2000 The Society for the Social History of Median!

Practice versus Theory: Tenth-century Case Historiesfrom the Islamic Middle East

ByCRISTINA ALVAREZ-MILLAN*

SUMMARY. Medicine and disease in medieval Islam have thus far been approachedthrough theoretical medical treatises, on the assumption that learned medical texts are atransparent account of reality. A question yet to be sufficiently explored is the extent towhich 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 asRhazes)the largest and oldest collection of case histories, so far as is known, in medievalIslamic medical literature. Since the author was a prolific medical writer, this study alsoincludes a review of his medical and therapeutic principles dealing with eye diseases, asdescribed in his learned treatises, and a comparison with those therapies actually employedin his everyday practice, as exemplified by the Casebook. The comparative analysis showsthat the medical knowledge and the therapeutic advice so meticulously described intheoretical works were not paralleled in the physician's medical performance. On thecontrary, it appears that learned treatises served other purposes than determining medicalpractice.

KEYWORDS: Medieval Islamic Medicine, Abu Bakr Muhammad ibn Zakariya' al-Razi,tenth century, Middle East, theory versus practice, Kitab al-Tajarib, Kitab al-Mansuri, Kitabal-Taqsim wa-al-tashfir, eye diseases

Not many years ago, a well-known historian of classical medicine wrote that 'atcertain times and places doctors appear to have depended upon literacy for theimprovement of their craft, the better organisation of its teaching, and the raisingof their own professional status. Yet the historian . . . is still left with the question ofthe extent to which practice was modified by this literary activity.'1 This statementis particularly appropriate to medieval Islamic medicine, since the practical aspectof medieval Islamic medical care has thus far been approached and describedthrough its prolific theoretical writings, on the assumption that learned medicaltexts are a transparent account of reality. Yet, while much ink has run on paperabout the achievements and practical dimension of medieval Islamic medicine asdepicted in academic treatises, case historiesthe source more likely to give us ahint of what learned medical practice actually involved in medieval Islamhaveuntil recently been largely neglected.

Case histories, reports of medical experiences, and a wide variety of clinicalaccounts which defy precise categorization are valuable instruments for medicalhistorians to study medicine and disease at a particular period. The earliest extant casehistories appear around the fifth to fourth century BC, in the seven books of Epidemicswithin the Hippocratic Corpus. Around the second half of the first century AD, Rumsof Ephesus left a collection of clinical accounts which have been preserved only in

* Universidad Complutense de Madrid.' I. M. Lonie, 'Literacy and the Development of Hippocratic Medicine', in F. Lasserre and P.

Mudry (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 insome of his works and also wrote a book in which he collected and described hismajor clinical cases.3 No further case histories beyond these ancient clinical accountsseem to have survived from Europe until the thirteenth century, when the Latintradition began to develop the medical genre of consilia.

In contrast to tenth-century Europe, from where no case histories appear tohave been preserved, the tenth-century Islamic tradition presents a rich body ofmaterials, from both eastern and western regions of the Islamic world. In thispaper, I will focus on clinical accounts recorded by the well-known physician AbuBakr Muhammad ibn Zakarlya' al-Razi , who died in AD 925. He was director ofhospitals in his home town of Rayy, near present Tehran, and in Baghdad, and wasa prolific author of medical writings, some of them very influential among Europeanphysicians and universities, such as his Kiiab al-Mansur't (Book for al-Mansur) and hisKitab al-Hawi (or Comprehensive Book on Medicine), known in the Latin tradition asLiber Almansoris and Continens, respectively.5 However, Razi's literary activity ofnearly 200 titles on different subjects seems to have been paralleled by his activity asmedical practitioner and teacher. In contrast to the lack of recorded case historiesin the tenth-century Latin tradition, Razi's medical practice as a clinician is attestedby approximately 1,000 case histories.

Although Razi included a number of case histories throughout some of histreatises, 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 isknown, within Islamic medical literature.6 I have divided this paper into twosections. The first one will deal with disease in the tenth-century Middle East. Thesecond will explore whether the theoretical principles of humoral medicine someticulously recorded in learned treatises were actually applied in practice or, inother words, to what extent medical practice was modified by or reflected thatliterary 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 hisstudents after his death. Since the purpose of collecting Razi's clinical consultationsis 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', inR. 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. Kuhne Brabant, 'al-Razi', in Storia della scienza, Instituto dellaEnciclopedia 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 worksother 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 conditionsencountered by a physician, Razi's Casebook actually constitutes an exceptionallyimpartial source for studying medical practice. Moreover, it reflects Razi's actualpractice as opposed to his formal medical writings, which present theories andideas that may not always have been implemented. What then is the Casebook'spicture of medicine and disease in the Middle East in the tenth century? Does itmatch 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 severalchapters on specific conditions, such as dropsy, colic, fevers, or skin disorders, anda final chapter devoted to recipes. In general, the clinical histories are not accountsof an illness from onset to recovery, but constitute brief notes taken at the patient'sbedside or in private consultations like the following one:He [Razi] was told of a young woman who had been coughing for five months and hadnow been vomiting a foamy blood for the last three days. He was presented with this in abowl, and it looked like pulmonary tissue. He said: 'This comes from the lung and waseasily 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 ofclassical Greek philosophy and Graeco-Roman medicine that were later elaboratedand developed by medieval Islamic authors in what is known as 'ArabizedGalenism'. In Razi's Casebook, sometimes diagnoses and theoretical explanationsappear in such terms as 'headache caused by a yellow bile vapour' or 'illness causedby an excess of bile that has crept to the head'; sometimes they are implicit in theuse of medical words such as 'epilepsy', 'pleurisy', or 'meningitis.' However, inmost 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 normalintestinal evacuation.'9 All these fragmentary expressions of the underlying diseasewere supposed to lead the physician towards the identification of the unbalancedhumour, and the counteracting treatment.

It is difficult at this distance to determine the nature of many cases as they aredescribed in Razi's Casebook. Often, the identification of the condition is pre-sumably implied by the enumeration of symptoms, instead of being explicitlyinterpreted from the theoretical point of view. For instance, in the chapter devotedto 'flatulence, colic, and constipation', a patient complains of pain in the belly,constipation, thirst, red urine, and discomfort when he eats something of a hotnature on an empty stomach.10 While the nature of that condition was presumablyclear to the medieval physician, the modern historian is at a loss to identify thenature of the disease (whether in humoral or in modern terms), to locate the actualseat 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 aparticular condition, since clinical accounts of a common combination of disordersdo not appear systematically together in any given section. For instance, in the firstchapter devoted to headache, the first patient presents with headache and night-blindness (ashawah) in one eye; the second patient suffers from headache and abilious vapour ascending from his stomach; in the third case, the patient complainsof headache, cough, and diarrhoea; the fourth patient complains of headache andpain in his right ear, which decreases when emptying his bowels, and so on.11Similar cases, however, are placed in the chapters devoted to eye conditions, chestailments, and ear disorders. A more significant example appears in the chapterdevoted to heart conditions: a woman is affected twice or three times a month by atype of fit. It begins with an itchy sensation of ants crawling over her body, fromher 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 ofthe hands and feet. When asked about her menstruation, the woman replies that ithas stopped, and the resulting diagnosis is 'suffocation of the womb (ikhtiriaq al-rahim).A2 Due to the variety of the symptoms, this case could actually have beenplaced in four other different chapters. Perhaps most of the woman's symptomswere understood as those of a heart disorder and, despite the final diagnosis, itremained in that particular chapter. On the other hand, in chapter four, dealingwith 'melancholy and different types of madness', we find a young man sufferingfrom 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 brickwalls. Another patient suffers from a fit of melancholia, accompanied by pensiveness(fikrah), desolation (wahshah) and anxiety (tafazzu). A third case is that of a womanwho speaks nonsense and laughs compulsively, accompanied by redness all overher face. Finally, the fourth case deals with a slave who looks mad and startled, hiseyes fixed; he does not speak and does not reply when addressed, his peristalticmovement had stopped five days before, and the condition had then set in. Hecould not stay in just one place, kept turning his face around, and unwillinglypassed water every nightone infers, in the bed.13 In the following chapter, wealso find a case in which the patient presents very similar symptoms. However,Razi's diagnosis is that the young manwho speaks nonsense, gets angry withoutreason, 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 toplace the case in the chapter entitled 'On palsy, numbness of extremities, and theremaining brain and nerve disorders.'

A further point relevant to the description of disease in the Casebook is that theundentanding 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 297regarding some conditions leads them to consider, for instance, diabetes as a diseaserelated to the kidneys, while some psychological affections are taken to be heartconditions, and a breast disorder such as the following one is included in thechapter devoted to chest conditions:A woman presented whose breasts had become dark and one of which was hard, as thoughit were a movable and protruding growth. He [Razi] said: 'This is a serious matter, since itfeels hot and is flushed; this heat is overpowering her and has unbalanced the humours. Onemust draw the conclusion that the tumour is a cancer, but the cancer does not protrude, forotherwise it could be extirpated.' He prescribed that she take one tnithqal of shabyar [asoporific electuary] every night, that she wash and then anoint [the tumour] with oil ofsesame or violet. Dietanything that moistens and soothes.15

Nevertheless, such an unusually large collection of case histories gives a livelypicture of diseases occurring in the tenth-century Middle East, and also some ideaof the most frequent complaints. Since there is no feature which would suggest thatit is a formal treatise adulterated with literary elaboration, we can perhaps assumethat this collection reflects the proportional occurrence of diverse conditions inBaghdad, or Rayy, or nearby regions.

In the Casebook, we find only a few patients suffering from migraine, epilepsy, earproblems, nosebleeds, running nose and catarrh, toothache, and inflammation ofthe tongue, or throat conditions such as pain, irritation, soreness, and difficulty inswallowing. There are also a small number of cases of pleurisy and asthma. Heartconditions for the most part seem to consist of palpitations, usually accompaniedby other symptoms and occasionally combined with additional disorders, suchas inflammation of the membrane of the oesophagus (hijab al-mari'), apnoea, oringuinal hernia. Other cases included in the chapter on heart disorders consist ofemotional and psychological troubles, such as desolation and heart constriction (diqal-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 givenconsist of swelling, heat, or pain in that organ. In different chapters, we find a fewcases relating to dropsy and jaundice. Also few in number are the patients sufferingfrom spleen disorders such as pain, inflammation, or hardness.

Concerning the rectum (maq'adah), most cases involve bleeding, caused eitherby ulcers, cracking (shiqacj), fistula ormore oftenby haemorrhoids. There arealso two patients suffering from intestinal worms (didan), and a man who cannotcontrol the air that he is passing. As for male genitalia (khusa wa-madhakir), patientsgenerally complain of swelling and/or pain in the testicles, but there are, too, patientswho complain only of a burning sensation in the penis or urethra (Mil), sometimesaccompanied by a bloody discharge. Complaints about uterine conditions are verydiverse: burning sensations, pain, ulcers, abscesses in the vagina or uterus; womensuffering from hypermenorrhoea; women whose menstruation has stopped; womenreporting only a slight menstruation after labour; women in labour who bleedmore than is normal; a woman who had delivered a child but not expelled theplacenta; 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 normalmenstruation and then bloodletting, as a consequence of which she was affected byunsteadiness (khiffah), anxiety, and diarrhoea.

There is a section in the Casebook devoted to patients who have fallen downwhile riding an animal or in the hammamthat is, steam bathbut none of thempresents any broken bones. Scattered throughout the work, we also find severalcases of cancer (saratan) affecting the eye, the stomach, the face, the back of theneck, and one affecting the leg. Hernia (fatq) was apparently not a sufficientlyinteresting or frequent occurrence to deserve a particular section. Five patientscomplaining of other disorders, however, are said to suffer from that condition. Inthe chapter devoted to stomach disorders, we find two cases of abdominal hernia,16and one case dealing with what is described as abdominal prolapsis.17 A patientaffected by a heart condition and another one suffering from diabetes also presentan inguinal hernia.18 Diabetes occurs several times, both in the chapter devoted tokidney conditions, and throughout the work as the cause of other complaints, as inthe case of a woman having problems with her vision.

The last chapter in Razi's Casebook deals with 26 unusual cases, including a manhit on the thigh by an arrow some time before the consultation; freckles (kalaf) onthe face; a man who, at the end of spring, sweats all over his body when he walks; aman who treated himself erroneously by taking litharge; a woman who had takeniron filings, causing pain in her chest; a secretary (one of the kuttab) whose armpitssweat heavily, causing him nausea; someone who cannot digest barley-water; a manwith a cut on his face caused by a sword; and a traveller who swallowed some coinsto 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 firstsymptom, presumably the first to be mentioned by the patients. These symptomsare combined or mixed with other disorders throughout the work. There are anumber of patients suffering from kidney and bladder conditions. Most of them aredescribed in terms such as 'burning sensation when passing water', 'burning sensationin bladder' accompanied by discharge or fever, 'pain in the bladder, passing waterdrop by drop', 'pain accompanied by discharge', 'blood in urine', 'difficulty inpassing water' combined with a burning sensation, with discharge, oras in onecasewith sexual impotence (dufquuwati-hi 'aid al-bah). Apart from a few patientssuffering from excessive urination (idrar al-bawt) or pained by ulcers or stones in thebladder or kidney, there are also some unusual cases, such as that of a child sufferingfrom a bladder stone which is passing out through his penis {qadlb) accompanied byan itch in the testicles. Additionally, there is the case of a woman who, after fallingdown a well, has weakness in her feet and is not able to pass water; or that of an oldman 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 299kidney and bladder disorders and on sexual intercourse', there is only one case of aman 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 about50 cases. Most of these complaints are accompanied by other symptoms such asconstipation or diarrhoea, headache, fever, nausea, trembling of the hand, anddifficulty 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 Medinaworm or Guinea worm (al-'irq al-madarii) is mentioned.20 This is a worm 5070 cmlong that lives in the subcutaneous tissue of human beings. On maturity, the headof the female breaks through the skin (usually of the lower leg) and dischargeslarvae into stagnant water in which the penon bathes. The larvae are then eaten byCyclops crabs, and, through drinking water contaminated by these crabs, humansthen get larvae in their stomachs, and the cycle begins again. It takes about ayear for a cycle to be completed. The condition was known to medieval Islamicphysicians, but they did not understand the cause and mistakenly thought it was avaricose vein. Significantly, given this confusion, no actual case appears to occurin 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. Forexample, in one patient the pustules look like apples under his armpit and on hisshoulder, and in another the pustule hangs like a red aubergine. Other skin disordenappearing in the work are scabies (jarab), general itching (hikkah), a type of itchyskin eruption (sharan), abscesses on the skin, and a type of ulcer (sa'fah), plus singlecases 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 involvingburning by fire, and the actual complaint consists in the area having remainedswollen and rough. In another section, but also dealing with skin conditions, wefind around ten cases of leprosy in different stages.22

Fever appears to have been one of the most frequent conditions, since, apartfrom being often mentioned as an additional symptom, it is the main complaint in77 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 widespreadcondition in the tenth-century Middle East. Apart from diarrhoea, andto amuch lesser extentdysentery (zahir), we find different types of colic, sometimesdiagnosed as such {qulanj, maghas, 'Maws), but more often described as 'pain in thebelly', accompanied by constipation or loose faeces. The chapter concerned withstomach disorders contains 98 case histories. Amongst them, 20 cases present ageneral 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

T h e r e are t w o cases o f black vit i l igo (bahaq aswad), t w o cases o f leprosy (bams) a n d six cases o fanother ulcerative skin condition (qawabi). For a discussion of these terms, all of which were used forsymptoms of leprosy, see M. Dols, 'Leprosy in Medieval Arabic Medicine', Journal of the History ofMedicine and Allied Sciences, 34 (1979), 314-33.

300 distinct Alvarez-Millan

stomach. Twenty-eight cases present stomach-ache, in some instances with thepain spreading towards the shoulder or elsewhere. Twenty-one patients complainof vomiting, five of them producing blood. Other recorded stomach conditionsare weakness of the stomach, inflammation, lack of appetite, flatulence (riyah, orpossibly some other disorder considered aerate in humoral terms), nausea, obstruc-tion, and a burning sensation in the stomach. We also find a number of cases inwhich vomiting, pain, inflammation and/or flatulence (riyah) appear together, aswell 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 ofthe 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 medievaltheoretical treatises approach disease in a different mannerthat is, in termsof humoral imbalance, employing a technical vocabulary specific to humoralpathologythe question arises of whether the medical disorders encountered byRazi and recorded in his Casebook actually correspond to the types of conditionsdescribed in theoretical treatises.

By way of example I would like to analyse the chapter in the Casebook dealingwith eye conditions, which, given the number of recorded cases, appears to havebeen one of the most prevalent disorders. The section contains 48 cases.23 Theophthalmic complaints which we have in Razi's Casebook include the following:

1 Ophthalmia (ramad)4 cases. In one case accompanied by a strong headacheand heaviness in the forehead; in another by headache and redness in the lefteye and constipation. A third patient presents swelling and redness in theeyelids and arrives at the consultation screaming because of pain in the tem-ples. In the fourth case, ophthalmia is accompanied by a burning sensation inthe head.

2 Trachoma (jarab)4 cases. One case is combined with pannus (sabal),24 andanother with headache.

3 Excessive lachrymation (darnah)4 cases. On one occasion it occurs onlywhen sneezing, and on another it is accompanied by redness in the eyes.

4 Nightblindness6 cases. The medical term for this condition (asha) isemployed only in a consultation by letter, while in three cases it is referredto by a synonym (ashawali); in two other cases, patients literally complain ofnot 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 byvessels from the limbus, usually being a sequela of trachoma. See E. Savage-Smith, 'Ibn al-Nafis'sPerfected Book on Ophthalmology and His Treatment of Trachoma and Its Sequelae', Journal for theHistory of Arabic Science, 4 (1980), p. 149.

Tenth-century Case Histories from the Islamic Middle East 3016 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 thepupil (intishar) or cataract although the eye is red, all of which turns out to be anacute ophthalmia. There is also one patient who complains of trembling in oneeye, accompanied by redness, traces of blood, and fever, while another patientpresents 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, swolleneyelids, 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 thesame inner surface due to engorgement of blood. A one-year-old child presents agreenish-black spot on the inner surface of one eyelid, which he has had since birthbut which has increased over the months.

Other conditions are described as dullness of vision (zulmah) in the eye whichincreases when the patient is hungry, the condition actually being caused bydiabetes; dullness of vision due to excessive smelling of musk; increasing darknessin both eyes when the patient's stomach is full; dullness of vision making itimpossible to see anything without intense focusing; dullness of vision in the eyeand the imaginary seeing of things as darker than they really are. There is also thecase of a tailor who feels pain in the pupil when looking at white things, followedby dullness of vision. Occasionally, he sees something like insects in between hiseyes and feels heat and roughness in his throat and a bitter taste in his mouth. Atraveller about to set off also complains of dullness of vision in one eye, but presentsno trace of cataract or dilation of the pupil. Finally there is the case of a womanwith an extended protuberance of a violet colour which conceals the pupil in oneof her eyes.

I would now like to look at the contents of two theoretical treatises written byRazi. 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 theeye, 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 7conditions out of these 18 occur in the case histories (ophthalmia, trachoma,pannus, pterygium, lachrymation, cataract, and nightblindness), or, put the otherway round, only 17 ophthalmic cases out of 48 in the Casebook are the subject oftheoretical 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 headto toe, gained widespread circulation in the Latin tradition, eventually seeingseparate printed editions and being commented upon by university scholars andanatomists like Vesalius. Here Razi deals with treatments for ophthalmia, ulcers inthe 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-nasural-kainfi amaq al-ayri). When Razi's Kitab al-Mansuri is compared with the casesin Kitab al-Tajarib (the Casebook), 10 conditions out of the 15 mentioned in theformer occur in real patients. Again, however, the majority of the complaints in theCasebook, with their complexity and mixtures of symptoms, are not described in thetheoretical treatise, whose popularity ostensibly derived from its practical character.

Tenth-century treatises devoted exclusively to ophthalmology, produce similarresults. For instance, in his Tadhkirat al-kahhalln, 'All ibn Tsa al-Kahhalwriting inBaghdaddescribes approximately 66 conditions affecting the eyelids, the innercorner, the conjunctiva, the cornea, and the iris.28 Out of these theoreticaldescriptions, only eleven seem to occur amongst the case histories in Razi's Kitabal-Tajarib.

We have been dealing with disease, but what about therapy? What do casehistories 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 MiddleEast as depicted in Razi's Casebook. The fact that some complaints do not matchany particular theoretical model implies that therapy must have been adjusted tothe particular needs of each patient. This is confirmed to some extent by thetreatments prescribed in Razi's clinical accounts, where diet and pharmacologicalagents vary from one patient to another, and venesection and cupping glasses areapplied to different parts of the body. Moreover, purgatives are prescribed invarying strengths and dosesthat is, from just the intake of prune juice with sugaror 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 M u h a m m a d ibn Zakariya" a l -Razi , Al-Taqsim wa-al-tashjjr: Taqaslm al-'ilal, edi t ion and

French translation by S. M . H a m m a m i (Aleppo, 1992), p p . 10635.27

Abu Bakr M u h a m m a d ibn Zakariyaf a l -Raz i , Kitab al-Mansun, Escorial, Rea l Biblioteca delMonas te r io , Arabic M S . 858 , fols. 116b-120a .

28 See 'All ibn 'Isa al-Kahhal , Memorandum Book of a Tenth-Century Oculist, trans. C . A. W o o d

(Chicago, 1936).29

A c o m p o u n d purgat ive r emedy in w h i c h drugs o f a b i t ter taste are mixed w i th aromat ic drugs,the main ingredients be ing aloe and c i n n a m o n ; see M . Levey, Early Arabic Pharmacology (Leiden,1973), pp. 85-6.

Tenth-century Case Histories from the Islamic Middle East 303combination of hiera with quqaya,30 and tryphera.31 Given the range of ophthalmicconditions in Razl's Casebook, the variation of treatment from one patient toanother is actually quite small, for therapy seems to have been concentrated onevacuation 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 expulsionof the humour at fault, these methods constituted the first line of treatment forevery type of disease.

The general characteristics of ophthalmic therapy apply to the entire Casebook. Itshould also be noted that no surgery is recorded amongst Razi's case histories.Likewise, no magical recipe, talisman, or astrological procedure occurs, and musictherapy is also missing. As for particularly revolting ingredients often associatedwith 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 fromroasted goat's liver, seasoned with long pepper (darfulful), is said to have particularproperties useful for nightblindness. However, this therapeutic agent is also praisedby Razi in his theoretical treatises.

What, then, is the relationship between therapy as prescribed in Razi's casehistories and that recommended in his theoretical works? For ophthalmia, Raziprescribes 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 athis Kitab al-Taqsim, however, he recommends different treatments according tothe cause. The most striking feature is that egg white and oil of roses are not referredto at all, and milk is mentioned only in passing, and with no specification that it comefrom a wetnurse. Instead, Razi recommends the topical application of one or moresubstances including a 'white' collyrium, a white ophthalmic powder (dhariir),mucilage offleawort (luab bizrqatunah), mucilage of quince seed (luab habb safarjal), acamphorated collyrium (shiyaf kafuri), mucilage of fenugreek (luab al-hulbah), and ayellow ophthalmic powder; alternatively he recommends rubbing the eyelid with amixture of myrrh, saffron, and acacia juice. In his Kitab al-Mansuri, the range ofsimple and compound drugs for ophthalmia is smaller than in the previous work,Kitab al-Taqsim; nevertheless, they differ substantially from therapy in the genuinecases recorded in his Kitab al-Tajarib.

With regard to trachoma, the prescriptions in the case histories and those givenin 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) isa scalpel provided with a coin-shaped (dinar!) head. The scraping is to be performeduntil 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 ofabsinthe or leaves of scammony, aloe from Socotra, and colocynth; see R. Dozy, Supplement auxdictionnaires 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 ofmyrobalans: 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 withcompound drugs. Table 1 summarizes the therapies for trachoma and pannus thatare advocated in the two theoretical treatises, Kitab al-Taqsim wa-al-tashjir and Kitabal-Mansurl, as compared with the therapies actually practised by RazI and recordedin 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 BakrMuhammad ibn Zakariya al-Razi

Casebook(Kitab al-Tajarib)

Kitab al-Taqsimwa-al-tashjir

Kitab al-Mansurl

TRACHOMA1 'red' collyrium

2 'green' collyrium3 egg white (at night)4 oil of rose (at night)5 steam-bath (hammam),the next day

CHRONIC TRACHOMA1 venesection (cephalic)2 cupping

3 decoction of myrobalan(every two weeks)4 eversion of eyelid andrubbing with 'red' and'green' collyria5 no sleep with full stomach

6 diet of prunes, apricots,andjulep

TRACHOMA WITH PANNUS1 venesection (cephalic),twice a month2 purging with myrobalanand hiera3 gargling with oxymeland mustard4 sneezing5 eversion and rubbing ofeyelid with 'green' collyrium6 washing with hot water7 a compound drug appliedto the eyes and temples8 no sleeping with fullstomach

9 avoidance of heavy foods10 another compoundremedy, applied at night

11 steam-bath (next day)

1 'red' collyrium

2 'green' collyrium3 venesection4 purging5 steam-bath (hammam)

1 'red' and 'green' collyria,regular application2 venesection3 purging4 steam-bath (hammam)5 avoidance of certainfoods

1 venesection 1 scraping2 scraping, with tabarzadsugar and a wardah3 rinse with vinegar

4 application of chewedcumin the next day

5 yellow ophthalmic powder(dhanir)6 'red' and 'green' collyria

LIGHT PANNUS:1 'red' and 'green' 1 excisioncollyria2 basiTiqun coUyrium

3 nirsana collyrium4 hot collyria5 purging

6 steam-bath, regular visits

THICK PANNUS:1 excision, liftingwith needles and hooksand cutting with scissors2 application of cuminwater and yellow ophthalmicpowder

Tenth-century Case Histories from the Islamic Middle East 305recommends the 'green' collyrium and a collyrium called basiliqun or 'royal'.Thick pterygium is to be removed by excision. However, the patient sufferingfrom that condition in Razi's Casebook is merely given a collyrium made of chickpeadissolved in rose water and chicory water.

As for incipient cataract, while in his Kitab al-Mansiiri Razi simply states that it isusually healed by treatment with drugs, in the Kitab al-Taqsim he recommendsa strong purgative (the pastilles of quqaya) and the avoidance of heavy foods,while advocating the application of cupping glasses, collyria made of gall, and juiceof rue (sadhab) and sagapenum (sakabinaj). In actual practice, however, in theCasebook the woman affected by an incipient cataract is treated only with juice offennel (raziyanaj), tryphera, and a collyrium made of sagapenum. On the otherhand, the tailor, who appears to present symptoms of incipient cataract, is pre-scribed evacuation with prune juice, myrobalan, and sugar, to be followed bytaking 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 eyeand 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, takingdrugs that cause sneezing, and the use of collyria made of gall. He also gives tworecipes 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. Thesecond simply consists of the juice rendered from a roasted goat's liver. In his Kitabal-Mansuri, Razi begins by describing how to prepare and apply that juice in amuch more detailed manner. Then he continues with a second recipe for a drugmade of goat's gall and honey, to be applied with a probe (mil). Finally, he states thatcollyria made of galls are even more useful, and that, if they fail, the patient shouldbe administered a purge, venesection, and a light diet. While in these theoreticaltreatises Razi certainly varies in the order in which therapeutic measures must beapplied as well as in his estimates of their effectiveness, in the Casebook, patientssuffering from nightblindness are given vastly different treatments from thoserecommended in the two theoretical treatises. Out of six patients, one is given asimple decoction of myrobalan; another is prescribed a drug (naqi') made of soakedaloe (sabr) and spices (afawih); a third is treated with hiera and a collyrium made ofsagapenum; while a fourth is treated with tryphera and a collyrium made ofsagapenum mixed with aristolochia (zarawand). Only one patient, after the intakeof pastilles of quqaya, is prescribed gargling, first with hiera and then with oxymel(sikanjubin) mixed with colocynth (hanzal). Afterwards, the patient is to instil juicerendered from goat's liver roasted with long pepper. The last of the six patients isalso prescribed the remedy made of goat's liver, which, Razi says, is 'particularlyeffective', although on this occasion the patient is both to instil the juice in the eyeand to eat the meat. Interestingly, the patient reported that he had not yet eaten athird bite when the veil disappeared, enthusiastically stating, in addition, that hehad employed cow's liver with an equally excellent result.

In conclusion, it appears that Razi depended upon medical writings not for theimprovement 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'sclinical accounts depict medicine and disease in a very different manner from thatof the theoretical treatises. The extent to which theory modified the overallintuitive spontaneity of Razi's treatments is difficult to assess, but it appears to haveplayed a relatively minor role. What is certain, however, is that the analysis of casehistories enables new questions to be raised, old problems to be reformulated, andtheoretical 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 Medicinefor providing me with a 'wellcome' atmosphere of scholarly exchange as well asmaterial support and library facilities. I also wish to acknowledge the generousassistance of Dr Emilie Savage-Smith in the preparation of this study, her help inthe identification of some ophthalmic conditions, and the translation into Englishof case histories.