B O O K S , T E A C H I N G A N D L E A R N I N G

The Transnationalism of Nephrological Treatises during the Middle Ages

Abstract

The paper presents the history of the dissemination of knowledge aboutrenal issues during the Middle Ages based on the transfer of manuscriptsfrom the centres of knowledge of the then known world to the periphery.Starting from the Greco-Roman world it follows the transfer of manuscriptsand ideas via three main roads. Firstly, the North Road extends till theremote Ireland on the West and Russia to the East, secondly, the South Roadreaching Arabia and Central Africa and thirdly, the East Road otherwisenamed the Silk Road. Emphasis is given to the role of monks (Greek

Orthodox, Catholics, and Taoists) and the Arab intellectuals. The ways bywhich this transport materialized and the people involved (merchants,pilgrims, soldiers) is also discussed. Allowances are made for the merging ofhistorical and mythological data, all of which represent the way societythen was viewing the kidney, its role and its ailments.

Key words: Medical Manuscripts, Medieval scribes, Spoils of war,Transnationalism

Athanasios Diamandopoulos

Hon. Professor National and Capodistrian Uiniversity Athens Panhellenic Society for the History and Archaeology of Medicine

Address correspondence to: Professor A. A. Diamandopoulos; Nephrologist - Archaeologist, Louros Foundation for the History of Medicine,Semitelou str. 5, Ampelokepoi, Athens.; Tel +30 210 7757177, email (personal) 1453295@gmail.com

During the 21 years of the IAHN’s existence 311papers had been promoted by it. Analyzing itfurther, it occurred that 114 of them came fromItaly and Greece while the rest from all the othercountries [1]. Thus, it looks that from the formerGreco-Roman culture the knowledge of the Historyof Nephrology was transferred via these papers toevery end of the world. This is the modern equiv-alent of the transnationalism of manuscripts. Inorder to understand what was happening in thepast it was decided to trace back the path of man-uscripts in our field by reconstructing its history.But this method will not have well defined sharpedges because as they say in Tibet: “When I walkon snow-laden paths of hills my each footprint appearsclear, deep and distinct through which I can trace mypath back without effort. But after a while due to windand fresh snowfall all traces of my footsteps are wipedout in the snow. The logic of today recalling the eventsof past times with indecisive evidences must surely beinaccurate in many different ways.[…] The line of de-marcation between history and legend is too thin to ob-serve while writing: the two overlap each other uncon-sciously and unknowingly” [2]. Hence, this paper willbe well documented in parts and walk in a hazein others while still trying to present a coherentbriefing of the transnationalism of NephrologicalTreatises during the Middle Ages. As the beginningof wisdom is the examination of names, we startthis article by examining the historical meaning ofthe terms Middle Ages and Nation. The same in-structions to start a lecture on medical topics withthe nomenclature gave the 1st century AD Greekauthor of the treatise “Diseases of the Bladder andthe Kidneys” Rufus of Ephesus, who said:“[…] forthe smith, the cobbler, and the carpenter first learn thewords for metal, tools and such like. Why should it be anydifferent in more noble arts?” [3] [4].

The first term “Middle Ages” refers to the his-torical period that started with the Fall of Rome tothe Goths and ended with the Renaissance. It roughlycovers the time between the 5th and the 15th cent.AD. Regarding the latter termnation, we should dis-tinguish between this noun, and the concept of state.A nation was – and is - characterized by the use ofthe same language, religion and morals, while a Stateis a political construction, based on the acceptance,directly or indirectly, of a ruling class as the mainbiding force of the people. In the Middle Ages, we hadhuge states with many different nations [Byzantine,Holy German, Papal, Arabic, Mongol, and Persian]and many states within the same nation [Italian,Russian and German principalities]. Indicatively, inFigure 1 we see the changes in the political map ofEurope during the greatest part of the period underdiscussion. It is evident that huge states appearedand collapsed, while the nations remained more orless intact. Thus, when we speak about the transna-tionalism of the medical treatises we mainly, but notexclusively, mean a trans - state transport. Departingfrom the field of philology, we discuss the meansof the transport of manuscripts and the people in-volved.Contrary to what is now believed about staticpopulations in that era, people moved around a lot.The difference with today’s mass movements is thelimited number of those on the go then. Another dif-ference is the speed of transport. We seldom re-member that, until almost two centuries ago, themain mode of transport was by horse and camel viavarious roads or by ore or mast via the sea [5]. Thus,travelling was slow and consequently so was the dis-semination of medical treatises. This was not a greatobstacle, as anyway, developments in medicalscience then were very slow. Thus, a few more weeksof delay made no difference. We can classify itinerantpeople in the following groups, with considerable

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overlapping between them: a) Merchants, b) Soldiers,c) Pilgrims and Monks, d) Scholars.Classical texts, i.e. Greek treatises on medicine,reached Western Europe during the Middle-Ages byvarious tongues, mainly either directly from the Hel-lenistic world – including Byzantium –, or indirectlythrough versions of the languages of the Middle-East,especially (Syriac)-Arabic [6]. There, they were trans-lated into Latin and much later in the vulgar localdialects. All of them were based on similar medicaltraditions. These were the Hippocratic/Galenic andtheir variations as created by Avicenna, Razes, Mai-monides and others and the botanical traditionseither as descendants of Dioscurides or as local“peasant” formularies. When the political and fi-nancial conditions allowed, many scholars – andtreatises – gathered in the same place and a formof medical school was established [Constantinople,Samarkand, Salerno, Monte Casino, Bologna, Cairoetc]. Thus, the political patronage had always beenthe condition sine qua non for a great collection ofmanuscripts. Beside the genuine interest in scienceand art, the establishment used these collections asa propaganda tool. It aptly has been said the “Theculture of power found its legislation on the power ofculture” [7].

From the very beginning, medical codices weremeant to travel. Hippocrates’s and Galen’s treatiseswere transported through the then known worldsince their own age. Hippocrates was the first keen

medical traveller, reaching as far north as Scythiain the Black Sea and Egypt in the South [8]. Rufusof Ephesus was the first medical author to devote awhole book to kidney problems in the first cent.AD[9]. He was highly respected and extensively quotedby Byzantine, Arabic and Latin authors. In his de-scription of diseases of the kidneys, he makes a con-certed effort to correlate structure and function, andto provide a rational explanation of the alteredfunction of the kidneys in disease [10]. Galen movedforwards and backwards from Asia Minor to Romeand Egypt and the same is true for many celebrateddoctors in the Greco-Roman world. Their manu-scripts, exclusively or partially containing nephro-logical issues, were the basis upon which medievalauthors elaborated and extended the relatedknowledge. Theirs and other medical authors’ worksmade the transnational journey either as com-panions of travelling scholars, the so-called VadeMecum, or by being bought and exchanged fromother monasteries or collectors,, and as gifts.Dioscurides’ Materia Medica, containing, amongstelse, many pharmacological substances affectingrenal function, is a characteristic example of thelatter. The most famous copy, the Codex Vidobo-nensis. Med. Gr 1 was given as a gift to the ImperialPrincess Juliana Anicia in Constantinople in the 6th

century. Another such copy made the transnationaljourney to Cordoba as a gift from the Emperor Con-stantinos Porphyrogenetos to the Caliph Ald-Al-

Figure 1.Figure 1.Changes in the political map of Europe during the greatest part of the period V – XII Century

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Rahman III in 949 AD handed down by the monkNicolaos who later translated it [11]. The last modewas via spoils of war and looting, the most wellknown was the infamous Fall of Constantinople tothe Crusades. Actually, looting was a much morecommon practice than thought. Conquering war-lords were fond of seizing manuscripts in the Islamiccountries [12]. Even today, many valuable manu-scripts are disappearing from the great Libraries ofSyria, Iraq, Timbuktu and it is highly probable thatthese will reappear after few decades in the re-spectable libraries of Great Western Institutions, ashad happened frequently in the past [13] [14].

Four were thee routs through which medicalmanuscripts reached the outer world. The first routwas the well known Mediterranean travel. All thesehad been extensively discussed in our Associationand I will not discuss them further. Naturally, therole of the Salerno School of Medicine and of theMonte Casino friars was rightly praised as themelting pot where Greek, Jewish and Islamic med-icine merged. The contribution of the Byzantines [anunhappy and inaccurate term] has also been re-viewed in our meetings [15] [16] [17]. Instead, we willdiscuss three other less well-known routes. Those tothe South, to the North and to the East.

The North route roughly starts from the Mediter-ranean and reaches as far as Ireland on one handand the Balkan countries and those around the BlackSea on the other [Figure 2]. From the first branch,we will present only the Irish phenomenon. The Irishcontribution to medieval intellectual life has beengiven little attention. In the early and middle MiddleAges when the European mainland was a backwardsarea, Irish monks starting from their remote, poorand rocky island travelled all over Europe and theMediterranean preaching their style of Christianityand absorbing the cultures of the lands they visited.It is interesting to note the similarities between earlyIrish Christian and Byzantine art in works like themagnificent Book of Celts. Many Cathedrals and bish-oprics in Europe were founded by those itineraryIrish monks like St. Columbanus, St. Cathaldus or St.Brendan [Figure 3] [18]. Thus, the classical medicalheritage reached Ireland. Even now many relevantmanuscriptsare still stored there. 25 medievalmedical manuscripts are catalogued in the DublinTrinity College Library, the Royal Irish Academy,Dublin, In the King's Inns Library, Dublinare, mostof them copies of Greek texts [19]. Of special interestare those on urines, and on the Hippocratic Apho-risms many of the latter dealing with renal issues [20].Two fragments of medical texts dated: c.1400–1520?are written in Early Modern Irish Language, the localvernacular, in an era when Latin was the standardmedical language [21] [Figure 4]. It is intriguing to seethe names of Galen and Hippocrates written in thisforgotten language.From the countries around theBlack Sea, a brief reference will be made to Russia,Georgia and Azerbaijan. The first contact of theRussian people with Greek medicine took placethrough the religious establishments. As Christianitywas imported to the Russians via the Greek Orthodox

Patriarchate in Constantinople, it was natural formedical texts to also be imported from there andcopied in the local monasteries. These manuscriptsincluded works of Classical Antiquity like Hip-pocrates’ Galen’s and Rufus’ and purely Byzantineworks such as Joannes Zacharias Actuarius’ andTheophilos Protospatharios’ On Urines. The formerhad even dedicated his treatise “De methodome-dendi” to the Grand Duke Ioannis Apocaucos whenthe latter started for his campaign in South Russia.In the 11th and 12th centuries, the first translations ofmedical works from Greek to Russian were written byGreek monks [22]. In Georgian medical manuscripts,dating to the VI century, the description of diseases,treatment methods and tools are mostly in line withthe structure and conceptual basis described in Greco- Roman and Arabic sources of the relevant period.The aforementioned refers also to nephrologic [uro-logic] diseases that are mostly described in theGeorgian Karabadins of medieval - XIII-XV centuries,Certainly, a conceptual basis is the Theory of Hu-moral Pathology [23]. During the Middle Ages, uro-logical diseases in Azerbaijan were treated with themethods of Islamic or Greco-Arab medicine. The richheritage of this medical school is reflected in themanuscripts of the 11th-18th centuries that are pre-served in the Institute of Manuscripts of the Azer-baijan National Academy of Science. More than11,000 of them are ancient manuscripts works. Thesetexts tell us about thoughts of people in the MiddleAges on medicine, astronomy, mathematics, poetry,philosophy, law, history and geography [24]. FromSerbia in the Balkans it is known that the first totranslate medical treatises from Greek to OldSlavonian was the monk – and later Saint – Naoumof Ochid who died in 910 AD [25]. Gordana SubaricGeorgevna has published the famous ChilandariMedical Manuscript. This is a collection of medicaltexts, written in Old Serbian Church Slavonic, dis-covered in 1952 in the Library of the ChilandariMonastery in Mount Athos, Greece. Presumably,these were translated from the Greek originals. Thesection on Uroscopy is considered to have beenwritten in the 13th or 14th century, although there aresome doubts about it, and consists of 35 text pagesdivided into 62 paragraphs. In the Chilandar MedicalCodex, there are about one hundred descriptions ofkidney and urinary tract diseases and disorders.Many symptoms and syndromes such as hematuria,dysuria, pyuria, renal colic, anuria, polyuria, edemaand dropsy, urine retention and fever, are incorpo-rated in the broader clinical pictures of lithiasis ofthe kidney and/or bladder, pyelonephritis, cystitis,necrotic renal disease indicative of renal tuberculosisand tumors, acute and chronic nephritis, renalfailure, and gout. Specific pharmacological prescrip-tions, mostly simple or compound herbal medicines,are given for eachof those renal ailments [26].The South Route includes the Arabic Peninsula andextends to the heart of Africa.Although the Arab’scontribution to the transnationalism of classical andmedieval medical manuscripts with nephrologicalinterest is invaluable, for brevity and for reasons ex-

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plained at the beginning of this paper will beomitted. Instead, the focus will be on the rather ne-glected contribution of Syrian doctors and trans-lators, on the St. Catherine Monastery at Sina, andon the surprisingly rich heritage of medieval medicalmanuscripts in Timbuktu, Mali. Syrians, those MiddleEastern Christians, constituted in the immediatelypre-Islamic period the majority of the populations of

Figure 2.Figure 2.The two branches of the North Rout joining the Mediterranean with a)Ireland and b) the Balkans and Russia?Source: BBC – Primary History-Vikings, Trade and exploration

Figure 3.Figure 3.St. Brendan crossing the Sea. German manuscript of St. Brendon andhis monks on the whale, c 1460 CE.

Figure 4.Figure 4.Fragment from a XV cent. Medical Text in Early Modern Irish tongue.Notice the names of Galen and Hippocrates in Medieval Irish

Syria, Palestine and Iraq, with substantial numbersalso in Iran, Arabia and the Gulf, as well as Indiaand China. The majority of these Christians [thoseoutside Egypt] read their Bible and conducted theirworship of God in the language called Syriac, whichis a dialect of Aramaic [which itself goes back to thesecond millennium BC]. Therefore, Middle EasternChristians came to be at home in two cultures, theirown, native and very ancient culture [with its rootsin ancient Mesopotamia and the world of the Bible]and that of the intellectual tradition of the Greeks.There is one person, above all, who embodies thisNestorian Christian involvement in the transmissionthrough translation of Greek science. This is Hu-naynibn Ishaq [809-73], who with his family and as-sociates did more than anyone else in this field. Hetranslated almost 130 medical treatises from Greekinto Syriac and from Syriac into Arabic. One of thembeing Rufus of Ephesus [Thus spreading his treatise“On Bladder and Kidney Diseases” into the Arabicmedical literature [27]. The next entity about a manu-script at the Sina monastery is very interesting to theauthor. During restoration works in this 15 centuriesold fortified building in May 1975 a hidden suite ofrooms was discovered in the North-Western section,containing a large number of parchment codices andfragments. In the collection of Slavonic manuscriptsthere were several written in the Glagolitic language.This is the oldest written Slavonic language, almostone century before the Old Slavonic Church of theChilandari Medical Manuscript. One of them was the11th century religious text called Psalterium Demetrii[Sin. slav. 3/N]. For no apparent reason, there wereinserted 3 double ff. parchment, with 22 recipes ofpractical medicine, without end [28]. The only ref-erences in the international literature about theircontent describe some treatments for cancer andnothing else. On a first reading of their Germantranslation, we traced several passages with renal in-terest. Soon we will start in-depth research on thesubject. It is stimulating to think about itinerary Slavclerics of the 11th century reaching Sina and carryingamongst their Prayers’ Books medical recipes forkidney problems. This is transnationalism at its best!

Going even farther South, we reach the Eastern -Central African State of Mali and its ancient city Tim-buktu.The literary heritage of Timbuktu dates backto the 15th and 16th centuries, when the gold-richkingdoms of Mali and Songhai traded across theSahara with the Mediterranean world. It took twomonths for merchant caravans to cross the desert,and while gold and slaves went north, books wentsouth [14] [29]. The scholarship focused on Islam butalso encompassed mathematics, astronomy, law, ge-ography, botany, medicine, and music. Plato, Aris-totle, Ptolemy, and Hippocrates were studied inArabic translations. This golden age ended brutallyin 1591 with the invasion of a mercenary army sentby the Sultan of Morocco. Their muskets shreddedTimbuktu’s defenders and the town’s libraries wereplundered. In fact, the conquered inhabitants savedmany manuscripts, hidden in villages, desert camps,and houses on dusty side-streets in TimbuktuIn the

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1970s, scholars began trying to find and preservethese precious relics before they were destroyedby—bugs, mould, neglect, time. The result was a floodof recovered manuscripts—according to the FordFoundation, more than 700,000 of them, several onMedicine. However, there are sad reports that therecent rebels in Mali destroyed many of these manu-scripts [30].

And now on the last branch of the journey, theEastern Road. Since the 19th cent. it has been calledthe Silk Road, although in reality it comprised threeroads [Figure 5]. We will omit again the repeatedlypresented transfer of medical knowledge from theEastern Mediterranean and Arabic areas [mainlySyria] into Persia and India. I will focus on a tiny spotof China, the Magao Caves in the Dunhuang regionvery similar to the monastic caves of Cappadokia[Figure 6]. Similarly to the uncover of manuscriptsfrom a sealed monk’s cell in the Sina Monastery, in1900 the Taoist monk Wang Yuanlu [Figure 7] acci-dently demolished a wall in a small cell which wassealed in 1035 bringing to light a huge collection ofearly medieval manuscripts dating from the 5th toearly 11th centuries [31]. In between the several re-ligious texts were scattered medical treatises. Dun-huang was a hive of activity where everything —from the works of famous Chinese medical authors toanonymous Tibetan collections of recipes for conta-gious illnesses — were copied, translated into manylanguages and taken away for the peoples of the SilkRoad by itinerary Buddist Monks. In Chinese med-icine, the internal organs in a human body can beclassified into five viscera organs [Wu Zang] in-cluding the kidneys and six bowel organs [Liu Fu][32].Οne common mode of treatment for them wasmoxibustion [Figure 8] [33]Approaching the end of this paper, two fables and anenigma will be discussed. There is a recurrent storyabout three wise men who, coming from farawaycountries, bring with them precious old manuscriptsfrom their homelands settle themselves to a par-ticular place, translate the manuscripts, thus startinga medical tradition there. The most well known suchtale concerns the establishment of the SalernoSchool. There, a Greek, an Arab and a Jew transferred

Figure 5.Figure 5.Silk Road (s)

medical manuscripts and initiated the Medicalstudies in South Italy and thence to the Latin West.A similar story is told about the origins of medicinein the other end of the world, Tibet. There, in the7th century three doctors were invited from India –Bharadvāja, from China – Hen-weng-hang-de andfrom Khrom of Stag-gzigs, Galenos [imagine! The1st/2nd cent. AD Greek doctor to supposedly to visit

Figure 6.Figure 6.Magao Caves in the Dunhuang region very similar to the monasticcaves of Cappadokia

Figure 7.Figure 7.Wang Yuanlu (c.a. 1849 - 1931) was a Taoist priest and abbot of theMogao

Figure 8.Figure 8.Moxibustion illustration form the Duahuang medical mauscripts,special plants to burn over the kidneys to treat ailments. ?Source: IDPEDUCATION

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References

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[2] Samdhong Rinpoche [Lobsang Tenzin] (1997). Forward. In: DebiprasadChattopadhyaya (ed) Tāranātha’s History of Buddhism in India, MotilalBanarsidass, Delhi, p. xi,

[3] Daremberg C and. Ruelle C.E. (1963) Oeuvres de Rufus d'Éphèse, A.M.Hakert (pbl), Amsterdam, p.133

[4] Bujalkova M Rufus of Ephesus and his contribution to the developmentof anatomical nomenclature. Acta medico-historica adriatica : AMHA2011;9(1):89-100

[5] Transnationalism in Ancient and Medieval Societies: The Role of Cross-Border Trade and Travel. (Kindle Edition), McFarland (pbl), Jefferson, NC

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[7] Weis M.A. (1992) Classics in Russia 1770-1855 Between the twoBronze horsemen. In: Vanderjagt A.J. (edt), Brill’s. Studies in IntellectualHistory, Vol. 33, Leiden, p. 68)

[8] Diamandopoulos A (2009) Hippocrates’ memories of Scythia: Storiesand fairytales. Bulletin of the Transilvania University of Brazov, • Vol. 6 (51)– 2009, Series 6: Medical Sciences Supplement – Proceeding of The IVthBalkan Congress of History of Medicine

[9] Edelstein L., and Nutton V. (2003) Rufus of Ephesus. In: Hornblower,Simon, and Anthony Spawforth (ed)The Oxford Classical Dictionary, OxfordUniversity Press

Tibet 5 centuries later] [34]. Although these storiesare imaginary in their details, still they representthe stored in the common memory the fact of thetransnational journey of medical treatises in MiddleAges. Relevant to our topic is the finding that onlyin Medieval Tibetan medical literature, mainly in thetreatise Lunar King, uroscopy play a central role incontrast with what was happening in neighbouringIndia and China. This is due to the absorption thereof the Greek, Arabic and Persian medical treatises,which were translated in Tibet [35] [36]. The secondsuch fable concerns a poisonous girl who wasbrought up consuming larger and larger quantitiesof poison, became immune but her biological fluids,being them perspiration, saliva, urine or vaginal ex-cretions killed anyone who came in contact withthem. Thus, she was used as a lethal gift to be sentto anyone’s illustrious adversary, to make love withhim and lead him to his death. In the Arabic lore, theauthor of this story was Rufus of Ephesus, the com-poser of the treatise “On the Diseases of the Kidneys”[37]. This was a false attribution but it shows the highregard Arabs had about Rufus and his works thatreach them by translations.

The enigma is about the Voynich manuscript.This is an illustrated codex hand-written in an un-known writing system. The vellum on which it iswritten has been carbon-dated to the early 15th

century [1404–1438], and may have been composedin Northern Italy during the Italian Renaissance. Themanuscript is named after Wilfrid Voynich, a Polishbook dealer who purchased it in 1912. Some of thepages are missing, but about 240 remain. The text iswritten from left to right, and most of the pages haveillustrations or diagrams. The Voynich manuscripthas been studied by many professional and amateurcryptographers, including American and British codebreakers from both World War I and World War II. Noone has yet succeeded in deciphering the text, andit has become a famous case in the history of cryp-tography. An intriguing feature of the book is the

abundance of illustrations showing water-pools con-nected with canals and several nymphs swimminginside them. There is a speculation that the wholemanuscript is a hidden medical treatise and it hadbeen even suggested that one of the illustrations ina cryptographic reference to the renal anatomy[Figure 9] [38].Before concluding, it is proper to pay tribute to allthose medieval monks [Greek Orthodox, ItalianFriars, Irish pilgrims, Buddhist hermits] wholaboured for years on end copying and illustrating allthose manuscripts we admire today by hand. Theywere heroes. But even heroes sometimes despair andcry out. And Lewis Lapham has collected some rel-evant marginalia in medieval manuscripts:

“New parchment, bad ink; I say nothing more - I amvery cold - That is a hard page and a weary work to read it -Let the reader’s voice honor the writer’s pen - This page hasnot been written very slowly - The parchment is hairy - Theink is thin - Now, I’ve written the whole thing: for Christ’ssake give me a drink” [39].

Figure 9.Figure 9.The two pools on fol. 78r of the XV century. Voynich Manuscript maybe meant to represent the kidneys.? Source: Ellie Velinska: TheVoynich Manuscript - Anatomy

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[15] Fourtunas C Perceptions of gout (podagra) during the Byzantine era,with a special focus on a poem by Michael Psellus. Journal of nephrology2013 Dec 23;26(Suppl. 22):110-112

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[26] Gorgieva GS Kidney disease in medieval Serbian manuscripts from theChilandar monastery (Mount Athos, Greece). Journal of nephrology 2006May-Jun;19 Suppl 10:S30-7

[27] Healey J.F (2007) The Syriac-speaking Christians and the Translationof Greek Science into Arabic. (www.muslimheritage.com Accessed:2007-04-02)

[28] Miklas H (2007) Slovo-ASO Project: St. Catherine's Monastery onMount Sinai. (slovo-aso.cl.bas.bg)

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[35] Yoeli-Tlalim R. (2010) On urine analysis and Tibetan medicine’sconnections with the west. in Sienna Craig, Mingi Cuomu, Frances Garrettand Mona Schrempf (eds), Studies of Medical Pluralism in Tibetan Historyand Society, Andiast: International Institute for Tibetan and BuddhistStudies pp 195–211

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