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Rediscovering medical history through ancient texts

February 24, 2013

Galen’s commentary on the Hippocratic Epidemics – by Simon Swain and Uwe Vagelpohl

From a translation of the Hippocratic Epidemics. Background: Wellcome Library

From a translation of the Hippocratic Epidemics. Background: Wellcome Library

This is the beginning of a medical case history that dates back to the fifth century BCE. It is preserved in the first book of a Hippocratic treatise entitled Epidemics. It describes the short and ultimately fatal disease of a man named Philiscus, an inhabitant of the Greek city of Thasos on the island of the same name. We follow the progression of his illness through the eyes of an anonymous observer who records various symptoms for each day. Other than that he lived in Thasos by an otherwise unspecified “wall”, the case history apparently offers little information about Philiscus himself. There is, however, more to his story. Thanks to a brief reference elsewhere in the Epidemics, we also know that he was the son of a man named Antagoras. Making these fragmentary connections takes us from ancient texts to a lost medical history awaiting rediscovery.

Contemporary inscriptions from Thasos tell us that this Antagoras held a ceremonial office in his town in the late fifth century BCE. Antagoras also happened to be the son of another patient discussed in this book, the (unnamed) wife of Epicrates. This name is again amply attested in inscriptions of the time, which list the political positions he held. In conjunction with these inscriptions, the Epidemics gives us a broad picture of Philiscus. He was a member of a prominent family in town, with a father and grandfather who held ceremonial and political office. Philiscus and his grandmother were both treated by the same physician (or group of physicians) who compiled the set of case descriptions from Thasos that figure prominently in the Epidemics. It is tempting to think of this physician (if he was indeed the same person) as a family doctor who attended to several generations of the family. The treatment Philiscus received was apparently limited to a clyster on the second day. His physician otherwise seems to have monitored the disease without intervening any further.

This case illustrates the kind of information we can recover from ancient medical texts. This one offers hints, not just about the diseases he and his contemporaries suffered from – in this case, probably malaria – and the treatments they received, but of the personal circumstances of the patient and the relationships between the inhabitants of this small but prosperous city-state in the Aegean Sea. In combination with archaeological findings from the site of ancient Thasos, we are even able to pinpoint the probable residences of some of the patients mentioned in the Epidemics.

In a wider sense, Philiscus’ case demonstrates the crucial role played by texts. They are our most important (and often only) source of information about medical practice, notably in terms of theory and the social history of medicine from Antiquity to the Middle Ages. Recovering and interpreting ancient and medieval medical texts is crucial for understanding how medicine was practised in the past and how it impacted on people’s lives. None of this is new or surprising. Texts have always been pivotal keys to the past. Yet before the medical historian can turn the key and open the door to a better understanding of older forms of basic healthcare, it is vital that the key first be found.

The task of recovering a text can be as complex and convoluted as writing medical history itself. Few texts are better suited to illustrate this process of discovery than one currently being edited and translated with the generous support of the Wellcome Trust: the Arabic version of Galen’s commentary on the Hippocratic Epidemics from which we have quoted Philiscus’ case history. To understand its significance, let us return to the Epidemics to retrace its fascinating history.

The Hippocratic corpus is a set of ancient Greek medical treatises written by a number of different authors and transmitted under the name ‘Hippocrates’. Together they mark, in many respects, the beginning of medical history. They remained reference texts for medical theoreticians and practising physicians for more than two millennia. One of the most important components of this corpus is the seven books of the Epidemics. These contain a broad range of disparate material, including numerous case histories, observations, medical maxims and prognostic advice.

The often very detailed case histories, some of them precise enough to identify the underlying disease, are particularly fascinating. They were without precedent at the time. In many respects they continue to represent a milestone in the transition from archaic medicine, in which illness and healing were attributed to magical or divine influences, to ‘rational’, evidence-based medicine, in which diagnosis, prognosis and therapy relied on empirically verifiable indicators. It is not a coincidence that this transition to some degree coincided with the transition from oral to written modes of recording and teaching medicine.

Physician talking to a patient with servants preparing medicaments. Persian cover of Avicenna’s Canon, 1632. Wellcome Library

Physician talking to a patient with servants preparing medicaments. Persian cover of Avicenna’s Canon, 1632. Wellcome Library

Many ancient medical authorities were drawn to this text and commented on it, and they already drew distinctions between supposedly authentic and inauthentic parts of the Epidemics. According to the celebrated Roman physician Galen (d. c.216 CE), only Books 1 and 3 were written by ‘Hippocrates’. He regarded Books 2 and 6 as compilations of authentic Hippocratic material produced by Hippocrates’ son Thessalus, and dismissed Books 4, 5 and 7 as inauthentic. Galen also wrote an extensive commentary on the books he deemed authentic. Among his many commentaries on Hippocratic writings, this is his longest and one of his most important.

It took the form of a lemmatic commentary: Galen quoted a small portion of the text (a ‘lemma’), commented on it and then proceeded to the next lemma. In this way, he incorporated almost the complete text of the Epidemics in his book. Galen’s commentary played a crucial role in the history of the Hippocratic text. It drew on numerous Hippocratic manuscripts and was informed by many of his predecessor’s writings, most of which are now lost. Essentially Galen provided readers with the context and theoretical background he thought necessary to interpret Hippocrates’ often abbreviated and obscure statements.

In his comments on the case of Philiscus, Galen explains at length that the fatal outcome was obvious early on. He then explains why in his view the patient died on the sixth day of his disease, rather than any other day, and clarified some of the terminology Hippocrates used. The theoretical context in which Galen situates Philiscus’ case was humoral medicine and the system of critical days that punctuate the course of diseases and determine their development. While these concepts do indeed appear in some Hippocratic writings, it was Galen who personally moulded the often diverging strands of medical thought represented in this and other Hippocratic texts into a consistent theoretical system. This system was to remain the almost universally accepted medical paradigm until well into the 19th century.

Thanks to its comprehensiveness and theoretical sophistication, Galen’s commentary quickly supplanted older, rival writings on the Epidemics. It also became an important vehicle for the transmission of the Hippocratic text itself. Syriac and Arabic scholars, for example, came to know the Epidemics only as part of translations of Galen’s commentary.

Today we are in the unfortunate situation that the Greek original of Galen’s commentary has not survived complete. Of the four books Galen commented on, two are extant in full (1 and 3), three-quarters of Book 6 are extant, and we only have fragments of Book 2. In addition, the reconstruction of the extant Greek text of the commentary has been complicated by the poor condition of the Greek manuscript sources. On the other hand, we have a witness for Galen’s text that has been preserved intact: a medieval Arabic translation.

The commentary was translated into Arabic in the mid-ninth century, based on a Syriac intermediate version. The translation formed part of a comprehensive effort (from the second half of the eighth century to the second half of the tenth) to make the entire Greek medical, scientific and philosophical heritage available in Arabic. The author of this particular translation was the celebrated Hunayn ibn Ishāq (d. c.870), an accomplished translator and practising physician. This text was only one of more than 100 Galenic works Hunayn translated into Arabic. It is not uncommon for an ancient Greek medical text that has been lost partially or completely to survive in an Arabic translation; this illustrates the importance of the Arabic ‘transmission channel’ for ancient medical knowledge.

Obviously, the parts of the commentary that are lost in Greek are particularly interesting, not only in themselves but also as sources for other lost ancient medical texts. For example, by discussing variant readings and quoting interpretations of the Hippocratic text from a variety of sources, Galen’s commentary preserves material from or about other ancient medical authorities that is otherwise lost. Beyond preserving lost Greek material, the importance of the Arabic tradition of this commentary also rests on the fact that it was based on Greek manuscripts several centuries older than the relatively late manuscripts available to us and to the Renaissance scholars who prepared the first printed editions of the Galenic and Hippocratic corpus. Hunayn translated Galen’s commentary on the Epidemics around the mid-ninth century from a Syriac version that was produced slightly earlier. This means that the Greek manuscripts available to the Syriac translator (which may also have been used to proof the Arabic translation) date at least to the first half of the ninth century and are therefore 300–500 years older than the Greek manuscripts of the commentary that have come down to us. The inferior quality of the Greek text preserved by these manuscripts shows how a text can suffer during such a long time: manuscripts deteriorate or become damaged; succeeding generations of copyists commit errors; some misread their sources or attempt to ‘correct’ a text; or, as happened with parts of this commentary, they were physically lost in Greek because general interest declined and texts were simply not copied any more.

In the case of the Hippocratic text embedded in the commentary, another development led to further modifications. Late medieval scribes sought to harmonise the differences between the text of the Epidemics transmitted inside the commentary and the independently transmitted Hippocratic text – but the Hippocratic lemmata preserved in the Arabic translation hand antedate this process of textual cross-contamination.

None of this would matter much if the Arabic translator had not also been a very careful philologist and an expert in Hippocratic and Galenic medicine. We know about Hunayn’s methods from his own writings, in which he described the painstaking process of collecting Greek manuscripts from all over the Middle East and then carefully collating and translating each text. The resulting translations are so close to their Greek original that they have become invaluable witnesses for modern scholarly editions of the Greek text of many Galenic works.

Besides serving as an important source for reconstructing the Greek original, these Arabic translations are also a crucial source for medical history in their own right. Embedded in Galen’s commentary and in the context of his interpretation, the Hippocratic Epidemics exerted a widespread influence on medical theory and practice in the Islamic world, especially in the nascent field of clinical medicine. Numerous Arabic medical authors discussed and quoted it; together with other texts, the commentary became the starting-point for original research in all medical fields. It became particularly prominent in contemporary medical teaching, for example in the form of abridgements and summaries in question-and-answer format, which were frequently referred to by later medical scholars. Medical practice in Islam especially profited from the Hippocratic case histories and their explanation by Galen. They inspired similar collections of medical observations by the prolific medical author and practitioner al-Rāzī (d. 925) and others. The discoverer of the pulmonary circulation of the blood, the Damascene physician Ibn al-Naf īs (d. 1288), wrote an entire commentary on the Hippocratic Epidemics, based on lemmata extracted from Galen.

The usefulness of the Arabic version of Galen’s commentary is not limited to medical history. It also promises advances in other fields, for instance the history and theory of translation. Many details of the history of the Greek–Arabic translation effort, of which this text formed only a small part, are still unknown. Unlike many other translations, this one is securely dated and, on the basis of internal and external evidence, firmly tied to Hunayn. Analysing this text, its terminology and its style will produce important results for the study of Greek–Arabic translations, the development of translation methods and the evolution of a stable Arabic medical and scientific terminology.

The philological work involved in recovering this and similar ancient and medieval texts is fascinating in itself and important for the history of medicine and science. Each text made available to historians becomes a key to not just one but many doors: medical history, social history, the history of ideas, translation, the transmission of knowledge across chronological, linguistic and cultural boundaries, and others. The Arabic medical tradition in particular promises exciting new findings: a large number of medical texts, ranging from translations of Greek material to textbooks, manuals of medical practice and treatises on a wide range of topics, remain unedited and understudied.

Other ancient and medieval medical texts may still await rediscovery: the holdings of numerous libraries in the Islamic world remain sporadically documented or entirely uncatalogued. It is tantalising to think that they may yet hold many more unique medical sources, including more translations of ancient Greek texts that have been lost in the original.

Dr Uwe Vagelpohl studied philosophy, Arabic and Islamic Studies in Bamberg, Cairo and Berlin before completing his PhD in Middle Eastern Studies at the University of Cambridge. He has held research positions at the University of California at Berkeley (2004–05) and Hampshire College (2005–08). He is currently a Wellcome Trust-funded Project Researcher at the University of Warwick, working on an edition of the Arabic version of the first two books of Galen’s commentary on Hippocrates’ Epidemics with the help of Professor Swain.

Professor Simon Swain works on the Greek culture and society of the Roman period. He has specific interest in the transformation of Greek culture in the later Roman Empire, and in the Arab legacy of Greek thought. He is currently Head of the Arts Faculty at the University of Warwick and was for many years Head of the Department of Classics and Ancient History. He welcomes enquiries from all those interested in the rediscovery of ancient medical texts (s.c.r.swain@warwick.ac.uk).

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4 Comments leave one →
  1. CLL permalink
    May 10, 2016 9:50 pm

    I cannot find the manuscript seen in the second image, “Physician talking to a patient with servants preparing medicaments. Persian cover of Avicenna’s Canon, 1632. Wellcome Library.” Any chance you could post a link to the catalogue? Thanks!

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