Thursday, June 7, 2007

Medical History


Arabic Medicine in the Mediteranean


The physician Razi (circa 865-925 C.E.) at the bedside of a young patient afflicted with measles.
by Charles Burnett Professor of the History of Islamic Influences in EuropeWarburg InstituteUniversity of London

In spite of differences of religion and language, a single scientific culture can be found throughout the Mediterranean region from at least the period of the Roman Empire until the early modern period. This culture was developed by the Greeks (who themselves owed much to the Egyptians, the Mesopotamian civilisations and the Indians), partly committed to Latin in Antiquity, but more comprehensively translated into Syriac and Arabic from the seventh century onwards; from the late tenth century onwards the slender threads of ancient science in Latin began to be woven into the rich fabric of Arabic science, so that, by the mid-thirteenth century, Latin culture in Europe enjoyed the same level of sophistication as Arabic culture in the Islamic world and relied on the same authorities: the Greek classics of arithmetic (Nicomachus), geometry (Euclid), astronomy (Ptolemy), astrology (again Ptolemy, but also Dorotheus and Vettius Valens), and medicine (Hippocrates and Galen), as well as the Arabic masters in arithmetic, algebra and trigonometry (al-Khwarizmi and Abu Kamil), in astronomy (again al-Khwarizmi, al-Battani, and az-Zarqali), astrology (Abu Ma‘shar and numerous others) and medicine (Hunayn ibn Ishaq, Ishaq al-Isra'ili, Ibn al-Jazzar, az-Zahrawi, and, again, numerous others). Moreover, through the spreading of Islam to Persia, Central Asia, the Indian subcontinent and beyond, the same scientific culture embraced an area far wider than the Mediterranean basin. Thus, a work written by an astronomer in Morocco in the thirteenth century can be found copied in a manuscript in Hyderabad. A `philosopher' at the court of Frederick II in Sicily, originating from Antioch, was trained in medicine and philosophy in Mosul and Baghdad, and served the Turkish Seljuks of Rum and the Armenian regent before coming to Western Europe. A scholar writing a philosophical work in Greek, also in Sicily in the thirteenth century, could use a Latin translation of a commentary on Aristotle by the Arabic Ibn Rushd, etc.
The history of this culture in respect to medicine can be summarised briefly. Ancient Greek medicine culminated in the work of Galen (who wrote in Greek in Rome in the second century CE). His works, several of which are commentaries on those of Hipppocrates of Kos, fill 39 volumes in their modern edition, but a selection of 16 of them was made for teaching medicine in Alexandria in late Antiquity. Greek medical centres flourished in Rome, Constantinople, Antioch, Edessa and Amida, and even spread into the Sassanid kingdom of Persia. After the rise of Islam, it was from one of these Persian centres, Gundishapur in southwest Iran, that, according to a well-known story of the time, a Nestorian Christian doctor called Jurjis ibn Jibra'il ibn Bakhtishu‘, came to Baghdad in the third quarter of the eighth century, and introduced Greek medicine to the caliph there. But other Syriac Christian communities within the Islamic caliphate were also sources for this medical knowledge. In the early ninth century, a ‘house of wisdom' was founded in Baghdad, as a library and a centre for the translation of scientific texts. It is here that Hunayn ibn Ishaq, another Nestorian Christian, translated into Syriac or Arabic a vast number of Greek texts, including (of Galen's works) some 95 into Syriac, and 34 into Arabic. (His son Ishaq ibn Hunayn, and his nephew Hubaysh, rendered the remaining Syriac texts into Arabic.) But Galen was not the only source of Arabic medicine: another Christian, Ali ibn Sahl Rabban al-Tabari, included a chapter on Indian medicine in his book The Paradise of Wisdom, written in 850.
Some who were concerned at the danger of the faith shown in Greek science generally as threatening Islam, established a ‘medicine of the Prophet', based on the sayings of Muhammad, and indigenous Arabic medical lore. However, the Galenic tradition became the main source of medical learning, and the great Arabic and Muslim medical writers belonged to it: Abu Bakr Muhammad ibn Zakariya al-Razi (865-925), Ali ibn al-‘Abbas al-Majusi (tenth century), and above all, Abu ‘Ali al-Husayn ibn ‘Abdallah Ibn Sina (Avicenna, d. 1037). These scholars and practitioners wrote their main works in Arabic, but by origin were Persian, and we can deduce from the name of al-Majusi that he came from a Zoroastrian family. During the eleventh century an important medical centre developed in Qayrouan in present-day Tunisia, and it is from here that a certain `Constantine the African' travelled to nearby Sicily and Salerno in Southern Italy in the third quarter of the eleventh century and introduced Arabic medicine to the West for the first time. In Salerno there was already a school of medicine, where a few Greek medical texts, mainly of a practical nature, were known in Latin translations. Constantine complemented, and a to a large extant, replaced these texts with his translation of the comprehensive medical textbook of al-Majusi, and several texts by the Qayrouanese doctors, Ishaq Isra'ili, Ishaq ibn ‘Imran, and Ibn al-Jazzar. In this context a short curriculum of five texts on medicine was established, called the Articella, which was based on translations from both Arabic and Greek, and included texts on determining medical conditions by examining urine and by feeling the pulse, respectively. Constantine's work was, in turn, complemented by the activity of Gerard of Cremona in Toledo (d. 1187) in the mid-twelfth century, who translated from Arabic several of the texts of Galen from the Alexandrian curriculum, as well as substantial works by al-Razi and the Spanish-Arabic authors, al-Zahrawi and Ibn al-Wafid. His most important contribution, however, was the translation of Avicenna's Canon of Medicine, which became the main textbook for medical education in Western universities until well into the seventeenth century.
What was the nature of this medicine? Avicenna gives the classical definition at the beginning of his Canon: ‘I say that medicine is a science in which one learns of the states of the human body with respect to what is healthy and what deviates from it, for the purpose of preserving health when it already exists, and restoring it when it has been lost.' The basis of this medicine was ‘humoral pathology', i.e. an understanding that the human body consisted of four humours: blood, yellow bile (choler), phlegm, and black bile (melancholy), which were related to other `quaterneries': the elements air, fire, earth and water; the seasons spring, summer, autumn and winter; the ages of man, childhood, youth, middle age and old age; and the triplicities of the signs of the zodiac. Good health depended on the four humours being well-balanced in respect to each other (the Greek term is ‘eukrasia' – a ‘good mixing', ‘temperament' or ‘complexion'). According to an account (reported, for example, by Petrus Alfonsi, the Arabic-educated Christian convert from Judaism in the early twelfth century), Adam was created with a perfect balance of the four humours. Galen, however, believed that each man had an individual complexion, determined by his nature and age, and by external factors such as the climate. Hence each person had a `temperament' which affected both his character and his health, and could be described as sanguine, choleric, phlegmatic or melancholic. The aim of medicine was to preserve the best temperament for each man, and to restore the balance of the humours when one or other became excessively strong or weak. For the first, comprehensive works on `diets' and `regimina sanitatis' (i.e. healthy living practices) were compiled, the best known being that of Ishaq Isra'ili, in which different `diets' are prescribed according to the temperament of the man, his age, the climate, the time of year, etc. For the second, it was necessary either to drain off or burn off the excessive humour (by `blood-letting' or `cautery' respectively), or to counteract the deficiency of one humour by prescribing medicines rich in the opposite one. Since each humour was conceived in terms of an element with two qualities (e.g. melancholy was earth, consisting of the cold and the dry), one used medicines which had the requisite complementary qualities. Thus plants, minerals, seeds, `waters' and the other `simple medicines' were described in terms of how hot, cold, dry and moist they were. For each quality there were four degrees, and these are listed in textbooks called `books of simples' or ‘of degrees'. For example, Ibn al-Jazzar (in a work translated by Constantine the African as ‘Liber de gradibus') writes that: `Aloes wood is hot and dry. both in the second degree: it strengthens the brain and all the interior parts of the body. It drives out superfluous moisture from the body, and especially dissolves ‘windiness' in the stomach (i.e. flatulence). It stops diarrhoea and attacks incontinence which results from coldness and weakness of the bladder'[1] .
The origin of this classification by ‘degrees', which is fully developed in Galen, is not clear. In Arabic medicine, however, the system is extended much further, probably under Indian influence. First, foods become classified under one of eight `tastes', each of which is associated with two qualities (e.g. sweet is hot-moist, and therefore associated with air and blood). Thus, the qualities of different foodstuffs can be gauged by tasting them. This leads some writers to say that taste is, in fact, the most dependable of the five senses, because it alone discerns the true nature of a substance. (Arabic doctors may owe their systematization of the tastes to Indian medicine, although the number of tastes for the Indians is six;[2] ) This classification is extended to the planets and to the signs of the zodiac, so that Jupiter is described as sweet and Mars, bitter; the triplicity of Aries is bitter, while, of the individual signs in the triplicity, Aries is hot in the second degree and dry in the first, Leo is hot and dry in the fourth degree and Sagittarius is hot in the first degree, and dry in the second.[3] The right amount of the relevant qualities can also be obtained by combining several different ingredients, in `compound medicines' or `theriacs' (the origin of our word ‘treacle'), which also formed a genre of medical literature.
Constantine the African, in the preface to his translation of al-Majusi, regards medicine as belonging as much to ethics as to natural science and logic/metaphysics (the two other divisions of secular science current in his day). In the same work, he translates al-Majusi's version of the ancient Hippocratic oath, of which some phrases may be given here: ‘Whoever a master undertakes to educate (in medicine), should be of good character and should in turn teach others, without payment.… aim should be to restore the health of the patient, and he should not do this in the hope of earning money, nor should he pay more attention to wealthy patients than to poor ones, or to the noble rather than the ignoble. He should not include harmful potions in his teaching, nor allow his pupils to do so, lest any lay person might overhear the lesson and mix a deadly potion on his own accord. Nor should he teach how to cause an abortion. When he visits the patient he should not pay amorous attentions to the wife (of the patient) or his maid or daughter… He should avoid overindulgence; he should beware of the delights of this world, including alcohol. Such things disturb the mind and strengthen the vices of the body… He should be god-fearing, humble, kind, and loving, and should seek to be helped by divine aid'.
A more basic ethical dimension, however, is intrinsic to Arabic medicine in itself. As I have already indicated, the complexions also determined the character of the individual--whether he is sanguine, melancholy etc.--and the whole idea of balancing the humours by avoiding excesses has a moral tone. But above all, this kind of medicine can be seen as encompassing both the body and the soul. Galen wrote a separate text on `how the nature of the soul follows the complexion of the body', and many symptoms that we might today characterise as emotional states, such as ‘love sickness' and `melancholy', were classified along with physical diseases. Correspondingly, therapies included pleasant recreations, and, especially, music.
Music
In certain texts `spiritual diseases' were separated from `bodily diseases'.[4] Thus al-Razi added to the book of medicine that he composed for his patron, Abu Salih al-Mansur, governor of Rayy, another book `on spiritual medicine' (al-tibb al-ruhani), which he begins as follows:
"Now that I have finished describing physical remedies, I am going to mention spiritual ones. Know that mental diseases are also amenable to treatment. But their treatment is carried out by means of musical instruments which convey to the soul through the sense of hearing the harmonious sounds which are created by the motions and contacts of the heavenly spheres in their natural motion, which affect the right perceptions…"
The Greek doctor, Rufus of Ephesus, dedicated a whole text to cures for melancholy, of which fragments have survived mainly in Arabic medical works. As a sample one may quote the following passage from Ibn al-Jazzar's Guide to the Traveller (Viaticum):
In the case of sickness caused by excessive love, to prevent men from being submerged in excessive brooding, tempered and fragrant wine should be offered, and hearing various kinds of music and speaking with dear friends (should be encouraged)… Rufus says: "Sadness is taken away not only by wine drunk in moderation, but also by other things like it, such as a temperate bath. Hence it is that, when certain people enter a bath, they are inspired to sing. Therefore, certain philosophers say that the sound is like the spirit, the wine is like the body, of which the one is aided by the other." Others say that Orpheus said: "Emperors invited me to feasts so that they might take their pleasure from me, but I am, rather, delighted by them, since I can turn their spirits in whatever direction I want to, for example from anger to gentleness, from sadness to happiness, from greed to generosity, from fear to boldness". This is the application of musical instruments and wine in respect to the health of the soul'.
In the Arabic world, the effects of music were made into a science of music therapy. The various `modes' (called maqamat) out of which melodies were composed, which differed by both rhythmic and melodic patterns, were brought into line with the humoral quaterneries that I have already described. At the simplest level `cold' maqamat could be used for refreshing patients during the day, while ‘hot' maqamat were appropriate to the evening and at night-time.
But more detailed combinations were devised: e.g. al-Kindi, the ninth-century ‘philosopher of the Arabs', assigned 12 maqamat to the twelve signs of the zodiac, with which they shared the corresponding elemental qualities. He extended the analogy further: the ratios which create musical harmony would have the same effects as the aspects of the planets, one to another, in the sky. A tenth-century writer, Ibn Hindu, describes how these theories should be put into practice:
`There is a maqam which arouses sadness, another which brings joy, one relaxing and tranquilizing, another disquieting and exciting, one which keeps one awake, another which induces sleep. Whenever we order those who suffer from melancholy to be treated with the respective modes, it helps them. The physician need not himself be a performer of the drum, the flute or the dance, just as he does not need to be a pharmacist or a phlebotomist, but rather he employs these people to aid him in his therapy.'
In the mid seventeenth century the Turkish sultan Bayezit is described as employing ten musicians for the cure of the sick, to strengthen the spirit of the mentally ill, and to reduce black bile. Three of them were singers, the rest were instrumentalists who played the flute, violin, flageolet, cymbals, harp and lute. They came three times a week and played a piece for the ill, whereupon many of them felt relieved. They understood most of the maqamat. When the maqamat Rast, Busalik and Zankula were played, they instilled life in the patients. He ends by saying that `all instruments and all maqamat provide nourishment for the soul.'
As in the classification of tastes, so in that of maqamat the Indians provide a close parallel in their doctrine of raga. Both could have influenced Arabic mentalities at the time when Indian astronomers arrived in Baghdad with texts on astronomical tables and astrology in the late eighth century.
Balance of Mind, Body and Spirit
I emphasize the role of music and astrology to underline the holistic nature of Arabic medicine. The balance within a human being depended on the balance within the natural world surrounding him, and the harmony within his body and soul (as the microcosm) reflected the harmonies of the universe as whole (the macrocosm) whether viewed in terms of the regular movements of the heavenly bodies, or in terms of the laws of musical harmony. It is quite apt, in this case, that one of the principal translators of Arabic texts in the mid-twelfth century, Hermann of Carinthia, should end his own cosmology (the De essentiis) with a description of man in the following terms:
"(God) fitted man into a certain miniature pattern through the agency of the consonant choruses of the Muses, following the example of the heavenly harmony, whose leading movements, by their perpetual guidance, would temper the modes of this related music in man's body and soul."
I would like to end my talk by describing al-Majusi's account of the spirit in man—i.e. the entity that is affected by music.[5] The Arabic doctor provides, in a succinct form, the common view expressed in Arabic medicine and its Latin derivatives as a whole. ‘Spirit' is a corporeal substance that is divided into three parts. The first is the `natural spirit': it arises in the liver, and facilitates the natural processes of growth, digestion etc. The second is the `vital spirit': it arises in the heart and facilitates the natural movements of breathing and sensation. This `vital spirit' rises from the heart through the carotid veins in the neck into the head, becoming progressively purer as it rises and as it is `sieved' by the `rete mirabile' (a latticework of nerves) at the base of the brain. (Its impurities are expelled through the mucus of the nostrils). By the time it has reached the brain it has become an extremely subtle body, but remains corporeal. Here it has different functions in different parts of the brain. In the forepart it gathers together all the sensations and forms images of them. These it passes to the middle part of the brain, where it brings reason to bear on these images. Then it either produces action as a result of this application of reason, or it saves the considered images in the back part of the brain, as memories. (Al-Majusi goes on to say that there is a small opening in the partition between the middle and back part of the brain, which is covered by a worm-like object. When one wishes to remember something one bows one's head so that this cover opens and lets the memory through). At this point al-Majusi asks whether the spirit in the brain is the soul, as many say. If this is so (as al-Majusi is inclined to believe), then, since the spirit is corporeal, the soul also is corporeal. Soul and body form one continuum, of which the spirit/soul is at the most refined end. Now, this way of looking at the soul caused great problems when Arabic medicine was introduced into the Christian West. For Christians believed that the soul was a distinct entity from the body: it survived as an individual after the body, and was capable of experiencing punishment or reward. Several texts were written from the early twelfth century onwards to try to reconcile these two positions, and in the end, at least in popular opinion, the idea of the separate entity of an immortal soul prevailed. But it is worth remembering that, in Arabic medicine, and consequently for many centuries in Western medicine too, through the idea of `spirit', the body and the soul were linked as closely as they are several forms of Eastern medicine.
[1] Mary Wack, in Constantine the African and ‘Ali ibn al-‘Abbas al-Magusi : The Pantegniand Related Texts, eds C. Burnett and D. Jacquart, Leiden, 1994, p. 177.
[2] See D. Wujastyk, `The Combinatorics of Tastes and Humours in Classical Indian Medicine and Mathematics', Journal of Indian Philosophy, 28, 2000, pp. 479-95.
[3] Pseudo-Galen, De spermate, and glosses in Oxford, Bodleian Library, Bodley 463.
[4] For further details concerning the following account of music therapy see C. Burnett, ‘‘"Spiritual Medicine": Music and Healing in Islam and its Influence in Western Medicine', in Musical Healing in Cultural Contexts, ed. P. Gouk, Aldershot, 2000, pp. 85–91, and C. B├╝rgel, The Feather of the Simurgh, pp. nos.
[5] The following paragraph takes information from C. Burnett, ‘The Chapter on the Spirits in the Pantegni of Constantine the African', in Constantine the African and ‘Ali ibn al-‘Abbas al-Magusi : The Pantegniand Related Texts, eds C. Burnett and D. Jacquart, Leiden, 1994, pp. 99–120.
by: Prof. Charles Burnett, Mon 29 November, 2004

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