Although medieval physicians, whether Muslims, Jews, or Christians, generally assumed that Galenism was a complete and perfect system, the great sages of Islamic medicine are of interest in their own right, not just in terms of their role in preserving classical medicine. Latin translations of the works of a few authors, including Rhazes, Avicenna, Albucasis, and Averroes, were most inﬂuential in Europe, but the Arabic works of many other scholars held a place in the Muslim world that had no parallel in the West. Some Muslim physicians, such as the mysterious Geber (Jabir ibn Hayyan, 721–ca. 815) became better known as alchemists or philosophers. Averroes (1126–1198; Abu’al-Walid Muhammad ibn Ahmad ibn Muhammad ibn Rushd) was best known for his commentaries on Aristotle, and his interests included medicine and jurisprudence. His reputation for rationalism and piety was based on his ideas about the nature of human intellect and the relationship between philosophy and religion.
Rhazes (ca. 864–ca. 925; al-Razi; Abu Bakr Muhammad ’ibn Zakariya ya-Razi) has been called the greatest physician of the Islamic world. His biographers said that when Rhazes became director of the ﬁrst great hospital in Baghdad, he selected the most healthful location by hanging pieces of meat at likely sites and ﬁnding the one where there was the least putrefaction. The indefatigable Rhazes was the author of at least two hundred medical and philosophical treatises, including his unﬁnished masterpiece the Continens, or Comprehensive Book of Medi- cine. The Continens was translated into Latin by the Jewish physician Faraj ibn Salim (known as Farragut, in Latin) for King Charles of Anjou. The text was completed in 1279 and ﬁnally printed in 1486. The printed volumes weighed more than 20 pounds.
Insights into the tension between orthodoxy and philosophy in the Muslim world can be found in The Conduct of a Philosopher, a book Rhazes wrote to rebut attacks on his personal conduct. In answer to charges that he had overindulged in life’s pleasures, Rhazes answered that he had always been moderate in everything except acquiring knowl- edge and writing books. By his own reckoning, he had written more than 20,000 pages in one year. Although Rhazes taught that a middle road between extreme asceticism and overindulgence was the most healthful, he confessed that his devotion to his work and his writing had caused grave damage to his eyes and hands. All biographical accounts agree that Rhazes became blind near the end of his life and that he refused treatment because he was weary of seeing the world and unwilling to undergo the ordeal of surgery. Eventually, biographers adopted the spurious but irresistible story that Rhazes lost his sight because his patron al-Mansur had beaten him on the head with one of his books as punishment for the failure of an alchemical demon- stration. Presumably, the text used in the beating was a minor treatise on alchemy; if the massive Continens had been used, the beating would have been fatal.
The case histories compiled by Rhazes provide insight into the range of complaints for which his contemporaries consulted physicians, which signs and symptoms the physician thought signiﬁcant, the kinds of treat- ment used, the occupations and family background of his patients, and the relationship between patient and physician. Just as physicians had ethical obligations to patients, patients had an ethical duty to trust and co-operate with their physicians. It was most important, according to Rhazes, for people to follow the doctor’s advice. ‘‘With a learned physi- cian and an obedient patient,’’ Rhazes promised, ‘‘sickness soon disappears.’’ Unfortunately, not all patients were obedient and not all physicians were learned or even competent. Rhazes had seen impostors who claimed to cure epilepsy by making a cut at the back of the head and then pretending to remove stones or blood clots. Other quacks pre- tended to draw snakes through the patient’s nose, worms from the ears or teeth, frogs from under the tongue, and bones from wounds and ulcers.
In dealing with wealthy and powerful patients, Rhazes was gener-ally ingenious and sometimes daring. Before initiating treatment when al-Mansur seemed to be suffering from an incurable crippling ailment, Rhazes asked the patient for his best horse and mule. The next day Rhazes had al-Mansur take a hot bath while he administered various remedies. Suddenly, Rhazes threatened his patient with a knife and shouted insults at him. In a frenzy, al-Mansur scrambled from the bath, but Rhazes ran outside where his servant waited with the horse and mule. Later, Rhazes sent al-Mansur a letter explaining that he had provoked him in order to use fear and anger as a means of increasing his innate heat and obtaining an instantaneous cure. Having recovered from both his ill health and his anger, al-Mansur showered his physician with gifts.
One of Rhazes’ case histories appears to be the ﬁrst written de-scription of ‘‘rose-fever,’’ to use the term adopted in the nineteenth cent- ury. Rhazes noticed that one of his patients seemed to suffer from a kind of catarrh (runny nose) or cold every spring. Convinced that the problem was caused by the scent of roses, Rhazes advised his patient to avoid aromatic things such as roses, herbs, onions, and garlic. If the symptoms became particularly troublesome, he recommended cupping on the neck and bleeding from arteries of the temples.
Rhazes’ book On Smallpox and Measles provides valuable infor-mation about diagnosis, therapy, and concepts of diseases. Among the ancients, diseases were generally deﬁned in terms of symptoms such as fever, diarrhea, skin lesions, and so forth. Therefore, Rhazes’ treatise on smallpox and measles is a major landmark in establishing the con- cept of speciﬁc disease entities. According to Rhazes, smallpox was caused by the acquisition of impurities from the maternal blood during gestation. When the child reached puberty, these impurities tended to boil up in a manner analogous to the fermentation of wine. The problem was essentially universal, and children rarely escaped the disease. Measles, which Rhazes recognized as a separate disease, was caused by very bilious blood, but even an experienced physician might have trouble distinguishing smallpox from measles. To protect his reputation, the physician should wait until the nature of the illness was clear before announcing his diagnosis. Proper management before the onset of smallpox might lessen its virulence and prevent blindness, but once the disease began the physician should encourage eruption of the pox by wrapping, rubbing, steaming, purging, and bleeding and by taking special precautions to prevent blindness. According to Rhazes, pustules that became hard and warty, instead of ripening properly, indicated that the patient would die. Various recipes were supposed to remove pock- marks, but the nearly universal presence of smallpox scars suggests that these remedies—which included sheep’s dung, vinegar, sesame oil, and the liquid found in the hoof of a roasted ram—were about as useful as modern antiwrinkle creams. In reality, once smallpox appeared, medicine does little to alter the course of the disease, except to make it worse, but an elaborate regimen gave the physician and the patient a sense of control, comfort, and hope.
Islam’s ‘‘Prince of Physicians,’’ Avicenna (980–1037; Abu Ali Hysayn ibn Abdullah ibn Sina), was the ﬁrst scholar to create a complete philosophical system in Arabic. Critics complained that his inﬂuence inhibited further developments, because no physician was willing to chal- lenge the master of philosophy, natural science, and medicine. According to Avicenna’s autobiography, when he was only 10 years old, he amazed his father and teachers by mastering the Koran. After surpassing his teachers in jurisprudence and philosophy, the young scholar turned to the natural sciences and was soon teaching medicine to established physicians. However, when Avicenna began to study clinical medicine, he realized that some things could be learned only from experience and not from books. Thereafter, Avicenna spent his days catering to his wealthy patrons and devoted his nights to lecturing his students, dictat- ing his books, and drinking wine. Temperance was certainly not one of Avicenna’s virtues. Eventually, wine, women, and work wrecked his constitution. Unwilling to wait for gradual improvement, he attempted a drastic cure by taking medicated enemas eight times per day. This regimen caused ulcers, seizures, colic, and extreme weakness. When his strength was all but gone, he abandoned all forms of treatment and died. Some of his rivals said that he actually died of an accidental, self-administered overdose of opium. His enemies exulted that his medi- cine could not save his life and that his metaphysics could not save his soul.
Avicenna’s great medical treatise, the Canon, was written for physicians, but the abridgment called the Poem on Medicine served as a layman’s introduction to medical theory. With Avicenna’s Canon as their guide, traditional healers still diagnose illness by feeling the pulse and inspecting urine, cure diseases that Western medicine cannot name, comfort their patients with satisfying explanations of their conditions, and care for patients who do not accept and cannot afford modern psy- chiatric methods. Followers of Avicenna learned to ﬁnd diagnostic clues in the size, strength, speed, elasticity, fullness, regularity, and rhythm of the pulse and the color, density, transparency, turbidity, sediments, quantity, odor, and frothiness of urine samples. Having made his diagnosis, the physician could ﬁnd much practical advice in the works of Avicenna for treating illness and maintaining the health of his patients under different conditions. For example, to provide partial relief from lice, the traveler should rub his body with a woolen ribbon that had been dipped in mercury and wear the ribbon around his neck—rather like a ﬂea collar—until a thorough attack on the pests was possible.
Establishing an appropriate regimen in infancy provided the foundation of a life-long plan for the preservation of health. Much of Avicenna’s advice on infant care seems quite sensible, but his remedies for deﬁcient lactation include a daily dose of white ants or dried earth- worms in barley water. Elderly patients required a regimen emphasizing moistening and warming measures, such as soothing olive oil baths. Boil- ing a fox or lizard in the oil made it more effective when treating severe joint pain. The physician had to be adept at assessing the quality of water, because bad water caused a host of disorders, including enlargement of the spleen, constipation, hemorrhoids, diarrhea, and insanity. Waters containing metallic substances and those infested with leeches were dangerous, but Avicenna noted that water containing iron strengthened the internal organs, stopped diarrhea, and stimulated the sexual organs.
Elegant expositions of the philosophical principles of medicine and the relationship between mind and body are woven into Avicenna’s case histories. Like Erasistratus, Avicenna demonstrated how physiological phenomena betray our hidden thoughts by using the pulse as a lie detec- tor. In treating a case of love-sickness, Avicenna unobtrusively kept his ﬁnger on the patient’s wrist and detected the irregularity of the pulse that corresponded to mention of the lover’s name. Another challenging case involved a young man who suffered from melancholy and the delusion that he was a cow. The man mooed loudly, refused to eat, and begged to be killed and made into stew. The patient cheered up immediately when Avicenna sent word that the butcher would soon come to slaughter him. Avicenna came into the sickroom with a butcher’s knife and asked for the cow. Mooing happily, the young man was bound hand and foot, but after a thorough examination Avicenna declared that the cow was too thin to be butchered. The patient ate so eagerly that he soon recov- ered his strength and was cured of his delusion.
Avicenna expected the physician to master surgical techniques for treating a wide variety of wounds and injuries. Although the doctor might prescribe drugs to relieve pain before the operation, the patient still had to be bound and restrained by the surgeon’s assistants. After the operation, the wound was washed with warm water, vinegar, or wine. Nevertheless, postsurgical infection was so common that the same Persian word meant both wound and pus.
A more specialized guide to Arab surgery was provided by Albucasis (936–1013; Abu ‘l-Qasim Khalaf ibn ‘Abbas al-Zahrawi), an ascetic man who devoted much of his time to working among the poor. Nevertheless, Albucasis offered harsh and practical advice to fel- low physicians. According to Albucasis, a wise physician would guard his reputation by recognizing incurable conditions and leaving such cases to divine providence. As demonstrated by his choice of subject matter, however, Albucasis was willing to deal with dangerous conditions. His On Surgery and Surgical Instruments is one of the ﬁrst comprehensive illustrated treatises on this important subject. Bleeding, cupping, and cauterization constituted the major forms of surgical practice at the time. On Surgery and Rhazes’ treatise on smallpox were among the earliest classical Arabic texts to be printed in England. In discussing the uses of cauterization from ‘‘head to heel,’’ Albucasis praised the cautery as an instrument with ‘‘universal application’’ for almost every disorder, organic or functional. Despite his piety, Albucasis was obviously not inhibited by the uncertainties surrounding the Prophet’s position on the use of the cautery. He prescribed cauterization to arrest hemorrhage, prevent the spread of destructive lesions, strengthen organs that became cold in temperament, and remove putrefactive matter. By counteracting excessive humidity and coldness of the brain, cauterization cured dis- orders such as headache, epilepsy, lethargy, and apoplexy. To perform the operation on the patient’s shaved head, the surgeon placed his hand on the root of the nose between the eyes and applied the cautery to the spot marked by his middle ﬁnger. If the bone was exposed when the siz- zling stopped, cauterization was complete; if not, the operation should be repeated. Some surgeons believed in keeping the wound open, but Albu- casis advised readers that it was safer to avoid further interventions. If the cautery failed to cure chronic migraine or acute catarrh, Albucasis suggested bleeding from the arteries.
Both Albucasis and Avicenna provided detailed discussions of the theory and practice of bloodletting. In all but the very old and very young, venesection was valuable for both the preservation of health and the treatment of disease. Drugs assisted the body in the elimination of noxious humors through purging, vomiting, and diuresis, but vene- section immediately removed excess humors in the same proportion as they were present in the blood vessels. As stipulated by Galen, venesection was even useful in the treatment of hemorrhages because it diverted blood to the opposite side of the body. Doctors commonly selected from about 30 sites for venesection: 16 of these were in the head, 5 in the arms and hands, and 3 in the legs and feet. Despite the danger of damage to nerves, the elbow veins were frequently used in the treatment of disorders of the chest, abdomen, and eyes.
The patient’s strength and the color of the blood determined the amount to be taken. If the blood was initially black, the doctor should continue bleeding until it became red; if the blood was thick, he should bleed until it became thin. Bleeding could be carried out in several small installments for a weak patient, but a person with hot, sharp, abundant blood and fever should be bled until he fainted. Albucasis warned the doctor to keep his ﬁnger on the pulse during bleeding to avoid the possi- bility that the patient might die rather than faint. For some conditions, leeches, cupping, and cauterization were preferable to venesection. Cupping, with or without scariﬁcation, was considered less debilitating than venesection, but leeches were sometimes more appropriate because the creatures could be applied to parts of the body beyond the reach of cupping vessels. Leeches were excellent for drawing blood from deep tissues, but they had to be carefully selected. Large-headed leeches that were black, gray, or green, or had hairy bodies with blue stripes, were said to cause inﬂammation, hemorrhage, fever, fainting, and paralysis. Albucasis described techniques for removing a leech stuck in the throat, but did not explain how the leech got there.
Female patients presented special difﬁculties because a chaste woman would not expose her body to a male doctor. If a woman required surgery, Albucasis suggested calling for a competent woman doctor, a eunuch, or an experienced midwife. The midwife should know the signs and manner of normal delivery, have wisdom and dexterity, and be skillful in dealing with abnormal presentations, prolonged labor, and the extraction of a dead fetus. It is interesting that Albucasis said that women doctors were ‘‘uncommon,’’ rather than nonexistent. The reference to eunuchs is also notable because castration was forbidden by Moslem law. Nevertheless, after apologizing for mentioning this operation, Albucasis described it in some detail.
Pharmacology, alchemy, and optics were also of great interest to Arab scientists. Arabic treatises on medicinal plants and drugs played a large role in shaping the development of pharmacy as an independent profession. The medical formulary of al-Kindi (ca. 801–ca. 866; Abu Yusuf Yaqub ibn-Ishaq al-Kindi) served as a model for Arabic treatises
on pharmacology, botany, zoology, and mineralogy. Persian and Indian drugs that were unknown to Hippocrates and Galen appeared in such formularies, as did new kinds of drug preparations. Linguistic analysis of the medical materials discussed by al-Kindi indicates that 33 percent of the drugs came from Mesopotamian and Semitic traditions, 23 per- cent from Greek sources, 18 percent from Persian, 13 percent from Indian, 5 percent from Arabic, and 3 percent from ancient Egyptian sources. Unfortunately, many of al-Kindi’s other writings—some 270 treatises in logic, philosophy, physics, mathematics, music, astrology, natural history, and medicine—were lost. al-Kindi’s interest in theories of vision and practical ophthalmology was probably stimulated by the high frequency of eye diseases in the Middle East. Many Arabic works deal speciﬁcally with the anatomy of the eye, its role in vision, and the treatment of eye diseases. Although the theory of vision might seem a rather esoteric branch of knowledge, al-Kindi argued that it would prove to be the key to the discovery of nature’s most fundamental secrets. The Latin version of his work on optics, De aspectibus, was very inﬂuential among Western scientists and philosophers.