2000 The Society for the Social History of Median!

Practice versus Theory: Tenth-century Case Histories

from the Islamic Middle East
ByCRISTINA ALVAREZ-MILLAN*
SUMMARY. Medicine and disease in medieval Islam have thus far been approached
through theoretical medical treatises, on the assumption that learned medical texts are a
transparent account of reality. A question yet to be sufficiently explored is the extent to
which the ideas and theoretical principles they contain were actually carried out in practice.
This paper deals with the description of diseases occurring in a tenth-century Casebook
(Kitab al-Tajarib) by Abu Bakr Muhammad ibn Zakariya" al-Razi (known to Europeans as
Rhazes)the largest and oldest collection of case histories, so far as is known, in medieval
Islamic medical literature. Since the author was a prolific medical writer, this study also
includes a review of his medical and therapeutic principles dealing with eye diseases, as
described in his learned treatises, and a comparison with those therapies actually employed
in his everyday practice, as exemplified by the Casebook. The comparative analysis shows
that the medical knowledge and the therapeutic advice so meticulously described in
theoretical works were not paralleled in the physician's medical performance. On the
contrary, it appears that learned treatises served other purposes than determining medical
practice.
KEYWORDS: Medieval Islamic Medicine, Abu Bakr Muhammad ibn Zakariya' al-Razi,
tenth century, Middle East, theory versus practice, Kitab al-Tajarib, Kitab al-Mansuri, Kitab
al-Taqsim wa-al-tashfir, eye diseases
Not many years ago, a well-known historian of classical medicine wrote that 'at
certain times and places doctors appear to have depended upon literacy for the
improvement of their craft, the better organisation of its teaching, and the raising
of their own professional status. Yet the historian . . . is still left with the question of
the extent to which practice was modified by this literary activity.'
1
This statement
is particularly appropriate to medieval Islamic medicine, since the practical aspect
of medieval Islamic medical care has thus far been approached and described
through its prolific theoretical writings, on the assumption that learned medical
texts are a transparent account of reality. Yet, while much ink has run on paper
about the achievements and practical dimension of medieval Islamic medicine as
depicted in academic treatises, case historiesthe source more likely to give us a
hint of what learned medical practice actually involved in medieval Islamhave
until recently been largely neglected.
Case histories, reports of medical experiences, and a wide variety of clinical
accounts which defy precise categorization are valuable instruments for medical
historians to study medicine and disease at a particular period. The earliest extant case
histories appear around the fifth to fourth century BC, in the seven books of Epidemics
within the Hippocratic Corpus. Around the second half of the first century AD, Rums
of Ephesus left a collection of clinical accounts which have been preserved only in
* Universidad Complutense de Madrid.
' I. M. Lonie, 'Literacy and the D evelopment of Hippocratic Medicine', in F. Lasserre and P.
Mudr y (eds.), Formes depensee dans la collection Hippocratique (Geneva, 1983), p. 145.
0951-631X Social History of Medicine Vol. 13 No. 2 pp. 293-306
294 Cristina Alvarez-Millan
Arabic.
2
In the second century AD, Galen included a number of case histories in
some of his works and also wrote a book in which he collected and described his
major clinical cases.
3
No further case histories beyond these ancient clinical accounts
seem to have survived from Europe until the thirteenth century, when the Latin
tradition began to develop the medical genre of consilia.
In contrast to tenth-century Europe, from where no case histories appear to
have been preserved, the tenth-century Islamic tradition presents a rich body of
materials, from both eastern and western regions of the Islamic world. In this
paper, I will focus on clinical accounts recorded by the well-known physician Abu
Bakr Muhammad ibn Zakarlya' al-Razi , who died in AD 925. He was director of
hospitals in his home town of Rayy, near present Tehran, and in Baghdad, and was
a prolific author of medical writings, some of them very influential among European
physicians and universities, such as his Kiiab al-Mansur't (Book for al-Mansur) and his
Kitab al-Hawi (or Comprehensive Book on Medicine), known in the Latin tradition as
Liber Almansoris and Continens, respectively.
5
However, Razi's literary activity of
nearly 200 titles on different subjects seems to have been paralleled by his activity as
medical practitioner and teacher. In contrast to the lack of recorded case histories
in the tenth-century Latin tradition, Razi's medical practice as a clinician is attested
by approximately 1,000 case histories.
Although Razi included a number of case histories throughout some of his
treatises, for the purpose of this paper I would like to focus on Razl's Kitab al-
Tajarib, or Casebook, the largest and oldest collection of case histories, so far as is
known, within Islamic medical literature.
6
I have divided this paper into two
sections. The first one will deal with disease in the tenth-century Middle East. The
second will explore whether the theoretical principles of humoral medicine so
meticulously recorded in learned treatises were actually applied in practice or, in
other words, to what extent medical practice was modified by or reflected that
literary activity.
Razl's Kiiab al-Tajarib, or Casebook, contains nearly 900 cases treated or super-
vised by him. These clinical accounts were recorded and compiled by one of his
students after his death. Since the purpose of collecting Razi's clinical consultations
is related to medical instruction, and since the nature of the diseases and the
2
Oxford, Bodleian Library, Oriental Collections, MS. Hunt. 461, fols. 38b-50a.
3
For a description of the stylistic features and purposes of these ancient collections, see C. Alvarez-
Millan, 'Graeco-Roman Case Histories and their Influence on Medieval Islamic Clinical Accounts',
Social History of Medicine, 12 (1999), 19-33.
4
See J. Agrimi and C. Crisciani, Les Consilia Medicaux, Typologie des sources du moyen age
occidental 69 (Brepols, 1994); P. Lain Entralgo, La historia dinica. Historia y teoria del relato palografico
(Barcelona, 1961), pp. 48-81.
3
For al-Razi's life and writings, see L. Richter-Bernburg, 'Abu Bakr Muhammad ibn Zakariya' al-
Razi (Rhazes) Medical works', Medicina net secoli, 6 (1994), 37799; E. Savage-Smith, 'Medicine', in
R. Rashed (ed.), Encyclopedia of the History of Arabic Science (London, 1996), vol. Ill, 903-62, esp. pp.
91319; E. Savage-Smith, 'Europe and Islam', in I. Loudon (ed.), Western Medicine: An Illustrated History
(Oxford, 1995), pp. 44-^5: and R. K uhne Brabant, 'al-Razi', in Storia della scienza, Instituto della
Enciclopedia Italiana, vol. II, Sez. B, Arabic Science, Part 7: Scientific Portraits (forthcoming).
6
On the contents and main features of this work, see my forthcoming article, 'Al-Razi's Kitab al-
Tajarib: Everyday Practice in Tenth-Century Islamic Medicine'; and for Razi's case histories in works
other than the Tafarib, see Alvarez-Millan, 'Graeco-Roman Case Histories'.
Tenth-century Case Histories from the Islamic Middle East 295
straightforward manner in which they are presented suggest the daily conditions
encountered by a physician, Razi's Casebook actually constitutes an exceptionally
impartial source for studying medical practice. Moreover, it reflects Razi's actual
practice as opposed to his formal medical writings, which present theories and
ideas that may not always have been implemented. W hat then is the Casebook's
picture of medicine and disease in the Middle East in the tenth century? Does it
match the image represented in the theoretical medical literature?
The clinical accounts in Razi's Casebook are divided into thirty-one sections,
dealing with the parts of the body from the head downward, including several
chapters on specific conditions, such as dropsy, colic, fevers, or skin disorders, and
a final chapter devoted to recipes. In general, the clinical histories are not accounts
of an illness from onset to recovery, but constitute brief notes taken at the patient's
bedside or in private consultations like the following one:
He [Razi] was told of a young woman who had been coughing for five months and had
now been vomiting a foamy blood for the last three days. He was presented with this in a
bowl, and it looked like pulmonary tissue. He said: 'This comes from the lung and was
easily expelled.' He asked: 'Is she in pain?' He was told that she felt pain on the right side.
He prescribed pastilles of poppy for her and barley-water without sugar.
7
The concept of disease in medieval Islamic medicine is founded on those of
classical Greek philosophy and Graeco-Roman medicine that were later elaborated
and developed by medieval Islamic authors in what is known as 'Arabized
Galenism'. In Razi's Casebook, sometimes diagnoses and theoretical explanations
appear in such terms as 'headache caused by a yellow bile vapour' or 'illness caused
by an excess of bile that has crept to the head'; sometimes they are implicit in the
use of medical words such as 'epilepsy', 'pleurisy', or 'meningitis.' However, in
most instances the condition is described in terms of symptoms, such as 'headache,
pain and cough, accompanied by redness in the left eye and lachrymation',
8
or
'continuous fever, red urine without cough, blisters in the mouth and normal
intestinal evacuation.'
9
All these fragmentary expressions of the underlying disease
were supposed to lead the physician towards the identification of the unbalanced
humour, and the counteracting treatment.
It is difficult at this distance to determine the nature of many cases as they are
described in Razi's Casebook. Often, the identification of the condition is pre-
sumably implied by the enumeration of symptoms, instead of being explicitly
interpreted from the theoretical point of view. For instance, in the chapter devoted
to 'flatulence, colic, and constipation', a patient complains of pain in the belly,
constipation, thirst, red urine, and discomfort when he eats something of a hot
nature on an empty stomach.
10
While the nature of that condition was presumably
clear to the medieval physician, the modern historian is at a loss to identify the
nature of the disease (whether in humoral or in modern terms), to locate the actual
seat of the condition, and even to determine its possible cause.
7
Abu Bakr Muhammad ibn Zakariya" al-Razi , Kilab al-Tajarib, Istanbul, Topkapi Saray, Ahmed
III, MS. 1975, fols.47a-47b.
8
Ibid., fol. 3a.
"Ibid., fol. 103b.
10
Ibid., fol. 59a.
296 Cristina Alvarez-Milldn
Likewise, it is difficult to ascertain the exact number of cases representing a
particular condition, since clinical accounts of a common combination of disorders
do not appear systematically together in any given section. For instance, in the first
chapter devoted to headache, the first patient presents with headache and night-
blindness (ashawah) in one eye; the second patient suffers from headache and a
bilious vapour ascending from his stomach; in the third case, the patient complains
of headache, cough, and diarrhoea; the fourth patient complains of headache and
pain in his right ear, which decreases when emptying his bowels, and so on.
11
Similar cases, however, are placed in the chapters devoted to eye conditions, chest
ailments, and ear disorders. A more significant example appears in the chapter
devoted to heart conditions: a woman is affected twice or three times a month by a
type of fit. It begins with an itchy sensation of ants crawling over her body, from
her feet up to her head. Then she feels a hot flush and a burning sensation (lah'ib)
ascending from the back of her neck towards her head, followed by palpitations,
pain in her nerves, and, finally, by an epileptic fit accompanied by contraction of
the hands and feet. W hen asked about her menstruation, the woman replies that it
has stopped, and the resulting diagnosis is 'suffocation of the womb (ikhtiriaq al-
rahim).
A2
D ue to the variety of the symptoms, this case could actually have been
placed in four other different chapters. Perhaps most of the woman's symptoms
were understood as those of a heart disorder and, despite the final diagnosis, it
remained in that particular chapter. On the other hand, in chapter four, dealing
with 'melancholy and different types of madness', we find a young man suffering
from melancholia, who, after he developed something like lumps in his testicles,
pulls out the hairs of his beard and enjoys himself removing the mud from brick
walls. Another patient suffers from a fit of melancholia, accompanied by pensiveness
(fikrah), desolation (wahshah) and anxiety (tafazzu). A third case is that of a woman
who speaks nonsense and laughs compulsively, accompanied by redness all over
her face. Finally, the fourth case deals with a slave who looks mad and startled, his
eyes fixed; he does not speak and does not reply when addressed, his peristaltic
movement had stopped five days before, and the condition had then set in. He
could not stay in just one place, kept turning his face around, and unwillingly
passed water every nightone infers, in the bed.
13
In the following chapter, we
also find a case in which the patient presents very similar symptoms. However,
Razi's diagnosis is that the young manwho speaks nonsense, gets angry without
reason, and laughs compulsivelysuffers from a humoral imbalance in his brain,
which has turned dry.
14
Here it seems that the stated diagnosis led the compiler to
place the case in the chapter entitled 'On palsy, numbness of extremities, and the
remaining brain and nerve disorders.'
A further point relevant to the description of disease in the Casebook is that the
undentanding and medical knowledge available to tenth-century Islamic physicians
11
Ibid., fols. 2a-2b.
12
Ibid., fol. 68a.
13
Ibid., fols. 8a-9b.
14
Ibid., fols. lOb-lla.
Tenth-century Case Histories from the Islamic Middle East 297
regarding some conditions leads them to consider, for instance, diabetes as a disease
related to the kidneys, while some psychological affections are taken to be heart
conditions, and a breast disorder such as the following one is included in the
chapter devoted to chest conditions:
A woman presented whose breasts had become dark and one of which was hard, as though
it were a movable and protruding growth. He [Razi] said: 'This is a serious matter, since it
feels hot and is flushed; this heat is overpowering her and has unbalanced the humours. One
must draw the conclusion that the tumour is a cancer, but the cancer does not protrude, for
otherwise it could be extirpated.' He prescribed that she take one tnithqal of shabyar [a
soporific electuary] every night, that she wash and then anoint [the tumour] with oil of
sesame or violet. Dietanything that moistens and soothes.
15
Nevertheless, such an unusually large collection of case histories gives a lively
picture of diseases occurring in the tenth-century Middle East, and also some idea
of the most frequent complaints. Since there is no feature which would suggest that
it is a formal treatise adulterated with literary elaboration, we can perhaps assume
that this collection reflects the proportional occurrence of diverse conditions in
Baghdad, or Rayy, or nearby regions.
In the Casebook, we find only a few patients suffering from migraine, epilepsy, ear
problems, nosebleeds, running nose and catarrh, toothache, and inflammation of
the tongue, or throat conditions such as pain, irritation, soreness, and difficulty in
swallowing. There are also a small number of cases of pleurisy and asthma. Heart
conditions for the most part seem to consist of palpitations, usually accompanied
by other symptoms and occasionally combined with additional disorders, such
as inflammation of the membrane of the oesophagus (hijab al-mari'), apnoea, or
inguinal hernia. Other cases included in the chapter on heart disorders consist of
emotional and psychological troubles, such as desolation and heart constriction (diq
al-qalb), attacks of fear, delusions (waswas), and grief for the loss of a dear person.
There are not many cases dealing with liver conditions, but those which are given
consist of swelling, heat, or pain in that organ. In different chapters, we find a few
cases relating to dropsy and jaundice. Also few in number are the patients suffering
from spleen disorders such as pain, inflammation, or hardness.
Concerning the rectum (maq'adah), most cases involve bleeding, caused either
by ulcers, cracking (shiqacj), fistula ormore oftenby haemorrhoids. There are
also two patients suffering from intestinal worms (didan), and a man who cannot
control the air that he is passing. As for male genitalia (khusa wa-madhakir), patients
generally complain of swelling and/or pain in the testicles, but there are, too, patients
who complain only of a burning sensation in the penis or urethra (Mil), sometimes
accompanied by a bloody discharge. Complaints about uterine conditions are very
diverse: burning sensations, pain, ulcers, abscesses in the vagina or uterus; women
suffering from hypermenorrhoea; women whose menstruation has stopped; women
reporting only a slight menstruation after labour; women in labour who bleed
more than is normal; a woman who had delivered a child but not expelled the
placenta; a woman who became like an epileptic when she was about to menstruate;
15
Ibid., fol. 49a.
298 Cristina Alvarez-Milldn
and a woman who after delivering a child with profuse bleeding had a normal
menstruation and then bloodletting, as a consequence of which she was affected by
unsteadiness (khiffah), anxiety, and diarrhoea.
There is a section in the Casebook devoted to patients who have fallen down
while riding an animal or in the hammamthat is, steam bathbut none of them
presents any broken bones. Scattered throughout the work, we also find several
cases of cancer (saratan) affecting the eye, the stomach, the face, the back of the
neck, and one affecting the leg. Hernia (fatq) was apparently not a sufficiently
interesting or frequent occurrence to deserve a particular section. Five patients
complaining of other disorders, however, are said to suffer from that condition. In
the chapter devoted to stomach disorders, we find two cases of abdominal hernia,
16
and one case dealing with what is described as abdominal prolapsis.
17
A patient
affected by a heart condition and another one suffering from diabetes also present
an inguinal hernia.
18
Diabetes occurs several times, both in the chapter devoted to
kidney conditions, and throughout the work as the cause of other complaints, as in
the case of a woman having problems with her vision.
The last chapter in Razi's Casebook deals with 26 unusual cases, including a man
hit on the thigh by an arrow some time before the consultation; freckles (kalaf) on
the face; a man who, at the end of spring, sweats all over his body when he walks; a
man who treated himself erroneously by taking litharge; a woman who had taken
iron filings, causing pain in her chest; a secretary (one of the kuttab) whose armpits
sweat heavily, causing him nausea; someone who cannot digest barley-water; a man
with a cut on his face caused by a sword; and a traveller who swallowed some coins
to avoid robbery and could not excrete them. There are also two cases of measles
(hasbah) and one of smallpox (/War/).
19
Headache, cough, diarrhoea, constipation, and vomiting often appear as the first
symptom, presumably the first to be mentioned by the patients. These symptoms
are combined or mixed with other disorders throughout the work. There are a
number of patients suffering from kidney and bladder conditions. Most of them are
described in terms such as 'burning sensation when passing water', 'burning sensation
in bladder' accompanied by discharge or fever, 'pain in the bladder, passing water
drop by drop', 'pain accompanied by discharge', 'blood in urine', 'difficulty in
passing water' combined with a burning sensation, with discharge, oras in one
casewith sexual impotence (dufquuwati-hi 'aid al-bah). Apart from a few patients
suffering from excessive urination (idrar al-bawt) or pained by ulcers or stones in the
bladder or kidney, there are also some unusual cases, such as that of a child suffering
from a bladder stone which is passing out through his penis {qadlb) accompanied by
an itch in the testicles. Additionally, there is the case of a woman who, after falling
down a well, has weakness in her feet and is not able to pass water; or that of an old
man who feels heaviness and pain in the groin. Although the section is entitled 'On
16
Ibid., fols. 64a and 66b-67a respectively.
17
Ibid., fol. 63b.
18
Ibid., fol. 67b and 73b-74a.
19
It is interesting to note that no case involving rabies or bites by poisonous snakes or insects is
recorded in Razi's Casebook.
Tenth-century Case Histories from the Islamic Middle East 299
kidney and bladder disorders and on sexual intercourse', there is only one case of a
man who had lost his sexual appetite (faqad al-bah) and wanted a drug to cure it.
Pain in the joints is the next most numerous category, represented by about
50 cases. Most of these complaints are accompanied by other symptoms such as
constipation or diarrhoea, headache, fever, nausea, trembling of the hand, and
difficulty in breathing. The chapter also includes one case of sciatica (irq al-nisa')
and four cases of gout {niqris). Interestingly, in the title of this section the Medina
worm or Guinea worm (al-'irq al-madarii) is mentioned.
20
This is a worm 5070 cm
long that lives in the subcutaneous tissue of human beings. On maturity, the head
of the female breaks through the skin (usually of the lower leg) and discharges
larvae into stagnant water in which the penon bathes. The larvae are then eaten by
Cyclops crabs, and, through drinking water contaminated by these crabs, humans
then get larvae in their stomachs, and the cycle begins again. It takes about a
year for a cycle to be completed. The condition was known to medieval Islamic
physicians, but they did not understand the cause and mistakenly thought it was a
varicose vein. Significantly, given this confusion, no actual case appears to occur
in Razi's Casebook.
There are about 70 patients presenting skin disorders, such as pustules (buthur)
of varying types, of diverse location, and, more particularly, of different size. For
example, in one patient the pustules look like apples under his armpit and on his
shoulder, and in another the pustule hangs like a red aubergine. Other skin disorden
appearing in the work are scabies (jarab), general itching (hikkah), a type of itchy
skin eruption (sharan), abscesses on the skin, and a type of ulcer (sa'fah), plus single
cases of cracking in the skin, scrofulas (khanazlr), boils on the face (damam'il), wart
(thu'lul), and a burning sensation. Interestingly, there is only one case involving
burning by fire, and the actual complaint consists in the area having remained
swollen and rough. In another section, but also dealing with skin conditions, we
find around ten cases of leprosy in different stages.
22
Fever appears to have been one of the most frequent conditions, since, apart
from being often mentioned as an additional symptom, it is the main complaint in
77 patients, usually accompanied not only by cough, diarrhoea, and perspiration,
but also by lethargy (inkisar), shivering (qusha'rlrah), heaviness, and pain. Gastro-
intestinal disorders, in general, seem by far to have been the most widespread
condition in the tenth-century Middle East. Apart from diarrhoea, andto a
much lesser extentdysentery (zahir), we find different types of colic, sometimes
diagnosed as such {qulanj, maghas, 'Maws), but more often described as 'pain in the
belly', accompanied by constipation or loose faeces. The chapter concerned with
stomach disorders contains 98 case histories. Amongst them, 20 cases present a
general or vague stomach disorder, often consisting of food turning acidic in the
20
Dracunculus medinensis or Filaria medinensis. Istanbul, Topkapi Saray, Ahmed III, MS. 1975, fol.
51a.
21
See Bennett, above, p. 290.
22
Th e r e ar e t wo cases of bl ack vi t i l i go (bahaq aswad), t wo cases of l epr osy (bams) and six cases of
another ulcerative skin condition (qawabi). For a discussion of these terms, all of which were used for
symptoms of leprosy, see M. Dols, 'Leprosy in Medieval Arabic Medicine', Journal of the History of
Medicine and Allied Sciences, 34 (1979), 314-33.
300 distinct Alvarez-Millan
stomach. Twenty-eight cases present stomach-ache, in some instances with the
pain spreading towards the shoulder or elsewhere. Twenty-one patients complain
of vomiting, five of them producing blood. Other recorded stomach conditions
are weakness of the stomach, inflammation, lack of appetite, flatulence (riyah, or
possibly some other disorder considered aerate in humoral terms), nausea, obstruc-
tion, and a burning sensation in the stomach. W e also find a number of cases in
which vomiting, pain, inflammation and/or flatulence (riyah) appear together, as
well as ones where they are combined with other types of disorders such as colic,
diarrhoea or thirst.
One of the features of Razi's Casebook which attracts attention is that many of
the conditions described 'sound' familiar to any modern reader. In other words,
most of the illnesses entail symptoms which anybody may have suffered themselves,
or may have seen in a relative, or may be aware affect other people. Since medieval
theoretical treatises approach disease in a different mannerthat is, in terms
of humoral imbalance, employing a technical vocabulary specific to humoral
pathologythe question arises of whether the medical disorders encountered by
Razi and recorded in his Casebook actually correspond to the types of conditions
described in theoretical treatises.
By way of example I would like to analyse the chapter in the Casebook dealing
with eye conditions, which, given the number of recorded cases, appears to have
been one of the most prevalent disorders. The section contains 48 cases.
23
The
ophthalmic complaints which we have in Razi's Casebook include the following:
1 Ophthalmia (ramad)4 cases. In one case accompanied by a strong headache
and heaviness in the forehead; in another by headache and redness in the left
eye and constipation. A third patient presents swelling and redness in the
eyelids and arrives at the consultation screaming because of pain in the tem-
ples. In the fourth case, ophthalmia is accompanied by a burning sensation in
the head.
2 Trachoma (jarab)4 cases. One case is combined with pannus (sabal),
24
and
another with headache.
3 Excessive lachrymation (darnah)4 cases. On one occasion it occurs only
when sneezing, and on another it is accompanied by redness in the eyes.
4 Nightblindness6 cases. The medical term for this condition (asha) is
employed only in a consultation by letter, while in three cases it is referred
to by a synonym (ashawali); in two other cases, patients literally complain of
not being able to see at night and of'darkness of sight' after dusk.
5 Pain in the eye2 cases. In one case there is no redness or any other symp-
tom.
23
Istanbul, Topkapi Saray, Ahmed III, MS. 1975, fols. 15b-22b.
24
In modern medicine, trachoma is considered a disease of the conjunctiva in which dense, hard-
packed papillae form on the inner surface of the eyelid. Pannus consists of an invasion of the cornea by
vessels from the limbus, usually being a sequela of trachoma. See E. Savage-Smith, 'Ibn al-Nafis's
Perfected Book on Ophthalmology and His Treatment of Trachoma and Its Sequelae', Journal for the
History of Arabic Science, 4 (1980), p. 149.
Tenth-century Case Histories from the Islamic Middle East 301
6 Adhesion of the eyelids (symblepharon, iltisaq)2 cases. It affects the patients
only at night.
7 Discharge2 cases. Two patients complain of matter discharged into one or
both eyes from the head or the brain.
8 Pterygium (zafarah) 1 case. It occurred in one eye and had dried up and
become hard.
9 Cancer (saratan)1 case.
10 Incipient cataract1 case.
11 Swelling (waram) I case.
12 Burning (iltihab)1 case.
Additionally, one patient complains of not being able to open his eyes in the sunlight.
Someone else complains of lack of sight in one eye, with no trace of dilation of the
pupil (intishar) or cataract although the eye is red, all of which turns out to be an
acute ophthalmia. There is also one patient who complains of trembling in one
eye, accompanied by redness, traces of blood, and fever, while another patient
presents a swollen eye, as large as an aubergine in size, so that the pupil is hidden.
Among eyelid conditions, we find single cases of heaviness, thickness, swollen
eyelids, and a greenish stain on the eyelid which does not cause any discomfort.
One patient complains of a swelling (waram) of the inner surface of the eyelid
(hamaljq) as well as the margins, and another one complains of a swelling of the
same inner surface due to engorgement of blood. A one-year-old child presents a
greenish-black spot on the inner surface of one eyelid, which he has had since birth
but which has increased over the months.
Other conditions are described as dullness of vision (zulmah) in the eye which
increases when the patient is hungry, the condition actually being caused by
diabetes; dullness of vision due to excessive smelling of musk; increasing darkness
in both eyes when the patient's stomach is full; dullness of vision making it
impossible to see anything without intense focusing; dullness of vision in the eye
and the imaginary seeing of things as darker than they really are. There is also the
case of a tailor who feels pain in the pupil when looking at white things, followed
by dullness of vision. Occasionally, he sees something like insects in between his
eyes and feels heat and roughness in his throat and a bitter taste in his mouth. A
traveller about to set off also complains of dullness of vision in one eye, but presents
no trace of cataract or dilation of the pupil. Finally there is the case of a woman
with an extended protuberance of a violet colour which conceals the pupil in one
of her eyes.
I would now like to look at the contents of two theoretical treatises written by
Razi. In his work Kitab al-Taqs'im wa-al-tashfir (The Book of Classification and Tabu-
lation of Diseases), the eye conditions described are: ophthalmia, ulceration of the
eye, leucoma, trachoma, pannus, ulcerative blepharitis, pterygium, lachrymation,
falling out of the lashes, blood spots on the conjunctiva, weakness of sight, trichiasis,
23
Pterygium is a triangular-shaped ingrowth of the conjunctiva onto either side of the comea, most
frequently on the nasal side; see Savage-Smith, ibid., p. 149.
302 Cristina Alvarez-Millan
cataract, nightblindness, enlargement of the pupil, lachrymal abscess and fistula,
lice on the eyelids, and stye.
26
A comparison with the Casebook reveals that only 7
conditions out of these 18 occur in the case histories (ophthalmia, trachoma,
pannus, pterygium, lachrymation, cataract, and nightblindness), or, put the other
way round, only 17 ophthalmic cases out of 48 in the Casebook are the subject of
theoretical discussion.
Razi's Kitab al-Mansurl was one of his most influential works. The ninth book,
devoted to therapy and arranged according to the location of diseases from head
to toe, gained widespread circulation in the Latin tradition, eventually seeing
separate printed editions and being commented upon by university scholars and
anatomists like Vesalius. Here Razi deals with treatments for ophthalmia, ulcers in
the eye, leucoma, trachoma, pannus, itching of the inner corners of the eye (amaq),
pterygium, blood spot, lachrymation, weakness of sight, inflammation of the eyelids,
trichiasis, cataract, nightblindness, dilation of the pupil, and lachrymal fistula (al-nasur
al-kainfi amaq al-ayri). W hen Razi's Kitab al-Mansuri is compared with the cases
in Kitab al-Tajarib (the Casebook), 10 conditions out of the 15 mentioned in the
former occur in real patients. Again, however, the majority of the complaints in the
Casebook, with their complexity and mixtures of symptoms, are not described in the
theoretical treatise, whose popularity ostensibly derived from its practical character.
Tenth-century treatises devoted exclusively to ophthalmology, produce similar
results. For instance, in his Tadhkirat al-kahhalln, 'All ibn Tsa al-Kahhalwriting in
Baghdaddescribes approximately 66 conditions affecting the eyelids, the inner
corner, the conjunctiva, the cornea, and the iris.
28
Out of these theoretical
descriptions, only eleven seem to occur amongst the case histories in Razi's Kitab
al-Tajarib.
W e have been dealing with disease, but what about therapy? What do case
histories say about medical treatment? Focusing on the chapter on eye conditions,
I would now like to suggest a general view of therapy in the tenth-century Middle
East as depicted in Razi's Casebook. The fact that some complaints do not match
any particular theoretical model implies that therapy must have been adjusted to
the particular needs of each patient. This is confirmed to some extent by the
treatments prescribed in Razi's clinical accounts, where diet and pharmacological
agents vary from one patient to another, and venesection and cupping glasses are
applied to different parts of the body. Moreover, purgatives are prescribed in
varying strengths and dosesthat is, from just the intake of prune juice with sugar
or a simple decoction of myrobalan (usually halllaj, black or chebulic myrobalan)
to a combination of the decoction ot myrobalan with hiera (lyaraf), or a
26
Abu Bakr Mu h a mma d i bn Zakariya" al - Razi , Al-Taqsim wa-al-tashjjr: Taqaslm al-'ilal, edi t i on and
French t ransl at i on by S. M. Ha mma mi ( Al eppo, 1992), pp. 10635.
27
Abu Bakr Mu h a mma d i bn Zakariyaf al - Razi , Kitab al-Mansun, Escori al , Real Bi bl i ot eca del
Monast er i o, Ar abi c MS. 858, fols. 116b- 120a.
28
See ' All i bn 'Isa al - K ahhal , Memorandum Book of a Tenth-Century Oculist, trans. C. A. W o o d
( Chi cago, 1936) .
29
A c o mp o u n d pur gat i ve r emedy in whi c h drugs of a bi t t er taste are mi xed wi t h ar omat i c dr ugs,
t he mai n i ngr edi ent s bei ng al oe and c i nna mon; see M. Levey, Early Arabic Pharmacology (Lei den,
1973), pp. 85-6.
Tenth-century Case Histories from the Islamic Middle East 303
combination of hiera with quqaya,
30
and tryphera.
31
Given the range of ophthalmic
conditions in Razl's Casebook, the variation of treatment from one patient to
another is actually quite small, for therapy seems to have been concentrated on
evacuation by means of venesection and/or cupping, and the use of purgatives,
light diet, bathing, and a rather small number of both simple and compound drugs.
Since it was argued that the proper treatment of all disease required the expulsion
of the humour at fault, these methods constituted the first line of treatment for
every type of disease.
The general characteristics of ophthalmic therapy apply to the entire Casebook. It
should also be noted that no surgery is recorded amongst Razi's case histories.
Likewise, no magical recipe, talisman, or astrological procedure occurs, and music
therapy is also missing. As for particularly revolting ingredients often associated
with folkloric practices (and with no apparent use from the modern point of view),
none has been found. In the chapter devoted to eye diseases, an extract made from
roasted goat's liver, seasoned with long pepper (darfulful), is said to have particular
properties useful for nightblindness. However, this therapeutic agent is also praised
by Razi in his theoretical treatises.
What, then, is the relationship between therapy as prescribed in Razi's case
histories and that recommended in his theoretical works? For ophthalmia, Razi
prescribes in his Casebook venesection or cupping, a decoction of myrobalan, and
(for topical application) egg white, oil of roses, and wetnurse's milk. If we look at
his Kitab al-Taqsim, however, he recommends different treatments according to
the cause. The most striking feature is that egg white and oil of roses are not referred
to at all, and milk is mentioned only in passing, and with no specification that it come
from a wetnurse. Instead, Razi recommends the topical application of one or more
substances including a 'white' collyrium, a white ophthalmic powder (dhariir),
mucilage offleawort (luab bizrqatunah), mucilage of quince seed (luab habb safarjal), a
camphorated collyrium (shiyaf kafuri), mucilage of fenugreek (luab al-hulbah), and a
yellow ophthalmic powder; alternatively he recommends rubbing the eyelid with a
mixture of myrrh, saffron, and acacia juice. In his Kitab al-Mansuri, the range of
simple and compound drugs for ophthalmia is smaller than in the previous work,
Kitab al-Taqsim; nevertheless, they differ substantially from therapy in the genuine
cases recorded in his Kitab al-Tajarib.
With regard to trachoma, the prescriptions in the case histories and those given
in Kitab al-Taqsim generally coincide. However, in the latter, theoretical, treatise,
Razi recommends scraping off the chronic trachoma, using first crystallized sugar
(tabarzad) and then an instrument called a wardah, which (as he explains in the text) is
a scalpel provided with a coin-shaped (dinar!) head. The scraping is to be performed
until the roughness disappears, and the eyelid must finally be rinsed with vinegar.
This procedure, however, is not performed on the patient in Razl's Casebook who
Or habb al-quqaya, laxative in the form of pastilles made of equal amounts of mastic, juice of
absinthe or leaves of scammony, aloe from Socotra, and colocynth; see R. Dozy, Supplement aux
dictionnaires arabes, 2 vols. (Leiden, 1881; reprinted Beirut, 1968), II, p. 428.
" Tryphera (Arabic trifil or atrlful) is an electuary or confection made of three different types of
myrobalans: black (or chebulic, halllaj), belleric (batilaj), and emblic (amlaj); see Dozy, Supplement, I,
p. 28, and Levey, Early Arabic Pharmacology, p. 86.
304 Cristina Alvarez-MilUn
suffers a chronic (atJq) trachoma. A similar pattern occurs with regard to pannus,
which in theory must be removed surgically, while in practice is treated only with
compound drugs. Table 1 summarizes the therapies for trachoma and pannus that
are advocated in the two theoretical treatises, Kitab al-Taqsim wa-al-tashjir and Kitab
al-Mansurl, as compared with the therapies actually practised by RazI and recorded
in Kitab al-Tajarib.
For pterygium, in both his Kitab al-Taqsim and Kitab al-Mansurl, RazI
TABLE 1. A comparison of the therapies recommended and the therapies actually practised by Abu Bakr
Muhammad ibn Zakariya al-Razi
Casebook
(Kitab al-Tajarib)
Kitab al-Taqsim
wa-al-tashjir
Kitab al-Mansurl
TRACHOMA
1 'red' collyrium
2 'green' collyrium
3 egg white (at night)
4 oil of rose (at night)
5 steam-bath (hammam),
the next day
CHRONIC TRACHOMA
1 venesection (cephalic)
2 cupping
3 decoction of myrobalan
(every two weeks)
4 eversion of eyelid and
rubbing with 'red' and
'green' collyria
5 no sleep with full stomach
6 diet of prunes, apricots,
andjulep
TRACHOMA WITH PANNUS
1 venesection (cephalic),
twice a month
2 purging with myrobalan
and hiera
3 gargling with oxymel
and mustard
4 sneezing
5 eversion and rubbing of
eyelid with 'green' collyrium
6 washing with hot water
7 a compound drug applied
to the eyes and temples
8 no sleeping with full
stomach
9 avoidance of heavy foods
10 another compound
remedy, applied at night
11 steam-bath (next day)
1 'red' collyrium
2 'green' collyrium
3 venesection
4 purging
5 steam-bath (hammam)
1 'red' and 'green' collyria,
regular application
2 venesection
3 purging
4 steam-bath (hammam)
5 avoidance of certain
foods
1 venesection 1 scraping
2 scraping, with tabarzad
sugar and a wardah
3 rinse with vinegar
4 application of chewed
cumin the next day
5 yellow ophthalmic powder
(dhanir)
6 'red' and 'green' collyria
LIGHT PANNUS:
1 'red' and 'green' 1 excision
collyria
2 basiTiqun coUyrium
3 nirsana collyrium
4 hot collyria
5 purging
6 steam-bath, regular visits
THICK PANNUS:
1 excision, lifting
with needles and hooks
and cutting with scissors
2 application of cumin
water and yellow ophthalmic
powder
Tenth-century Case Histories from the Islamic Middle East 305
recommends the 'green' collyrium and a collyrium called basiliqun or 'royal'.
Thick pterygium is to be removed by excision. However, the patient suffering
from that condition in Razi's Casebook is merely given a collyrium made of chickpea
dissolved in rose water and chicory water.
As for incipient cataract, while in his Kitab al-Mansiiri Razi simply states that it is
usually healed by treatment with drugs, in the Kitab al-Taqsim he recommends
a strong purgative (the pastilles of quqaya) and the avoidance of heavy foods,
while advocating the application of cupping glasses, collyria made of gall, and juice
of rue (sadhab) and sagapenum (sakabinaj). In actual practice, however, in the
Casebook the woman affected by an incipient cataract is treated only with juice of
fennel (raziyanaj), tryphera, and a collyrium made of sagapenum. On the other
hand, the tailor, who appears to present symptoms of incipient cataract, is pre-
scribed evacuation with prune juice, myrobalan, and sugar, to be followed by
taking mucilage of fleawort with crystallized (tabarzad) sugar every night and pome-
granate juice in the morning. If the pain recurs, he is to apply cold water to the eye
and consume acidic drinks; venesection is directed should the eyes become red.
The treatment for nightblindness can serve as a final example. In his Kitab al-
Taqsim, Razi recommends evacuation by means of a type of hiera, gargling, taking
drugs that cause sneezing, and the use of collyria made of gall. He also gives two
recipes for drugs to be instilled in the eye which he says are 'particularly useful'.
The first one combines pepper, long pepper, and honey in equal amounts. The
second simply consists of the juice rendered from a roasted goat's liver. In his Kitab
al-Mansuri, Razi begins by describing how to prepare and apply that juice in a
much more detailed manner. Then he continues with a second recipe for a drug
made of goat's gall and honey, to be applied with a probe (mil). Finally, he states that
collyria made of galls are even more useful, and that, if they fail, the patient should
be administered a purge, venesection, and a light diet. While in these theoretical
treatises Razi certainly varies in the order in which therapeutic measures must be
applied as well as in his estimates of their effectiveness, in the Casebook, patients
suffering from nightblindness are given vastly different treatments from those
recommended in the two theoretical treatises. Out of six patients, one is given a
simple decoction of myrobalan; another is prescribed a drug (naqi') made of soaked
aloe (sabr) and spices (afawih); a third is treated with hiera and a collyrium made of
sagapenum; while a fourth is treated with tryphera and a collyrium made of
sagapenum mixed with aristolochia (zarawand). Only one patient, after the intake
of pastilles of quqaya, is prescribed gargling, first with hiera and then with oxymel
(sikanjubin) mixed with colocynth (hanzal). Afterwards, the patient is to instil juice
rendered from goat's liver roasted with long pepper. The last of the six patients is
also prescribed the remedy made of goat's liver, which, Razi says, is 'particularly
effective', although on this occasion the patient is both to instil the juice in the eye
and to eat the meat. Interestingly, the patient reported that he had not yet eaten a
third bite when the veil disappeared, enthusiastically stating, in addition, that he
had employed cow's liver with an equally excellent result.
In conclusion, it appears that Razi depended upon medical writings not for the
improvement of his craft, but for the raising of his own professional status, and
306 Cristina Alvarez-Millan
perhaps for the better organization of his teaching. Moreover, it is clear that Razi's
clinical accounts depict medicine and disease in a very different manner from that
of the theoretical treatises. The extent to which theory modified the overall
intuitive spontaneity of Razi's treatments is difficult to assess, but it appears to have
played a relatively minor role. What is certain, however, is that the analysis of case
histories enables new questions to be raised, old problems to be reformulated, and
theoretical writings to be interpreted from new standpoints.
Acknowledgements
This paper has been made possible by a research project entitled Al-Razi's
'Kitab al-Tajarib': Edition and Study, funded by The Wellcome Trust (grant no.
045064/Z/95). I wish to thank the Wellcome Institute for the History of Medicine
for providing me with a 'wellcome' atmosphere of scholarly exchange as well as
material support and library facilities. I also wish to acknowledge the generous
assistance of D r Emilie Savage-Smith in the preparation of this study, her help in
the identification of some ophthalmic conditions, and the translation into English
of case histories.