The Best Doctor Is Also a Historian
The Rootcutter's inaugural essay series aims at exploring connections between ancient and modern medicines—and not only the connections we make, but also why we make those connections and what impact they have on how we think about and conduct modern medical practices, both as healthcare experts and as service users. This series has been generously funded by the Society for Classical Studies Ancient Worlds, Modern Communities grant.
by Zsuzsanna Csorba
August 2, 2023
In the middle of his 10th century medical handbook Kitāb al-Manṣūrī fī al-ṭibb, al-Razi describes how to keep a army healthy while on campaign. Zsuzsanna Csorba outlines al-Razi's recommendations and examines how the details missing from his account can speak loudly about the realities of war and disaster, both in his time and our own.
Zsuzsanna Csorba is a researcher of the history of medieval Islamicate medicine with particular focus on travel medicine and manuscript studies at the Avicenna Institute of Middle Eastern Studies (Hungary).
The medieval Islamicate world produced a rich tradition of Arabic literature about such topics as strategy, archery, and horsemanship. Apart from these texts on the art of war, a handful of treatises found in medieval Arabic medical encyclopedias address the medical and health concerns of battle. Rather than theoretical discussions, etiologies of disease, or anatomical expositions, these so-called “military regimens” focused on the more practical medical concerns, presenting guidelines for the preservation of health within armies that are on the move or engaged in armed conflict. Al-Rāzī’s On the Regimen of Military Camps, a short section in his medical handbook, Kitāb al-Manṣūrī fī al-ṭibb (The Book Dedicated to al-Manṣūr on Medicine), provides a useful example of such a regimen. It can shed light on what the key issues were for keeping an active army healthy and how these issues were approached according to the learned medical tradition of al-Rāzī’s time. This not only enriches our understanding of health aspects of everyday military life and the workings of medical theory and practice during this period but also attests the specialization of healthcare practitioners in this era. Moreover, taking a closer look at the topics this military regimen focuses on provides valuable insight into what were the considered to be the major health risks of a marching army. They are familiar to us even in the present day and reflect the types of casualties that occur in both modern war zones and the aftermath of environmental disasters.
Kunnāsh al-Manṣūrī, Rāzī, Abū Bakr Muḥammad Ibn Zakarīyā, manuscript ~1400, Library of Congress no. 200840168
Al-Rāzī (d. 925 or 935 CE) was born in Rayy , near present-day Tehran, but he studied and practiced medicine in Baghdad before moving back to Rayy to direct its hospital at the request of the governor, al-Manṣūr, whom al-Rāzī served as both physician and drinking companion. Later on, al-Rāzī returned to Baghdad to head a new hospital there, and he spent the remainder of his life residing between these two cities. As both philosopher and alchemist, as well as physician, hospital director, clinician, and teacher, al-Rāzī valued qualified experience and observations, and he combined these with a robust theoretical framework. His masterwork was a systematic and complete guide to medicine in ten books, dedicated to al-Manṣūr, that was later translated into Latin and Hebrew and became immensely influential in the medieval period and beyond. Al-Rāzī wrote the sixth book of this handbook for travelers, covering such topics as the health risks of travelling in hot or cold weather, how to ensure water is safe to drink, or how to avoid seasickness. He included On the Regimen of Military Camps, a text for armies specifically, within this book on travel. The reason for this placement is that a change of circumstances and routine poses a great health risk, and this remains true both for merchants, wanderers, or soldiers. In the case of soldiers, an added challenge arises, since soldiers generally travel in huge groups. This produces its own unique dangers for health.
In this text, Al-Rāzī grouped his instructions around five main issues: (1) setting up the camp; (2) the quality of the air; (3) quarantining the sick; (4) handling vermin; and (5) general diet.
"Christian And Moor Playing Chess," The Book of Games of Alfonso X, fol. 64r, 13th century
Al-Rāzī’s first theme is the proper organization of the camps. During summer, the tents were to be set up on hills and high places, facing the northern wind, with ample space between them and away from animals intended for riding. In the winter, the regimen should be the opposite. During this season, the best camping grounds were in depressions, and he advised his reader to seek shelter near thickets and at the base of hills and mountains; tents were to be oriented to the south and east and were to be placed close together, as well as near the pack animals. This is so straightforward that one might begin to wonder if setting up a healthy military camp is so complicated after all.
The second issue discussed by al-Rāzī is the quality of the air. When there were sultry, moist, southern winds, al-Rāzī instructs his reader to decrease the soldiers’ rations, forbid the consumption of wine, and increase the amount of physical exercise. When the air was rough and dry, the regimen was the reverse: soldiers could eatmore food, gain permission to consume wine, and exert themselves less. Although drinking wine seems to contradict the Islamic prohibition of its consumption, it is nevertheless found not only in medical recommendations and recipes but also cookbooks, and we can also read about its cultural role in Muslim societies over the ages.
These recommendations align with the medical theory prevalent in al-Rāzī’s time: health was considered the result of safeguarding the balance of the body. Sultry and moist southern winds were thought to have a moistening and cooling effect. By consuming less food and drinking no wine, soldiers could avoid amplifying these effects, while through exercise, they warmed and dried their bodies.
"Wine Drinking in a Spring Garden," ca. 1430, Iran, possibly Tabriz. MET Museum, NYC. Cora Timken Burnett Collection of Persian Miniatures and Other Persian Art Objects, Bequest of Cora Timken Burnett, Acc. No. 57.51.24
Rough and dry air, meanwhile, was thought to have a drying and warming effect. In this case, less exercise would ensure a limited degree of further drying and warming, while eating more and drinking wine would ensure additional moistening and cooling. Thus, these measures aimed to counteract the effects of the climate, therefore protecting the soldiers’ internal balance.
Al-Rāzī does not explain any of this reasoning in his book, and we do not know for sure whether the underlying theory was familiar to military personnel. For ordinary soldiers, this is unlikely; for commanders, who might have had more access to education, obtaining a basic understanding of medical theory was a possibility. Nevertheless, these instructions are clear and simple enough to follow, regardless of theoretical knowledge.
"Preparing Medicine from Honey", from a Dispersed Manuscript of an Arabic Translation of De Materia Medica of Dioscorides," Calligrapher 'Abdullah ibn al-Fadl, dated 621 AH/1224 CE, Baghdad, Iraq. MET Museum, Bequest of Cora Timken Burnett, Acc. No: 57.51.21
Al-Rāzī continued his regimen with a statement that should be familiar to readers these days: “When many creatures fall ill in [the camp], they should camp on a site far away and not downwind but upwind.” (Kitāb al-Manṣūrī fī al-ṭibb, ed. Ḥāzim al-Bakr al-Ṣiddīqī, p. 295). That is to say, the sick were to be kept away from the healthy, with particular attention paid to relocating them to a place from where the wind could not carry their diseases back to the camp. Al-Rāzī did not use the word “contagion” (ʿadwā/عدوى). Instead, he focuses on the idea of miasma—the theory, common across the premodern world, that diseased matter (whether a sick person, stagnant water, or some other rotting substance) discharging noxious vapors that, when mixed with the air and inhaled by a healthy person, transmit disease.
Al-Rāzī’s emphasis on miasma over contagion is likely an attempt to avoid getting embroiled in heated theological debates of the time. The concept of contagion is particularly problematic in Islam, since it implies that a sick person might infect someone else, which contradicts the Islamic teaching that God causes disease.
This conflict was eventually resolved by various scholars working within the framework of what is called Prophetic medicine, which sought to reconcile medical theory with the sayings and practises of the Prophet, some of which were connected to contagion and plague. Since On the Regimen of Military Camps is meant to be a practical collection of guidelines and instructions, this is a sensible decision, as a theoretical debate on the nature of contagion would only distract from the functionality of this text.
"The Ascetic and his Guest with the Mouse Steal the Ascetic's Food", Folio from a Kalila wa Dimna, 16th century, Gujarat, MET Museum, The Alice and Nasli Heeramaneck Collection, Gift of Alice Heeramaneck, 1981, Acc. no. 1981.373.58
Al-Rāzī wrote that if there were vermin at the campsite, as many as possible were to be killed, and, for the remainder, vermin repellents and poisons were useful. Here, al-Rāzī made use of the fact that he was writing an encyclopedia: instead of listing such preparations and procedures, he redirected his reader to a separate chapter on this issue. However, he did suggest that his readers might burn the weeds and trees that generate pungent, harmful winds, or camp on a site out of reach of such winds, since those provide a suitable environment for vermin.
This is not the first appearance of vermin in Arabic medical literature: ʿAlī ibn Sahl Rabban al-Ṭabarī (d. ca. 864) mentions vermin-laden waters in his regimen for travelers and armies, and Qusṭā ibn Lūqā (d. 912) dedicates a whole chapter of a treatise written for pilgrims to prophylaxis against vermin-spread diseases. It seems that vermin posed health risks daily and that medicine had to respond. Al-Rāzī’s instructions in the section on military camps suggests that preventive methods against vermin is not specific knowledge necessary only for military regimens or travel regimens.
This aspect of the text is even more interesting if we think about, for example, the Black Death (which has a more complicated story, as Monica Green has outlined) or the Justinian Plague. Disregarding the literary and medical plague literature and focusing only on the above examples from other regimens and our specific text, this small section shows that the physicians, and thus, medicine, realized that vermin could be disease vectors.
The last piece of advice al-Rāzī gave in his regimen for armies was to examine their food and drink, since these could cause illnesses affecting a large portion of the army, and to avoid dangerous comestibles. Al-Rāzī stopped here, without providing further details or guidance; this was a task for an educated physician and not simply a question of following written instructions, as elsewhere in the regimen. To analyze all the possibilities and complexities of diet required an understanding of the properties of foods, drinks, and drugs. Al-Rāzī discusses these at other points in his encyclopedia, as they are part of the knowledge an educated physician should have. With the information that food and drink could cause illnesses and the instruction to avoid dangerous substances, we have reached the limits of what the ordinary layperson was expected to understand.
Bowl with Arabic Inscription, Nishapur, Iran, 10th century. MET Museum, Acc. No. 65.106.2
Al-Rāzī’s On the Regimen of Military Camps might be understood as intended for a physician accompanying an army. Looking at the section as a whole, we might make a curious observation: there is no reference to where or how wounds were to be treated. Such matters belonged to the realm of surgeons rather than physicians. Yet, al-Rāzī’s medical encyclopedia does contain a section on bone-setting and wounds, which suggests that al-Rāzī did expect physicians to possess some relevant knowledge. The fact that he did not even refer the reader of his military regimen to this part of his book tells us that, when it came to the health of an army, regimen was potentialy considered more important than surgery. This assumption might show us that ancient physicians were aware that illness and diseases killed more soldiers than combat and wounds, an assessment often made in case of pre-nineteenth and pre-twentieth century warfare.
"Abu'l-'Abbas al-Saffah proclaimed as the first 'Abbasid Caliph," Folio from a Tarikhnama (Book of history) by Balami, 14th century.
This knowledge of, or rather familiarity with the conditions during warfare is not that surprising if we consider the fact that the period was laden with political and military turmoil. Al-Rāzī was born during the decade of anarchy in the then capital of the Abbasid Caliphate, Samarra (861–870). This was followed by the third Zanj rebellion (869–883) during which the battles and ambushes between the Zanj and Abbasid troops ravaged Lower Iraq and southwestern Persia (present-day Iran). Then came the conflict with the Saffarids from present-day Afghanistan who overran Persia. Although the caliphal forces defeated them near Baghdad in 876, the Saffarids kept their control over most of the region until about 910, when the Abbasids regained its southwestern provinces. Arriving at the time of al-Rāzī’s death, a new emerging dynasty, the Buwayhids or Buyids brought dynastical and political stability to the region for some time. Al-Rāzī’s guide was written in a time of war.
Perhaps this context can help us read On the Regimen of Military Camps as more intimately connected to horrors and realities of war than its almost serene recommendations might first let on. Up until World War I, disease killed more soldiers than actual military action. Taking as examples the Crimean War or the American Civil War, about two-thirds of the casualties were due to diseases as opposed to being killed in action or succumbing to wounds. The most notable reasons were crowded and unsanitary conditions, inadequate diet, lack of potable water, faulty regimen, inability to acquire medicines, and the scarcity or absence of disease treatment, any or more of which can be worsened by destroyed infrastructure or harsh weather conditions. These factors are very much the same conditions that civilians have to face even in the present, whether in military conflicts like that in Ukraine from 2022, or during natural disasters, such as the earthquake in Turkey and Syria in 2023. Reading a military manual, even when its recommendations seem straightforward at times, can reveal the harsh realities that underpin its composition, as the dangers that al-Rāzī discussed in his text more than 1100 years ago remain much the same today.
Abū Bakr Muḥammad ibn Zakariyyāʾ al-Rāzī (d. 925 or 935): Kitāb al-Manṣūrī fī al-ṭibb [‘The book dedicated to al-Manṣūr on medicine’], ed. Ḥāzim al-Bakr al-Ṣiddīqī, Kuwait: Maʿhad al-Makhṭūṭāt al-ʿArabiyya, 1987, p. 295.
Frölich’s English translation from the 1880s is quoted in Fielding Hudson Garrison: Notes on the history of military medicine, Washington, DC: Association of Military Surgeons, 1922, p. 82. The translation is quoted partially from Garrison’s work in Guy Geltner’s article ‘In the camp and on the march’, 55 (open access, see below).
Manfred Ullmann: Islamic medicine. Edinburgh: Edinburgh University Press, 1978.
Peter Pormann – Emilie Savage-Smith: Medieval Islamic medicine. Cairo: The American University in Cairo Press, 2007.
Gerrit Bos (ed., transl.): Qusṭā ibn Lūqā’s medical regime for the pilgrims to Mecca, The Risāla fī tadbīr safar al-ḥajj. Leiden–New York–Köln: E.J. Brill, 1992. [Chapter 11 on vermin: pp. 64–67; Commentary: pp. 130–136]
Piers Mitchell: Medicine in the Crusades, Warfare, wounds, and the medieval surgeon. Cambridge: Cambridge University Press, 2004.
Guy Geltner: ‘In the camp and on the march: military manuals as sources for studying premodern public health’, Medical History 63/1 (2019), pp. 44–60.
Emilie Savage-Smith on hospitals [in [The Online Version of] A Brochure to Accompany an Exhibition in Celebration of the 900th Anniversary of the Oldest Arabic Medical Manuscript in the Collections of the National Library of Medicine, 1994].
Emilie Savage-Smith on al-Rāzī [in [The Online Version of] A Brochure to Accompany an Exhibition in Celebration of the 900th Anniversary of the Oldest Arabic Medical Manuscript in the Collections of the National Library of Medicine, 1994].
Ibn Abī Uṣaybiʿah’s account on al-Rāzī and the hospitals he was involved with [in E. Savage-Smith, S. Swain, G.J. van Gelder (eds.): A Literary History of Medicine. Leiden: Brill, 2020].
What did you first imagine a guide to keeping an active army healthy would include? How did that differ from al-Razi's account? What can that tell you about your own ideas about wars and disastre zones?
How should we understand the inclusion of this section on military medicine alongside other accounts of "travel"? Can this shape how we understand Islamicate or ancient conceptions of military life? Where do your own ideas about what war looks like come from?
How can reading a medical text for what's missing help illuminate ideas from other cultures? What are the potential pitfalls of this approach? Can you read a modern medical text for what's missing? What can that tell us?
