NDT Advance Access originally published online on September 12, 2007
Nephrology Dialysis Transplantation 2007 22(12):3413-3421; doi:10.1093/ndt/gfm494
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Diseases of the kidney in medieval Persia—the Hidayat of Al-Akawayni
1Tuberculosis and Lung Disease Research center and 2Department of Nephrology, Tabriz Medical University, Tabriz, Iran, 3Department of Cell Biology, University of Alabama at Birmingham, Birmingham, AL and 4Renal Section, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
Correspondence to: Mohammadali M. Shoja, MD, Postal Code: 51738-47661, Amir Kabir Ave., Kar Pisheh Crossing, Tabriz, Iran. Email: shoja.m{at}gmail.com
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Abstract |
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The centralization of socioeconomic resources following the rise of the Islamic empire in the 7th century nurtured an initial gathering and translation into Arabic of extant medical texts in Greek, Syriac, Hindu and Chinese. As Arabic became the lingua franca of scholarship, there followed a second period of assimilation, original observations, commentary and systematization of medical knowledge in Arabic texts, which became the basis of revival and learned medicine in the West in the 12th century. However, not all medical texts of the period were written in Arabic. As central power eroded, provincial principalities arose, and regional cultures flourished, medical texts began to be written in local dialects, particularly in Persia. Notable amongst those and probably the oldest is the Hidayat al-Muallimin fi-al-Tibb (Learner's; guide to medicine) written by Abubakr al-Akawayni al-Bokhari in the closing decades of the 10th century. Written in Farsi and dedicated to his son and other students of medicine, the Hidayat is a relatively short and simplified pandect of medicine at the time and provides a glimpse of the teaching of medicine of the period. The present article is a translation of the sections of the Hidayat related to the kidney and urinary tract and their diseases. These early writings provide insight into the care of patients with kidney disease during the Middle Ages in general, and in Persia in particular.
Keywords: Akhawayni; history of nephrology; kidney disease history; medieval nephrology; Persian medicine
The flourishing of the sciences in the Near East, following the rise of the Islamic Empire, stands in sharp contrast to their disastrous decline in the West during the Middle Ages. The medicine that developed during this era has been variously termed Islamic, Arabian, Arab and Arab-Islamic [1–4]. It is not actually correct to speak of any of these alone, for they were not strictly Islamic, Arab or Arabian. Almost all the inhabitants of this region contributed to its development, whether they were Muslim, Christian or Jew; or Persian, Arab or Greek—albeit most of them wrote in Arabic and under Arabic sounding names [5]. In fact, the evolution of the sciences during this period went through two phases: a period of translation and assimilation (ca. 750–900), and a second of compilation, original observations and expansion (ca. 900–1100). Whereas Christians dominated the first phase of accumulation and translation, Persians dominated the second phase of innovation, commentary and systematization. In fact, three of the most dominant medical figures of the entire period were of Persian origin: Muhammad Ibn Zakariya al-Razi (ca. 865–925), Ali Ibn al-Abas al-Majusi (930–994) and Abu-Ali al-Husayn Ibn Abdallah Ibn Sina (981–1037), known to the West respectively as Rhazes, Haly Abbas and Avicenna [5–7]. The Continens of Rhazes, the Liber Regius of Haly Abbas and the Canon of Avicenna were the foundations on which the revival of learned medicine in the West began in the 12th century and continued to influence it well into the 17th century.
The centralization of political and socio-economic power during the expansion of the Islamic empire, initially in Damascus and subsequently in Baghdad, which nurtured the initial momentous gathering and translation efforts, was of limited duration. Factional infighting, internal strife, religious schisms, sibling rivalry and power struggles soon diminished central power and led to the emergence of regional principalities. Provinces began to break away from control by the 9th century, and while the Abbasid rulers in Baghdad kept the title of caliph, the power base and economic strength began to be taken over by various regional rulers and dynasties. This was nowhere more evident than in Persia, which had not completely merged into the world of Damascus of the Umayyads or of Baghdad of the Abbasids. In fact, both Rhazes and Avicenna served in the courts of Arab as well as the principalities in Persia [5,7,8]. Arabic remained the lingua franca of original scholarship in which Rhazes and Avicenna wrote, but it was no longer the sole medium of communication in the Persian principalities where Farsi began to be used in the arts and sciences with increasing nationalistic vigour. One of the first dynasties to establish autonomy and nurture the revival of Persian literary traditions was the Samanids (875–999). It is during this period that Firdawsi (ca. 935–1020) composed in Farsi his Shah Nameh (The book of kings), an epic poem of tales of heros of ancient Persia [7].
Three of the first medical authors to write in Farsi were: Hakim Maysari, who completed a poem on medicine (Danishanameh) in 980; Abu Mansur Muwaffaqi Haravi, who compiled a book on remedies (al-Abniyah and haqaiq al-adwiyah) at approximately the same time; by far the most substantial work of the three was that of Abubakr al-Akhawayni al-Bokhari, one of the earliest pandects of medicine of the period, the Hidayat al-Mutallimin fi-al-Tibb (Learner's guide to medicine) written in the closing decades of the 10th century [9]. None of these works has received the credit they deserve. Only one of them (Muwaffaqi's book on remedies) is mentioned briefly in the extensive compendium of medicine of the period assembled by Lucien Leclerc in his Histoire de la Medicine Arabe [1]. The present article on the Hidayat of Akhawayni is an attempt to fill one of the many gaps that still exist in our knowledge of medicine of the period, specifically on diseases of the kidney during the Middle Ages.
Little is known about the life of Akhawayni [10]. He was born, trained and practiced in Bokhara, and hence his name al-Bokhari. Bokhara, a city currently at the Republic of Uzbekistan, was located along the Silk Road, in the vicinity of the ancient Samarkand. It prospered during the Samanid era, when it became one of the intellectual centres of the Islamic world, and for a period of time was also the residence of Avicenna.
Throughout his book, Akhawayni acknowledges his teacher as Abu al-Quasim Moqanei, a student of Rhazes, who practiced in Bokhara. Apart from being one of the earliest pandects of medicine of the period, having been written half a century before the Continens of Avicenna, and being written in Farsi, what distinguishes the Hidayat is its dedication. Unlike the custom of the times of dedicating books to powerful rulers or wealthy patrons, Akhawayni dedicated his book to his son and to other students of medicine, emphasizing that he wrote it in a ‘light and simple’ style to help beginners (Figure 1). A similar dedication has been attributed to Thabit ibn Qurra (ca. 835–901), one of the earliest and most productive translators of Syriac and Greek medical texts into Arabic [11]. For credentials, Akhawayni mentions his own 23 years of experience in the practice of medicine, during which he claims to have tested the teachings of his predecessors with his own investigations.
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There are three known manuscripts of the Hidayat; all three copied some years after the death of the author [12]. The oldest is the manuscript in the Bodleian Library, Oxford (Bodleian, 2841, Persian C 37) copied in 1058 (Figure 2). The second, dated 1100, is in the Fatih Library of Istanbul (Fatih 3646), and the third, copied sometime in the 11th century, is in the Iranian National Library of Malek in Tehran (Tehran 4501) [9]. Dr Jalal Matini, a contemporary Persian writer, compared the three extant manuscripts and published a literary edition of the Hidayat in 1965 [12] that has been used in the present translation. The Hidayat is written in middle Persian or Farsi-e Dari [4]. Several of the terms used, especially for drugs, are unfamiliar and present difficulty in translation.
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The Hidayat consists of 184 chapters (Bab), arranged in five major sections. The first six chapters are a brief introduction on the humors (akhlat) and faculties (quwa); followed by 28 chapters on anatomy; 21 on physiology, symptoms and comments on diet and hygiene; 121 chapters on the diseases of various organs discussed in order from head to toe; six chapters on fever; one chapter on toxicology and a final chapter on the pulse and urine. There are three main chapters on the kidney and urinary tract anatomy, seven chapters on the kidney and urinary tract diseases and a single closing chapter on uroscopy. What follows is a translation of the chapters related to the kidney and its diseases.
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On the anatomy of the kidney |
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The kidney are two in number, one on the right side and another the left side. Both are adjacent to the vertebral column and posterior muscles. And each kidney has a covering sheet, around which is fat. The right kidney is longer than the left one and is close to the liver. The kidney tissue is homogeneous [hard] and its inside is empty. Each kidney has two ducts; one of them is to the liver and is near the vessel emerging from the convex surface of the liver. Another duct is to the urinary bladder, the so-called ureter. The extract of blood travels through the [former] ducts, which is called Talean (?), from the liver to the kidneys and from the kidneys, through the ureters, to the urinary bladder.
The description of the kidney is brief and consistent with Greek texts. Akhawayni errs on the size of the kidneys, which reflects Galen's notion of kidney function and circulation, in which blood was thought to ebb back and forth between the liver and the kidneys [13].
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On the anatomy of the urinary bladder |
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The urinary bladder is located between the pubis and rectum, and consists of two layers. When urine comes to the bladder from the kidneys through the ducts that are named the ureters, the ureter penetrates one of the bladder layers and traverses between these two layers until it reaches the bladder neck where it penetrates the other layer and the urine enters the bladder. The reason for the creation of this part in such a way is that the urine can not return to the same duct as upon the reversion of the urine, the inner layer compresses that intramural part [of the ureter] against the outer layer to tighten the passage, and for the urine not to return into the ureters. This looks like the heart valves where leaflets whose opening is from the exterior toward the interior closes by the same way I mention for the bladder, and those valves whose opening is from the interior toward the exterior are closed in a like manner, as one leaflet is compressed on the other one to make the passage tight and closed. There is a large muscle at the head of the bladder, which completely wraps it so as to prevent involuntary urination. Upon the urge [for urination], the head of the bladder dilates voluntarily and the urine is excreted. The constitution of the bladder substance is neural, and within it are arteries and veins.
This accurate description of the structure and function of the bladder, ureterovesical junction and the bladder neck, to which Akhawayni refers to as the head of the bladder, is consistent with prevailing notions expounded in Greek texts. Both Galen (130–200) and Rufus of Ephesus (1st–2nd century) made note of the anti-reflux mechanisms of the bladder [13,14]. The analogy to the heart valves appears to be original. Galen refers to the oblique course of the ureters through the bladder wall and how their opening into the bladder acts as a covering comparable to a lid [15,16]. These concepts were modified by Rhazes, from which they seem to be incorporated by Akhawayni. Notably, Rhazes disagreed with the presence of a valve at the insertion of ureter as implied by Galen, but accepted its oblique course as a potential anti-reflux mechanism and additionally proposed a role for the opposing bladder layers as a valvular mechanism [17]. An observation emphasized by Akhawayni in giving the analogy to the heart valves, which seems to be original.
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The chapter on the kidney diseases |
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The kidney is subject to diseases like any other organ including functional impairment [dysfunction], structural disorders and disruption, and some specific disorders like stones and inflammation, and renal weakness and atrophy, namely, "Hozal". Hematuria (Khoon Raftan) and pyuria (Rim Raftan) are due to the inflammation involving the kidney, and [in which the pus] is excreted with the urine from the urethra and [there is] difficulty in urination (dysuria).
Nevertheless, the manifestations of a warm temperament of dysfunction, which occurs in the kidney are intractable thirst, and excessive and frequent drinking [polydypsia] and consequently the frequent urination, and the urine becomes such clear as is the water in the river, because the urine does not stay enough in the kidney to get [its] color, and the humor does not stay long enough in the liver to get there the color too. It is for the warm kidney that more water is required, and this disease, in Parsi (Farsi), is called "Bar Miz", in Arabic "Dawarrah", and in Greek "Diabetes".... Indeed, it is like a bucket (Doulab) filling from one side and emptying from the other side.
When such a dysfunction becomes chronic (persistent), the kidney weakens and the urine comes out sanguineous, bloody, and back pain ensues and the sexual power [libido] is lost totally. Its treatment is basilic venesection on the same side of the pain and ....
Again, if there is inflammation in the kidney and this inflammation is warm, the manifestations are that [the patient] has high fever that is not intermittent, and sometimes there are chills and sometimes no fever, and such a patient bends forward or may assume a quadruped position as if a heavy weight is carried on his back.
The outcomes of kidney inflammation are not outside three: resolves, becomes infectious, or becomes dense (hard). If [the inflammation] was resolved, the kidney recovers by itself. If it turned out infectious, [the pus] inevitably enters the urine. If this occurred, warm water in which are brewed Chamomile (Anthemis nobilis), Yellow Melilot (Melilotus officinalis), Fenugreek (Trigonella foenum-graecum), and Persian violet (Exacum affine) must heavily be laid down on his back, and then the patient should stand and jump on one foot or come down a ladder fast, or have the kidney massaged or the patient shaked until suddenly the pus comes out ....
Otherwise if the inflammation becomes hard, the patient would have pain and heaviness in the kidneys, and the urine becomes scanty and colorless, and the extremities soon become swollen leading to dropsy (anasarca) ....
Again, when the kidneys become slender (atrophic) the signs are that the body becomes lean (cachexia), the sexual power (libido) is lost, the urine increases (polyuria) and becomes transparent, and the back continuously hurts ....
Diseases of the kidney are subdivided into functional (polyuria, and polydypsia), and structural (stone, inflammation) disorders. The brief description of the warm functional disorder of diabetes is consistent with the prevailing notion that it was a disease of the kidneys due to the loss of their retentive power. This was first recorded by Areteus (early 2nd century C.E.) as a defect of the bladder and the kidneys, and subsequently localized to the kidneys by Galen, who demonstrated experimentally that the source of the urine is the kidney [13,18]. Akhawayni refers to it by its Greek name of diabetes and gives the Arabic name of ‘dawarrah’, which Avicenna termed ‘aldulab’ or water wheel.
His description of the diseases of the kidney is not easy to follow but considered in its entirety indicates the occurrence of a progressive kidney disease of various aetiologies whose symptoms of cachexia, weakness and dropsy are consistent with the clinical manifestations of kidney failure. What he refers to as renal atrophy (Hozal), subsequently giving its signs and symptoms, suggest end-stage kidneys with the onset of cachexia, polyuria, swellings and dropsy. Relevant in this regard is his referral to the inflamed kidneys that heals, forms an abscess or fails to heal and becomes ‘hard’. Taken together with his previous referral to the kidney as atrophic, he seems to suggest the small, hardened kidneys of end-stage kidney disease associated with dropsy. This had been described by Rufus of Ephesus in his Diseases of the Kidney and Bladder [14]. Credit for reference to hardened end-stage kidneys has been given to William (Gulielmus) of Saliceto (1210–1277), when in fact it was described by Rufus of Ephesus in the 2nd century and re-stated two hundred years earlier by Akhawayni [14,19].
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On the presentations of the urinary stone |
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Know that when the stone enlarges in the kidney it hinders the urine, causes intolerable pain, and may lead to mental confusion from pain. Each occasion of the pain is called an episode (the pain is intermittent). During the episode of pain the patient should sit in a tub of warm water in which the leaves of cabbage (Brassica oleracea), leaves of marsh-mallow (Althaea officinalis), chamomile (Anthemis nobilis), dwarf yellow (Astragalus hamosus), fenugreek (Trigonella foenum-graecum), flaxseed (Linum usitatisimum), seed of mingwort (Artemisia absinthium), and star-thistle (Centaurea calcitrapa) have been brewed. And after getting out of the water tub, the back [of the patient] should be massaged gently with the oil of wallflower (Cheiranthus cheiri), and then he should jump [up and down] on one foot, or ride a horse trotting in place, or climb fast down a ladder until the stone comes out of there ....
If the stone lodges in the penis, its sign is that of penile pain. If so, [the penis] must be sucked with the mouth to expel [the stone], or [the patient must] put the penis in the warm water and massage it to expel [the stone] and even have marsh-mallow decoction and violet oil instilled in the urethra and milked outward to expel the stone. If the stone is large or lodged transversely and cannot be expelled then an incision [of the urethra] has to be made to extract the stone.
And again those single medicines [used] for the extraction of stone are that I mention: Jews' Stone (Lapis Judaicus) grinded in clean water and three Deram-Sang (1 Deram-Sang 
12.5 gram) of it consumed, root of cumin (Cuminum cyminum), Scholopendriun (?), seed of Caper (Capparis spinosa), Capillaire (Adimantum capillus-veneris), round cypress (Cyperus rotundus), root of star-thistle (Centaurea calcitrapa), Caraway (Cuminum cyminum), seed of Melon (Cucumis melo), seed of Cucumber (Cucumis sativus), seed of pentaphyllum (Gynostemma Pentaphyllum), and Beetroot (Beta vulgaris) concentrate; these drugs are the first line [medications]. And ground pine (Teucrium chamaepitys), dittany (Marrubium pseudodictamnus), herb ivy (Ajuga iva), decoction of black pea (Lathyrus niger), asparagus root (Asparagus officinalis), Indian Djatrah (?), crown of the root of agrimony (Agrimonia eupatoria), seed of radish (Raphanus sativus), and ...; these drugs are stronger, and the strongest of them is beetle (Cantharidae), but care should be taken as it could lead to bladder ulceration.
Now that I gave the guidelines [for treatment], I proceed to pay attention to stone prevention. As it is known that the etiologies of stone are concentrated materials, natural heat, and obstruction in the ducts, I have to mention, briefly highly concentrated foods like ... fresh fruit, and cow and camel meats, and ... and everything that is concentrated should be avoided, particularly fresh cheese ....
And also the use of those drugs that dilate the urinary duct like the seed of melon, cucumber, white cucumber (Cucumis anguinu), seed of marsh-mallow, seed of sweet squash (Cucurbita maxima Duchesme), and ... is recommended.
The discussion of nephrolithiasis is similar to that of other physicians of the period and previous Greek authors. All mention the fact that heavy foods and dairy products, which are considered condensing aliments, can cause stones and that the clinical symptoms of urethral calculi are predominantly seen in males because females have a shorter bladder neck [13,15,20].
One of the features of the Hidayat is its systematic and structured guidelines for treatment [12]. Akhawayni presents a long list of natural substances that are lithoclastic and urinary tract dilators, arranged from less toxic but less effective to more effective but with higher toxicity. Several of these substances are mentioned by Dioscorides (1st Century) and in other Greek texts [20]. Akhawayni frequently uses Persian but occasionally Greek, Arabic and Urdu terms for herbals. Some of these terms are hard to find in modern dictionaries; one particular difficulty with translation is that a given name sometimes has alternative meanings in different languages [21].
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On urine retention |
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Now I mention the chapter on urine obstruction, which could be from the kidney, or from the bladder also, or ureters, or penile duct (urethra), and the one that is from the urethra could be due to the stone, tissue overgrowth, inflammation, blood clot, or pus. Now I describe them one by one.
But urine obstruction when it is from the ureters, manifests in [a way] that the bladder is empty and devoid of urine, and there is heaviness in the back. And if the obstruction is in the penis, its sign is that the bladder is full, and also, if the stone is in the bladder. And if the stone is in the kidney, the bladder is empty. Remember these rules for not making mistakes. And when the bladder is full, on palpation it appears like an inflated bag, and the pain is severe, the bladder is stretched, and this pain may extend to the scrotum.
The [obstruction] of the urethra, may be due to the stone, which I have already mentioned its treatment, or from [granulation] tissue grown within the urethra following its ulceration, or from a wart like the one that appears on the skin, and its treatment is difficult. Its sign is that the urine flows scanty, [but] as time passes, the urine decreases until it completely ceases. For treatment, put [the patient] in a water tub and use softener pomades and rub the oil of Cruciferae until urine starts to come out and the duct [ureter] becomes dilated. When [the obstruction] is not at the ureters but in the urethra, it could be cured with the "Mabowleh", which is a hollow pin made of silver or gold or brass over the head of which are many holes resembling a lance ....
It is possible for the urinary obstruction to be due to a stone lodged at the bladder outlet. Its sign is that when the patient lies down on their back, and elevates the feet and wags them, the stone is dislodged and the urine comes out. Its treatment is with those agents that bring the stone out of the bladder, which I will mention in the chapter on the bladder stone.
It is possible for urine retention to be secondary to the bladder weakness when its expulsive force is decreased, the sign of which is that if you put your hand on [the bladder] and compress it, the urine comes out .... Again when the bladder is full, avoid using the diuretic agents as it brings death.
Again, when the stone is in the bladder this is more common in children, while in the elderly it occurs in the kidney, the signs are that the urine is white and of a fair appearance and when [the patient] wants to urinate, penile erection occurs, and in such a child the penis is mostly erect. He scratches the base of the penis. The pain is so severe and occasionally, the [penile] base may be pulled off from the extensive scratching. When the bladder is full, make the patient lie on his back and elevate his legs and shake them, urine comes out.
And this stone has several types: one type is soft and is removed with medications, and another is hard and is not removed with medications. For one month, treat [the patient] with medicines, may be [the stone] is abated, unless [the patient] develops hectic fever and dies. If so, and you treated for one month, [but the stone] does not come out, now you must handle [it] with iron and apply those things that bring the stone out as I mentioned previously.
This section shows a step-by-step analysis based on observation and physical examination, to differentiate between the different levels of urinary tract obstruction and the various causes of decreased urine output. Akhawayni emphasized that these should be kept in mind, in order to avoid mistakes in diagnosis and treatment. He also tried to differentiate between mechanical and functional obstruction of the bladder due to loss of its expulsive power, in which after compression of the bladder the urine comes out.
He noted that bladder stones are more common in children and males. He again noted that priapism in a child could be a sign of a bladder stone. He also described a fatal, febrile condition as a consequence of unresolved urine retention resembling the clinical scenario of septic shock or urosepsis. He referred to two types of bladder stones: soft (?uric acid stones) that are relatively easy to treat medically and hard stones (?struvite) which are difficult to treat with medicines [22]. He recommended that if you cannot manage the bladder stone with drugs in 1month, you should stop the medical therapy and use the iron (surgery? bladder instrument?). The instrument (mabowleh) he described is in some ways reminiscent of modern catheters. It is also mentioned by the same name by Rhazes, but without a description [23]. It seems to be similar to the one described in detail and illustrated by Albucasis (936–1014) in his Kitab al-Tasrif. It was inserted in the urethra to relieve obstruction and presumably for access to the bladder for dripping the medicines he describes, or for crushing and extracting stones.
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Urinary incontinence |
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The so-called urinary incontinence is that the urine comes out unintentionally, which are of two types; one with burning sensation and another without burning .... Again, if there is burning with unintentional urination, two types also are discernible that are with or without pus. If associated with [an excretion of] the pus, this [pus] could be from the kidney that I told you its signs and treatment previously, or from the bladder that I will now describe in the chapter of bladder ulcer.
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Bladder ulcer |
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Bladder inflammation is warm [in nature], and its manifestation are that there is great irritation and severe pain, and the urine is halted, the fever is high with delirium and the tongue blackens and those symptoms [of confusion] that are [seen] in brain inflammation (meningitis) are brought about. Its cure is with the same [way] I mentioned for meningitis: firstly, a basilic venesection must be done ....
Akhawayni described a complicated urinary tract infection with septicaemia, high fever delirium and confusion. He characterized this condition as being similar to meningitis and recommended bleeding from the basilic vein, a recommendation similar to that found in Byzantine medical texts [23].
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On urine |
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I described the urine in the chapter on fevers as much as it was needed there and am mentioning the remaining here. Black urine, which is of the color of straw wine or pea decoction, is the urine of pregnant women, those with dropsy, those with hectic [fever], or those with a chronic, warm intra-abdominal inflammation. A urine resembling cheese water or beer, which is fair [in color] indicates that there is pus mixed up with it and its owner has bladder, kidney or urethral ulcer ....
[From] those things that appear in the urine, one is called sediment, which I mentioned [previously], and [the other] is a crude, phlegmatic humor deposited in the urine, [but] when shaken, it mixes with and tarnishes the urine and does not precipitate. And the third one is pus. When shaken, it is s dispersed in the urine, and makes it turbid and then soon precipitates at the bottom of the glass. It (pus) is of a fetid smell while the phlegmatic humor is not putrid. And the fourth [one] is gravel, which is of two types: one type is like the Meccan sand of goldsmiths, is red in color and [for that] it is from the kidney. The other one is white or greyish or earth-coloured, and [for that] it is from the bladder ....
Throughout the history of medicine, uroscopy has been important in diagnosing disease and determining prognosis, as is evident in the most ancient extant medical texts. It was even mentioned by Firdawsi in Shah Nameh (Book XX, 8), where he refers to a physician as [8]:
A youthful leech who diagnosesThe succinctness with which uroscopy is presented by Akhawayni sounds Greek in origin, and more Hippocratic than Galenic in its composition. The translation of his extensive discourses on uroscopy is beyond the scope of this article. Interestingly, Akhawayni points to his own experience with a patient who had survived after contracting black urine, while referring to black urine as being fatal. Similar references to personal experiences are not infrequent in the Hidayat [12].disease by making uroscopy.
So long as he is at court, the Shah
will never ail.
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Discussion |
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The Hidayat of Akhawayni reflects the general format and content of texts of the period. It begins with a theoretical discussion of the elements and humors, followed by brief sections on anatomy and physiology, and then a detailed consideration of diseases and their treatment classified by the affected parts of the body. Although the medicine of the period integrated components of Far Eastern and Indian medicine, it remained essentially Greek [3,7]. In fact, by far the most quoted author mentioned by Akawayni is Galen, followed by Hippocrates, Rhazes, Yuhanna ibn Masawaih and Johannitus with occasional mention of Dioscorides and Aristotle. When Akhawayni wrote the Hidayat, the translation phase of medicine was over and Greek medicine had permeated and was accepted in medicine of the period, as is evident in extant writings of the times and in particular those of Rhazes, his most immediate predecessor with whom his teacher had trained [3].
When Akhawayni wrote his book, Bukhara was already an intellectual centre of the Islamic world and he probably had access to the writings of Rhazes and other translated classics. The Hidayat is really a practical and condensed compendium of what was known then. It lacks the commentary and clinical detail presented by Rhazes in the Continens. Although quite inclusive in content, the Hidayat is an abridged version of medical knowledge that pales in comparison to the encyclopaedic content of the Canon of Avicenna. The major contributions made during the compilation and expansion phase of medicine of the period were the descriptions of new clinical manifestations of diseases and expansion of the materia medica used for their treatment [3,7,10]. The best example of the former is the detailed description of clinical features in the case studies of the Continens by Rhazes, and of the latter, the chapters devoted to drugs by Avicenna in his Canon. Some of this therapeutic detail is evident in the Hidayat and Akhawayni is credited with describing 10 chemical remedies he is said to have invented [10].
The originality of the book lies in the insights it provides to the teaching and practice of medicine of the times. Most histories of medicine recount the life and contributions of famous figures such as of Rhazes and Avicenna. These and other illustrious physicians were also jurists, theologians, ambassadors and astrologers, who earned their living practicing medicine. Their contributions were diverse and the medical care they provided might have not been available to everybody. Information on medical care of urban populations outside major cities is scant. It is in this regard that Akhawayni and his book provide some insight. Akhawayni learned his medicine and practised it in his native city of Bokhara, where he spent the rest of his life taking care of the local population. He does not seem to have travelled from court to court. Whether he had the broader education of the better-known physicians of the period is not known. The only book he seems to have authored was on medicine. Its dedication is especially revealing for the insight it provides into medical education.
Medical education of the day was not institutionalized or regulated, and the profession was less structured than it ultimately became in the West. It was informal, open-ended and ultimately dependent on the initiative and drive of the individual, as clearly exemplified in the career and achievements of such giant figures as Rhazes and Avicenna [3,7]. There were different ways to prepare for a medical career. Several of the best-known medical figures of the time, such as Avicenna, were self-taught. In many cases, sons would follow a physician into the profession. The Bakhtishus and Qurras are examples of families whose descendants practiced medicine in Baghdad for centuries [2,4,7]. Others gained their education through study with a teacher, who taught them in their houses, mosques and hospitals (bimaristan). Reading and mastering medical texts was a very important component of this education. Whatever the source of study, it was customary to have some practical training by working with a practising physician. Besides passing examinations [6], some form of authorization was generally required to practise medicine in larger cities. The two principal questions asked by examiners were whom the applicant had studied with and what books he had used [7].
In larger teaching centres such as Baghdad, courses seem to have had some structure and the texts studied were the classics translated into or written in Arabic. For those who could not afford to travel to Baghdad, had no access to libraries or who could not read Arabic, learning medicine presented a challenge. It is this gap that Akhawayni bridges with his relatively simple and short pandect written in Farsi. His son and other aspiring students of medicine, who did not know Arabic nor had access to the larger and more expansive texts, now had a simple book written in a language they could speak in order to begin their study of medicine. Unfortunately, there is no information on the extent of use or popularity of the Hidayat. The fact that its extant manuscripts were copied, a century after it was first written, can be construed as an indication of its widespread use [24].
Conflict of interest statement. None declared.
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Accepted in revised form: 28. 6.07
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