NEW FRAGMENTS OF RUFUS OF EPHESUS’ ON THE RETENTION OF MENSES

Abstract

Rufus of Ephesus (fl. c.100 c.e.) was a prolific medical author and practitioner in the Imperial period whose historical importance has been obscured by the loss of most of his works. One of the largest gaps in our knowledge of Rufus’ corpus is his gynaecological writings, none of which survives in full. This article assembles and comments on several fragments from Rufus’ lost gynaecological work On the Retention of Menses (perhaps Περὶ τῶν ἐπεχομένων ἐμμήνων). Comparison of overlapping passages from the authors Ibn al-Jazzār (tenth century) and Aëtius of Amida (sixth century) reveals that more fragments of this work in Arabic and Greek have survived than previously thought. These fragments provide new evidence for the analysis of Rufus’ medical thought, and further our understanding of gynaecology in the Roman empire.

I. INTRODUCTION

Rufus of Ephesus (fl. c.100 c.e.) was not only an esteemed practitioner of medicine during the Imperial period but also a prolific author of several dozen works. His literary corpus has fared better than that of most doctors from that era, whose writings were gradually displaced in favour of Galen's (129–c. 216 c.e.), though only a handful of Rufus’ texts are fully extant. The process of identifying the remains of Rufus’ corpus has already spanned several centuries of scholarship;¹ and the more we learn about Rufus, the more we understand the intellectual milieu in which doctors of the Imperial era worked. All too often, our principal source for this period in the history of medicine is Galen, whose biases against his predecessors and contemporaries loom large in his rhetoric. None the less, Rufus seems to have been admired by Galen, and the disappearance of his works since the Islamic period was not reflective of the value accorded to him by ancient and medieval authors.² New fragments of Rufus continue to be identified in the works of authors who wrote in Arabic, though even the Greek fragments of Rufus preserved in the late antique medical encyclopedias of Oribasius (fourth century), Aëtius of Amida (sixth century) and Paul of Aegina (seventh century) have not been exhaustively explored.³ One such example is Rufus’ On the Retention of Menses (perhaps Περὶ τῶν ἐπεχομένων ἐμμήνων), of which only two Greek fragments were previously thought to survive.⁴ In this article, we identify more fragments in Arabic and Greek by comparing overlapping passages from Ibn al-Jazzār's Provisions for the Traveller and Nourishment for the Sedentary (Zād al-musāfir wa-qūt al-ḥāḍir, tenth century) and Aëtius of Amida's Medical Books.

Menstrual retention and Rufus’ gynaecological texts

In Graeco-Roman (and later Islamicate) medicine, regular menstruation was considered to be vital to the health of women between the ages of menarche and menopause.⁵ Menstruation was conceived of as a cyclical ‘purging’ (κάθαρσις) of excessive blood. Interruptions to that process were regarded as pathological not only because excessive amounts of blood were thought to harm the body but also because regular menstruation was linked to fertility. One of these interruptions could be menstrual retention (ἡ τῶν καταμηνίων ἐπίσχεσις uel sim.), a condition in which the menses have been prevented from leaving the body through the proper channel.⁶ This condition is mentioned throughout the gynaecological works in the Hippocratic Corpus. Accordingly, it comes as no surprise that Rufus of Ephesus wrote about menstrual retention, as we learn from the lists of Rufus’ works compiled by the medieval authors al-Nadīm (tenth century) and Ibn Abī Uṣaybiʿa (thirteenth century).⁷ As with other fragments of Rufus, it is unclear whether this work on menstruation was originally a stand-alone treatise or a section drawn from another work.⁸ Whatever its exact nature, Rufus’ interest in gynaecology is attested by other fragments and citations. Based on this collective information, the titles of Rufus’ other gynaecological works are thought to include: On Regimen for Maidens (Περὶ παρθένων διαίτης), Regimen for Women (Δίαιτα γυναικῶν), Regimen for Pregnant Women (M. Fī tadbīr al-ḥabālā),⁹ Treatment for Women Failing to Become Pregnant (Μὴ κυϊσκομένων θεραπεία) and more.¹⁰ A passing remark in Rufus’ On the Affections of the Kidneys and Bladder seems to imply that he wrote his gynaecological works after that treatise;¹¹ otherwise, we know little about the compositional timeline of his literary corpus.

The context of Rufus’ work

Before presenting the new fragments, it will be useful to reflect on their potential for improving our understanding of gynaecology in the Roman empire. For medicine during the Classical Greek period scholars have recourse to the Hippocratic Corpus, which contains several gynaecological treatises.¹² In contrast, when it comes to the Hellenistic period, the majority of medical texts have been lost and survive only as fragments and testimonia. What we know about gynaecology in this period and thereafter relies for the most part on a single work by Soranus of Ephesus (approximately late first century):¹³ his Gynaecology, or On the Affections of Women (Περὶ γυναικείων παθῶν), whose many doxographical sections give the impression that gynaecological literature was thriving during the Hellenistic period if not also in the first century.¹⁴ Slightly before Soranus, Celsus (early first century) wrote a valuable work on medicine in Latin, though he only addresses matters of gynaecology in passing. And slightly after Soranus, there are the works of Galen, who makes various remarks about the nature of women's bodies throughout his corpus but never seems to have written a gynaecological treatise in the same sense as Soranus.¹⁵ Thus, the new fragments of Rufus’ On the Retention of Menses that we identify are a welcome addition both to his corpus and to our knowledge of gynaecology in the Roman Imperial period.

Rufus lived at a time of considerable diversity in the practice of medicine. The name of Hippocrates still carried weight as the proverbial father of the art, but the body of writings attached to his name left much to the imagination. Much as new schools of philosophy arose during the centuries following Socrates’ death in 399 b.c.e., each laying claim to his legacy, so too had new medical sects arisen by the time of Rufus with their own epistemological approaches to medicine. Some of the new fragments (F 3a and c) provide an indirect example of this diversity. There, Rufus recommends phlebotomy on the elbow or ankle for treating menstrual retention. Comparison with Soranus and Galen reveals that doctors were divided on the role of phlebotomizing female patients. In severe cases of retained menses, Soranus preferred phlebotomizing the arm rather than the ankle.¹⁶ Galen approved of phlebotomy on the ankles, but claimed that bleeding the elbow may cause retention instead of treating it.¹⁷ However, it seems that not every doctor would have agreed that bloodletting helps to improve this condition. Galen recounts in one of his polemical works how a group of doctors in Rome ended up killing a young woman with menstrual retention because they refused to open up a vein, insisting instead on fasting as treatment.¹⁸

Beyond the subject of phlebotomy, the new fragments of Rufus also serve as a source for the reception of Hellenistic gynaecology. As noted throughout, there are various instances where Rufus’ ideas about the aetiology and treatment of menstrual retention have similarities with passages in Celsus, Soranus and/or Galen. In such instances, one may presume that Rufus and the others were adapting ideas from their predecessors to fit within their own vision of medicine. For Rufus, that vision would have been informed by a process which Hanson has dubbed the ‘restructuring of female physiology’.¹⁹ In the Hellenistic world, women became increasingly visible in public spaces. Hence medical thought during the Hellenistic and Roman Imperial periods grew to accommodate aspects of this shifting landscape, where women were no longer passive entities bound to the home, as the authors of the Hippocratic Corpus had mostly envisioned them. While intercourse and childbearing were still considered vital to women's health—a Hippocratic holdover that would prove influential for centuries to come—medical thinkers transitioned to a revised framework that admitted a greater degree of parallelism between men's and women's bodies. Rufus believed that women benefit from an active lifestyle and insisted that women have no less need for regular exercise than men, though he considered some forms of exercises more appropriate for women owing to certain differences in their physical make-up (φύσις).²⁰ Some of the new fragments (F 1a, b and c) shed light on the expanded role that exercise could play in maintaining women's health.

The text of On the Retention of Menses

One of our major sources for the works of Rufus is Aëtius of Amida (sixth century), who assembled a compilatory work known as the Medical Books. In the sixteenth book, which focusses on gynaecology, Aëtius explicitly attributes two of his chapters solely to Rufus.²¹ As with other passages in the Medical Books, these attributions occur in the chapter headings, which specify the topic under discussion in addition to the author(s) from whom the content derives.²² The two relevant chapters for our purposes are 16.50, which bears the heading ‘On retained menses, from the works of Rufus and Aspasia’ (Περὶ τῶν ἐπεχομένων ἐμμήνων. Ἐκ τῶν Ῥούφου καὶ Ἀσπασίας), and 16.51, with the heading ‘Treatment for women ceasing to menstruate because of excessive heat, from the works of Rufus’ (Θεραπεία τῶν διὰ πλείστην θερμότητα μὴ καθαιρομένων. Ἐκ τῶν Ῥούφου). Before now, Johannes Ilberg used Aët. 16.50–1 as the basis for including On the Retention of Menses among Rufus’ works, though Ilberg speculated that any material belonging to Rufus in Aët. 16.50 was taken indirectly through the works of Aspasia.²³ However, it is not possible to test Ilberg's theory because little is known about this so-called Aspasia, whom Aëtius alone excerpts.²⁴ Moreover, Ilberg was unaware that the medieval physician Ibn al-Jazzār (tenth century) quotes portions of the same material from Rufus in a chapter from the sixth book of his Provisions for the Traveller and Nourishment for the Sedentary (Zād al-musāfir wa-qūt al-ḥāḍir), where al-Jazzār discusses menstrual retention without mentioning Aspasia's name. Comparison between al-Jazzār's Provisions 6.9 and Aët. Medical Books 16.50 not only reinforces Rufus’ authorship for most of 16.50 but also reveals that some of the chapters following Medical Books 16.51 were drawn from Rufus without attribution. It seems more plausible that the overlapping material between Aëtius and al-Jazzār was adapted from Rufus (or from an epitome of Rufus) rather than from Aspasia—an author who, as far as we know, was never translated into Arabic separately from Aëtius.²⁵ Also, Ilberg's theory does not adequately account for the loss of most of Oribasius’ Medical Collections (fourth century)—a major source for Aëtius. It is possible that Aëtius drew 16.50–1 directly from portions of the Medical Collections and, likewise, that al-Jazzār drew his material from Oribasius (whose work had been translated into Arabic during the ninth century).²⁶

The identification of fragments from Rufus’ On the Retention of Menses involves guesswork. Al-Jazzār makes brief and explicit use of Rufus only in Provisions 6.9 without specifying his source. Nevertheless, many of the passages that make up the new fragments are nearly verbatim between Aëtius and al-Jazzār, though sufficiently different to rule out al-Jazzār's reliance on Aëtius directly. If al-Jazzār did not use an Arabic translation of On the Retention of Menses, he may have found his information in a compilation or in another author quoting Rufus. The same applies to Aëtius: if he did not use Rufus directly, then he could have drawn his material from an intermediary source. Whatever the situation, al-Jazzār and Aëtius operated within their own historical milieus and had their own reasons for drawing on Rufus—which leads to certain limitations in their use as witnesses. The objective of comparing these two authors cannot be to determine who ‘better’ represents the ipsissima uerba of Rufus, because neither author set out to do so. Moreover, Aëtius remains of limited value for placing the fragments into their original order because he rearranged Rufus’ words across multiple chapters to suit his own organizational scheme within the sixteenth book. However, Rufus’ recommendation of working from cause to cure (F 3a and b) seems to have inspired the logic behind Aëtius’ structuring of the chapters on menstrual retention.²⁷ Each of the causes of menstrual retention mentioned in Aëtius’ chapter headings may correspond to the causes originally addressed by Rufus.

Lastly, most chapters related to menstrual retention in Aëtius cannot be directly corroborated through al-Jazzār. It is tempting to attribute these chapters to Rufus, but there would be risks in doing so. The chapters in the Medical Books where Aëtius synthesizes material from two authors are not always marked as hybrid or ‘double chapters’ in their headings, meaning that any chapter attributed to a single author can in fact be derived from multiple authors.²⁸ Nor does Aëtius always intervene when his sources draw on earlier authors so as to parse out which material belongs to whom. For instance, in 16.50, attributed to Rufus and Aspasia, there is a passage drawn from Soranus without acknowledgement.²⁹ And in at least one instance in the second book Aëtius attributes a chapter to Rufus and Galen, but the content appears to derive only from Galen.³⁰ Thus, in the absence of independent evidence, one runs the risk of misattributing passages in Aëtius to the wrong author. To avoid that, the passages from the sixteenth book which could not be obviously corroborated through comparison with al-Jazzār or with other fragments of Rufus are listed in the Appendix at the end of this article. Nothing in terms of their content or style prevents them from belonging to Rufus, though nothing that we encountered confirms it.

The critical edition of the sixteenth book of Aëtius typically cited is S. Zervos, Gynaekologie des Aëtios (Leipzig, 1901), but a new working edition was produced by Romano in 2006, which we follow here.³¹ Although it lacks a critical apparatus, Romano's edition improves on Zervos's by drawing on more manuscripts and correcting mistakes in Zervos's chapter numbering that make his edition confusing to navigate. The corresponding chapter headings in Aëtius are included for every Greek passage. For the sixth book of Ibn al-Jazzār's Provisions, we reproduce the edition and translation of G. Bos, Ibn al-Jazzār on Sexual Diseases and their Treatment (London, 1997). The fragments are arranged according to their order in al-Jazzār rather than the order in which they may have appeared in Rufus’ original work.

II. FRAGMENTS

F 1a Ibn al-Jazzār, Provisions for the Traveller and Nourishment for the Sedentary (Zād al-musāfir wa-qūt al-ḥāḍir), Book 6, ch. 9 (page 127, line 507 – page 128, line 511 Bos). Transl. Bos (page 263).

وقد زعم روفس أنّ النساء الاتي يعملن ويكثرن الحركة لا حاجة لهنّ في كثرة إنزال الطمث، والنساء الاتي يلزمن الخفض والدعة ويكثرن الأكل فهنّ محتاجات إلى كثرة إنزال الطمث.

Rufus said that women who work and engage in much activity do not need the emission of much menstrual blood, but that women who stick to a calm and comfortable life and eat much need a heavy menstruation.³²

F 1b Aëtius of Amida, Medical Books, Book 16, ch. 50 (page 370 Romano = page 69, lines 13–15 Zervos).

ν´. Περὶ τῶν ἐπεχομένων ἐμμήνων. ’Εκ τῶν Ῥούφου καὶ Ἀσπασίας.

καὶ τὸ σύμπαν εἰπεῖν ταῖς θερμοτέραις τῶν γυναικῶν καὶ ταῖς ὑπὲρ τὸ δέον γυμναζομέναις καὶ ἀγροίκοις, οὐ πάνυ δαψιλεῖς αἱ καθάρσεις γίνονται.

50. On Retained Menses. From the Works of Rufus and Aspasia.

And to speak in general, women who are warmer, who exercise more than is necessary, and who have a rustic lifestyle do not have very plentiful menses.³³

F 1c Aëtius of Amida, Medical Books, Book 16, ch. 51 (page 374 Romano = page 72, lines 9–15 Zervos).

να´. Θεραπεία τῶν διὰ πλείστην θερμότητα μὴ καθαιρομένων. ’Εκ τῶν Ῥούφου.

ὀρθότερον μὲν οὖν πρὸς ἅπασαν τὴν ὑγείαν πᾶσιν³⁴ ἐξευρεῖν δίαιταν, ὑφ’ ἧς ξηραινόμενον τὸ σῶμα τῆς γυναικὸς ἔσται πρὸς τὸ μὴ δεῖσθαι τῆς καταμηνίου καθάρσεως, ἀλλὰ εἰς τὴν κύησιν οὐδαμῶς τοῦτο συμφέρον⋅ αἱ γὰρ μὴ καθαιρόμεναι οὐδὲ κυΐσκουσι⋅ διά τε οὖν τὴν κύησιν καὶ ὅτι αἱ πλείους ἀταλαιπώρως διαιτώμεναι καθαίρεσθαι χρήζουσι, δίκαιον καὶ θεραπείας γράψαι πάσῃ γυναικὶ μὴ καθαιρομένῃ.

51. Treatment for Women Ceasing to Menstruate because of Excessive Heat. From the Works of Rufus.

Now, in terms of the overall health of all women, it would be better to devise a regimen by which the woman's body becomes so dry that it no longer has need of menstruation. But that is not helpful at all for pregnancy, since women who cease to menstruate do not get pregnant. Therefore, in light of pregnancy and the fact that most women need menstruation because they lead inactive lives,³⁵ it is fitting as well to write down treatments for all the women who cease to menstruate.

Commentary

These fragments centre on the relationship between physical activity and menstruation. Al-Jazzār's quotation (F 1a) of Rufus is paralleled in Aëtius (F 1b), who also links an active lifestyle to a smaller quantity of menses. We can assume that Rufus maintained the reverse (that is, that an inactive lifestyle leads to greater quantity of menses). This idea is obliquely stated in F 1c, which, though not itself paralleled in al-Jazzār, dovetails with what we know about Rufus’ gynaecological theories (more on which below). Furthermore, Aëtius has separated in chapter 51 what may have been Rufus’ prefatory remarks to On the Retention of Menses, given that the chapter does not apply exclusively to menstrual retention caused by excessive heat; evidently, Rufus is taking the whole of women's health (ἅπασαν τὴν ὑγείαν πᾶσιν) into consideration.³⁶

The ideas expressed in F 3c complement what is found in the remains of Rufus’ Regimen for Women. Rufus believed that women are colder and moister than men; therefore, they should conduct their regimen in such a way that increases their heat so as to balance out their excessive coldness.³⁷ He also believed that women do not purge properly (χρηστῶς), by which he meant that their lifestyle does not facilitate the full purging of excess blood from their bodies, thereby resulting in the need for cyclical discharge of blood in the form of menses.³⁸ In F 1c, then, Rufus takes his theory about the female body to a logical extreme, only to dismiss it in practice. Since women are always moister in make-up, they would benefit from a regimen that dries out their body, but a dry body would eliminate the menses, thereby hindering women's ability to reproduce—for which regular menstruation was considered a prerequisite. Rufus viewed reproduction as essential to woman's health, as did the Hippocratics, though no author of the Hippocratic Corpus went so far as to suggest that a woman could take steps to cease menstruating altogether.³⁹ Furthermore, Rufus believed that women should regularly exercise for the sake of health⁴⁰ and, as we learn from F 1b, he thought that menstruation was affected by the amount of physical activity in which women participate. Although exercise for women is not forbidden in the Hippocratic Corpus,⁴¹ its applications are more restricted when compared to Rufus.

F 2a Ibn al-Jazzār, Provisions for the Traveller and Nourishment for the Sedentary (Zād al-musāfir wa-qūt al-ḥāḍir), Book 6, ch. 9 (page 128, line 511 – page 130, line 536 Bos). Transl. Bos (pages 263–4).

وأما لكيفية المادّة فمثل غلظها ولزوجتها أو لزيادة البرودة أو لإفراط اليبس. فإنّ الدم إذا غلظ سد المجاري ولم ينحدر انحدارا سلسا، وكذلك إذا كان الدم باردا أو يابسا لم يسلك في العروق سلوكا سلسا. فأما احتباسه بحركة المادّة فإذا هي مالت إلى عضو آخر مثل ما يأتي من عروق المقعدة أو بالرعاف. وقد قال روفس إنّ من النساء من ترعف كثيرا أو منهنّ من تنزف الدم من علّة البواسير، ومنهنّ من تنفث الدم من صدرها ومنهنّ من يخرج منها الدم لانصداع عرق من عروقها. فهذه الانواع كلّها وما يشبهها ممّا يمنع نزول الطمث. وقد يفسد طمث المرأة أيضا الحزن الدائم والهمّ الدائم وغير ذلك من أنواع أوجاع النفس شبه الغضب والفزع فإنّها كلّها علل فساد الطمث واحتباسه. فإذا تطاول احتباس الطمث ولّد عللا يصل ضررها إلى المعدة فيذهب شهوة الطعام ويعرض للمرأة الغثيان الدائم وتشتهي أغذية رديئة مثل الفحم والتراب وما أشبه ذلك. وقد يعرض من ذلك أعراض غير ما وصفنا مثل وجع الصلب والرقبة والرأس والعينين وقد يعرض لهنّ حمّيات لهبة وتكون أبوالهنّ إلى السواد وإلى الحمرة وربّما كان يشبه ماء لحم طرّي وأبدانهنّ في الجملة مستعدّة لحدوث بعض الأمراض العظام مثل الاستسقاء والسلّ والاختلاط المتكوّن من المرّة السوداء.

[The menstrual blood is retained] because of the quality of its matter when it is, for instance, thick, viscous, or excessively cold or dry. For when blood becomes thick, it closes the passages so that it does not flow down smoothly anymore; likewise, when the blood is cold or dry, it does not flow smoothly through the veins. As for the case when the blood is retained because of the movement of the matter, this happens when the blood streams towards another organ as, for instance, that which streams from the veins of the buttocks, or by a nosebleed. Rufus has said that some women have many nosebleeds, other women lose much blood because they suffer from haemorrhoids, other women bring up blood from their chest, and [still] other women lose blood because of a rupture of a vein. All these kinds of afflictions and similar ones stop the streaming of the menstrual blood. The menstruation of a woman may also be corrupted by continuous sorrow or anxiety or similar psychical afflictions, such as anger and fear, for all these afflictions cause corruption and retention of the menstruation. If, however, the menstruation [of a woman] is retained for a long time, it causes diseases which affect the stomach, so that she loses her appetite, is constantly nauseous, and craves for bad food, such as charcoal, earth and the like. But it can also cause other afflictions, apart from those which we have described, as, for instance, pain in the loins, neck, head and eyes, or burning fevers. The colour of such women's urine will tend towards black and red, and sometimes it will look like the juice of fresh meat. Their bodies will, in short, be susceptible to some serious diseases, such as dropsy, consumption and a humour consisting of black bile.

F 2b Aëtius of Amida, Medical Books, Book 16, ch. 50 (page 372 Romano = page 70, lines 12–18 Zervos, and page 374 Romano = page 71, line 19 – page 72, line 5 Zervos).

ν´. Περὶ τῶν ἐπεχομένων ἐμμήνων. ’Εκ τῶν Ῥούφου καὶ Ἀσπασίας.

ἐπέχεται δὲ ἡ κάθαρσις, καὶ ἐφ’ ὧν τὸ αἷμα ἢ παχύτερον ἢ γλισχρότερον γίγνεται ἢ δι’ ἑτέρων τόπων φέρεται, οἷον διὰ μυκτήρων ἢ ἕδρας⋅ ἔνιαι δὲ καὶ ἐκ θώρακος πτύσασαι αἷμα οὐκέτι ἐκαθάρθησαν, ἄλλαι δὲ φλεβοτομηθεῖσαι ἄκρως, ἐπεσχέθησαν τὴν ἔμμηνον κάθαρσιν, καὶ ἐκκρίσεις δὲ ἄλλαι γιγνόμεναι, ἐπέχουσι τὰς ἐμμήνους καθάρσεις. […] ἐπέχεται δὲ τὸ καταμήνιον καὶ διὰ φροντίδα ὑπερβάλλουσαν καὶ διὰ φόβον ἰσχυρὸν καὶ διὰ λύπην μεγίστην. μὴ καθαιρομένῃ τοίνυν γυναικὶ ὡς εἴθισται, κίνδυνος καὶ αἷμα πτύσαι καὶ ἀπόπληκτον γενέσθαι⋅ παρέπεται γὰρ ταύταις ἐπεχομένων τῶν συνήθων ἐκκρίσεων συμπτώματα χαλεπά, οἷον βάρους αἴσθησις ἐν ὅλῳ τῷ σώματι, καὶ ἄσαι καὶ ἀνορεξίαι καὶ ἀνωμαλίαι καὶ φρικώδεις διαδρομαί, συνεδρεύουσαι⁴² ὀδύναι κατ’ ὀσφὺν καὶ μηροὺς καὶ τράχηλον καὶ βρέγμα καὶ κατὰ τὰς τῶν ὀφθαλμῶν βάσεις, πυρετοὶ συνεχεῖς καὶ οὖρα μελαινόμενα μετ’ ἐρυθροῦ τινὸς ἰχῶρος, καὶ δυσουριῶσι καὶ ἰσχουριῶσιν⋅ ἔνιαι δὲ αὐτῶν καὶ εἰς μελαγχολίαν ἢ μανίαν ἐνέπεσον.

50. On Retained Menses. From the Works of Rufus and Aspasia.

Menstruation is retained in instances where the blood becomes too thick or too viscous,⁴³ or when the blood is transported through other parts of the body such as the nostrils or buttocks.⁴⁴ Some women cough out blood from their chest and then no longer menstruate,⁴⁵ while other women cease to menstruate after bloodletting thoroughly. Other kinds of excretions also cause retention of the menses. […] The menses are also retained because of excessive worrying, a strong feeling of fear, and major grief. Now, when a woman does not menstruate as usual, she is in danger of spitting blood and becoming apoplectic. When the usual excretions of the menses are retained, serious symptoms follow, such as: a heavy feeling throughout the whole body, nausea, loss of appetite, malaise, shivering sensations; pains occurring in the loins, thighs, neck, forehead and in the base of the eyes; continuous fevers and black urine with a red liquid. They also have difficulty urinating and they retain urine. Some women fall into melancholy or mania.

Commentary

These fragments expand on the aetiology of menstrual retention, offering several possible causes such as changes in the consistency of blood, bleeding from other parts of the body, or even mental disturbance. The accompanying explanations in al-Jazzār (F 2a) as to why the thickness or temperature of blood affects its movement could belong to Rufus, as they seem like details that Aëtius might curtail during the compilation process. Moreover, the absence of haemorrhoids in F 2b seems to be explained by the chapter heading of Aët. 16.59 (Θεραπεία τῶν δι’ ἑτέρων τόπων κενουμένων, δι’ αἱμορροΐδων ἢ μυκτήρων, καὶ διὰ τοῦτο μὴ καθαιρομένων), which suggests that Aëtius may have saved Rufus’ remarks on haemorrhoids for a subsequent chapter.

Towards the end of F 2b, a similarity with a passage in Galen's On the Affected Places calls for explanation. The portions below printed in bold type are almost verbatim:⁴⁶

τοιαῦτα μὲν οὖν ἕπεται συμπτώματα ταῖς τῶν καταμηνίων ἐπισχέσεσι, καὶ χωρὶς τούτων ἀλγήματα κατ’ ὀσφῦν καὶ τράχηλον καὶ βρέγμα καὶ τὰς τῶν ὀφθαλμῶν βάσεις, πυρετοί τε καυσώδεις καὶ οὖρα μελαινόμενα μετ’ ἐρυθροῦ τινος ἰχῶρος, ὥσπερ εἰ κρεῶν νεοσφαγῶν πλύμασι μίξαις ἀσβόλην⋅ ἔνιαι δὲ καὶ δυσουροῦσι καὶ ἰσχουροῦσι.

All these symptoms of menstrual retention are mentioned in al-Jazzār (F 2a) and Aëtius (F 2b), with the exception of the comparison between the red liquid discharged during urination and sooty water, which is mentioned only by al-Jazzār (F 2a) and Galen. There are a few possible explanations for the similarities. First, we may rule out a scenario in which Rufus quoted Galen, since On the Affected Parts was written late in Galen's life.⁴⁷ It is plausible, however, that Galen borrowed from Rufus without acknowledgement. Pormann recently suggested that Galen did so elsewhere in On the Affected Parts during his discussion of melancholy.⁴⁸ Moreover, while Galen's comparison between the red liquid and sooty water might sound original, it probably makes use of generic imagery.⁴⁹ If Galen is not the original source, another explanation would be that this list of symptoms for menstrual retention belongs to Rufus or to an earlier author used by him.⁵⁰ Another explanation (not exclusive with the previous) could be that Aëtius inserted words from Galen's text (F 2b) but removed the comparison with the red liquid. If that scenario is correct, then either (i) al-Jazzār's source also inserted words from Galen or (ii) al-Jazzār quoted from Galen (F 2a) without mentioning his name. Scenario (i) would not be surprising since Rufus’ words were sometimes mistakenly attributed to Galen.⁵¹ Scenario (ii) seems less plausible because al-Jazzār constantly mentions Galen throughout the Provisions and explicitly quotes from Galen next after Rufus in Provisions 6.9.

F 3a Ibn al-Jazzār, Provisions for the Traveller and Nourishment for the Sedentary (Zād al-musāfir wa-qūt al-ḥāḍir), Book 6, ch. 9 (page 130, line 533 – page 131, line 540 Bos). Transl. Bos (page 264).

وقد ذكر روفس الحكيم أنّ الطبيب إذا عرف علّة احتباس الطمث هان عليه علاجه بأيسر الوجوده. فينبغي أن يداوي احتباس الطمث بإزالة الاسباب المولّدة له. ونبدأ من علاج ذلك بفصد المرأة في الرجل في العرق المسمّى الصافن، فإنّ الفصد في الرجل مع أنّه يجذب الطمث إلى ضدّ الجهة التي يميل إليها فقد يعين على دروره. فإذا أردنا أن نفعل ذلك يوجّهنا إلى فعله في اليوم الثالث والرابع من حيض المرأة.

Rufus the physician said that, when a doctor knows the cause of retention of the menstrual blood, he will be able to treat it in the easiest way. The retention of the menstrual blood should be treated by eliminating its causes. One should start its treatment by bleeding the woman from her foot—namely, from the vein called the ‘saphenous’. For venesection in the foot, although it attracts the menstrual blood in a direction opposite to the one it [naturally] tends to take, helps to let it flow copiously. If we want to perform this [procedure], we plan to do so on the third and fourth day of the menstruation of the woman.

F 3b Aëtius of Amida, Medical Books, Book 16, ch. 61 (page 390 Romano = [ch. 60] page 82, lines 27–8 Zervos).

ξα´. Θεραπεία τῶν δι’ αἰτίαν τινὰ τῶν περὶ τὴν ὑστέραν μὴ καθαιρομένων.

θεραπεύειν οὖν προσήκει πρότερον τὴν διάθεσιν τὴν τῆς ἐποχῆς αἰτίαν, καὶ οὕτως ἐπὶ τὰ προτρέποντα πορευτέον.

61. Treatment for Women Ceasing to Menstruate because of Some Problem with the Womb.

It is fitting, then, to treat first the condition causing the retention, and in this way one should proceed towards the things promoting [sc. menstruation].⁵²

F 3c Aëtius of Amida, Medical Books, Book 16, ch. 55 (pages 384–6 Romano = [ch. 55bis] page 79, lines 13–22 Zervos).⁵³

νε´. Θεραπεία τῶν διὰ πλείστην πιμελὴν μὴ καθαιρομένων.

ἡ δὲ ἴασίς ἐστιν ἀφελεῖν τὸ πλεῖον τοῦ αἵματος. τὴν κατ’ ἀγκῶνα οὖν τμητέον φλέβα ἢ τὴν πρὸς τὸ σφυρόν⋅ μετὰ δὲ τὴν κένωσιν τοῦ αἵματος καὶ τὰ ἄλλα ποιεῖν ὡς πρόσθεν εἴρηται, προποτίζοντα καὶ πυριῶντα τοὺς τόπους⋅ φανέντων δὲ τῶν καταμηνίων, κατακλίνειν χρὴ τὴν γυναῖκα καὶ ἐν ἡσυχίᾳ τηρεῖν καὶ ἀκινησίᾳ, καὶ λουτρῶν καὶ σιτίων ἀπέχεσθαι τὴν πρώτην, τὴν δὲ δευτέραν σιτία μὲν διδόναι πτισάνης χυλὸν συνηψημένου ἀνήθου, ἔπειτα λαχάνων τι τῶν ἐπιτηδείων, τῇ δὲ τρίτῃ λούειν καὶ διαιτᾶν συνήθως.

55. Treatment for Women Ceasing to Menstruate because of Excessive Fat.

The treatment [sc. for retained menses] is to remove the excessive amount of blood. Thus, one should cut open the vein in the elbow or the vein near the ankle.⁵⁴ After the blood is drained, do the other things as described earlier while offering a drink and warming the genitalia. After the menses appear, the woman must lie down and keep watch in silence without moving. She must abstain from bathing or eating for the first day, but for the second day give her barley gruel boiled together with dill for food, and then some vegetable that is suitable. On the third day, she must bathe and conduct her usual regimen.

Commentary

These fragments speak to the modus operandi that Rufus recommended when treating menstrual retention. Both authors mention the significance of the third day, though al-Jazzār (F 3a) does not excerpt the same instructions as Aëtius (F 3c). The timing and circumstances under which the specified treatment should be carried out are also unclear. Al-Jazzār presents phlebotomy as a general form of treatment for menstrual retention. He specifies that it will treat menstrual retention but also that the patient should be phlebotomized three or four days after menstruation begins, which would imply in this case that menstrual retention is not necessarily an absolute absence of the menses. Like al-Jazzār, Aëtius begins the treatment with phlebotomy but presents the rest of the instructions as subsequent steps. Moreover, by separating his information into different chapters, Aëtius creates the impression that the above treatment is only for menstrual retention caused by excessive fat.

III. APPENDIX OF UNCORROBORATED PASSAGES

The following passages from the sixteenth book of Aëtius of Amida's Medical Books have a similar subject matter with the fragments above and therefore may derive from Rufus of Ephesus’ On the Retention of Menses, but we find no obvious corroboration in the sixth book of Ibn al-Jazzār's Provisions for the Traveller and Nourishment for the Sedentary.

1. Ch. 50 (pages 370–4 Romano = page 69, lines 4–12, 15 – page 70, line 12, and page 70, line 18 – page 71, line 19 Zervos). Attributed to Rufus and Aspasia.

2. Ch. 51 (pages 374–6 Romano = page 72, lines 15–25 Zervos). Attributed to Rufus.

3. Ch. 55 (pages 384–6 Romano = page 78, line 10 – page 79, line 5 Zervos).⁵⁵ Unattributed.

4. Ch. 55 (pages 384–6 Romano = [ch. 55bis] page 79, lines 8–13 Zervos). Unattributed.

5. Ch. 56 (page 386 Romano = page 79, line 25 – page 80, line 5 Zervos). Unattributed.

6. Ch. 57 (pages 386–8 Romano = page 80, line 8 – page 81, line 11 Zervos). Unattributed.

7. Ch. 58 (page 388 Romano = [ch. 55bis] page 79, lines 8–13 Zervos). Unattributed.

8. Ch. 59 (pages 388–90 Romano = [ch. 58] page 81, line 16 – page 82, line 5 Zervos). Unattributed.

9. Ch. 60 (page 390 Romano = [ch. 54, sic] page 82, lines 8–17 Zervos). Unattributed.

10. Ch. 61 (page 390 Romano = [ch. 60] page 82, lines 21–6 Zervos). Unattributed.