Brilliant Lights of the Dark Ages of Medicine

Richard Colgan, MD
University of Maryland

We best learn the art of medicine by working alongside modern day healers who exemplify what it means to practice the art as well as the science. We can also learn from history, as many great physicians set the bar for how we should practice today. The dark ages had luminaries who taught us much about the art of medicine. Rhazes, Avicenna, and Maimonides stand out as the most influential physicians of this era. In this editorial we will look at how the Persian physician Rhazes is still relevant today.

Abu Bakr Muhammad ibn-Zakariya Razi (865 After the Common or Christian Era, ACE – ca. 923 ACE) was one of the greatest physicians of the Middle Ages. Known as Rhazes, this man was regarded as an influential alchemist, philosopher, and Persian scholar. Rhazes was known not only for what he contributed to the art of medicine, but for his commitment to scholarly work as well.

Historically, Rhazes is remembered for numerous writings on medicine, including pediatrics, ophthalmology, neurosurgery, and pharmacy. A prolific author of his time, he published books and articles in the disciplines of alchemy, religion, and philosophy as well. He is perhaps best known for having authored a nine-volume compendium entitled Continens Liber or The Large Comprehensive. But the focus of this editorial series is to highlight the contributions which the greatest teachers of medicine and other healing arts have given us as they apply directly to the physician–patient relationship. In short: How is it that we—as clinicians—come to regard a specific behavior or style of practice as exemplary? Who can we look to as a role model? Who are the icons that have shown themselves as masters of the art of caring, specifically as it pertains to the physician-patient relationship? How do we know a great healer when we see one? Rhazes helped us to understand by example what we now recognize as superb practice.

Rhazes, like Imhotep and Hippocrates, advocated for use of the power of observation, and in doing so he encouraged scientific inquiry in caring for the patient. Since the time of Hippocrates, the humoral theory was held by physicians as the basis for their understanding of disease. According to Galen of Pergamum, a prominent philosopher of Greek origin, a person was sick if one of the four humors—black bile, yellow bile, phlegm, and blood—was out of balance. Humoralism was closely linked to the Greeks’ theory of four elements—earth, wind, fire, and water. By observing his patients in a specific and particular manner, Rhazes challenged the notions of those before him. He was the first to refute the opinions of Galen in Doubts About Galen, which ultimately led to the dismissal of humoralism and its consideration of being non-scientific. This change in thinking did not occur quickly, and Rhazes was met with much resistance for many years. In fact, his thinking was not fully accepted until Rudolph Virchow developed his thesis on cellular pathology in the mid eighteen hundreds.

Rhazes urged practitioners to think independently, to learn from their experiences with disease through meticulous observation and constant questioning. Using these practices himself, he published some of the first scientific descriptions of medical illnesses, and he is even credited with providing the first accounts of such diseases as smallpox and measles. Rhazes also disagreed with Galen over the nature of fever and urinary ailments, basing his opinions on his own practice and patient observations. He taught, “All that is written in books is worth much less than the experience of a wise doctor.” Living by his own lessons led him to many discoveries. He was the first to describe allergic rhinitis and asthma in a scientific manner. His writing A Dissertation on the Cause of the Coryza (acute inflammation of the mucous membranes of the nasal cavities) which Occurs in the Spring When the Roses Give Forth Their Scent is the first known publication on hay fever.

Rhazes advocated for the practice of evidence-based medicine in the Middle Ages. He developed standards of question and practice that provided the foundation for modern thought on evidence-based medicine, which few physicians would argue against today. Rhazes taught that physicians should look at whether or not a disease was truly curable versus non-curable with implication of multiple treatments; further, they should use the information gained to change their practices for the betterment of the patient. When it came to caring for those with cancer and leprosy, Rhazes urged that the physician not be blamed for his patient’s poor outcome. He was a fierce independent thinker who, while urging diligent study and the pursuit of knowledge, also taught humility and caution when it comes to unrealistic expectations of being confident in what we seemingly know. He taught that “truth in medicine is an unattainable goal, and the art as described in books is far beneath the knowledge of an experienced and thoughtful physician.”¹

In addition to promoting the skills of observation and independent thinking, Rhazes argued that we should be ethical and moral about our daily routine:

“The doctor’s aim is to do good, even to our enemies, so much more to our friends, and my profession forbids us to do harm to our kindred, as it is instituted for the benefit and welfare of the human race, and God imposed on physicians the oath not to compose mortiferous remedies.”¹

Although he was a physician to the rich and powerful, Rhazes’ devotion to medical education and treatment of the poor made him highly sought after as a teacher by medical students of his day. Rhazes was known for treating the impoverished sick free of charge during a time when medical care by physicians of such repute was mainly enjoyed by those of wealth. He pioneered the teaching of medicine by the bedside, and wrote a self-help, home remedy guide for the common man—recognizing that many could not afford to seek professional medical care.

Rhazes possessed the wise and insightful thinking that physicians should be mindful of their patient’s mental health just as well as their physical health. He wrote of the importance of a sound mind and a sound body and discussed the significant positive impact afforded to those physicians humble enough to be friendly with their patients. He has been called “probably the greatest and most original of all Muslim physicians.”² Rhazes was known as much for his intelligence as for his kindness and compassion to others. He was troubled by poverty and suffering and gave away his fortune, such that he died in destitution.

Richard Colgan, MD, is associate professor of family and community medicine at the University of Maryland School of Medicine in Baltimore, Maryland. He was the School's nominee to the Association of American Medical Colleges for its Humanism in Medicine Award, the recipient of numerous faculty teaching awards including the School's Golden Apple Award for excellence in teaching. Dr Colgan is the author of Advice to the Young Physician: on the Art of Medicine. For more information, go to www.advicetotheyoungphysician.com.