Islamic civilisation developed a system of healthcare that, at its apogée, was envied by both friend and foe. Therefore, medicine evolved into a highly complex and variegated discipline from the 7th to the 21st century in the various lands of Islam...
Prof Peter E. Pormann, signing 1001 Cures books at the end of the event, Royal Society, London (Source)
Since physical well-being is of paramount importance in our lives, the pursuit of health is fundamental to human experience. Many civilisations have contributed to the development of medicine as a discipline, including those of Ancient Egypt and the Fertile Crescent, on which classical Greek culture drew when developing its own systems of medicine, science, and philosophy.
Islamic civilisation developed a system of healthcare that, at its apogée, was envied by both friend and foe. Therefore, medicine evolved into a highly complex and variegated discipline from the 7th to the 21st century in the various lands of Islam. Medicine transcended the confines of country and creed, as physicians from diverse religious, linguistic, and ethnic backgrounds shared in its scientific discourse. Islamic medicine also had a profound impact on surrounding cultures, notably European university medicine as it developed from the 12th century onwards. It survives today, in modified form, in many Muslim countries, and among Muslim communities across the world.
The present volume, 1001 Cures, aims to capture the dynamism and interest that existed in the medical tradition as it unfolded in the Middle East during the medieval period. In this introduction, I discuss some aspects of this multifaceted process by highlighting the various topics covered in the chapters of this book. At the end, I shall also talk briefly about the close link between medical traditions in Muslim civilisation and in Europe, which can only be understood in the context of their interconnectedness.
Islam emerged in the Arabian Peninsula. Among its desert-dwelling population, various medical techniques appear to have been known. Issues such as coughing (suʿāl), ophthalmia (ramad), and various injuries (often caused by tribal warfare) all figured in poems of the pre-Islamic and early Islamic periods, and the cures were often simple: camel urine and honey, for instance, had some prominence. In the two centuries before the emergence of Islam, the Arabs also came into contact with the two great empires of the time, the Sassanian and the Byzantine, as well as the Syriac-speaking Christians who often had to flee from religious persecution at the hands of their coreligionists who declared them to be heretics. Each of these communities possessed a quite sophisticated medicine, with that of the Greeks clearly standing out among the others.
Syriac-speaking Christians and the medical schools of Alexandria played a crucial role in one of the greatest enterprises in knowledge transfer: the Graeco-Arabic translation movement, the topic of the first chapter. Over the course of the 9th century, most available Greek medical texts were translated into Arabic, often via Syriac intermediary translations. The history of the translation movement from Greek into Arabic can be illustrated nicely by the example of Galen’s On Simple Drugs, which was twice rendered into Arabic. A certain al-Biṭrīq (fl. c. 754–75), about whom little is known, rendered the Greek in a rather paraphrastic way with many of the more technical terms left in transliteration. Fifty years later, Ḥunayn ibn Isḥāq (d. c. 873) and his circle had developed a highly refined translational style and further enhanced the medical terminology. When they translated On Simple Drugs into Arabic, they were able to express even extremely complicated medical ideas in sophisticated Arabic. In other words, the technical medical language, which had largely been shaped through the translation, had come of age. Translation continued to play a prom-inent role in the development of medicine, as medical knowledge permeated various cultures via Syriac, Hebrew, Latin, and Arabic well into the early modern period.
The theory known as ‘humoral pathology’ dominated medical discourse in the Islamic and the European worlds until the advent of germ theory in the second half of the 19th century, and Pauline Koetschet discusses this fundamental concept in the second chapter. According to humoral pathology, good health is dependent on a balance (iʿtidāl) of the four humours, blood (dam), phlegm (balgham), yellow bile (mirra ṣafrāʾ), and black bile (mirra sawdāʾ). Each of these four humours was thought to have two of the four primary qualities, hot or cold, and dry or moist. For instance, black bile was considered to be cold and dry, whereas blood was hot and moist. The belief was that when an imbalance in the four humours occurs, disease ensues. Therapy then aimed to restore the balance by removing excessive humours — for instance blood through venesection (faṣd) and cupping (ḥijāma) — and regenerate deficient humours — for example through consumption of a diet that produces blood or phlegm, and so on.
Following in the footsteps of their Greek forebears, physicians in the medieval Islamic world took an acute interest in anatomy (tashrīḥ), to which Nahyan Fancy devotes the next chapter. Like the Greek term anatomḗ, the Arabic tashrīḥ was ambiguous, denoting both the study of human physiology (what we nowadays call ‘anatomy’ in English), and dissection, the ‘cutting open’ of human and animal bodies, either dead (dissection) or alive (vivisection). Anatomy in the modern sense was a greatly esteemed pursuit. Not only did physicians repeatedly state that students must study it, but theologians such as al-Ghazālī (d. 1111) also prized it highly, since it made man understand God’s providence (ʿināyat Allāh). In other words, the wonderful structure of the human body shows God’s intelligent design. Although dissection was not regularly performed, there was no taboo against its practice on human bodies. We even have a number of famous cases where Muslim physicians challenge Galenic anatomy. In his commentary on the Canon by Ibn Sīnā (known as Avicenna in the Latin West, d. 1037), for instance, the physician and philosopher Ibn al-Nafīs (d. 1288) discovered the pulmonary transit: the fact that blood does not pass from the right ventricle of the heart to the left via an opening (manfadh) in the septum, but rather passes through the lungs.
Figure 1. A medieval cupping (ḥijāma) glass
Already in late antiquity, physicians divided medical practice into prophylactics and therapeutics. In the chapter on preventive medicine, Maḥmūd al-Miṣrī argues that Arab physicians paid greater attention to prevention than their Greek forebears. Diet or regimen (tadbīr) played a crucial role. Food obviously has a direct effect on one’s well-being, and foodstuffs were integrated into the system of humoral pathology and primary qualities. Some were seen to generate good humours such as blood, whereas others gave rise to diseases. Exercise was also recognised as preserving health. In this way, physicians manipulated the ‘six non-naturals’ to prevent a patient from becoming ill. The ‘six non-naturals’, as they were known — namely 1) the surrounding air 2) food and drink 3) sleeping and waking 4) exercise and rest 5) retention and evacuation, and 6) the mental state — also affected the health of a person. Too much exercise (under 3), for example, could cause excessive heat in the body, which had other physiological consequences; lack of sleep (under 4) could lead to health problems; and so on. Retention and evacuation referred to the bowel movement and urination of the patient, but could also take other forms such as sexual intercourse, during which semen is evacuated (in both men and women). Sexual hygiene evolved into a separate subject with monographs by authors such as al-Kindī (d. c. 870), Abū Bakr al-Rāzī (d. c. 925) and Avicenna.
The mental state is the last of the six ‘non-naturals’, and Pauline Koetschet explores the mind-body relationship in Chapter 5. The link between mental and physical states was a strong one. On the one hand, sadness, sorrow, grief, fright, and fear could cause bodily reactions leading to disease. On the other hand, mental states were seen as the result of a person’s mixture or temperament (mizāj, Greek krâsis). Galen had written a treatise with the programmatic title ‘That the Faculties of the Soul Follow the Mixtures of the Body’, which was translated into Arabic. For instance, melancholy (malinkhūliyā) was thought ot be, as its name suggests, a disease caused by black bile (al-mirra al-sawdāʾ, Greek mélaina cholḗ). Yet, it could be acquired in a variety of ways: the wrong food was thought to lead to melancholy, but also the wrong lifestyle, and even mental activities, such as excessive thinking. Melancholy was only one of many mental disorders for which physicians in the Islamic world developed sophisticated categories and therapies; moreover, music played a particular role in the care of those suffering from mental diseases.
The regulation of the ‘six non-naturals’ was important in preventing disease and curing it. Medication, however, occupied an even more prominent place. In her contribution, Leigh Chipman discusses the subject of pharmacology. Here one has to distinguish between simple drugs (adwiya mufrada) and compound drugs (adwiya murakkaba). Simple drugs are single substances such as mint, honey, arsenic, or opium, which possess certain qualities, both primary (dry, moist; hot, cold) and others (e.g. styptic, purging). Following Galen, these qualities were often rated in degrees from one (lowest) to four (and occasionally higher). Compound drugs consist of more than one ingredient, and could, at times, be very complicated. For instance, some recipes for theriac (tiryāq, from Greek theriakḗ) — a drug originally made to counter the effect of snake bites, and later used as a sort of panacea — contained dozens and dozens of different, and at times difficult to procure, ingredients. From a modern point of view, some ingredients seem highly effective (e.g. opium), whereas the usefulness of others is disputed.
Another means of therapy is surgery (jirāḥa), discussed in the chapter by the late Professor Rabie E. Abdel-Halim. Surgery ranged from milder and simpler interventions such as bone-setting (jabr) to quite complex operations. For instance, excessive blood could be removed both through venesection (or phlebotomy, faṣd) and cupping (ḥijāma). In the former technique, one of the patient’s veins was incised, and the blood would then run out. At times, blood was let in this way until the patient fainted. Two types of cupping existed: dry cupping and wet cupping. In both cases, cupping glasses were applied to suck disease matter and superfluities out of the body. In the latter case, small incisions on the skin were also made, and some blood would come out of them. Physicians and surgeons also frequently resorted to cauterisation (kayy): a heated iron (or cautery, mikwāh) would be placed on the skin to burn it; this would staunch bleeding and disinfect to some extent. Sometimes, extremely hazardous surgical procedures are explained in great detail, but it is doubtful that they were ever performed.
Next, Aileen Das tackles the topic of gynaecology and female practitioners by considering if there were any female physicians and how conditions specifically affecting women were treated. Much of the standard medical care, the ‘bodywork’, was probably carried out by women. Whether as mothers, sisters, aunts, grandmothers, wise women, or nurses, women played a significant role in the medical marketplace. Yet, because the medical historiography was largely a male domain, and as the society as a whole was highly patriarchal, women’s voices only reach us faintly across the centuries. Still, we have indirect evidence that women practiced medicine in various guises. Women were not only practitioners, but also patients. Even if women might, at times, feel shame to be treated by male physicians, it appears that, in extreme cases, male doctors would even examine female genitalia. Such practices are justified by the Islamic legal principle of ‘necessity (ḍarūra)’: the woman’s welfare outweighs other considerations.
Gynaecological conditions include not just menstruation, but also pregnancy and breastfeeding, which feature in manuals on paediatrics. This topic is addressed by Maḥmūd al-Miṣrī in a chapter that first reviews the paediatric literature in Arabic. This literature is particularly rich and a testament to the care and attention paid to children by physicians in the medieval Islamic world. The chapter then discusses advice about rearing children and some specific conditions affecting them.
Some parts of the body require special attention, such as the eyes. Therefore, ophthalmology developed into a specialist area, which Aileen Das discusses in Chapter 10. It generated its own genre of monographs by authors such as Ḥunayn ibn Isḥāq, who wrote the famous Ten Treatises on the Eye (Al-ʿAshr maqālāt fī al-ʿayn), ʿAlī ibn ʿĪsā al-Kaḥḥāl (10th century), ʿAmmār ibn ʿAlī al-Mawṣilī (fl. c. 1000), and Khalīfa ibn Abī al-Maḥāsin al-Ḥalabī (fl. c. 1250s–70s). Although physicians drew heavily on the Greek legacy in this area, they also made new discoveries and distinguished previously unknown ailments, as the example of sabal (pannus) shows. This disease, in which blood vessels from the limbus invade the cornea, does not appear in the classical Greek medical works. Yuḥannā ibn Miskawayh and his pupil Ḥunayn ibn Isḥāq, however, included it in their ophthalmological works, and advise on its treatment.
Figure 2. Bone-setting illustrated in a Latin translation of Avicenna’s Canon of Medicine (1001 Cures)
A hotly debated topic was contagion and whether or not one should leave a locality infested by plague or other epidemic diseases. Justin K. Stearns investigates both the medical and the theological discourses surrounding this topic. The Prophet Muḥammad reportedly had denied the existence of contagion. Yet there is another tradition, linked to the plague of Emmaus (ʿAmwās, located some twenty miles north-west of Jerusalem) that occurred in the year 638. Here, the faithful were enjoined not to enter a region affected by the plague if they were outside it, nor to leave it if they were there. Medical sources, however, recognised contagion in certain cases, although here, too, the theory of miasmas, inherited from Hippocratic works, remained one of the aetiological explanations.
The exchange of medical ideas across the Mediterranean through translation continued into the modern period. Two examples illustrate this. Dāwūd al-Anṭākī (d. 1599), a physician from Syria, wrote the Memorandum Book for Those Who Have Understanding and Collection of Wondrous Marvels (Tadhkirat ulī l-albāb wa-l-jāmiʿ li-l-ʿajab al-ʿujāb). In it, he drew not only on the earlier Graeco-Arabic tradition exemplified by Avicenna’s Canon, but also incorporated descriptions of new diseases such as syphilis together with some European recipes. Likewise, the court physician Ṣāliḥ ibn Naṣr ibn Sallūm (d. 1669) commissioned the translation of a treatise entitled The New Chemical Medicine of Paracelsus (Kitāb aṭ-Ṭibb al-jadīd al-kīmiyāʾī taʾlīf Barākalsūs), in which a Christian colleague, called Nicolas, translated the work of two German followers of Paracelsus’ chemical medicine. Natalia Bachour discusses this ‘new chemical medicine’ in her chapter and shows that the exchange of ideas between East and West continued in the Ottoman Empire. Even the many encounters with colonial medicine throughout the 19th century are not always ones of Western superiority.
Not only new treatment, but also new ideas about how medicine should be regulated were developed by physicians in the medieval Islamic world. They wrote on medical deontology (or medical ethics), discussed in Chapter 13 by Hinrich Biesterfeldt. Elite physicians endeavoured to distinguish themselves from other practitioners in the medical marketplace, with varying degrees of success. On the one hand, they argued for a canon of medical knowledge that all physicians should master in order to have access to the profession. For instance, in a manual on market inspection (ḥisba) from the 13th century, its author, the physician al-Shayzarī, demanded that physicians be tested according to the instructions given in Ḥunayn ibn Isḥāq’s On the Examination of the Physician (Fī Miḥnat al-ṭabīb). Other manuals on medical ethics such as those by al-Ruhāwī (fl. c. 850s) and Ṣāʿid ibn al-Ḥasan (d. 1072), or on how to examine physicians such as that by al-Sulamī, also refer to a canon of testable knowledge, largely based on Greek texts in Arabic translation. The famous physician and philosopher ʿAbd al-Laṭīf al-Baghdādī (d.1231) even urged his readers to return to the example of Hippocrates and Galen. In this way, the medical canon of textbooks serves as a touchstone. Yet, it is clear, too, from the same manuals on medical ethics and testing physicians that the medical elite rarely succeeded in excluding their competition. Moreover, there are injunctions to treat patients for free and not derive financial gain from exercising the medical profession.
A prominent topic in recent scholarship is the Islamic hospital, discussed by Ahmed Ragab. What are the antecedents of the Islamic hospital and in what way was it original? Certainly Byzantine institutions and notions of Christian charity, as well as late antique Greek medicine played an important role. I have argued elsewhere, however, that five factors came together in Islamic hospitals which render them unique, and which, together, mark a significant departure from previous institutions (Pormann 2008a; 2010c). They are, briefly: 1) legal and financial security through the status of pious foundation (waqf) in Islamic law; 2) the ‘secular’ character of the medical therapy; 3) the presence of elite practitioners; 4) medical research; and 5) medical teaching. The combination of these factors certainly constitutes innovation. Moreover, only the institutional setting made it possible for physicians like Abū Bakr Muḥammad al-Rāzī to carry out large-scale research or to encounter rare diseases. Ragab touches on these aspects and presents fresh evidence from his recent research.
The two chapters which follow focus on two great medical men, perhaps the two most significant physicians in the Arabo-Islamic medical tradition. Interestingly, both hailed from Persian backgrounds, yet both wrote nearly exclusively in Arabic. The first, Abū Bakr Muḥammad ibn Zakarīyāʾ al-Rāzī — discussed here by Pauline Koetschet — is arguably the greatest clinician of the medieval period. For instance, he wrote a major and highly influential treatise on Smallpox and Measles (Fī al-Judarī wa-l-ḥaṣba), in which he distinguishes between the two conditions and offers tools for differential diagnosis, a topic on which he also wrote a separate work with the title What Differentiates [between Diseases] (Kitāb mā l-Fāriq). On Smallpox and Measles continued to be highly influential not only in the East, but also in Europe, with Latin, English, and French translations appearing in the 18th and 19th centuries.
Ibn Sīnā, discussed in Chapter 16, is arguably the most influential physician after Galen of Pergamum. His Canon of Medicine represents a true watershed in the writing of medical encyclopaedias, and much medical instruction, whether in the East or the West is subsequently based on the Canon and the many commentaries, super commentaries and abridgments have been written on it. Avicenna also penned a number of shorter texts, in both prose and poetry, and his Urjūza (or ‘poem on medicine’) is particularly famous. There is recent debate as to whether Avicenna was actually a practicing physician and original medical thinker, but I argue here that he was.
The last three chapters explore the relationship between medicine and other disciplines such as literature, philosophy and religious scholarship. Arabic literature (or ‘belles-lettres’(adab)) contains a number of medical anecdotes. The 10th-century author and judge al-Tanūkhī, for instance, reported some extraordinary cases, such as that of Siamese twins, joined at the hip, who had to do everything together; or that of the girl at death’s door because of a tick in her vagina (its removal caused her great shame). Emily Selove tackles the relationship between literature and medicine by looking at rhetorical devices in medical discourse, and by exploring how physicians wrote literature. The famous Physician’s Dinner-Party (Daʿwat al-aṭibbāʾ) by Ibn Buṭlān (d. 1066), a doctor from Baghdad who died in 1066, is a work of adab, in which the author makes fun at the expense of his colleagues. Moreover, Selove investigates how medical discourse also pervaded literature, both prose and poetry.
In his chapter on medicine and philosophy, Peter Adamson first investigates how both disciplines arrived in the Arabic tradition through acts of translation, and how the translators of medical texts were often the same as those who also rendered philosophical works.
He then reflects on the fact that physicians were often also philosophers, with famous examples including al-Rāzī and Avicenna. But some works such as the Paradise of Wisdom by al-Ṭabarī (839–923) or the Benefits of Bodies and Souls by al-Balkhī (10th century) actually constitute works on both medicine and philosophy, mixing the two disciplines. Moreover, many medical ideas also entered philosophical discourse, not least in terms of the interrelationship between mind and body.
In the final chapter, Nahyan Fancy discusses the relationship between medicine and religion, and rejects the notion that religion hampered medical progress in the Islamic world. Rather, there is a large body of religious scholarship which actively encourages the pursuit of medicine. After all, the Prophet reportedly said that ‘God did not send down any disease without also sending down a cure for it (mā anzala llāhu dāʾan illā wa-anzala lahū dawāʾan)’. Fancy also discusses the genre of prophetic medicine (al-Ṭibb al-Nabawī), also known as ‘Medicine of the Prophet (Ṭibb al-Nabī)’. This genre of medical (or rather, legal-medical) literature developed from the 10th century onwards. Legal scholars drew on collections of utterances of the Prophet (ḥadīth) and reports about the behaviour of the Prophet (sunna) to establish a religiously sound medical tradition. This genre gained greater prominence from the 13th century onwards.
Religion also played a role in other ways. When faced with illness, many Muslims, Christians, and Jews reacted by praying to God and seeking His succour. But they went further: at times, they would, for instance, write certain sūras on a piece of paper which they would carry as a pendant, or drink water from bowls inscribed with Qurʾānic verses. Here the line between licit religious practice and illicit use of magic (siḥr) is not always clear.
The chapters of this book thus provide a rich and detailed study of medicine as it developed in the medieval Islamic world. Yet this tradition also had a tremendous impact on Europe during the Middle Ages and the Renaissance: in Italy, Spain, and Antioch, many Arabic medical texts were translated into Latin. The two figures who excelled in these endeavours were Constantine the African (d. before 1099), and Gerard of Cremona (d. 1187). They translated not only the great encyclopaedias by Abū Bakr al-Rāzī (known in Latin as the Book for al-Manṣūr (Liber ad Almansorem)), al-Majūsī (fl. c. 983) (Royal Book (Liber regius)) and Avicenna (Canon Medicinae), but also many monographs such as that by Isḥāq ibn ʿImrān (d. c. 904) On Melancholy (De Melancholia) or that by the Ibn al-Jazzār (d. 980) On Sexual Intercourse (De coitu). The Introduction to Medicine (al-Mudkhal fī l-Ṭibb) by Ḥunayn ibn Isḥāq became known in Latin as Isagoge Ioannitii, and was core curriculum in most of the nascent European universities from the 13th century onwards. Likewise, during the European Renaissance, Avicenna’s Canon was printed and reprinted dozens of times; it was also (together with the Qurʾān) the first book to be printed in Europe in Arabic for the Arabic market (Siraisi 1987). Even the great Renaissance anatomist Andreas Vesalius (d. 1564) wrote a Paraphrase of al-Rāzī’s ‘Book for al-Manṣūr’. There can, therefore, be no doubt that Arabic medicine in Latin translation had a profound and lasting impact on the history of medicine in the West. Some physicians during the Renaissance, however, resented the prominent position of Arabic medicine, and fought vigorously to erase the Arab and Muslim contribution to medicine (Pormann 2010e). At times, they succeeded in sidelining and removing Arabic and Islamic heritage from the history books, although this trend is now declining.
Islamic medicine is also a continuous tradition. In many Muslim countries, the texts of Avicenna are eagerly read, and in the souks one can buy the ingredients necessary to create the various drugs. On the Indian sub-continent, this medical tradition has developed into what is nowadays called Yūnānī Ṭibb (lit. ‘Greek Medicine’). Next to Ayurveda, it constitutes the major classical medical tradition, and together with Muslim migrant communities, has now reached most corners of the world. Likewise, the medicine of the Prophet enjoys great popularity, and many of the works mentioned remain in print in numerous editions. Finally, there is also a large market for what one could call ‘fusion medicine’, syncretic collections of Greek humoral pathology and modern (Western) medicine that are commercially highly successful. Therefore, in many ways, the medical tradition that developed in the medieval Islamic world continues to thrive and grow in many different ways.
This work is one of history: it aims to trace the complex development of medicine within the medieval Islamic world. ‘Islamic’ here refers to societies dominated by the religion of Islam, where it was also embraced by the ruler. Many medieval Islamic societies, however, were open to others, and mostly more tolerant than their Christian counterparts (see e.g. Cohen 1994). Medicine in particular provides an excellent example of this pluralism in medieval Muslim culture: the physicians and medical practitioners hailed from a wide variety of backgrounds – Muslim and non-Muslim, Arab and non-Arab – and developed a discourse that went beyond country and creed. This book, therefore, tells the story of this intercultural exchange and interaction: how medicine emerged against the backdrop of Greek humoral pathology, and how it grew to be envied by both friend and foe. Yet, it should be stated at the outset that this is not primarily a work about Islamic medicine in the sense of how Islam as a religion viewed matters of health and disease. Prophetic medicine, for instance, will only be touched upon briefly, insofar as it constituted a historic development. Nor do we aim to elucidate and explain what the Qurʾān , Ḥadīth, and Sunna said about treating patients or how medicine should be practised according to them. To be sure, in a society in which Islam was the dominant religion, we will, on occasion, mention different religious attitudes and debates, for instance that about contagion in Justin Stearns’ chapter. Yet, fundamentally, our approach is historic, not religious.
For a study of the sources, the works by Ullmann (1970) and Sezgin (1970) remain fundamental. Good introductions include Ullmann (1978a), Pormann/ Savage-Smith (2007), Shefer-Mossensohn (2009), and Pormann (2011, 2013a), all with further literature. For a thorough assessment of medieval Arabo-Latin translations, see Burnett (2009).