TEXTS AND DOCUMENTS
A
MEDIEVAL ARAB MEDICAL CERTIFICATE
H. D. ISAACS
Among
the Geniza writings preserved in Cambridge University Library's
First, a word or two about the
document under consideration. The certificate is written on paper measuring 11.8cm x 10.4cm, and,
as can be seen from the photograph,
it has suffered the ravages of time (see the plate). In two places, in fact, parts of the document have, at some time, become
detached from the main body of the certificate and for the moment appear
to be lost. Be that as it may, enough of the text
survives to enable us to identify the nature and the date of the document and
to translate its essence. Doctors nowadays have a reputation for bad
handwriting, but it would seem that it was ever thus, for the writing of our
document at times verges on the illegible, and indeed, in the case of
one or two words, illegibility precludes certain translation.
It may be translated into English in the following manner:
In the name of God the Compassionate, the merciful.
Those who set their hand hereto and have fully declared their names, among
those men in positions of trust whose word
in their attestations is accepted,
hereby attest that they attended
Ibrahim al-Yahudi [i.e., Abraham the
Jew],
who has been affected by- such black bile as has caused him to develop
leprosy, and that fact is such that it debars him from mixing freely
with the
Muslims and from earning his living. Having ascertained the truth of the
matter by their having attended and
established an accurate diagnosis of his
illness, and, having been
requested to issue an attestation of their finding,
they have complied with the
request, such attestation being issued on the first day of
Rabi` al-Akhir of the year six
hundred and sixty [23 February AD 1262].
Testimony Testimony
I attended the above named and The Am-in All ... in him, which
is his
found him to be suffering from illness ...
leprosy. He may
not mix freely with Signed by Ahmad b. `Ali Ishaq the Muslims
because that condition is a transmissible and communicable disease.
Signed by Abu al-Tahir b. al-Husayn
H.
D. Isaacs
Let us now look, however briefly, at
leprosy in history with special reference to the disease in the contexts of biblical antiquity and then of medieval
Islam.1 Of all the diseases of
antiquity leprosy stands out as one of the most controversial with regard to
its signs, symptoms, diagnosis, and transmissibility, and its connections with
diet and mores.` The mystery of the spread
of the disease, as well as the conditions under which leprosy is contracted, were the cause of greatly
exaggerated and uneasy dread on the part of the general public regarding its
infectivity. Many still regard it as a disease apart, and this "separatist" attitude has in consequence even
extended to leprosy. workers
themselves. It was thought that any person with this disease scattered his "infection" over almost all the area in
which he resided. It was believed that the disease could be transmitted from one victim to another by
breath, direct contact or by some intermediary
contaminated by the sick person.
The
subject of contagion in general has deservedly attracted much attention, both from the
profession and legislatures. Even as late as the nineteenth century, we find many statements by doctors and lawyers
so contradictory that, instead of illuminating the subject, they only throw a thicker veil of darkness on that which
was obscure enough before.3
Leprosy
was known to the ancient Egyptians,4 and the Babylonians recognized its transmissibility and took measures to combat it.5 However, it is doubtful whether the leprosy of the ancient Egyptians and Babylonians was true leprosy.6 For in this confusion we
must remember that some of the early cutaneous phenomena of leprosy may simulate to some extent the characteristic
lesions of such skin diseases as morphoea
and leucodermia. Similarly, the early Biblical mention of sara`ath (lepra), which occurs in
Leviticus 13, seems to be more applicable to certain other skin diseases such
as psoriasis or vitiligo. In reading the Biblical description of the disease
one is immediately struck by the absence of
all allusion to the hideous facial deformity, sensory loss or other concomitant signs such as rotting parts of the
extremities. If such conspicuous manifestations had existed, they could not
possibly have escaped the keen eyes
of the officiating kohen (priest).? One is justified in concluding that the priest
252
A
medieval Arab medical certificate
scarcely appreciated the difference
between leprosy, the constitutional disease, and the "scaly
disease", which may have been psoriasis. In commenting on the curious character of this
so-called leprosy, Maimonides did not try to rationalize the Biblical description of the
disease nor to suggest that it need all to be taken literally. He concurred that the
sara'ath of the Bible is a
comprehensive term covering sundry skin lesions.8
Leprosy was known to the ancient Greeks
chiefly as "elephantiasis"-"one of the several skin
diseases which produce in the affected part the appearance of an elephant hide".9 It appears from
the description of the disease by Aretaeus of Cappadocia (AD 120-200) that he
had some knowledge of a disease similar to what is known as nodular leprosy. 10
So far as Islam is concerned, the term judham,11 used later by the Arab writers to denote leprosy,
is not applied to that disease in the Koran. The disease mentioned in 5:133 is baras. a term, however, interpreted as vitiligo.
There are several hadiths (traditions of the
Prophet Muhammad) about leprosy, some of which are unauthentic and sometimes
contradictory. 12 There are others which may be reliable and which are quoted in most
sources. In one hadth the Prophet
denies transmissibility of disease: "La '
In spite of the
contradictions in hadith literature, Muslim
physicians stated unanimously in their medical works that leprosy is
transmissible. `Alt ibn Rabban
H.
D. Isaacs
al-Tabari, for
example, observed in his ninth-century work Firdaws
al-hikma that leprosy is one of the diseases which
are transmissible (al-amrad allati tu'di), 17
'Ali ibn 'Abbas al-Majusi (d. AD 994), known to the medieval Latin as Haly Abbas,
concurred with al-Tabari that leprosy is transmissible and added that it
is also transmitted to the progeny (tu'di
al-nasl)18-a theory advanced by Avicenna (AD 980-1037) in his Canon.19 All referred to leprosy as
da'
al-asad (leontiasis), and, for his part al-Tab added another term, da' al-fil (elephantiasis).20
The theory of
transmissibility produced by the humours, and only secondarily of the air, was
proposed by Arab physicians who drew on Greek sources. The theory of the need
for antecedent, predisposing humours goes back to Galen.21 Al-Majusi stated that a predominance of black bile (al-khilt al-sawdawi) is a concomitant cause of leprosy. In our Geniza document, dominant black
bile is said to have led to leprosy (,We
line 4, Arabic text) arid
apparently constituted the evidence on which the two certifying
witnesses based their diagnosis of the
disease. Whether one or both of the two persons who signed the document were doctors is not clear. It is possible that
they were both accredited doctors,
for they mention that they both "attended" (basharu)
the patient and opined that he should not be allowed to mix
freely among the Muslims. On the other hand, one of the two, namely
'All, inasmuch as he is specifically designated al-amin (he who is entrusted with something or some office)
may well have been an officially recognized medical officer, as it
were, or perhaps some other local official empowered to act as co-signatory to certificates.'-`
As early as about 639 AD the
Caliph 'Umar ibn al-Khattab is said to have passed a destitute Christian
leper colony in Syria and ordered arrangements to be made for the sufferers' sustenance.23 In other words, he condoned their isolation.
However, the first
254
A
medieval Arab medical certificate
explicit reference
to expulsion or isolation of the lepers from the Muslim community is contained in the
work of the annalist and historian al-Tabari (AD 839-923), who credited the 'Umayyad
Caliph al-Walid ibn 'Abd al-Malik ibn Marwan (reg. AD 705-715) with
having been the first to restrain the lepers from going out among the people.
but having at the same time made provision for them, so that they would not be forced to beg
for their living. )4 However. it was
in Muslim Spain that a place of residence was specially reserved for
lepers. This was in Cordova, and the place was known as rabad al-marda (suburb of the sick).25
The lamentable
and rigid rule of universal and compulsory segregation of lepers practised by
men of authority and by doctors in medieval Christian Europe did not apply in exactly
the same way to medieval Islamic society, as Professor Dols has shown in his
article on this subject.26 and as some Cairo Geniza documents have recently similarly
revealed.27 Although
"doctors generally did not advise flight from the leper or isolation of
the diseased",28 there was
restriction of movement, as our document shows when it states that the
leper Ibrahim al-Yahudi was to be debarred from mixing freely with the Muslims. This
document does not make clear whether legislative enactments were passed
empowering doctors or muhtasibs (the "market inspectors")
to examine and isolate lepers.29 We learn from one of the signatories that leprosy is one
of the "transmissible and communicable" diseases (al-amrad al-mu'diya al-muntiqila,
see
lines 11 and 12, Arabic text). It would also appear from this document that the
authorities were concerned to protect the Muslim community and not society as a whole. This
attitude appears discriminatory but it need not be interpreted as such. For
Christians and Jews constituted separate communities within Muslim society, ahl al-dhimma,30 each with its own rights. It
could have been up to the head of
H. D. Isaacs
each of those
communities to deal with such matters as concerned them. Be that as it may, the Muslim
approach as revealed in our medical certificate seems on the it to be nothing more than a
protective half-measure.
Yet, there may
be far more to our document than meets the eye. An alter interpretation
that is worthy of consideration is as follows.31 First, the
certificate suggests that Ibrahim's
condition was at a stage early enough to require m confirmation that it was, in
fact, leprosy, not being immediately recognizable a; by laymen. Second, the document can have been
preserved in the Geniza only be Ibrahim himself kept it; but why did he do so?
Hardly because it set restrictions c freedom of movement and enforced his
isolation. After all, if his condition was not obvious, he could, in the
short term, have carried on his business without arousing suspicion. More probably, the certificate was an
asset. But what asset, one may Could
it be that it gave him the right to charitable support without which he would,
in due course when his leprosy was
plain for all to see, risk severe hardship, or, death from starvation? We have seen from our Arabic sources that in early
Islam, at least, provision was also
made for non-Muslim lepers. Does our certificate testify to the desire of the Muslim authorities to ensure
that confirmed lepers-as oppose, beggars
and charlatans-received assistance, regardless of their religious
affiliatiation? If so, the case for concern is unsustainable. In the
present state of our knowledge, cannot do
other than reserve judgement.
Jewish lepers
were evidently able to come and go freely as they wished among their co-religionists.
What is more, we know from other sources, some were even allowed travel across
countries under Muslim rule and notably to
In their letter
to their brethren in
256
A
medieval Arab medical certificate
alleviate the suffering of their
unfortunate brethren in Tiberias by sending them "money orders" (dioqne) through agents and messengers.36
Finally, I should
add that our certificate demonstrates beyond doubt that Muslim doctors
considered leprosy a transmissible disease despite the fact that the Prophetic hadiths are equivocal. It also fills a gap in the
history of leprosy from Islamic medical writings. Whether the issuing of such a
certificate constituted the exception rather than the norm will, however,
require further study.
*Dr H. D.
Isaacs. Taylor-Schechter Genizah Research Unit,
I wish to thank the Librarian and
Syndics of the Cambridge University Library for having granted permission to publish the
manuscript appearing in this article: and to record my gratitude for the
helpful suggestions
made by Dr Lawrence I. Conrad and Professor J. D. Latham.
t For a detailed survey of leprosy
and its medical and institutional treatment from Babylonian times onwards (including a discussion of
the disease in Arabic literature), see J. H. Wolf, Aussatz:, Lepra, Hansen-Krankheit,
2 Saul N. Brody, The disease of the soul: leprosy in medieval
literature, Ithaca, Cornell
University Press, 1974, pp. 107-46;
see also Richard Palmer, 'The Church, leprosy and plague in medieval and early
modern Europe', in W. J. Shiels (ed.),
The
Church and healing, Oxford,
Blackwell, 1982, pp. 70-101.
3 In the British Medical Journal of 29 December 1866 (p. 725),
there appears a report by the Royal College of Physicians of
4 Ebers Papyrus, see R. Major, A history of
medicine.
5 Arturo Castiglioni, A history of medicine,
6 R. G. Cochrane and Frank Davey, Leprosy in theory and
practice,
8 Fred Rosner, Medicine in the
9 Vivian Nutton. 'The seeds of
disease', Med. Hist., 1983, 27: p. 10, n.52.
10 Cochrane and Davey, op. cit., note
6 above, p. 4. quoting Aretaeus' description of leprosy; see also Rudolph E. Siegel, Galen's system of physiology and medicine,
11 For further reading see Michael W. Dols's article in the Encyclopaedia of Islam, new ed.,
Supplement, under Djudham,
L On the problematic nature of hadith material see Ibn Qutayba (d. An 276/AD 889) Ta'tiril mukhtalif al-hadih in the French translation: G. Lecomte, La traite des divergences du hadith
d'Ibn Qutayba,
13 A. J. Wensinck, Concordances et indices de la
tradition muselmane,
Manfred Ullmann, Islamic medicine, Edinburgh University Press, 1978,
p. 87: and Michael W. Dols, Medieval Islamic medicine, Los Angeles, University of
California Press, 1984, p. 19. Medieval Arabic made no distinction between
"contagion" and "infection": see Dols, `The leper in
medieval Islamic society', Speculum, 1983. 58: 891-916, on p. 895.
14 Al-Bukhari Al-Sahih, ed. L. Krehl, Leiden, 1862-1908,
vol. 4, p. 55 no. 19, and lbn Hajar, Fath al-bari bi-sharh al-Bukhari, Cairo, 1959, vol. 12, pp. 240. 216, 244-69.
Is lbn Maja, Sunan, n.p., 1953,
vol. 2, p. 1172.
I6 ibid.
17 Al-Tabari, Firdaws al-hikma,
18 Al-Majusi, Kamil al-sina‘a.
19 Ali ibn
Sina, Al-Qanun fi al-tibb,
20 It is worth noting that Arab writers confused
"elephantiasis" with anasarca (dropsy). Ibn al-Athir in his Kamil attributed
the death of al-Muwaffaq, son of the
Abbasid Caliph al-Mutawakkil, to this syndrome: "thumma sarat 'illatun birijlihi-da' al-fil-wa-huwa waramun 'azimun yakunu fi al-saqi yasilu minhu ma'un" (Then he was struck with a disease in his
legs-elephantiasis-which is an enormous swelling in the legs from which water flows). Ibn al-Athir, Al-Kamil,
21 Manfred
Ullmann has rightly rendered "predisposition" for isti'dad: Ullmann, op. cit., note 13 above, p. 90.
22 In the text of the certificate both signatories
are said to have belonged to the rank of umana', i.e., men in positions
of trust,
the plural of amin-but amin seems to be
used in its general sense. However, the fact that 'All's name as signatory is prefixed by
al-amin, whereas Abu Tahir's is
not, suggests that in this context the term
is used in a rather technical sense. In the Muslim West, i.e., Spain and
North Africa, amin (see the Encyclopaedia,
note I I above, vol. 1, p. 437)
was the recognized head of his trade or profession in the town in which he resided, and, as such, he represented
its members in their dealings with the n:ulitasib whose duty it was to regulate the conduct not only of market
traders but also of physicians and pharmacists (ibid.. vol. 3, p. 487f.). It is in fact worth noting that
Merinid Sultan 'Uthman 11 (AD 1310-31) actually appointed his physician, Abu Tammam Ghalib of
23 Al-Baladhuri, Futuh al-buldan, ed. M. de
Goeje,
24 Abu Ja'far Muhammad ibn Jarir al-Tabari, Ta'rikh al-rusul wa al-muluk.
25. E.
Levi-Provencal, Histoire de l'espagne musulntane.
26 Dols. 'The leper , note 13 above. p. 916. In another article,
'Leprosy in medieval Arabic medicine', J. Hist. Med., 1979, 34. p. 332. Professor Dols has contrasted
the severe treatment of lepers by Christian medieval physicians with the more humane treatment undertaken by their
Muslim counterparts. Luke D maitre in
his 'The description and diagnosis of leprosy by fourteenth century physicians.
Bull. Hist. Med, 1985. 59, pp. 336-7, has rightly pointed out that the
harsh moral stigmata-mores melancholici
27. Moshe
Gil.
28.
Dols,
“T he leper”, note 13 above, p.
913.
29.
One of the muhtasib’s jobs was
to stand at the entrance of the public baths and see that "no person suffering from
elephantiasis
or leprosy be admitted". R. Levy. Ma'alim al-Qurba' br Ihn Al-Ukhuwwa, Gibb Memorial New Series Oxford University Press 1938 pp.
12, 52
30. Ahl al-dhimmaa are
non-Muslim subjects who, in return for paying poll-tax.
enjoy protection and safety. See the Encyclopedia,
note 11 above under dhimma..
31 1 am
indebted to Dr Lawrence Conrad for his valuable suggestions on this subject.
32 Gil,
op. cit., note 27 above, vol. 1, p. 152; see also the article by Hava
Lazarus-Yafeh, 'Some halachic differences between Judaism and Islam', particularly on that
which relates to the leper, in Tarbiz, 1982, p. 215.
33 J. Mann, The Jews in
34 Jewish Quarterly Review (
35 The letter is written in Hebrew, but
addressed in Judaeo-Arabic to Sidi abu al-tayyib al-hazan ibn abi faraj. Gil, op. cit., note 27 above, vol. 2, p. 457.
36. Ibid. vol. 1 p. 152
257