
advice on 15 gods 32, 81, 93, 248, 280
bad 15, 134, 172 Great Peace movement (Taiping) 34
frugal 170 grief 105, 113, 124, 126
good 5, 51, 56, 116, 118
vegetarian 181 Han Dynasty 23–​33
dietetics 88, 162, 224. See also hygiene happiness 64–​5, 76, 78, 81, 109, 125, 129–​31,
disease 22, 24, 33, 48, 54–​5, 65–​6, 159, 166, 172–​3, 181, 183, 190, 197–​9,
185–​91, 194–​6, 199–​201, 223, 241–​2, 249, 302
269, 289–​90 heaven 11–​14, 18, 24, 33
bone 178 mandate of 26
chronic 189 hedonism 16, 77
epidemic 143, 145, 243 herbs 35, 138–​40, 159
foot and mouth 43 Hippocratic Oath 44
 Index of Terms 355

homosexuality 3, 289–​90, 304 medicine 2, 182, 186, 310–​11

hospital 35, 38, 145 ancient views on 75–​85, 90
psychiatric 268 Aristotle’s view on 86
Hume, David 231, 241 Avicenna’s view on 61–​2, 72
Treatise on Human Nature 232 Bacon’s view on 167–​8
humors 2–​3, 51–​2, 111, 113, 134, 139, 167–​8, of body 56, 107–​112, 191–​4 , 198–​200, 210
185, 225 Classical Chinese 24, 30–​1, 38–​9
balance of 45, 68, 72, 109–​10, 145–​6, 151, Descartes’ view on 193–​213
156–​7, 161, 164, 169, 225 early modern 153
the four 46, 161 Ficino’s view on 163–​4
imbalance of 47–​8, 68, 208 Galenic view on 55, 143
melancholic 161 holistic 312
pathology of 46–​50, 54, 69, 74, 145, 242 medieval 138–​9
peccant 170 of mind 3, 5, 190–​2, 195–​8, 107–​12
hun (cloudsouls) 21 modern 183, 295, 311
Hundred Schools. See Baijia school naturopathic 211, 218, 221
Hygieia 249 object of 79
hygiene 147, 149, 153, 186, 209, 236, 247–​9 and philosophy 189
manual of 143 Plato’s view of 86–​7
moral 234 prophylactic 50
Renaissance 142 psychosomatic 104, 188–​90,
sexual 23, 27 209–​11, 218–​20
hypochondria 68, 100, 153 Santo’s view on 159
hysteria 238, 308 scientific 183, 214, 217, 312
meditation 10–​12, 13–​16, 20, 40
Iatrosophistry 54 Platonic on death 141
identification 259 metabolism 152–​3, 224
immortality 12, 21, 31, 33–​6 metaphysics 13, 38, 42, 86, 195, 200–​6,
Tithonus’ predicament 172 213, 232
tradition 22 methodism (medical) 54, 73
inoculation 241–​3 microbe 140
insomnia 60, 134, 172 midwife 244
Islam 3, 46, 56–​7, 103, 105, 261 ming 7, 37, 41

joy 51, 58, 62, 63, 209–​11 natural

order 173, 296
karma 35 power 146, 205
six non-​naturals 69, 72, 142, 148–​54,
leech (physician) 136–​40 159, 160, 162, 171, 212
luan (chaos) 29 world 189–​90, 200, 291, 42, 136, 140
naturalism 290–​8
madness 288 nature 17, 25, 29, 42, 63, 113, 124–​5, 129, 133,
malaria 48 142, 146, 149, 151–​2, 154, 166–​71, 194–​
malnutrition 186 5, 200–​6, 212, 291
masturbation 308 of body 8, 47, 86–​9
356 Index of Terms

nature (cont.) Chinese 9, 19

and causes 88 early modern 183, 186, 195
errors of 200, 205, 214 Eighteenth century 237, 242
forces of 166, 208, 211 medieval 136
human 91, 93, 144, 190, 192, 231–​2 Methodist 56
non-​natural 51, 53, 58, 62–​3, 69, 72, 142, Renaissance 142–​3, 154, 156–​60, 163,
147–​5, 159–​61, 171–​2, 207, 212–​17, 224, 168, 171
228–​9, 230, 235–​6, 278 physiology 153, 198–​200, 203, 209, 214, 223–​7
principles of 88, 149, 182, 203, 291 Descartes’ 216
of soul 86 mechanical 203, 219
unnnatural 110, 125, 149, 150–​1, 153 plague 58, 63–4, 175, 186, 240
neo-​A ristotelianism 303 bubonic 239, 243, 245
normativism 289–​309 Platonism 123, 125, 141–​3, 188, 193
nutrition 111, 142, 152, 158, 171, 227 po (whitesouls) 21
post traumatic stress disorder (PTSD) 276
obsessive compulsive disorder prana 10
(OCD) 265–​7 prescription 5, 58, 73, 171
osteology 176–​9 projection 259
prophylaxis 73, 143, 149–​51, 154–​9, 166, 169
passions 76, 80, 123, 150, 153–​4 , 158, 160, mental 162
168, 183, 188, 191, 198, 207, 211, 220, proportion. See balance
237–​9, 285 psychoanalysis 251–​2, 268–​78, 280–​1
paternalism 310–​11 purity 14, 44, 247
pathology 80, 153, 219, 223–​4 , 227, 236 putrefaction 155–​7, 169
humoral 46, 48, 50, 54, 69, 74 Pyrrhonism 79, 89, 90–​3
psycho-​  254, 275 Pythagoreanism 44, 225
phantasm (idola) 168
phantasy 252–​60, 265 qi 2, 7, 10–​31, 41–​2
philosophy 2, 5–​6, 8, 10, 20, 41, 67, 78, 80, haoran zhi 11
163, 168, 190, 192, 217–​18, 232, 272, 317 xingqi ming 11–​12
of biology 292 ying 30
early modern 182, 190 qiyās (reasoning) 131
first 86 quarantine 243
of medicine 161, 193–​213, 222
moral 62, 191 rage 132, 260, 266–​71, 280
of nature 25, 81, 86–​7, 148, 157, 191, 195, Rat Man 265–​6
198, 202 relativism 16, 146, 308–​9
political 25 REM sleep 273, 276
as therapy or spiritual medicine 73, 75–​85, dreaming 264, 273, 276
87, 90–​1, 93, 104, 160, 189, 194, 197, 314 repression 253
physicians 2
ancient 44–​5, 48–​9, 51–​2, 78–​9, 80, 83, sadness 51, 104–​6, 114, 121, 124–​8, 134,
86–​8, 91–​2, 96–​7, 101, 147 178, 210–​11
Arabic 56, 58, 61–​6, 73–​4 , 106 sanitatis latitudo 144
Cartesian 212–​21 schizophrenia 268–​70
 Index of Terms 357

serenity 159–​60, 164 process 258

shaman 22 strategies 200, 208, 211–​12, 214, 219, 221
sheng 36 therapy 51, 59, 68, 73, 77–​80, 85, 99, 149–​50,
shenming 28 217, 258. See also philosophy as therapy
sin 3, 34, 228 Apollonian 159
Six Dynasties 33–​5 biomechanical 210, 214, 216
skeleton 174–​9 Cartesian 195–​8, 207–​13
skeptic 16, 196, 217 chemo-​  313
sorrow. See sadness drug 9
soul 86, 148, 155, 159, 165–​6, 232 Freudian 251–​2
Descartes view on 111, 207 mechanical 208
diseases of 78, 80, 103–​5, 303 naturopathic 218
human. See nature, human principles of 88, 90
lower 128–​33 psychosomatic 210
passions of 76, 160 tian di ren 24
physician of 78, 83, 142 transcendents (xianren) 32–​4 , 38
rational 128 transference 258
seat of 175 trauma 276–​7
tripartite 5, 110 trinity 62
spirit 18, 21, 28–​9, 42, 142, 148, 150, tuberculosis 178, 282
159–​60, 164, 173
animal 154, 163–​4 vomiting 58, 63, 139
bodily 161
spiritual 162, 173, 178, 185 Warring States Period 8–​23
benefit 12 wine 58–​9, 63, 68, 159, 236
experience 151 witchcraft 138–​9
guide 188 wuwei 20
health 41 wuxing 24
insight 16 xing 7, 18, 35–​41
path 36
regeneration 20 Xuanxue (Mystery) School 37
spiritus 161, 165–​7
Stoicism 4, 45, 51, 85, 120, 125, 183, 189, yangsheng 7, 22–​3, 27
191, 210 definition of 13
sublimation 271 literature 18, 35–​6
suicide 260, 269–​70 practice of 17, 37, 42
superego 260 Yellow Emperor 26
supernatural 136, 138–​40 yi (medicine) 30
symptom 95, 140, 185, 261–​5 yinyang 27, 29, 38, 42
cosmology of 24–​5
teleology 4, 6, 203–​4 , 211
therapeia 76, 79 zai ying po 21
therapeutic 49, 184, 196, 222 Zeus 280
arguments 92 Zhou Dynasty 9
 Index of Authors and Works

ʿAbd al-​Laṭīf al-​Baġdādī 66 Austen, Jane 238

Aëtius of Amida 58 Avicenna 1, 5, 46, 56, 60–​2, 69, 70–​3, 153
Alcmaeon 44 Canon of Medicine 60–​1, 69–​72, 159
Andreae, Tobias 184, 213, 219–​20
Antisthenes 79 Bacon, Francis 157, 165, 167–​8, 173,
Arbuthnot, John 242–​3 182, 190–​1
Aretaeus 58 Essayes 148
Aristotle 1, 88, 114–​18, 123, 133, Advancement of Learning 190–​1
149, 158–​9, 169, 175, 223, 303 De Augmentis scientiarum 190
History of Animals 175 New Organon 191–​3
Metaphysics 86 Bald’s Leechbook 136–​40
Nicomachean Ethics 105, 114, al-​Balḫi, Abū Zayd 105–​14, 121, 126,
116, 159 130, 133–​4
On the Soul 133 Benefits for Souls and Bodies 104, 108,
Parts of Animals 223 112–​14, 121, 125, 133
Parva naturalia 149, 158, 169 Ban Gu 30
Arnald of Villanova Generalities 70 Barbeck, Friedrich Gottfried 184,
Aselli, Gasparo 181 213, 219–​20
D’Aumont, Arnulphe 228–​9 Bernard, Claude 224

359
360 Index of Authors and Works

Blackmore, Richard 237 Meditations on First

Boerhaave, Herman 225 Philosophy 196–​7, 200–​6
Institutiones Medicae 225–​7 Rules for the Direction of the
Le Boursier du Coudray, Mind 197–​8
Angélique-​Marguerite 244 Passions of the Soul 197, 211
Boyle, Robert 2, 182, 232 The World 199
Brasavola, Antonio Musa 146 Treatise on Man 199, 202
Breuer, Joseph 252–​3 Diagnosis and Statistical Manual
(DSM) 289–​90
Cabrol, Barthélémy Alphabet Anatomic 176 Diderot, Denis 231
Canguilhem, Georges 224 Digestion 51, 58, 147, 151–​4 , 158
Cardano, Girolamo 143–​4 , 151–​2, 154, Diocles of Carystus 88, 90
156–​60, 162–​4 , 168, 171–​2 Diogenes of Sinope 45
Discorsi intorno all vita Sobria 143 Dionis, Pierre 178
De sanitate tuenda 143, 149 Dubois, Jacques 176
da Carpi, Berengario 176 Duverney, Joseph-​Guichard 179
Chambers, Edward Cyclopedia 227
Chaucer, Geoffrey, Canterbury Tales 69 Empedocles 1
Cheyne, George The English Malady 237 Epictetus 125
Chrysippus 78, 80 Epicurus 77–​81, 85
Cicero 78, 80 Erasmus, Desiderius 146
Tusculan Disputations 78
Clauberg, Johannes 184, 219–​20, 213 Fangji. See Methods and Techniques
Clodius, Frederik 188 al-​Fārābī 107
Coiter, Volcher 177 Farragut. See Ibn Sālim, Farağ
Comte, Auguste 224 Ficino, Marsilio 143, 148, 156, 159–​72
Condillac, Abbé 231 De vita libri tres 157
Confucius 16, 32 da Foligno, Gentile 70
Constantine the African 67–​8 Frank, Johann Peter, System einer
On Melancholy 68 vollständigen medicinischen
On Sexual Intercourse 68–​9 Polizey 245
contentment 172, 197–​9, 209, 246, 249 Freud, Sigmund 51, 251–​81
Conway, Anne 187–​9
Cornaro, Alvise 154–​7, 164, 169–​71 Galen of Pergamum 2–​3, 5, 45–​6, 49–​54,
Corti, Matteo 144 60, 62, 73, 103–​5, 109–​15, 117–​20,
Courbet, Gustav 283, 286 129–​31, 135, 143–​46, 149, 152–​4 ,
Craanen, Theodor 219 159–​60, 168–​9, 175–​6, 225
About His Own Books 49
Daodejing 13, 19–​23, 41 About His Own Opinions 49
Darger, Henr 286 About the Order of His Own
Defoe, Daniel, History of a Plague Books 49
Year 186 Hygiene 147, 150–​1, 160, 168–​9
Democritus 76, 80, 85 Medical Art 143
Descartes, René 156, 167, 182–​4, 193–​221, 279 On Affections 50
Discourse on Method 194–​7, 202 On Anatomical Procedures 174
 Index of Authors and Works 361

On Ancient Medicine 50, 73 Hippocratic Corpus 46–​9, 73, 97

On Bones 176 Airs, Waters, Places 48
On Character Traits 103, 117–​18, Aphorisms and Prognostics 54, 57, 96
128–​9, 131 Diseases 100
On Compound Drugs According to Epidemics and Regimen in Acute
Genera 53 Diseases 96, 233
On Compound Drugs According to Gynaikeia (Women’s Matters) 97–​101
Places 53 Nature of Man 46, 48
On Exercise with a Small Ball 51 On Affections 48
On Mixtures 50 On Ancient Medicine 47–​8, 87
On Passions of the Soul 127–​8, 133 Places in Man 223
On the Affected Parts 53 Sacred Disease 100
On the Avoidance of Grief 51 Hobbes, Thomas 182
On the Elements According to Hobson, Alan 275, 277
Hippocrates 54 Hogarth, William, Marriage à la
On the Method of Healing 52 Mode 248
On the Nature of Man 73 Homer, Iliad 43
On the Powers of Foodstuff 51 Hooke, Robert 182
On the Sects for Beginners 49, 54, 60 Hunter, William 177
Alexandrian summary of Galen’s 55 Huygens, Christian 182
On Therapeutics for Glauco 52, 54
That the Soul Depends on the Body 111, ibn ʿImrān, Iṣhāq 68
133, 144 Ibn al-​Ğazzār, Provisions 67
The Living Being as a Whole 165 Ibn al-​Quff 65–​6, 73
The Opinions of Hippocrates and Plato 144 Ibn Buṭlān 46, 56, 64
Usefulness of the Parts 223 Almanac of Health 56, 62–​4 , 70–1, 73
Gassendi, Pierre 182 Chessboard Tables of Health 71
Gauguin, Paul 284–​5 Ibn Ğazla 71 Almanac of Bodily
Gerard of Cremona 69 Health 71
Géricault, Theodore 282–​3 Ibn Sālim, Farağ 70
Graunt, John 181–​2, 240, 242
Guan Zhong 12 Ji Kang 39–​40
Guanzi 12–​17, 41 Jurin, James 242–​3
Guibert, Philibert 181
Kant, Immanuel 279
von Haller, Albrecht, Discussion on the al-​K indī 105–​6
Sensible and Irritable Parts of On Dispelling Sorrow 105–​6, 125
Animals 232 Klein, Melanie 265, 271
Harvey, William 2, 152, 181
Heinrich Cornelius of Agrippa 159 du Laurens, André 176
von Helmholtz, Hermann 255, 272 Laozi 19
van Helmont, Francis Mercury 187–​8 Leibniz, Gottfried Wilhelm 182,
Herophilus 56, 89–​90 193–​4 , 221–​2
Hippocrates 2, 5, 46, 48–​50, 54, 65, 73, Littré, Emile 97
85–​6, 95, 97, 144, 149, 160 Liu Xiang 30, 32, 38
362 Index of Authors and Works

Liu Xin 30 Plempius, Vopiscus Fortunatus 177, 199

Locke, John 2, 182, 189, 231 Pomponazzi Pietro 142
Lü Buwei 25 du Pont de Nemours, Pierre Samuel 241
Pott, Percivall 178
Malebrache, Nicholas 182
Malpighi, Marcello 181 Da Raey, Johannes 184, 213, 217–​18
Marcus Aurelius 49 Ramírez, Martin 286
Mengzi (Mencius) 11, 13, 16 al-​R āzī, Abū Bakr 2, 46, 56–​60, 66, 70, 73,
Methods and Techniques ( fangji) 30–​2 104–​14, 119, 121–​34
Da Monte, Giambattista 144–​5 Book for al-​Manṣūr 57–​9, 105, 107
Miskawayh 105, 104–​18, 123–​35 Comprehensive Book 57, 70
Refinement of Character Traits 104–​6, Spiritual Medicine 104, 110, 113, 122,
108, 111–​12, 117, 123–​4 , 126 126–​8, 132
Monet, Claude 287 Regius, Henricus 2, 184, 213–​18, 216, 218
Montagu, Mary Wortley 242 Fundamentals of Physics 215
More, Henry 187–​8 Fundamentals of Medicine 215
Morris, Robert 287 Physiology or the Knowledge of
Mozi 16 Health 215
Richardson, George, Iconologia 248
Nagel, Thomas 284 Richardson, Samuel, Pamela 237
Neurocritic 264–​5, 268 Rohault, Jacques 184, 213–​14, 216–​17
Newton, Isaac 182 Treatise on Physics 215
Rousseau, Jean-​Jacques 231, 237
Oribasius 57 Roussel, Piere 238
Ruysch, Frederik 177
Paschetti, Bartholomeo 181
Paul of Aegina 5, 58 Saks, Elyn 268–​9
Pauw, Peter 176–​7 De San Juan, Juan Huarte 144, 158
Petrarch 141 Santorio, Santorio 181
Petty, William 240–​1 Santo, Mariano 159–​60
Philinus of Kos 89 de Sauvages, François Boissier 238
Philo of Larissa 78 Scott, Judith 286
Piccolomini, Alessandro 148 Seneca 76
Plato 4, 77, 81, 84–​9, 107, 110–​13, 119, 122, Sextus Empiricus 79, 89, 92
132, 159, 164, 279–​81 Shanren, Bada 286
Charmides 77 Shushu (Arts and Calculations) 30
Clitophon 84 Smith, Adam 231, 241
Euthydemus 84 Socrates 79, 82–​3, 278, 280
Gorgias 77, 81–​6 Songs of the South (Chu ci) 21
Laws 86 von Sonnenfels, Joseph 241
Phaedrus 86 Soranus 56
Republic 84, 107, 109, 279 Spinoza, Baruch 182
Sophist 77 Spring and Autumn Annals of Mr. Lü 25
Timaeus 159 Sun Simiao 37
 Index of Authors and Works 363

Sydenham, Thomas 2, 181 Wittichius, Christopher 219

Sylvius. See Dubois, Jacques Wollstonecraft, Mary Vindication of the
Rights of Women 238
Telesio, Bernardino 144, 165–​6 Wölffli, Adolf 285–​6
Tissot, Samuel Auguste 234–​5
Essay on the Illnesses of Fashionable Xingqi ming 11
People 234
Tiberius Caesar 212 Yang Zhu 16
Titian 287 Yellow Emperor’s Inner Classic 28–​9
Tryon, Thomas 181 Yin Zheng 25
von Tschirnhaus, Enrenfried Yiwen zhi (Bibliography of Arts and
Walther 221 Letters) 30
Turgot, Anne-​Robert-​Jacques 241
Zedler, Johann Heinrich
Van Gogh, Vincent 283–​5 Universal-​Lexicon 228
Viennese Tables 56 Zhuang Zhou 16, 18
Zhuangzi 13, 16–​18, 39–​41
Whytt, Robert 233 zi literature 10
Williams, Bernard 184 Zola, Émile The Masterpiece 285
Willis, Thomas 181 Zou Yan 25