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On the Meaning of Birsām and Sirsām

A Survey of the Arabic Commentaries on the Hippocratic Aphorisms
Nicola Carpentieri
p. 81-92


Cet article est une étude préliminaire de l’utilisation des termes birsām et sirsām dans les commentaires arabes sur les Aphorismes d’Hippocrate. Certaines études précédentes ont affirmé que les œuvres de la médecine arabe ont utilisé les deux termes de façon interchangeable ou sans la clarification nécessaire. Nous pouvons à présent affirmer que ce n’est pas le cas dans les commentaires arabes sur les Aphorismes, où les deux termes reçoivent une définition précise, selon la partie du corps souffrant de maladie. Ces définitions connaissent de légères variations, qui s’amplifient avec le temps. Je propose ici une périodisation pour l’utilisation de ces deux termes dans les commentaires arabes, périodisation qui reflète ces évolutions sémantiques.

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  • 1 Ullmann, Islamic Medicine, p. 29
  • 2 Ibid.
  • 3 Dols, Majnūn, p. 57
  • 4 Pormann, Theory and Practice in the Early Hospitals, p. 217

1In his 1978 Islamic Medicine, Manfred Ullmann underscored the “serious terminological confusion”1 about Arabic translations of the Greek term φρενίτις. The disease known in Hippocratic medicine as phrenitis, says Ullmann, was translated by Arabic authors into either birsām or sirsām, two Persian words that made their way into Arabic medical terminology. Etymologically speaking, birsām designates an inflammation of the chest: the word derives from the Persian bar, chest, and sam, inflammation. The second word, sirsām, derives from sar, head, and sam, inflammation, and would therefore define an inflammation of the brain. Ullmann pointed out that while some authors used the terms interchangeably, others understood them to designate different pathologies.2 Ullmann attributed the confusion between sirsām and birsām to the frequent use of the latter term in pre-Islamic poetry. In his Maǧnūn (1992), Michael Dols3 echoed Ullmann’s remarks stating that Arabic translators “did not create a clear, shared nomenclature” for phrenitis. More recently, Peter Pormann pointed out that the two terms birsām and sirsām were used “nearly synonymously”4 in Arabic medicine to designate an acute illness with fever caused by an inflammation of the meninges.

2The present paper is a preliminary study on the usage of the terms birsām and sirsām in the Arabic commentaries on the Hippocratic Aphorisms. With the aid of previously unpublished materials, I show how the usage of the two terms by commentators on the Aphorisms changed over time and can be periodised in two stages: an early stage, which ranges from the 9th to the early 10th century, and a later stage, from the mid-10th century onwards. In the early stage, birsām defined two illnesses with similar symptoms. It referred to an inflammation of either the meninges (brain fever) or the diaphragm (diaphragmatic fever). Both inflammations would cause delirium, high fever, and were, typically, fatal. In the second and later stage, the usage of birsām became more restricted, designating only diaphragmatic fever. Brain fever, on the other hand, came to be referred to only as sirsām. The terminological confusion, for what concerns the commentaries on the Aphorisms, is due in part to the fact that Ḥunayn first translated Hippocrates’ and Galen’s φρενίτις with birsām. Yet, Ḥunayn’s understanding of phrenitis does not seem to correspond exactly with Galen’s.

  • 5 Galen, trad. Siegel, On the Affected Parts, p. 149
  • 6 Ibid.

3In his On the Affected Parts book 5, chapter 4, Galen discusses the etymology, symptoms and aetiology of phrenitis. Galen also discusses the question of whether the diaphragm is involved or not in this disease. He remarks that the ancients believed that phrenitis was caused by an inflammation in the diaphragm since, when this gets inflamed, it causes a continuous delirium.5 The same kind of delirium happens in phrenitis. However, Galen specifies that when a patient is affected by phrenitis the brain is not involved by sympathy during this disease but by idiopatheia (intrinsic disease) or protopatheia (primary seat of disease). When the inflammation is in the diaphragm, the patient is affected by fever and paraphrosyne, i.e. delirium, together with other symptoms which are similar to those of phrenitis. Patients suffering from this kind of paraphrosyne, or delirium, become “almost phrenitic”. The physician, says Galen, can discern between diaphragmatic fever and phrenitis (brain fever) from the patient’s respiration: in diaphragmatic fever the breathing is shallow and frequent, while in phrenitis breathing is deep and long.6

Ḥunayn Ibn Isḥāq

4Arabic scholars obtained the writings of Galen mainly through the translations of Ḥunayn ibn Isḥāq (9th c.). Ḥunayn’s work reveals how he carefully rendered Greek into Arabic, strictly following Galen’s texts with recourse to his extensive study of Greek medical works. However, in his Arabic version of Aphorisms, vi. 11 Ḥunayn gives a definition of phrenitis which does not overlap with that given by Galen in On the Affected Parts. After translating the lemma and Galen’s commentary, Ḥunayn adds his own remarks on lexicon and translation. There, he explains each medical term contained in the aphorism. On phrenitis, he says:


  • 7 All Arabic texts, unless stated otherwise, are preliminary editions prepared by the Arabic Commenta (...)

قال حنين: ... [الأطبّاء] يَعنون بالبرسامِ حمًّى تكون من ورمٍ حارٍّ يعرِضُ في أَغْشيةِ الدماغِ أو في الحِجابِ، ويعرِضُ معها ضرورةً اختلاطُ العقلِ، ويسمّونهُ باليونانيةِ فَرانِيطِس7.

Ḥunayn said: ... [Doctors] mean by ‘birsām’ a fever from a hot inflammation occurring in the meninges or in the ḥiǧāb, and delirium necessarily occurs with it. They call it in Greek frānīṭis.

  • 8 Ullmann, Worterbuch, p. 819.

5We must look carefully at the term al-ḥiǧāb. Its translation is not immediate. Ullmann records ḥiǧāb al-dimāġ as ‘meninges’.8 But here al-ḥiǧāb occurs alone. A survey of Ḥunayn’s translation of the Aphorisms reveals how his hiǧāb consistently translates the Greek διάφραγμα or φρενοον. Here are some examples:
Aphorism II.33: حجاب translates διάφραγμα
IV.18: حجاب translates φρενοον
VI.18: حجاب translates φρενοον
VI.27: حجاب translates διάφραγμα

6This consistency in usage points to the fact that Ḥunayn is in fact referring to the diaphragm with ḥiǧāb in the text quoted above. Therefore, if Ḥunayn’s ḥiǧāb refers to the diaphragm, while aġšiyat al-dimāġ refers to the meninges, then Ḥunayn’s birsām is an umbrella term for a disease coming either from an inflammation in the diaphragm or in the brain. The discrepancy with Galen’s definition is striking for, of course, Ḥunayn was well acquainted with Galen’s views on phrenitis. A possible explanation is that Ḥunayn, in this passage, is referring to common usage of the word birsām among doctors, as his phrasing seems to suggest. Another passage, from Ḥunayn’s translation of Galen’s commentary on Epidemics I, gives us a better understanding of Ḥunayn’s nomenclature for phrenitis, intended as an inflammation of the meninges or the brain:

  • 9 Ḥunayn, Commentary on Hippocrates’ Epidemics, p. 306.

ومتى تمكَّنَ ذلك المَرارُ في الدماغِ والأغشيةِ الّتي تحويهِ حدثَ البرسامُ الّذي يقالُ له السِرسامُ9.

And when this yellow bile settles in the brain and its membranes that envolve it, then the birsām which is called sirsām occurs.

7When the brain becomes inflamed because of yellow bile, says Ḥunayn, there happens “the birsām which is called sirsām”. In other words, for Ḥunayn sirsām has a specific meaning: an inflammation occurring specifically in the brain or the meninges. Birsām, on the other hand has a more general meaning. This statement reinforces our understanding of the previous passage. Ḥunayn uses birsām as an umbrella term for fever and delirium caused by an inflammation occurring either in the diaphragm or in the brain or meninges, the latter case is more specifically called sirsām, which at this point seems to be a subcategory of the more general birsām. Incidentally, it should be noted that Vagelpohl’s translation is unsatisfactory. It runs as follow:

When this bile settles in the brain and its enclosing membranes, the inflammation of the brain called phrenitis results.

8Vagelpohl seems to have overlooked Ḥunayn’s statement: al-birsām allaḏī yuqālu lahu al-sirsām.

Arabic Commentators After Ḥunayn

9Ḥunayn’s double aetiology of birsām is not found in later commentaries. The 12th century commentator ʿAbd al-Laṭīf al-Baġdādī closely paraphrases Ḥunayn’s text seen above, with an important change:

vi. 11

قال عبد اللطيف:... وأمّا البرسامُ فهو ورمٌ في أغشيةِ الدماغِ أو حجابِهِ مع حمَّى، ويعرِضُ منه اختلاطُ الذهنِ ضرورةً، ويسمّى باليونانيةِ فرانيطِس.

ʿAbd al-Laṭīf said: As for birsām, it is an inflammation in the meninges of the brain or its ḥiǧāb, with fever, and this necessarily brings about mental derangement. In Greek it is called frānīṭis.

10While al-Baġdādī essentially reproduces Ḥunayn’s statement (vi.11 seen above), it is clear that he understands “al-ḥiǧāb” to be a part of the brain, as the use of the third person possessive pronoun (ḥiǧābihi) demonstrates. In al-Baġdādī’s text, al-ḥiǧāb could thus refer to the meninges. Yet, if this is the case, we are at odds with al-Baġdādī’s location of the affected part, for in his text ‘meninges’ is repeated twice. We can conjecture that ʿAbd al-Laṭīf quoted Ḥunayn emending the latter’s definition according to his own understanding of phrenitis, namely, an affection of the brain or meninges. He thus read al-ḥiǧāb as ḥiǧābihi, i.e. the “ḥiǧāb” (or membrane) of the brain.

11In the 12th century, another commentator on the Aphorisms proffered yet another definition of birsām and sirsām. Ibn al-Nafīs, a Syrian physician who practiced medicine in a Cairene hospital, addressed the two terms as follows:


الشرح: وما كان من اختِلاطِ الذِّهنِ عن ورمٍ، إمّا في الدِّماغِ وهو السرسامُ، أو في الصَدْرِ وهو البرسامُ فظاهرٌ.

When delirium happens because of an inflammation, if the latter is in the brain, it is called sirsām, if it happens in the chest, then it is called birsām, and this is clear.

12We see that Ibn al-Nafīs reports sirsām as delirium (iḫtilāṭ al-ḏihn) caused by an inflammation in the brain. When delirium is caused by an inflammation in the chest then the pathology is called birsām. Ibn al-Nafīs does not feel the need to elaborate on this nomenclature, a fact that indicates that by the time he is writing the demarcation between the two terms must have been common knowledge.

13A contemporary of Ibn al-Nafīs, the Syrian Christian physician Ibn al-Quff, proffered a similar definition, which he reiterated in various passages of his own commentary on the Aphorisms. Like Ibn al-Nafīs, Ibn al-Quff identified birsām as an inflammation of the diaphragm and sirsām as an inflammation of the meninges or the whole brain. Both pathologies cause fever and delirium.


البحث الثالث: اختلاطُ الذهن تارةً يكون عن ورمِ أغشيةِ الدماغ وهو السرسام، وتارةً يكون عن ورمِ الحجابِ الحاجز وهذا هو البرسام.

Third Inquiry: Delirium occurs at times due to an inflammation in the meninges, and that is called sirsām, and at times due to an inflammation of the diaphragm (al-ḥiǧāb al-ḥāǧiz) and this is called birsām.


والبرسامُ ورمٌ حادٌّ يحدث في الغشاء المسمّى أفرغما وهذه اللفظة فارسيّة، والسرسام أيضًا ورمٌ حادٌّ يحدث في أحد غشائَيْ الدماغ أو في جرمه، خلافًا للرازيّ. وهذه اللفظة فارسيّة أيضًا والسر هو الدماغ، والسام هو الورم، والبر هو الصدر والسام هو الورم وهذا المرض يلزمه في الأعراض ما ذكره. والبرسام أعراضه شبيهة بأعراض السرسام والفرق بينهما من وجهين. أحدهما أنّ السرسام يتقدّم فيه اختلاطُ الذهن على ضرر التنفّس، والبرسام بعكس هذا. ثانيهما أنّ السرسام لا تكون الحمّى معه قويّة كما في البرسام.

Birsām is an acute inflammation which happens in the membrane called afraġmā and this is a Persian term. Sirsām is also an acute inflammation that happens in one of the two membranes of the brain or in the whole brain (in the bulk of it), in spite of what al-Rāzī says. And this term is also Persian, sar means brain, bar means “chest” and sām means inflammation. This illness is accompanied by the aforementioned symptoms. The symptoms of birsām are similar to those of sirsām, the difference between them is twofold: on the one hand, in sirsām delirium precedes shortness of breath, in birsām, the opposite occurs. On the other hand, sirsām does not cause a fever as intense as birsām does.


وقد جاء في بعض النسخ عوضُ السرسام البرسام، والمرادُ به اختلاطَ العقل على ما عرفتَ لأنّ مادّة الرئة تنتقل إلى الغشاء القاسم، فتوجب المرض المذكور.

Some manuscripts report, in lieu of sirsām, birsām, which means delirium, as you have learned, because the matter of the lungs moves into the diaphragm (al-ġišāʾ al-qāsim), so that it causes this disease.


والسرسام وهو المسمّى باليونانيّة فرانيطس وهو عبارةٌ عن ورمِ أحد حجابَيْ الدماغ أو جرمه على ما عرفتَ ويلزمه اختلاطُ العقل وقد جاء في بعض النسخ عوضُ السرسام البرسام وهو خطأ. فإنّ كلام أبقراط في أمراض الدماغ والبرسام من أمراض الصدر.

Sirsām: it is called in Greek frāniṭis, and it means an inflammation of one of the two meninges of the brain, or its bulk, as you have learned; it is followed by delirium. In some manuscripts we find birsām instead of sirsām and this is a mistake, because Hippocrates is here talking about the disease of the brain and birsām is a disease of the chest.

14The first passage, ii.2, proffers the same classification of birsām and sirsām seen in Ibn al-Nafīs’ commentary. Interestingly, the second text, iv.50 mentions a membrane called afraġmā, which seems a plausible derivation of the Greek φράγμος or of διαφράγμα. According to Ibn al-Quff, when this membrane becomes inflamed, there occurs birsām. On the other hand, sirsām is an inflammation of the meninges (aġšiyat al-dimāġ), or the bulk (ǧirm) of the brain.

15The symptoms of these two illnesses, says Ibn al-Quff, are very similar. The physician can however discern the two pathologies based on two main differences: firstly, in sirsām mental derangement precedes difficulty in breathing, while in birsām the contrary occurs. Secondly, the fever in sirsām is not as intense as in birsām.

16The third text is taken from Ibn al-Quff’s commentary to vi.11, the aphorism discussed above. Sirsām, says Ibn al-Quff, translates the Greek φρενίτις. Ibn al-Quff states that some manuscripts report the reading birsām for sirsām, and, he says, that is a mistake.

17It is important to underscore, at this point, that Ibn al-Quff is here commenting on the same Aphorism previously seen in Ḥunayn’s translation, which we should recall now. There Ḥunayn translated phrenitis as birsām: an inflammation, he said, either of the diaphragm or the meninges. Here, Ibn al-Quff changes the translation of phrenitis to sirsām, attributing the transmission of birsām to a scribal error. Based on a philological enquiry, Ibn al-Quff explains that, since aphorism vi.11 is about illnesses of the head, it makes no sense to use birsām here, for birsām is an illness of the chest. However, an examination of the manuscripts of Ḥunayn’s translation reveals that Ḥunayn consistently used birsām in his translation of vi.11. Ibn al-Quff’s intention to systematize the usage of birsām retrospectively is, in fact, but wishful thinking!

Antecedents of Ibn al-Nafīs
and Ibn al-Quff

  • 10 On Rāzī and Avicenna’s view on phrenitis see also, Dols, Majnūn, p. 57‒59, 73‒91.
  • 11 This text was kindly given to me by Prof. Peter Pormann, who is currently preparing an edition of K (...)

18It can be argued that Ibn al-Nafīs and Ibn al-Quff’s classifications draw upon the writings of previous Arabic scholars, namely al-Kaskarī (10th century), al-Rāzī (10th century) and Avicenna (10th‒11th century). I can here only make a passing reference to their definitions, which are however relevant for a periodization of the usage of birsām and sirsām.10 I am compelled, however, to fully quote Kaskarī’s classification, from a yet unpublished edition of his work:11

في البرسام: اسمُه باليونانيّة فرينيطس وهو ورمٌ يحدث في غشاء الدماغ تتبعه حمًّى حادّة مطبّقة أو يحدث ورمٌ حارّ في الحجاب المسمّى ديافرغما وهو الّذي يفصل بين آلات التنفّس وبين آلات الغذاء وتتبعه أيضًا حمًّى حادّة يسمّى برسام أيضًا وهو بالفارسيّة لأنّ اسمَ الصدر عند الفرس بر والرأس عندهم اسمُه سر فما كان من ورمِ حجاب الدماغ يسمّى سرسام وما كان من ورم حجاب الصدر يسمّى برسام لأنّ الصدر حاوٍ للحجاب فاشتقّ له اسمٌ من ذلك.

On birsām: its name in Greek is frīnīṭis and it is an inflammation that occurs in the meninges, followed by acute fever or there occurs an acute inflammation in the membrane called diāfraġmā and this is the one that is located between the respiratory organs and the digestive organs. It is also followed by acute fever. It is also called birsām, and this is a Persian word, because the name of “chest” in Persian is bar and the head it is called sar. Therefore what comes from an inflammation of the meninges is [really] called sirsām, and what comes from an inflammation of the diaphragm is called birsām, because the chest contains the diaphragm and therefore the name is derived from this.

19Kaskarī states that birsām is called phrenitis in Greek and it is an inflammation of the meninges followed by fever. Birsām is also used for an inflammation in the membrane (ḥiǧāb) which is called in Greek diafragma and that stands between the respiratory and the digestive organs. Kaskarī also states that the word comes from Persian, bar being “chest” and sam being an inflammation. Kaskarī concludes that birsām should be used when the inflammation is in the chest, and sirsām when the inflammation is in the brain. We here find a remarkable affinity with Ḥunayn’s nomenclature and usage of the two terms.

  • 12 al-Rāzī, al-Ḥāwī, XV, p. 65.
  • 13 Ibn Sīnā, Qānūn, II, p. 44‒54.

20In his al-Ḥāwī fī al-ṭibb, Rāzī states that birsām is used for two diseases: one is šawṣa, a kind of pleurisy, or inflammation of the chest, and the other is an inflammation of the brain, which is properly called sirsām.12 Avicenna criticises the usage of birsām and sirsām as synonyms saying that “only people who know nothing about languages ignore that birsām is an inflammation of the chest” and sirsām an inflammation of the brain. More interestingly, Avicenna states that birsām and sirsām can occur simultaneously, when the diaphragm, the bladder, the stomach or the womb are involved sympathetically with the brain. Avicenna also reports that medical writers have different classifications for this disease, however, he says, the technical use (al-istiʿmāl al-ṣināʿī) of sirsām is as he describes.13


21With the evidence presented above, I hope to have shed some light on the usage of the two terms birsām and sirsām in the Arabic commentaries on the Hippocratic Aphorisms. We can periodise this usage in two main stages. In the first stage (Ḥunayn) birsām translates both Galen’s phrenitis and his diaphragmatic paraphrosyne, as they are defined in On the Affected Parts. Birsām is, at this stage, used as an umbrella term to denote a fever with delirium that originates from tissue inflammation. The inflammation is located either in the diaphragm or in the meninges. Ḥunayn specifies that when the inflammation is located in the meninges the more correct term is sirsām. A second stage is found in the commentaries by Ibn al-Nafīs and Ibn al-Quff. Here, birsām is classified as an inflammation in the diaphragm, accompanied by delirium and fever, which mirrors Galen’s diaphragmatic paraphrosyne. More importantly, according to Ibn al-Quff only sirsām translates properly Galen’s φρενίτις.

22The evidence gathered from manuscript sources points to the fact that these Arabic authors did not use birsām and sirsām interchangeably. The first medical writers probably had to adapt the existing lexicon and its usage to the Greek terminology. Greek and Arabo-Persian lexicons did not always match perfectly and some concessions had to be made, we infer, to common usage. Later writers adjusted the terminology based on philological inquiries, possibly under the strong influence of Avicenna. In their commentaries, they aimed at rectifying previous usage which they understood to be confusing. Thus, since al-Rāzī and onwards, the two terms birsām and sirsām come to assume a specific connotation, which, we can now say, remains clear and shared in the later exegetical writing thus far analysed.

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Primary Sources

Galen, Commentary on Hippocrates’ Epidemics, Book I, ed. Uwe Vagelpohl, De Gruyter, 2014.

Galen, Opera omnia, Kühn, C.G. (ed.), Lipsiae, Prostat in officina libraria Car. Cnoblochii, 1821–1833, 20 vols.

Ibn Sīnā, Kitāb al-qānūn fī al-ṭibb, New Delhi, 1982.

al-Rāzī, Kitāb al-ḥāwī fī al-ṭibb, Hydarabad al-Daccan, Matbaʿat Maǧlis Daʾirat al-Maʿārif al-ʿUṯmaniyya, 1955.

Secondary Sources

Dols, Michael, Majnūn: The Madman in Medieval Islamic Society, Oxford, Clarendon, Press, 1992.

McDonald, Glenda Camille, Concepts and Treatment of Phrenitis in Ancient Medicine, Doctoral Dissertation, Newcastle University, 2009.

Pormann, Peter E., “Theory and Practice in the Early Hospitals in Baghdad – Al-Kaskarī on Rabies and Melancholy”, Zeitschrift für Geschichte der Arabisch-Islamischen Wissenschaften 15, 2003, p. 197‒248.

Siegel, Rudolph, Galen on the Affected Parts. Translation from the Greek Text with Explanatory Notes, Basle, Karger, 1976.

Ullmann, Manfred, Islamic Medicine, Edinburgh, Edinburgh University Press, 1978.

Ullmann, Wörterbuch zu den griechisch-arabischen Übersetzungen, Wiesbaden, Harrasowitz, 2002.

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1 Ullmann, Islamic Medicine, p. 29

2 Ibid.

3 Dols, Majnūn, p. 57

4 Pormann, Theory and Practice in the Early Hospitals, p. 217

5 Galen, trad. Siegel, On the Affected Parts, p. 149

6 Ibid.

7 All Arabic texts, unless stated otherwise, are preliminary editions prepared by the Arabic Commentaries on the Hippocratic Aphorisms research team:

8 Ullmann, Worterbuch, p. 819.

9 Ḥunayn, Commentary on Hippocrates’ Epidemics, p. 306.

10 On Rāzī and Avicenna’s view on phrenitis see also, Dols, Majnūn, p. 57‒59, 73‒91.

11 This text was kindly given to me by Prof. Peter Pormann, who is currently preparing an edition of Kaskarī’s medical handbook.

12 al-Rāzī, al-Ḥāwī, XV, p. 65.

13 Ibn Sīnā, Qānūn, II, p. 44‒54.

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Nicola Carpentieri

Universitat Autònoma de Barcelona

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