12 May

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.

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