Ophthalmology in medieval Islam



The oculist or kahhal (کحال), a somewhat despised professional in Galen’s time, was an honored member of the medical profession by the Abbasid period, occupying a unique place in royal households.

Of all the branches of Islamic medicine, ophthalmology was certainly the foremost. The specialized instruments used in their operations ran into scores. Innovations such as the “injection syringe”, a hollow needle, invented by Ammar ibn Ali of Mosul, which was used for the extraction by suction of soft cataracts, were quite common.

Muslim physicians deserve much praise for their descriptions of ophthalmological pathology. They, not the Greeks, were the first to describe such conditions as pannus, glaucoma (described as ‘headache of the pupil’), phlyctenulae, and operations on the conjunctiva. They were the first to use the words 'retina' and 'cataract'. They also pioneered the field of optics. The list of Muslim contributions to Ophthalmology is anything but brief.

Fertile grounds for their emergence
The scientific achievements of the late Abbasid period may perhaps be attributed to the worldview that had developed as a result of the establishment of the House of Wisdom, and intermingling of scholars from India, Persia, and the west, in Baghdad. There, an ideology began taking shape in which unlike their early Islam predecessors, did not recognize a disparity between faith and reasoning, though many doubtlessly continued to do so. The Moorish Lisan al-Din ibn al-Khatib, himself a great vizier and a man of medicine, is famous for once declaring that “whatever the traditions of the prophet might say, their remarks about exhalations from Hell cannot stand against the evidence of careful observation.” And put another way by Ibn Tufayl: “Faith is for the people. But its understanding in the light of reason, is the privilege of the intellectual elite.”

Their education
To become a practitioner, there was no one fixed method or path of training. There was even no formal specialization in the different branches of medicine, as might be expected. But some students did eventually approximate to a specialist by acquiring proficiency in the treatment of certain diseases or in the use of certain drugs. “The Prince of Physicians”, the Persian (Iranian) Avicenna, for example, was held to be more proficient than most others in his treatment of nervous diseases, and hence a large number of psychological cases were brought to him, the most famous being the Samanid prince Nooh ibn Mansur who thought of himself as a cow, and who was cured by Avicenna who was no more than 17 years of age. Avicenna himself benefited from the instruction of many teachers, ranging in subject from geometry to theology.

Nevertheless it was standard and necessary to learn and understand the works and legacy of predecessors, if one was to excel and surpass others in the field. Among those one can mention ‘the alteration of the eye’ by Yuhanna ibn Masawayh, the great Nestorian Christian physician, whose work can be considered the earliest work on Ophthalmology, only to be eclipsed by that of none other but Hunain ibn Ishaq, known in the west as Johannitius, for his work ‘The ten treatises of the eye’. Other famous landmarks are Alhazen’s Opticae Thesaurus, Rhazes’ Continens, Ali Ibn Isa’s Notebook of the Oculists, and Jibrail Bukhtishu’s Medicine of the Eye, among numerous others.

Certification and malpractice
Being an ophthalmologist was not an easy profession then, for a license was required to be able to practice. The granting or withholding of this rested with the hakim-bashi, the chief physician to the Caliph. However, in addition to this test of certification, there was an additional means of checking for malpractice: Aside from the chief physician whom to which the Caliph delegated his powers to, there was another official known as the Muhtasib, or Inspector–General, who was appointed to oversee the practice of medicine by all physicians.

Before the year 931CE, there was hardly any means of professional certification, for in that year the Abbasid Caliph al-Muqtadir, was informed that the mistake of a private medical practitioner had resulted in the death of a patient. The Caliph therefore issued orders to the Inspector-General Ibrahim Muhammad ibn Abi Batiha to see to it that the practice of medicine by anyone who had not been examined and approved by Sinan bin Sabit bin Qurra be prohibited. Sinan thus only authorized physicians to practice whom he personally endorsed. He furthermore would suggest to each applicant what branch of medicine he ought to practice in. It is said that he examined a total number of physicians exceeding the number 860 in Baghdad alone during the first year.

The chairing of the board was later passed to Sinan’s son Ibrahim, who became chief physician of Baghdad, and Abu Sa’id Yamāni of Basra who certified the practice of 700 physicians through examinations. The board continued to function, being chaired by the likes of Ibn al-Tilmiz, court physician to caliph Al-Mustazhir.

Both the offices of the chief physician and the inspector general formed part of the royal caliphate. Among the Muhtasib’s duties were the administering of the Hippocratic Oath, which required physicians to swear that they would prepare, administer, or entrust no poisonous drafts to any unauthorized persons: that they would avoid gazing upon unrelated women folk within the sick household they visit: and that they would never reveal to any third person anything revealed to them in confidence by the patient. So important was this oath that Hunain ibn Ishaq was said to have reminded the Caliph of his oath when asked to prepare a lethal poison for an enemy of the Amir.

It was also the Muhtasib’s duty to see that physicians possessed proper instruments of his calling that were necessary and befitting for practice, as was with all the other branches of medicine. He would further, if he wished, require them to undergo a further examination. For example, physicians would be required to be thoroughly familiar with the ‘Ten treatises on the eye’, and were forbidden to practice unless they demonstrated knowledge of the gross anatomy of the eyeball. Rhazes, for instance, when about to undergo an operation for his deteriorating vision, orally examined his surgeon on the anatomy of the eye, and finding him lacking in knowledge refused to submit to his blade for the operation.

Ophthalmologists hence had to satisfy the examiner that they knew the principal diseases of the eye as well as their intricate complications, and were able to properly prepare collyria and ophthalmic ointments. Moreover they had to assert under oath not to allow unauthorized persons access to any surgical instruments, such as the lancet that was used for cases of pannus and pterygium, or the curette used for cases of trachoma.

The penalties for disregarding proper professional conduct varied from the warning of divine punishment on the Day of Resurrection, to more drastic measures such as the beating of the soles of the feet. The Muhtasib had such authority as to even inspect shops during after hours, as frequently and unexpectedly as he wished. He could enter shops and observe operations being performed. The inspector-general would oversee the preparation of certain ointments and destroy jars that he determined to be old or smelly. The rules for maintaining sanitary conditions were quite severe for such places including those of the druggists, public eating houses, and butchers. In earlier days, the Muhtasib had the right to punish, even by death, gross neglect of the health of the public. It was not uncommon to hear of a baker be thrown into his own furnace for selling poisonous corn, or for a cook to be boiled in his own cauldron for selling carrion or putrid meat.

Still, the sheer number of ignorant and fraudulent eye-charlatans caused many problems. So shocking was the conduct of these ignorant doctors that it was the declared duty of the Muhtasib to see that such men perform no operation upon the eyes, and never give a patient any preparation intended to be applied within the lids. Rhazes poured out his wrath when encountering quacksters and charlatans.

Fees and income
There was a good deal of drama surrounding the men of medical professions in those days. A physician could on the one hand receive no less than an astronomical sum of 4,000,000 dirhams a year, as did Bukhtishu ibn Jurjis, chief physician to the great Caliph Harun al-Rashid; or pay for the unfortunate death of his patient or failure of his treatment with his own life, as was often the case with physicians treating many a royalty.

But in general, the fee varied according to the status of the physician and the patient. The life of Ibn Masawayh, can perhaps be quite instructive in this regard: When still unknown and still a so called “road-side” physician in Baghdad, in return for successfully treating a servant suffering from Ophthalmia, he was paid with a daily allowance of bread and meat and sweets and a promise of a monthly salary of a few silver and copper coins. When The Vizier fell ill and Ibn Masawayh achieved similar success with him, his salary rose to 600 silver dirhams a month, food for two mules, and the services of five servants. And when he finally obtained the rank of chief ophthalmologist to the Khalifah, his salary was fixed at 2000 dirhams a month plus gifts valued at 20,000 dirhams a year, including forage for his mules as well as the services of a number of servants.

However, fees paid to ophthalmologists were measly in comparison to the elephantine fees which others were apt to receive overall. At the time when Ibn Masawayh received 2000 dirhams a month as ophthalmologist-in-chief to the Caliph Harun al-Rashid, Jibrail the physician was receiving 10,000 dirhams per month. As to the means of obtaining the fee, in cases deemed chronic requiring multiple visits, they would receive the fee only on the fair conclusion of the case. If the patient recovered, there was, in most cases, no question of refusal to pay. But if the case ended fatally, then the relatives could if they so choose, show the chief physician of the city a copy of all prescriptions and medicaments which he ordered for the sick person. If the Hakim-bashi determined they were proper and fitting for the case and that the physician was exempt of any negligence or fault, he could declare that the person’s life had reached its allotted span by the will of Allah, and that the fees had to be paid in full. If on the other hand, the chief physician found evidence of neglect, he would direct the relatives to collect dieh (or blood money) for their kinsman from the physician, ‘for it is he who slew him by his poor skill and negligence.’

Nevertheless, some ophthalmologists would be fortunate enough to work as personal ophthalmologist to an Amir of good heart and intellect, and some Caliphs were even known to have kept a personal ophthalmologist in addition to a personal physician.

So well ingrained did the science of ophthalmology become in medieval Islamic culture that the word used for "wisdom" in Arabic is "al-Basirah", meaning the ability to see. In fact, one refers to loved ones as "Nour al-Ayni" meaning the light of my eyes.