Ancient doctors’ literacies and the digital edition of papyri of medical content

In her seminal article about “Doctors’ literacy and papyri of medical content” (2010), Ann E. Hanson showed how the multifarious evidence provided by the Greek papyri from Egypt bears witness to a widespread medical literacy in the Graeco-Roman world.* This term—“medical literacy”—is used to encompass a wide range of personalities, comprising both specialized physicians and learned laymen with specific interests in medicine and related topics, and points to the ability of reading, understanding and producing a written text dealing with medical subjects. In this contribution, I wish to develop her overview, showing that ancient medical writings on papyrus are in fact characterized by multiple ‘literacies’ that can be better understood through the categories of transtextuality and better represented (and studied) in their complexity with the digital infrastructure of multitext.

First of all, we can highlight at least three categories of’ ‘authors’ of medicine-related texts, that is possessing a certain degree of ‘medical literacy’: (a) academically trained physicians, endowed with wide cultural horizons and authors of the main reference works in medical literature (Galen above all, then e.g. the leaders of the ancient medical schools, authors of treatises on their own); (b) practicing physicians, educated both from the formers’ treatises (and the derived handbooks) and from their own experience. They do not author literary works but nonetheless often prove very skilful and well-trained, such as the two doctors of P.Mert. I 12 (AD 58, August 29th), who maintain a written correspondence discussing pharmacological issues, [1] and the Egyptian iatroklystes of P.Lond. I 43 = UPZ I 148 (II century BC), who “employed in his practice a Greek interpreter, a man familiar with the Egyptian script, presumably to communicate with indigenous assistants and Greek-speaking patients alike” [2] (c) learned laymen, not scholarly trained but possessing some degree of medical knowledge, such as the Psenpaapis of O.Claud. II 220 (ca. AD 137–145), who asks his brother Gemellus to go to the doctor to get some saffron and to send it to him, because he did not receive the medicinal kollyria. [3] It seems apparent that Psenpaapis—clearly an Egyptian character—is willing to reproduce the eye-salve by himself. [4]

This overall scenery of medical literacy can be further declined from the broader sociological point of view, where the (plural) concept of ‘literacies’ has been recently developed to refer to “text-oriented events embedded in particular sociocultural contexts,” [5] stressing for example the use of reading/writing abilities, as well as communication strategies. This fits particularly well the situation of ‘medical literacy’, since the relevant papyrological sources—of the most diverse typologies and formats, spreading from literary treatises to practical handbooks, from didactic manuals to collections of recipes, from official reports to private letters mentioning medical topics, chronologically ranging from the III century BC to the VII AD [6] —show a complex degree of textuality that can be described through the concept of transtextuality as investigated by Gérard Genette since the Eighties. Transtextuality defines all the various possible relationships among texts (“all that sets the text in relationship, whether obvious or concealed, with other texts” [7] ) and encompasses five subcategories that are sketched as follows: [8]

• Intertextuality is the relation between parallel text, in the form e.g. of quotation or allusion.
• Paratextuality is the relation between one text and what surrounds the main body of the text (e.g. titles, headings, and—we may add—graphical devices).
• Metatextuality is the explicit or implicit critical commentary of one text on another text.
• Hypotextuality/hypertextuality is the relation between a text and a preceding hypotext that is transformed, modified, elaborated or extended.
• Architextuality is the designation of a text as a part of a genre or genres.

Focusing now on the cultural products of ancient ‘medical literacy’, while bearing in mind the preceding scheme, we can outline the following main stages of use of reading/writing abilities and communications strategies, i.e. what is sociologically defined as ‘literacies’:

• Written scholarship, producing ‘literary’ treatises. The importance of the written text for ancient medical knowledge is stressed as earlier as in the Hippocratic corpus: “I consider the ability to evaluate correctly what has been written as an important part of the art,” says the author of the Epidemics, stressing however its instrumentality: “He who has knowledge of it and knows how to use it will not commit, in my opinion, serious errors in the professional practice” (Epid. III 16 K. = III 10, 7 ff. L.). [9] Papyrus witnesses of written treatises spread throughout the Hellenistic and Roman times, attesting to both known and unknown ancient medical scholarship. [10]
• Written teaching, performed by compilers producing manuals and handbooks, borrowing from elaborate treatises or other technical books (see below) and influencing, in turn, the following literature. [11]
• Oral teaching, producing hypomnemata (notes) later expanded in book format. In the introduction to the treatise On his own books, Galen himself explains how in the context of the oral lesson one used to take written notes, thence moving to the publication of memoranda that would become the hypomnemata of the lessons heard. [12] Orality also influenced the proper treatises. [13]
• Personal practice, producing annotations of various types. For instance Iatrika grammateia, “medical writings” on tablets (pinakia), [14] refer to the use of writing down the doctors’ personal annotations or clinical files in order to keep medical archives. [15] Some Hippocratic treatises (e.g. the Epidemics) exhibit a listthirddt fig1 here]]earbook 1989–s@mparison here?vious chapters do not. Remove?like format, in a raw syntax, being proper catalogues of diseases, symptoms, therapies, sometimes prognostics and aetiology, apparently derived from the physicians’ personal experience (i.e. from the clinical tablets or similar annotations) and serving as helpful guidelines for the future too. [16] The doctors’ personal practice was also at the origin of integrations and additions to existing treatises [17] and to pharmacological texts (see below and Bonati 2016, 65–66 for the latter instance).
• Textual transmission (the actual copying of physical books), producing interferences and variants. The ancient practice of collating several copies (antigrapha) of medical texts is attested above all by Galen, who noted several degrees of manuscript divergences, ranging from small linguistic variations to major discrepancies in the content, e.g. in the ingredients and quantities, [18] but we know of other cases in which the ancient readers produced “personal” copies that became, by means of reformulations and abbreviations, new recensions of the same text. [19] The fragmentary state of the papyri containing medical texts is an exacerbated form of interference where physical damages and linguistic variations condition the state of the original text. [20]

Each one of the abovementioned stages is deeply interrelated with the others. One main transtextual connection is given by intertextuality, i.e. direct or indirect quotations: for example, most of the late antique medical literature is represented by compediasts (Oribasius, Aetius, Paulus of Aegina) who took and interwove excerpts from the earlier authors in order to create composite texts, with the purpose of assembling the best from previous writings. [21] Yet there are paratextual, metatextual, and hypotextual devices that characterise ancient medical writings as technical texts in flux and that clarify the concept of “ancient medical literacies.” The older treatises are annotated, commented, collated often against annotated and commented copies, [22] transcribed with additions, corrections, and updates; the collections of personal notes on clinical cases, therapies or remedies are constantly revised on the ground of practice; prescriptions are transcribed, gathered in the receptaria and passed down; handbooks of different typologies are used to teach again, and so on, keeping written trace of every stage of transmission and use, even of the oral one. Moreover, each transtextual link is deeply rooted in the very meaning of the text itself, which means that the medical texts cannot be understood and appreciated without considering this complex network of connections. [23] Let us take Ann Hanson’s specimina (being both as widespread and basic as technical enough to be perfectly representatives of the ancient ‘medical literacies’) and try to consider them from the perspective of Genette’s textual theory.

The first medical text type on papyrus that Ann Hanson deal with is the questionnaire or catechism (erotapokrisis), a sort of technical school-text or reference handbook providing medical notions in a dialogue format, where a question about theoretical definitions or practical procedures is followed by a more or less detailed answer. [24] Such a format is clearly derived from and devoted to some sort of oral teaching, and this explains why the scribes took care of highlighting the articulation of the text by means of a wide set of paratextual devices affecting the overall layout: the questions are very often indented in eisthesis, and further marked with paragraphoi, line fillers or some other lectional marks that introduce the answers as well. In this way, the orality of the discipline was wisely adapted to the written medium. [25] Yet there exists a considerable similarity with the literary genre of the “definitions,” connected with the research and teaching practice of Hellenic medicine and attested in the Greek Pseudo-Galenian treatise Horoi or Definitiones Medicae (XIX 346–462 Kühn) and in the Latin Pseudo-Soranian Quaestiones medicinales. [26] In fact, David Leith has recently distinguished two types of question-and-answer medical texts: the proper catechisms, being introductory manuals for the student of medicine, and wider treatises on remedies. [27] The suggestion comes from the similarities detected between erotapokriseis on papyrus like P.Turner 14 and PSI inv.3783 and the excerpts from the physicians Herodotus and Antyllus to be found in Oribasius’ Collectiones Medicae [28] (but one may recall the similarities between the surgical catechism P.Gen. inv.111 and the treatise known as Cirurgia Heliodori [29] as well). These are architextual, intertextual and hypotextual relations that contribute to shape the essence of the texts, and derive from the complex set of “literacies” possessed by their ancient compilers.

The second case presented by Ann Hanson is that of pharmacological and therapeutic recipes. [30] The oral origins of medical prescriptions are clear from their strong formulaic structure [31] as well as from their first transcription on supports traditionally connected to the temporary writing of oral discourses, tablets and papyrus/parchment slips. [32] The progressive integration of these medical ‘fragments’ [33] into proper books goes together with interesting transtextual issues. In his pharmacological treatise De compositione medicamentorum secundum locos 1,1 (XII 422,13–426,8 K.), Galen reports that a recipe he just copied into his own book was discovered by a friend a colleague of his, Claudianus, in a leather notebook once belonging to another doctor, now deceased: the learned author does not rely only on his own knowledge, but integrates it with references and additions, and promises updates. [34] The notebook discovered by Claudianus is apparently one of the first stages of written transcription of the oral prescriptions: it recalls some significant papyrological examples, such as PSI VI 718 (fourth century AD), a parchment sheet containing part of a list of recipes, the original ‘fragmentarity’ of which is preserved and even stressed by the paratextual use of lectional marks—paragraphoi, coronides, line fillers that keep the prescriptions separated from each other, as autonomous textual units. A more complex case is provided by the so-called Michigan Medical Codex (P.Mich. XVII 758, fourth century AD), a receptarium commissioned by a practicing physician. [35]

Intertextuality, hypotextuality and similar connections merge together, creating a very complex and unique clockwork: “although individual recipes in a collection on papyrus often resemble items in the known authors, each extensive collection on papyrus has thus far proved to be a unique assemblage.” [37] The paratextual function of critical and lectional marks stresses the “composite” structure of the text, acting as a bridge between its oral roots and its later outcomes. [38]

The inadequacy of the traditional philological/stemmatological model to represent in full the textual features of these complex and fluid technical writings has already been pointed out by Ann Hanson herself in an earlier work. [39] This corresponds to the inadequacy of the traditional ‘literacy’ model to describe and understand the textual facts. The “accretive model of composition,” advanced by her to provide a suitable description of the phenomenon, seems to me perfectly pertinent to the plurality or network of ‘literacies’ revealed by the texts in question, mostly dependent on the original oral aspect of the discipline and on the primary role of actual practice.

The new digital tools allow us to reconsider this point of view and to develop new infrastructures in order to enhance the digital edition of such complex ancient sources, so that the final product is not a fixed philological layout simply reproducing the paper editions, but something closer to the original sense of the text and to its network of literacies. The current database of papyrological texts (Papyrological Navigator: http://papyri.info) is devoted to documentary papyri and, though being an advanced collection of hypertexts integrated with catalogues of metadata, is basically a digital avatar of a philological paper edition. Not by chance the sophisticated markup language that is used to encode the papyrus texts has been named Leiden+, an evolved version of the Leiden system of philological critical signs. Though it overlays an advanced XML semantic annotation layer, its syntax is deeply indebted to the papyrological print conventions and the platform is designed to display it in an output that resembles very much a paper edition. [40] The new and ongoing project Digital Corpus of Literary Papyri (DCLP), held at the University of Heidelberg and aimed at collecting the digital texts of the literary and paraliterary papyri, [41] is based on the same mechanics, but the more articulated needs of literary texts urged to consider several enhancements to the Leiden+ syntax and to the underlying XML scheme. [42] The project Corpus of the Greek Medical Papyri Online, held at the University of Parma under the direction of Prof. Isabella Andorlini with the purpose of creating a digital databank of the Greek medical papyri, [43] has been among the first partners of the DCLP in providing texts and suggesting technical improvements from the point of view of technical ‘paraliterary’ texts. The attention, for the moment, has been focused on the paratextual apparatus (critical and diacritical signs, layout features and the like [44] ), but it is clear that also the intertextual and the other transtextual correlations must be taken into consideration in order to give a full digital representation of our texts and of their network of literacies. [45]

It is in particular in the concept of multitext that—in my opinion—we can find the most suitable architecture for representing complex and fluid textual products stemming from the horizon of the multiple ‘literacies’ that have been sketched so far. A multitext model has already been employed with success for the case of Homeric oral poetry, [46] and is particularly suitable for fluid, multiform text traditions hardly containable in rigid definitions and fixed schemes. A multitext is basically a dynamic collection of multiple critical editions, a network of versions with a single root. As Monica Berti described it,

Archaic epic is of course an extreme case. In Albert Lord’s words,

Mutatis mutandis, these considerations apply to ancient medicine, an oral knowledge intertwined with practical know-how and with a deep and complex relationship with writing, and even more to ancient medical texts preserved on papyrus, which attest to a much wider variety of technical, specialised writings. A multitext model, after all, is being successfully applied to different textual traditions than the mere Homeric poetry: namely, the fragments of the ancient historians. [49] Given the fragmentation of ancient medical writings on papyrus, [50] this is an interesting and suitable precedent. According to Monica Berti,

This paradigm can be easily exported to the case of Greek medical papyri, [52] provided that most of the infrastructures (markup, metadata) are already available through the existing and the forthcoming papyrological platforms.

Creating a multitext edition of Greek medical papyri means to give a digital representation of both the paratextual and the other transtextual connections that make up the network of ancient medical literacies as described above, translating them into a new network of “digital literacies,” meaning the capability to handle multiple textual and cultural traditions at the same time. Of course, it is not possible to leave digital multitext editions of the literary manuscript tradition out of consideration, because of the thick intertextual links between the technical writings preserved on papyrus and the literary treatises, but also because of the interesting philological variants that appear in the papyrological sources. One meaningful example will suffice. P.Tebt. II 272 verso (late second century AD) is a fragment of Herodotus Medicus’ De Remediis, describing the symptomatology of thirst and its treatment. [53] The text corresponds in part to an excerpt preserved with Oribasius (Coll. med. V 30,6—7 Raeder = CMG VI 1,1). At line 5, where the text reads αἰτίαι τῆς προσφορᾶς introducing the different reasons for giving the sick something to drink, the scribe added two groups of three letters between dots above the line : *τῶν* above τῆς, and *ρῶν* (i.e. προσφορῶν) above ρᾶς. This is not a supralinear addition, since it cleary stands for a morphological variant of the syntagm below (plural instead of singular), and it is not clear whether it is a correction [54] or the juxtaposition of two different versions of the same passage. [55] The papyrological variant is unattested in the manuscript tradition, i.e. in Oribasius’ passages quoting Herodotus Medicus, which all have the singular form: this makes our source extraordinarily interesting also as regards the evaluation of ancient medical “literacies,” and deserves a suitable digital treatment. [56]

A multitext edition envisaging multiple textual layers seems also to be the best way to represent linguistic variation in the fluid medical written tradition. [57] This has an outcome in terms of representation of “literacies” too, as the following, last example can show. P.Oslo inv. 1576, a fragment of a catechism dealing with tumour-like diseases, [58] partly overlaps with P.Oxy. LXXX 5239 (both date back to the second–third century AD). The latter is more likely a “treatise” than a questionnaire, as its editor David Leith notes (see above for this distinction), and the difference may be perceived from the lack of eistheseis in its questions. The scarceness of the surviving portions of text makes it hard to say whether the questionnaire derives from the treatise or they are two different outcomes of a same ascendant. As far as the extant parallel text is concerned, the wordings diverge from each other only for one variant: ὑδροκήλη (P.Oslo, l. 5) / [ὑ]γ̣ροκήλη (P.Oxy., l. 15). The latter is usually considered as a minority variant (LSJ, quoting Poll. IV 203) of the former (used e.g. by Ps.Gal. Def.med. 424 = XIX 447,12–13 K.), but it is attested three times among the medical writers (Orib. Syn.Eust. III 28, 6 and 9 = CMG VI 3, p. 75, 15–16 and 21 Raeder; Steph. In Hipp. Progn. Comm. II 1 = CMG XI 1,2, p. 140,25 Duffy). Are we facing a trivialization in the Oslo papyrus, or a phonetic variant in the Oxy papyrus, or just two different traditions bearing the same degree of ‘correctness’, attesting to a fluid notion of ‘literacies’? Moreover, in the following line of the Oslo papyrus (no more paralleled by its P.Oxy. counterpart) we read ἐρυτρ[οειδῆ, which looks like a phonetic variant of ἐλυτροειδήϲ “lid-like,” “cover-like” (attribute of one of the membranes enveloping the scrotum). Rho for lambda is indeed a very frequent phonetic exchange in the language of the Greek papyri, [59] but the same variation is to be found among the manuscripts preserving Ps.Galen’s Introductio seu Medicus, containing a descriptive passage (XIV 719,5–10 K.) of the same anatomical part. [60] Once more time, the impression is that we are facing a peculiar intersection of multiple “literacies” that can find a proper representation through a multitext digital model only.

The following picture resumes the preceding observations by applying a multitextual ontology to a textual fragment of the abovementioned Michigan Medical Codex. The witness is unique, but the transtextual relationships create a multitextual network that clearly goes beyond the mere fixation of a canonical archetype and does justice to a complex and fluid interconnection of multiple literacies. [61] In details, what the image depicts is a tentative ontology of a fragmentary page of the codex (boxes and circles represent layers, arrows show the connections between layers). In the middle of the box stands the text as it is on the papyrus came down to us (“hypotext”), including lacunas (square brackets) and unresolved abbreviations (l. 2). This text is linked, with reciprocal relations, to the reconstruction of the same passage as originally intended by the scribe (“hypertext,” in the top box). This is of course the product of an ecdotic process: indeed there is an editorial alternative as to the supplement at l. 3, which is rendered as a connected (“parallel”) layer rather than in the apparatus. The same strategy is deployed in the case of abbreviations (the resolved word is in a parallel layer) and—most importantly—of linguistic variation (κέ for καί, l. 5). In this way, the “variant” and the “standard” forms are encoded and displayed at the same textual level, not in an artificial hierarchy dictated by the apparatus. A phonetic variant corrected by the ancient scribe (χιμέθλαϲ → χιμέτλαϲ, l. 5) is annotated in a different but analogous way, so that both words are encoded properly and fully searchable. The right-hand box represents the marginal notes added by the owner of the codex (metatext), with abbreviated indications resolved as above and another modern editorial alternative affecting the interpretation of the first abbreviation. The bottom box contains the owner’s personal addition into the lower margin of the page (metatext again): an entire new prescription, separated from the previous one by means of a horizontal rule (paragraphos), encoded as such in a paratext layer. [62] This added recipe finds a strict parallel in pharmacological literature (Paul of Aegina), which is appropriately recalled in an intertext layer to the right. [63]

To conclude, the new possibilities offered by the digital infrastructures can pave the way to the creation, as wished by Gregory Crane, of a larger and well-defined corpus of texts, [64] where the multitext architecture can help giving ancient medical sources back their deep link with ancient medical literacies through new, modern digital literacies.