Transcript: 127 - Peter E Pormann on Medicine in the Islamic World

A double dose of Peters, as Pormann joins Adamson to discuss medicine and philosophy in the Islamic world.
Podcast series

Note: this transcription was produced by automatic voice recognition software. It has been corrected by hand, but may still contain errors. We are very grateful to Tim Wittenborg for his production of the automated transcripts and for the efforts of a team of volunteer listeners who corrected the texts.

PA: Perhaps we can start by talking about the sources of medicine in the Islamic world. Would it be fair to say that the situation is similar to philosophy and that the main sources are Greek? 

PP: Indeed they are, so the two big authorities, the two names that are mentioned over and over again in the Islamic tradition are on the one hand Hippocrates and on the other Galen. But then there are some lesser-known physicians such as Rufus of Ephesus who dies around the year 100 and then there is for instance Paul of Aegina, a seventh century physician who worked in Alexandria and presumably because of his name hailed from the island of Aegina which is just opposite Athens or Piraeus. But generally speaking, when it comes to the medical tradition, humoral pathology, the idea that blood, phlegm, yellow bile and black bile when in balance create health and when in imbalance create disease. This humoral pathology, this idea basically dominates the Islamic tradition. And that's a Greek idea which we first find in the treaties On the Nature of Man by Hippocrates which was then adopted so that's the fifth century BC and which was then adopted by Galen, the physician who lives roughly from 1 to 9 till 216 AD and this physician Galen wrote a commentary on it and he adopted and adapted that humoral pathology and that's the cornerstone of medicine as it developed in the Islamic world. 

PA: And I suppose that most of the medical authors who are working in Arabic are at the mercy of the translators, I mean not Hunayn ibn Ishaq who is one of the most important translators of medical works into Arabic, but most medical authors would have just had to work with the Arabic versions that were given to them by the translators. 

PP: Yeah that's correct, I mean it's not entirely correct for the ninth century so we have somebody called al-Tabari who probably knew Syriac, there's somebody called Ibn Serapion or Ibn Sarabiyun in the late ninth century who writes in Syriac and then is translated into Arabic. So some people would have had a notion or a knowledge of Syriac because they are Christians or some people would have a notion or some knowledge of Greek although for the vast majority and certainly the most important figures that is true so the people of whom we know and whom we admire, kind of the luminaries of the Arabic medical traditions, people like al-Razi, Ibn Sina, Avicenna and others, they totally relied on the translations. 

PA: And even the Arabic technical terminology that's used in medical works is to some extent based on Greek technical terminology just like in philosophy? 

PP: Yes and no, so basically there were three procedures or three ways in which the Greek vocabulary was adapted and adopted. So the first is just to translate one term with another since the concept of mixture, you know, krasis in Greek is very important so how are the four humours mixed. That's called mizaj in Arabic, that's an Arabic term, maybe has also a cognate in Syriac but I mean like it's a good Arabic word. So other terms then are translated as what we call calques or loan translations. For instance, there's a disease called alopecia, alopecia, you know the disease literally of the fox, alopex, which is basically a loss of hair which you Peter might be familiar with and now this disease alopecia is then translated into Arabic as the ath'alab, so literally the disease of the fox. So alopecia, kind of the fox disease in Greek, becomes the disease of the fox in Arabic, that's a loan translation and for this obviously the Greek word structure is important. And then sometimes we have just transliteration, take phrenitis, you know, a brain fever, a disease which is sometimes nowadays associated with meningitis, that is often just transliterated, ‘faranitis’ and that's a procedure which also occurs. But in all these three cases, whether it's just replacing a Greek word with an Arabic word or finding a loan translation or just transliterating the word, the Greek concepts are important that are behind that. 

PA: To what extent do you think we're being misled by the fact that mostly what we've got access to here is these very learned texts which are grounded in this translation movement. I mean, on the ground was a lot of the medical care that people were actually receiving, was it actually influenced by Greek medicine or is this more like a literary tradition? 

PP: Well, it is both. So on the one hand you have a massive translation movement in the ninth century about which you talked in an earlier episode and that obviously, so these translations, these texts are very important. But on the other hand, you have a tradition on the ground. So even in pre-Islamic and early Islamic poetry, you find certain Greek technical terms mentioned. Now that doesn't depend on a learned tradition, that's just because the Arabs lived in close contact with the Greeks or with the Byzantines and took certain ideas and concepts over from them. So it's not just one channel. The practice is important, and the theory is important. But what did not happen is just that the text got translated and then all of a sudden, some Arab author first reads them and then kind of applies the principles. There is a tradition, there are physicians for instance, Christian physicians who practice medicine, who draw on these texts and who are then imitated. So one thing which is very important is the curriculum at Alexandria in late antiquity that is more or less adopted wholesale in Baghdad in the ninth century. So there's on the one hand transfer of knowledge, but on the other hand then there is innovation and there are new ideas that stem from or that are built on this fundament, on this basis of Greek humoral pathology. 

PA: That's actually the next thing I was going to ask you. What sorts of innovations or discoveries were made in the Arabic medical tradition? 

PP: Well there are numerous innovations and that's first and foremost a very important point. I just like to give you a few examples from different areas. So for instance the first anatomical illustrations of the muscles of the eye which we have occur in an Arab manuscript in Hunayn Ibn Ishaq's text, the Ten Treatises on the Eye. So there you find the first illustration of, you know, like an anatomical illustration. So you know perhaps they're Greek antecedents and we don't have them, but for us as far as we know this is the first manuscript where we see it. It's by the way Cairo Tiptaimur 100. So it's nowadays kept in Cairo in the National Library there. So that's one thing, you know, illustration, anatomy. Another thing is the discovery of new diseases or the differentiation between diseases about which people did not know beforehand. So Hunayn Ibn Ishaq, that translator and physician who dies in the 870s for instance, describes in his work on eye diseases a condition called pannus nowadays, P-A-N-N-U-S, sabal in Arabic and it's basically an overgrowth over the eye and this is a condition which was not known or which we do not find in Greek sources and which for the first time is described in this text. So new diseases are discovered or al-Razi, Abu Bakr Muhammad Ibn Zakariya al-Razi who dies in 925 roughly distinguishes between smallpox and measles for the first time, a distinction not made in earlier Greek sources. So you know new diseases are described. But also new therapies are found. So obviously the Greek recipes, you know, like are very important, Galen and Dioscorides an author who lived in the first century AD. 

PA: You mean drug recipes for medicines. 

PP: Medicines, yes. So again, Dioscorides in the first century AD and Galen in the second century AD write on simple drugs, write work on simple drugs and Galen also on compound drugs. So many, many recipes, a lot of information how individual medical substances, the so-called symbols work, you know. And that is translated into, but it's not just that people just take the recipe and don't do anything with it. So the recipes are further developed. It's like a cook who can't, you know, who can't refuse the temptation to innovate when he sees a recipe. Similarly, you know, like a lot of recipes are altered and also a lot of drugs come in from the East for the first time. The last innovation which I'd like to mention is the hospital. Obviously, there were Byzantine hospitals, but when we come to the Arabic or Islamic world in the 9th and 10th century, these institutions are much more sophisticated. They have teaching, they have research, they are secure in law, they have elite medicine practice there, so the best physicians practice in hospitals and some of them at least are, you know, like not confessional, so Christian, Jews and Muslims equally practice there as physicians and come there as patients. So also on the social level there's a lot of innovation. 

PA: Right. So the next time one of us is in hospital then we should give thanks to the Arabic medical tradition. 

PP: Well, I mean, we could say that some of these innovations foreshadow modern developments, but it's always difficult, one should always resist the temptation to find the present in the past. 

PA: Well said, a nice aphorism to go along with Hippocrates' aphorisms. 

PP: [Laughter] Of course, yes.

PA: One disease you've worked on quite a bit is a disease that was recognized in the ancient tradition, but the understanding of it was developed further in the Arabic tradition and this is melancholy. Can you tell us a bit about that? Because I think it's philosophically interesting.

PP: Yes, so melancholy is a disease which has different manifestations and melancholy or the Greek word melaina chole from which melancholy is derived actually means black bile. So melancholy is the disease of the black bile and the different types of this disease and the Greek physician who's really the most influential for the subsequent tradition is Rufus of Ephesus, whom I mentioned earlier, who lived around the year 100 AD. And he wrote a treatise on melancholy and he distinguishes, for instance, between innate melancholy and acquired melancholy. Some people are just melancholic by character or by disposition, but they have too much black bile and they have certain tendencies and some people acquired. And the disease manifests in different ways. I mean nowadays when we say somebody's melancholic it just means he has the blues, so he's sad or whatever. But melancholy in those days was really a form of madness. So you have delusions. So for instance, some people thought they are made of parchment and they're so dry that if somebody touches them they're brittle. Others thought they were made of porcelain and they could be crushed and crumble. Other people thought that Atlas, who holds the world on his arms, could get tired and then the sky would fall or the world would crumble and they were afraid of that. There's a famous case of an astronomer who thought that some thought they were cocks, you know, like basically chicken and cried like chicken and flapped their wings like chicken. So some became aggressive and would attack people. Other became despondent. Many people died from this disease. So it's a huge spectrum of symptoms which come under melancholy, which is kind of madness. And it is caused by an axis of black bile and there are various ways and I won't go into all the details. But melancholy is interesting because it really poses the question ‘how does my bodily constitution influence my mental capacities?’ 

PA: Right, which is obviously a matter of great importance to philosophers as well as to doctors.

PP: Yes.

PA: And that brings us to someone you've mentioned who actually I talked about on the last episode of the podcast who is al-Razi. And he was both a doctor and a philosopher. And I would say is unusual in that we have quite a lot of medical writings of his, some philosophical writings. So along with Avicenna, he's a thinker for whom we have both sides represented. To what extent would you say that his medical output is in tension with his philosophical output? 

PP: Well, I mean, let's take for instance the topic of sexual intercourse. Obviously, we all want to stay healthy, and we all want to stay happy. Or happiness is a philosophical goal whereas health is a medical goal. In some of his philosophical works, for instance, his philosophical way of life, al-Razi advocates that sex is bad for you and under no circumstances should you engage in or seek sexual pleasure. Obviously, he stands in a long philosophical tradition. I mean even Epicureans were wary of sex. But certainly, the Stoics were and others were too. They just said, you know, like, don't seek the pleasures of the flesh because they are transient, and they might go away or they might last only for a short period of time or they might give you grief. You know, try to find pleasure in things which are longer lasting. So, this is a position which has become nearly commonplace by late antiquity and which al-Razi adopts in his philosophical works. But when it comes to medicine and he writes a number of manuals, I mean he writes two manuals on sexual intercourse, he has a more nuanced position. He says for some people sex is actually good and it can have medical benefits. For instance, in order to combat melancholy, you know, sex and entertainment and wine, drinking wine in moderation are things that are advocated in order to overcome melancholy and he recognizes that. So his philosophical position is very strict and his medical position is very nuanced. And I always thought there is this wonderful phrase where he says for some people sexual intercourse is actually beneficial. I always thought that he was thinking of himself as being in that category. But of course, I'm speculating. 

PA: I wouldn't be surprised. Another area where I think his medical output is interesting philosophically is what he has to say about methodology and in general I suppose that one of the more obvious places to look for philosophically interesting aspects of medicine in Greek, in Latin and in Arabic is when they start talking about how doctors go about discovering new remedies, identifying diseases and so on. What does al-Razi have to say about that? 

PP: A very, very interesting figure in that area. So obviously you're right in saying that nowadays we still debate how can we discover drugs. You know, now we have double-blind trials and we have a huge literature and a lot of thought is going into the question ‘how do we know that a drug works’. I mean think of the placebo effect, you know, how can we exclude that and so on and so forth. Obviously, what happens in the 9th and 10th century, what happens with al-Razi is not quite as sophisticated but there's a fundamental debate about how to arrive at the right treatment already in Greek times. Galen writes On the Sects for Beginners. Galen again in the second century AD. 

PA: These are different kind of sects. So this is S-E-C-T-S.

PP: Sects, not on sex for beginners, On the Sects for Beginners. Unless I pronounce this incorrectly. And he says that there are basically two important sects. There's a third one, the Methodist, but they don't need to concern us here. They're the empiricists who say let's do what works, you know. If we see that a drug works, we don't have to ask why or what the inner bodily functions are. It's too complicated. We will never be able to ascertain that. So let's do what works. And then the rationalists and they say okay let's think about how the body works, the humorous fonts and other things and then because we understand how the body works, we will be able to find the right treatment. Now this is a debate of which al-Razi was aware and to which he contributes. So he obviously knows about empiricists and rationalists and he, like Galen, adopts a middle ground. He says empiricism alone certainly will not help us but nor would just book learning without using other principles help us. So he occupies a middle ground like Galen. And there are things in which he's very innovative. For instance, when talking about phrenitis, brain fever, mentioned earlier when I talked about translations, when dealing with this condition he said that once he tried to bleed, to phlebotomize, to bleed one group of patients and they did not contract the disease and then he left another group of patients deliberately and did not bleed them. So we have the notion of a control group which we redefine for the first time in al-Razi. Obviously they're not randomized controlled trials as we have them nowadays but that's quite a sophisticated way of doing things. At another time he talks about statistics. He talks about large cohorts of patients. So in different ways, so to speak, he finds means to, he finds ways to refine that theory about medical epistemology which he inherits from the Greeks and that too he innovates. 

PA: One thing that makes clear these kinds of examples is that al-Razi was really a medical practitioner. He saw lots of patients. He worked in hospitals. And looking ahead to another philosopher who I haven't covered yet, I think we should discuss because he's so important in the history of Islamic medicine, is Avicenna. Some people have thought that Avicenna, unlike al-Razi, wasn't particularly involved with medical practice but really was more of a book learning figure in the history of medicine, very important as a transmitter of ideas about medicine but maybe not someone who actually had a lot of hands-on practice with patients. To what extent do you think that that is true? 

PP: Well, I mean, Avicenna Ibn Sina was first and foremost a philosopher and a great intellect. But I don't think, I don't believe in these either-or scenarios, just because he was mainly, so let's say his Canon of Medicine is mainly a book in which he condenses previous Greek and Arabic medical theory and arranges it very intelligently. So that's for me also an area of innovation, like the arrangement of knowledge by division, by the principle of division in a very interesting way. But that doesn't preclude that he had some medical experience. So there are some 30 times in his Canon where he says, you know, I tried this or I, you know, you confirmed this by experience or whatever. And there are like some stories in various sources in his biography but also in the later text talking about his life, which confirmed that he was a practicing physician. And I don't think that we have any, I mean that there's any doubt that he practiced some medicine. You know, it probably wasn't what he did most of the time, but he certainly had practical experience. Now in his autobiography, he boasts that at the age of 16 he had already mastered all of medicine and was a very easy subject and so on and so forth. That is rhetoric and that's a philosophical stance and there's external evidence which shows that he actually learned from other earlier physicians later in life. So I think, I personally think, and I have argued this in print in one of your forthcoming books that Avicenna is both a great theoretician but also has practiced medicine. There's no doubt about it. 

PA: So actually, maybe we could even say that he's sort of the reverse of al-Razi. Al-Razi is basically a doctor but also does some philosophy. Avicenna is basically a philosopher but also does some medical practice. 

PP: Well I think you say this because most of al-Razi's philosophical writings are lost. I mean it is true to a certain extent but al-Razi was labelled a zindiq, an apostate or like an unbeliever. And the later tradition wasn't very kind to his philosophical writings. So I think if we had more we would appreciate his philosophy more. But generally speaking, I think that's right. 

PA: While we're on the topic of Avicenna I wanted to come back to something you mentioned earlier which is that in this tradition it's common to think about psychological states as being somehow dependent on states of the body. And one area where this arises is that Avicenna associates various psychological faculties, things like imagination and so on, with organs of the body and in particular the brain. So could you say a little bit about that? 

PP: Well I mean Avicenna has this theory of the five inner senses. So each sense, you know, outside sense like sight to each outside faculty of sensation that corresponds in like something in the brain and it is situated in the brain. It's a difficult topic because again in his medical work, in his philosophical works he formulates that theory slightly differently. But what is clear is that he situates these faculties inside the brain and so he tries to come to some understanding of how the interface so to speak between the soul or the mental faculties and the physical faculties of sensation work. And I think that his take on this is actually quite a bit of a departure from what happened before because like the common sense for instance is already found in Aristotle but what he makes of it and the way he describes it and how he links it to the five outer senses to the five inner senses is innovative but that's probably something you know more about than I do. 

PA: And actually maybe I'll talk about it more when I get to Avicenna and I'm talking about his psychology. Before we end, I just wanted to give you a chance to say more generally where is the state of research into this whole field? I mean is it in its infancy or is there a lot still to be done researching Islamic medicine? 

PP: Well, we stand on the shoulders of giants of course so the generation of my teachers have produced wonderful and brilliant work. I mean I can mention Manfred Ullmann, Emilie Savage-Smith, Remke Kruk, and others. But in my generation, we are very few and you know like I'm in my early 40s now and there's not, well I shouldn't say this. 

PA: He looks younger. 

PP: [Laughter] But in any case there are fairly few people. I mean if you think of a major figure like Avicenna, you know his Canon of Medicine is full of interesting philosophical things. His medicine, you know like he's the most important, the most influential medical author and there are very few studies done by people who work with the Arabic sources and do something you know kind of who are trained in the history of medicine. So, the state is really on some level in its infancy and we certainly need more people to move into it. 


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