734 Journal of the Royal Society of Medicine Volume 83 November 1990

Medieval Judaeo- medicine as described in the Geniza

H D Isaacs University Library, West Road, Cambridge CB3 9DR

Keywords: Judaic; Arabic; medieval; Geniza; Cairo

'Search and examine, seek and find' Jews practising medicine and pharmacy was quite Paper read to (Ben Sira) impressive, as one gathers from the works of Arab Section of historians and biographers, like Ibn abi Usaybiah4, History of In a specially controlled environment at Cambridge al-Qifti5, Ibn Khallikdn6, Bar Hebraeus7 and Ibn Medicine, University Library are stored over 100 000 fragments S.a'id al-Andalusi8. 4 October 1989 of documents relevant to medieval history, which Like Muslims, Jews who lived under Islam were together constitute one of the world's important exposed to Greek culture. At the beginning, the sources of knowledge about Mediterranean life a attitude of Jewish rabbis and Muslim divines to the thousand years ago. The fragments, which are of outside world was one of circumspection and paper, vellum, cloth and papyrus, were discovered in eclecticism. The rabbis did not raise any objection to the Ben Ezra synagogue of (Fostat) in the study of such secular subjects, of which they 1896/97, lying in the Geniza which literally means already had some knowledge because they were a storeroom or depository in a synagogue, particularly included in their Talmudic writings. Another reason of such material on which the name of God or any is that the eagerness of both Muslims and Jews to reference to Him is inscribed. master Greek learning was of a utilitarian nature. The story ofits discovery is fascinating. In the wake This utilitarian approach was furthered by the fact of Bonaparte's sweeping conquests in the Near East that many of the great scientists and astronomers a new phase of history began, and a new attitude were also practising physicians. However, as time towards the national past developed in . People passed their interest in these subjects grew to a from all over Europe started to travel to Egypt to see remarkable degree. Hippocrates and Aristotle became the newly discovered antiquities, and Cairo thus objects of their respect, and Galen, Rufus and Plato became the centre ofthe sale and purchase ofall sorts their adoration. of curios, artifacts and manuscripts. The Jewish component of Arabic medical writings Among those who ventured to travel then to the has been a favourite topic of Jewish scholarship. It Near East were two exceptionally learned Victorian is, however, still difficult to distinguish between the ladies - a Mrs Lewis and a Mrs Gibson' - who apart Jewish and the Muslim contribution to what is known from having studied the classicallanguages, had some as 'Arabian medicine', for they were so knowledge ofHebrew, Arabic and Aramaic. On their interdependent that both wrote in the Arabic return from their fourth visit to Egypt they had language - a language which the literate Muslim been successful in obtaining a rare fragment of a could read. But, for the Jew, who was literate in Hebrew manuscript, which was identified by Rabbi Hebrew but had no opportunity to learn to read and Dr , Reader in Rabbinics, as part write Arabic, there was a problem. Jewish scholars ofEcclesiasticus - a book ofthe Apocrypha, which had solved this problem by adopting Hebrew characters hitherto existed in Greek and Syriac versions. The in their Arabic writings, later to be known as Judaeo- excitement at such a discovery was great, and through Arabic, in which most of the Geniza fragments are the generosity of Dr Charles Taylor, Master of written. St John's, Schechter was able to travel to Cairo and Next is Hebrew, the language used in the Geniza. bring back with him the whole collection of the Arabic medical works were, as a general rule, the text Geniza, which was later presented to the University books and manuals required for every aspiring doctor, Library of Cambridge2. The present study refers to and most of them were translated into Hebrew and the medical material. Translations of some of the used by Jewish doctors in Egypt and, later, by the poems are now available, and it has been stated that Renaissance doctors. The Hebrew anatomical terms, about 40% of the Geniza material consists of poetry3. which Vesalius gives in his epoch-making work De This collection of fragments shed light on many Humani Corporis Fabrica9, are, for most part, aspects of Jewish life in Egypt, particularly between similar to the ones, if not the same, found in the the 9th and 14th centuries, and indicates the Geniza medical fragments and are, in turn, taken important role of the Jews in the medical profession from a Hebrew version of Avicenna's Canon in its and its allied m6tiers such as pharmacy, bone-setting original Arabic (fragments T-S NS 181.54 and NS and herbalism. The opportunities of earning a 90.75 folios 2 and 4). living in medicine were far greater than any other comparable scientific pursuit. The advantages ofsuch Medical contents 0141-0768/90/ a profession are obvious, for medical knowledge was In considering the subject matter of the medical 110734-04/$02.00/0 an entr6e to the court of Muslim rulers in a society material found in the Geniza it is convenient to divide © 1990 governed by absolute autocratic rule, and access to the it into the following categories: The Royal ruler was an important, and often the only, avenue (1) Those dealing with medicine proper, ie description Society of to positions of power and influence. The number of of diseases, causes and treatment. Medicine Journal of the Royal Society of Medicine Volume 83 November 1990 735

(2) Description of the simple drugs and herbs, their Arabic letters by the misplacement of dots and action and uses. diacritical points. T-S NS 90.72, which is in Hebrew, (3) Household remedies which were meant for the deals with sarsam (loosely translated from Persian laity. as inflammation of the head). In such a case, if the (4) Quasi-medical subjects such as astrology, amulets patient is delirious, the author, quoting Alexander of and divination. Tralles (525-605), warns against the use ofopium for (5) Miscellaneous fragments dealing with social and concomitant headache - a rather interesting clinical ethical aspects of the medical profession. advice. Of all the medical subjects discussed in the Geniza Ofall the Jewish names in the Geniza, fragments eye diseases and fevers are the most stands out prominently, and so much has been written prominent, for both were endemic in Egypt. Trachoma, about him that to add another item would seem known to the Arabs as ramad was a scourge, and its superfluous; but we have some medical fragments in ravages caused blindness. Little wonder that the Judaeo-Arabic which are supposedly autographed French, whose entire army fell victim to it during the by him. They are T-S Ar 44.97 Ar 44.51 and Misc. Napoleonic campaign in Egypt in 1798-99, dubbed 34.24, and they relate to his famous treatise on sexual Egypt 'Le pays des aveugles' 1. matters. An Arabic version, which most probably is The description of this disease and its four stages the original, was studied by Kroner13. This treatise are discussed in full, and its complications - trichiasis was commissioned by an important dignitary, most and pannus. The appearance ofthe red follicles, bleb- probably al-Malik al-Muzaffar, a nephew of . like excrescences, which later assume the appearance On the subject ofmateria medica and pharmac, the of sago grains, are described by the Geniza writer as Geniza contains a vast collection of prescriptions for 'similar to the inside of a fig when cut in half'. As various ailments, since the art ofherbalism flourished for trichiasis, 'the treatment', he goes on to say, among the Arabs. There was an intensive commercial 'is to remove the offending eyelashes which strike activity in importing herbs and drugs from India and against the cornea with a pair of tweezers; later on Persia. They are listed alphabetically and their action, an operation will become necessary'. The description uses and sometimes their toxicity are discussed. There of this operation is found in fragment T-S Ar 43.81. are difficules in trying to define the various medicinal It is a primitive form ofplastic surgery on the upper herbs listed in the Geniza as the nomenclature eyelid, not unlike modern surgery. It deals with the becomes very confusing; for some may have three or instructions for the removal of a wedge-shaped strip four names, or have acquired corrupted versions of of the upper eyelid11. Greek or Persian equivalents. However, Arabic names The subject of fevers and the types of fevers is of the drugs were preferred to Greek, particularly discussed in numerous fragments. The one in Hebrew as the author was not quite certain of their Hebrew (T-S K 14.42), which comprises 46 folios, is a major names. Maimonides greatly facilitated the identifi- part of a complete text. Neither author nor date is cation of these drugs. The glossary of his book mentioned, but it is well written in a clear cursive Regimen sanitatis is quite helpful in this respect14. script. The classification of fevers fits in well with Most ofthe prescriptions are adorned with benedic- those ofIsaac Israeli (850-950), Galen (130-200) and tions. These are expression of piety, common to all, Avicenna (980-1037). There are, however, some slight both Muslims and non-Muslims; for example, 'to be variations where the writer diswses pestilential taken -with God's blessings', or the usual Muslim fevers. He also quotes Yuhanna ibn Masawayh formula: 'In the name ofGod the Compassionate and (777-857), Rhazes (841-926) and Qusta ibn Liiqa the Merciful'. They mostly ended with such remarks (d,923). like: 'It will help, if God will' or 'Thanks are due to Fragments dealing with commentaries on Avicenna's God alone', or 'this has been tried with success'. Canon abound. T-S Ar39.282 deals with the definition [The writer, whilst in Baghdad in the late thirties, of disease (Book 1), aetiology and symptomatology. came across a similar case when a pharmacist had Others are concerned with the 'simples' as listed in the ingenious idea of promoting the sale of his the Canon. T-S Ar 45.45 discusses vomiting and medicines by adorning the labels on the containers diarrhoea, and the differential diagnosis between with the Koranic quotation: '. . . Wherein there is cure upper and lower abdominal complaints. T-S Ar 43.154 to man' (Koran XVI, 68).] A reference to a written draws on The Principles of Phlebotomy by an source, especially in the form ofa personal name, such unknown author. T-S Ar 41.4 is taken out ofFirdaws as Hippocrates, Galen, Rhazes or Avicenna, was al-H.ikma (Paradise ofWisdom) by Ali ibn Rabban al- merely a ritualistic performance to emphasize the Tabari (c850) and T-S Ar 43.174 relates to a Treatise curative value of that recipe and not as a learned on Melancholia by Stephanus Basileus (c640). footnote or an act of scholarship. The rendering ofGreek medical words into Arabic, Scattered here and there are many prescriptions then into Hebrew, and finally into Latin wasfraught which can be related to certain branches ofmedicine; with linguistic hazards. For example, in one Hebrew for example, one finds reference to excessive uterine text (T-S NS 90.71 b) the term karabitus comes under bleeding and its treatment in T-S Ar 43.21, for the title 'Diseases of the Head and Brain'. This recogiition ofearly signs ofpregnancy in T-S NS 90.36, meaningless term, according to E G Browne, is and for inducing abortion T-S Ar 45.30. Of the skin actually rendered verbatim into the Latin translation diseases, tinea ofthe scalp was a common complaint, ofAvicenna's Canon, printed at Venice in 1544;- and for which a compound is found in T-S Ar 43.2, and on folio 198a of this Latin version one finds the for itching see T-S NS 222.67. Recipes concerning following: 'Sermo universalis de karabito qui est dentisry and oral hygiene are found in T-S Ar 43.306 b apostema capitis sirsem'. In the Arabic text, however, and T-S NS 164.80 a. Forjoint pain a few recipes are it is qar?nitus, and in other Arabic texts it is reduced found in T-S 222.70. One recipe, in particular, is to faranitus, similar to the Greek phrenitis which is recommended for nephritikos16 - a term attributed to frenzy12. This shows the sort of havoc wrought on Alexander ofTralles, but rarely used by Arab writers. 736 Journal of the Royal Society of Medicine Volume 83 November 1990

The author goes on to say that it is useful for kidney obtain letters of recommendation from a person of pain. authority and standing such as a w-ali (governor) or Very often the patient bought his medicine from a a g&ai (judge), as well as a certificate of good conduct pedlar, though probably the roving herbalist relied from the police'8. for his sale either upon his own diagnosis and method Our Geniza records seem to indicate that it was the of treatment, or upon his clients prescribing for more prominent doctors who worked in hospitals. themselves, ie self-medication. These pedlars were Abraham, the son of Maimonides, states in a letter chased by a quasi-health offlcial known as written in October 1233 that he was unable to attend muhtasib'6, who was well-versed in religious matters the wedding celebration of a favourite colleague and whose duties included the inspection and assaying because it was his tur-n ofduty in the hospital on that of drugs. particular night and, for special reasons, he did not As for diet, the regimen of the patient shows how like to ask another colleague to deputize for him'9. important the doctor regarded the question of Specialization of function in the recognition and nutrition ofthe sick. Diet has a very important place treatment ofa particular disease was not an essential in the medicine of the Geniza. It was one of the feature of Arabic medicine, though many treatises efficient weapons the doctor wielded in his combat were written by experts on one particular subject. with disease and part of the system on which he There was a considerable number ofmen who limited prided himself. Quantity and quality offood required their Twork to one field ofthe healing art - one might special attention. Foods for the invalids are listed call 'division of labour'; thus we fmd oculists, in many fragments (T-S Ar 44.57, Ar 44.205. and phlebotomists, surgeons and bone-setters. T-S As 178.122). In T-S Ar 43.225, the author lists a The majority of physicians were 'generalists' who number of fruits and discusses their food value. conducted their business from shops, or visited their Truffles and other fungi are recommended but patients at home. Some prepared their own compounds fragment T-S Ar 38.76 deals with the, poisonous and carried with them certain stock remedies on varieties and their antidotes. their visits. A well-preserved fragment T-S K 15.9 b, As for astrology, the attitude of Jewish doctors which appears to be an inventory, gives us an idea of did not differ much from that of their Muslim what a doctor's dispensary looked like. From the list colleagues. The prophet Muhammad forbade the we gather it was full of glasses, flasks for inspecting Muslims to associate themselves with astrologers, and urine, scales, a mortar and other implements which rebuked those who put their trust in birds and omens. indicate that the said doctor prepared the medicaments Yet, in spite of such warnings and restrictions, a himself, or had one ofhis assistants preparing them. predilection for the mysterious induced the Muslims In some cases treatment was administered by proxy. to cultivate with great assiduity the art of astrology, Fragment T-S AS 152.34 is a short letter from a which went hand in hand with the respectable science patient to his doctor asking for advice regarding his of astronomy. Unfortunately, the caliphs regarded complaint. The doctor writes on the back ofthe letter astrology with some favour, and thus astrologers giving his instructiQns and adding his short script abounded and were well received as part of the with 'May the Healer heal you'. caliph's retinue. This created an inimical rivalry As for fees, these varied according to the status of between physicians and astrologers, and led some the physician and that ofthe patient. The treatment doctors to dabble in astrology in order to please for a sore eye was 3 dirhems per week. On the other their patrons. But astrology did not make inroads hapd 1000 dinars were promised to a physician in into the medicine of Avicenna or Maimonides.-The Tripoli for the successful treatment of the of charlatans and quacks who mushroomed in the cities Gabes in Tunis. Poor patients, who were receiving were publicly ridiculed for their incompetence and weekly ration of bread and who were needy and foppish way of life. The rabbis severely criticized handicapped were automaticaly exempt from paying these men who busied themselves with astrology, any fees (T-S 8J 20.26 and Or 1080 J1). and Maimonides, in his famous letter to the Jews Many doctors appearing in the Geniza were affluent of Marseille, warns against believing it in, or and influential. There were others who possessed only making it their creed and thereby bringing harm to modest means and were struggling to make a living. themselves'7. Fragment Or 1081 J5 is a letter from a doctor-who left Qalyub (a small town 12 miles north of Cairo), Medical education and the profession to start a practice in the place from which he The teaching ofmedicine followed the Greek methods was writing, probably Cairo. He laments.,that the and was heavily tinged with a sophisticated interest competition among hie colleagues is fierce to a degree in rhetoric and debates. The ways in which theoretical ofenmity. He writes with deep feeling and sorrow to knowledge and practical skill needed for the exercise his wife that he is sending her a collyrium, for he ofthe profession varied widely. We learn this fiom the heard that her eyes were troubling her. He adds a Geniza fragments and the biographies of doctors, in postscript in the margin ofhis letter asking his wife other sources. Some students gained their knowledge to visit a woman,- who is in the late months of her and experience by being apprenticed to a physician pregnancy, so that she will be able to be present at of repute. Others attached themselves to a hospital her confinement. - where reading ofpublic lectures to students seems to have been a common practice. Religion and medical ethics A further period ofhospital work was essential for It is noteworthy that a grt number ofdoctors named those practitioners who were keen to improve their in the Geniza were well-versed in religious matters, medical knowledge and enhance their careers. It must and some were actually holders of a religious office; have been rather difficult for some to attain such a yet, their contribution to the corpus of medical goal; for judging from certain letters found -in the knowledge was purely secular. Of all the medical Geniza, it was imperative for a young aspirant to fragments which I have gathered during the last Journal of the Royal Society of Medicine Volume 83 November 1990 737

6 years ofresearch, I have come across only a few that References can be traced to the or other religious 1 Whigham Price A. The Ladies of Castlerae. The life of writings. Fragment T-S NS 222.71 (folios 3&4), which A S Lewis and M D Gibson. Durham: Presbyterian relates to personal hygiene is copied from the Historical Society of England, 1964 Talmud20. 2 Bentwhich Norman. Solomon Schechter. A Biography, Cambridge: Cambridge University Press, 1938 The principle, primum non nocere, which gained 3 The Penguin Book of Hebrew Verse. Carmi T, ed. and prominence in recent medical writings, is not incom- translator. Harmondsworth, Middlesex, England: patible with the Hippocratic tradition. It is not Penguin Books Ltd, 22-23 surprising that it can be traced to Psalms 34:15 and 4 Ibn abi Usaybia Tabaq7at al-Atibb7a (Classes of 37:27. It should also be noted that the duty of Physicians), Cairo: August Miiller Vol. 1 1882; beneficence, which is frequently cited in the Koran Koenigsberg Vol. 2, 1884. (2:100, 3:106), and the duty ofnon-maleficence, which 5 Ibn al-Qifti. Tarikh al-Hukama, ed. August Muller, is more astringent than beneficence, are both precepts Leipzig: Julius Lippert, 1903 to which the Psalmist subscribes. 6 Ibn hallikan. Wafaviat al-A'yan, Biographical Diction- ary translated by Baron M G MacGvekin de Slane, Paris: Firmin Didot, 4 vols, 1842-71 Doctors in society 7 Wallis-Budge EA. The Chronography ofBar-Hebraeus, Physicians, although enjoying an envious status, and London: Oxford University Press, 1932 thought ofvery highly in the Geniza, were not exempt 8 Blachere Regis. Ibn Sa'id al-andau4 Kitab Tabaqat al from the imperfections attached to all human beings. Umam (Livre des categories de nations) Paris: L'Inst. des hautes 6tudes marocaines, 1935:155-61 Attacks against an individual doctor did not mean 9 Vesalius Andreas. De Humani Corporis Fabrica. Basel much and provided no validjustification for condemn- 1543:166-68 ing the whole medical profession. There is much 10 Duke-Elder WS. System of ophthalmology. London: reason to believe that most ofthe hostile criticism of Henry Kimpton, 1964;VIII pt 1:260 the profession in the Geniza, of which some issues 11 Ibid. 295. A similar operation is described by John from the public, may be traced to inadequacies ofthe Walker Folk Medicine in Modern Egypt, translated from professional structure and the attitudes ofthe doctors Abd Al-Rahman, London: Luzac & Co, 1934:50 themselves and their relationship to each other. The 12 Browne EG. Arabian medicine. London: Cambridge authors ofsuch fragments, who are not identified, in University Press, 1921:113 their satirical and sometimes sceptical style, bring 13 Kr6ner H. 'Eine Medicinische Maimonides-Handschrift aus-Granada'. Amsterdam: Janus, 1916;21:203 out the connection between the profession and the 14 Muntner S. Hebrew Translation. Hanhaghath Havriuth. societies in which the doctors find themselves. In Jerusalem, 1957 fragment T-S Ar 43.37, a timeless criticism of the 15 Liddle HG, Scott R. A Greek English Lexicon. Oxford: two-tier system of medical -practice, the author Clarendon Press, 1966 laments the present state of the doctors in the town 16 Levi-Provencal. Un manuel hispanique de hisba. Paris: where he lived. He writes that doctors are of two L'Inst. des hautes 6tudes marocaines, 1931 types, those for the common class 'the plebeians' and 17 Jacobovits I. Irrational Medical Beliefs in Jewish Law. those for the special class 'the patricians'. He New York: Harof6 Ha'ivri, 1957;1:98-109. Cf. Marx, condemns the practice of those doctors whose aim is Alexaander. 'The Correspondence between the Rabbis of financial gain. Southern France and Maimonides about Astrology', Hebrew Union College Annual, Cincinnati, USA, Finally, the accomplishments of Jewish physicians, 1926;3:52 gathered from the Geniza, are on the whole merit- 18 Goitein SD. A Mediterranean Society. Los Angeles: orious. For never had the Jews been so closely affected University of California 1971;II:253 by an outside culture as when they lived under Islam 19 Ibid. 256 in the Middle Ages. This imperishable legacy of 20 Talmud Babli, Nedarim, 81 cultural symbiosis forms part of the records of A Mediterranean Society, the title which the late Professor Goitein aptly gave to his magnum opus'8. (Accepted 1 March 1990)