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The Muslim Roots of European Medicine
by
David W. Tschanz
In
the "General Prologue" of The Cantenbury Tales, Geoffrey Chaucer
identifies the authorities used by his "Doctour of Physic" in the
six lines quoted above. The list includes four Arab physicians:
Jesu Haly (Ibn 'Isa [Haly Abbas, Ali ibn al-Abbas al-Majusi]),
Razi (al-Razi, or Rhazes), Avycen (Ibn Sina, or Avicenna) and
Averrois (Ibn Rushd, or Averroes). These four did not make
Chaucer's list only to add an exotic flavor to his
late-14th-century poetry. Chaucer cited them because they were
regarded as among the great medical authorities of the ancient
world and the European Middle Ages, physicians whose textbooks
were used in European medical schools, and would be for centuries
to come. First collecting, the translating, then augmenting and
finally codifying the classical Greco-Roman heritage that Europe
had lost, Arab physicians of the eighth to eleventh century laid
the foundations of the institutions and the science of modern
medicine.
After the
collapse of the western Roman empire in the fifth century, Europe
lost touch with much of its intellectual heritage. Of Greek science,
all that remained were Pliny's Encyclopedia and Boethius's treatises
on logic and mathematics; the Latin library was so limited that
European theologians found it nearly impossible to expand their
knowledge of their own scriptures.
The center
of Europe's new world view became the church, which exerted profound
new influences in medicine. Because Christianity emphasized
compassion and care for the sick, monastic orders ran fine hospitals
- but they did not function as hospitals do today. They were simply
places to take seriously ill people, where they were expected to
either recover or die as God willed. There were no learned
physicians to attend them, only kindly monks who dispensed comfort
and the sacraments, but not medicines.
Because the
Christian church viewed care of the soul as far more important than
care of the body, medical treatment and even physical cleanliness
were little valued, and mortification of the flesh was seen as a
sign of saintliness. In time, nearly all Europeans came to look upon
illness as a condition caused by supernatural forces, which might
take the form of diabolical possession. Hence, cures could only be
effected by religious means. Every malady had a patron saint to whom
prayers were directed by the patient, family, friends and the
community. Upper respiratory infections were warded off by a
blessing of the throat with crossed candles on the feast of Saint
Blaise. Saint Roch became the patron of plague victims. Saint
Nicaise was the source of protection against smallpox. Kings,
regarded as divinely appointed, were believed to be able to cure
scrofula and skin diseases, among other maladies, with the "royal
touch."
With the
study of disease and of patients neglected, licensed medicine as an
independent craft virtually vanished. Those physicians who endured
were mostly connected with monasteries and abbeys. But even for
them, the generally accepted goal was less to discover causes, or
even to heal, than to study the writings of other physicians and
comment on their work. In the middle of the seventh century, the
Catholic church banned surgery by monks, because it constituted a
danger to their souls. Since nearly all of the surgeons of that era
were clerics, the decree effectively ended the practice of surgery
in Europe.
At roughly
the same time, another civilization was rising in the east. The
coming of Islam, also in the seventh century (See Aramco World,
November/December 1991), led to a hundred years of continuous
geographical expansion and an unprecedented era of ferment in all
branches of learning. The Arabs rapidly melded the various cultures
of the Islamic domain, and Arabic - the language of the Qur'an -
became the universal language. By the 10th century a single language
linked peoples from the Rann of Kutch [India] to the south of
France, and Arabic became to the East what Latin and Greek had been
to the West - the language of literature, the arts and sciences, and
the common tongue of the educated.
Medicine was
the first of the Greek sciences to be studied in depth by Islamic
scholars.
After
Plato's Academy was closed in 529, some of its scholars found refuge
at the university at Jundishahpur, the
old Sassanid capital of Persia, which had also sheltered
excommunicated Nestorian Christian scholars - among them
physicians - in 431. Persia became part of the Islamic world in 636,
and Arab rulers supported the medical school at Jundishahpur; for
the next 200 years it was the greatest center of medical teaching in
the Islamic world. There, Islamic physicians first familiarized
themselves with the works of Hippocrates, Galen and other Greek
physicians. At the same time, they were also exposed to the medical
knowledge of Byzantium, Persia, India and
China.
Recognizing
the importance of translating Greek works into Arabic to make them
more widely available, the Abbasid caliph Harun al-Rashid (786-809)
and his son, al-Ma'mun (813-833) established a translation bureau in
Baghdad, the Bayt al-Hikmah, or House of Wisdom, and sent embassies
to collect Greek scientific works in the Byzantine Empire. (See
Aramco World, May/June 1982.) This ushered in the first era in
Islamic medicine, whose effects we feel today: the period of
translation and compilation.
The most
important of the translators was Hunayn ibn Ishaq al-'Ibadi
(809-73), who was reputed to have been paid for his manuscripts; by
an equal weight of gold. He and his team of translators rendered the
entire body of Greek medical texts, including all the works of
Galen, Oribasius, Paul of Aegin, Hippocrates and the Materia Medica
of Dioscorides, into Arabic by the end of the ninth century. These
translations established the foundations of a uniquely Arab
medicine.
Muslim
medical practice largely accepted Galen's premise of humors, which
held that the human body was made up of the same four elements that
comprise the world - earth, air, fire and water. These elements
could be mixed in various proportions, and the differing mixtures
gave rise to the different temperaments and "humors." When the
body's humors were correctly balanced, a person was healthy.
Sickness was due not to supernatural forces but to humoral
imbalance, and such imbalance could be corrected by the doctor's
healing arts.
Muslim
physicians therefore came to look upon medicine as the science by
which the dispositions of the human body could be discerned, and to
see its goal as the preservation of health and, if health should be
lost, assistance in recovering it. They viewed themselves as
practitioners of the dual art of healing and the maintenance of
health.
Even before
the period of translation closed, advances were made in other
health-related fields. Harun al-Rashid established the first
hospital, in the modern sense of the term, at Baghdad about 805.
Within a decade or two, 34 more hospitals had sprung up throughout
the Islamic world, and the number grew each
year.
These
hospitals, or bimaristans, bore little resemblance to their European
counterparts. The sick saw the bimaristan as a place where they
could be treated and perhaps cured by physicians, and the physicians
saw the bimaristan as an institution devoted to the promotion of
health, the cure of disease and the expansion and dissemination of
medical knowledge.
Medical
schools and libraries were attached to the larger hospitals, and
senior physicians taught students, who were in turn expected to
apply in the men's and women's wards what they had learned in the
lecture hall. Hospitals set examinations for their students, and
issued diplomas. By the 11th century, there were even traveling
clinics, staffed by the hospitals, that brought medical care to
those too distant or too sick to come to the hospitals themselves.
The bimaristan was, in short, the cradle of Arab medicine and the
prototype upon which the modern hospital is
based.
Like the
hospital, the institution of the pharmacy, too, was an Islamic
development. Islam teaches that "God has provided a remedy for every
illness," and that Muslims should search for those remedies and use
them with skill and compassion. One of the first pharmacological
treatises was composed by Jabir ibn
Hayyan (ca. 776), who is considered the father of Arab
alchemy. The Arab pharmacopoeia of the time was extensive, and gave
descriptions of the geographical origin, physical properties and
methods of application of everything found useful in the cure of
disease.
Arab
pharmacists, or saydalani, introduced a large number of new drugs to
clinical practice, including senna, camphor, sandalwood, musk,
myrrh, cassia, tamarind, nutmeg, cloves, aconite, ambergris and
mercury. The saydalani also developed syrups and juleps - the words
came from Arabic and Persian, respectively - and pleasant solvents
such as rose water and orange-blossom water as means of
administering drugs. They were familiar with the anesthetic effects
of Indian hemp and henbane, both when taken in liquids and
inhaled.
By the time
of al-Ma'mun's caliphate, pharmacy was a profession practiced by
highly skilled specialists. Pharmacists were required to pass
examinations and be licensed, and were then monitored by the state.
At the start of the ninth century, the first private apothecary
shops opened in Baghdad. Pharmaceutical preparations were
manufactured and distributed commercially, then dispensed by
physicians and pharmacists in a variety of forms - ointments, pills,
elixirs, confections, tinctures, suppositories and
inhalants.
The
blossoming of original thought in Arab medicine began as the ninth
century drew to a close. The first major work appeared when Abu Bakr
Muhammad ibn Zakariya Al-Razi (ca. 841-926) turned his attention to
medicine. Al-Razi, known to the West as Rhazes, was born in Persia
in the town of Rayy, near Tehran. After a youth spent as a musician,
mathematician and alchemist, Al-Razi went to Baghdad to take up the
study of medicine at the age of 40. Completing his studies, he
returned to Rayy and assumed the directorship of its hospital. His
reputation grew rapidly and within a few years he was selected to be
the director of a new hospital to be built in Baghdad. He approached
the question of where to put the new facility by hanging pieces of
meat in various sections of the city and checking the rate at which
they spoiled. He then ordered the hospital built at the site where
the meat showed the least putrefaction.
Al-Razi is
regarded as Islamic medicine's greatest clinician and its most
original thinker. A prolific writer, he turned out some 237 books,
about half of which dealt with medicine. His treatise The Diseases
of Children has led some historians to regard him as the father of
pediatrics. He was the first to identify hay fever and its cause.
His work on kidney stones is still considered a classic. In
addition, he was instrumental in the introduction of mercurial
ointments to treat scabies. Al-Razi advocated reliance on
observation rather than on received authority; he was a strong
proponent of experimental medicine and the beneficial use of
previously tested medicinal plants and other drugs. A leader in the
fight against quacks and charlatans - and author of a book exposing
their methods - he called for high professional standards for
practitioners. He also insisted on continuing education for already
licensed physicians. Al-Razi was the first to emphasize the value of
mutual trust and consultation among skilled physicians in the
treatment of patients, a rare practice at that
time.
Following
his term as hospital director in Baghdad, he returned to Rayy where
he taught the healing arts in the local hospital, and he continued
to write. His first major work was a 10-part treatise entitled
Al-Kitab al-Mansuri, so called after the ruler of Rayy, Mansur ibn
Ishaq. In it, he discussed such varied subjects as general medical
theories and definitions; diet and drugs and their effect on the
human body; mother and child care, skin disease, oral hygiene,
climatology and the effect of the environment on health;
epidemiology and toxicology.
Al-Razi also
prepared Al-Judari wa al Hasbah, the first treatise ever written on
smallpox and measles. In a masterful demonstration of clinical
observation, Al-Razi became the first to distinguish the two
diseases from each other . At the same time, he provided still-valid
guidelines for the sound treatment of both.
His most
esteemed work was a medical encyclopedia in 25 books, Al-Kitab
al-Hawi, or The Comprehensive Work, the Liber Continens of al-Razi's
later Latin translators. Al-Razi spent a lifetime collecting data
for the book, which he intended as a summary of all the medical
knowledge of his time, augmented by his own experience and
observations. In Al-Hawi, Al-Razi emphasized the need for physicians
to pay careful attention to what the patients' histories told them,
rather than merely consulting the authorities of the past. In a
series of diagnosed case histories entitled "Illustrative Accounts
of Patients," Al-Razi demonstrated this important tenet. One
patient, who lived in a malarial district, suffered from
intermittent chills and fever that had been diagnosed as malaria,
but nonetheless seemed incurable. Al-Razi was asked to examine him.
Upon noting pus in the urine, he diagnosed an infected kidney, and
he treated the patient successfully with
diuretics.
Al-Razi's
clinical skill was matched by his understanding of human nature,
particularly as demonstrated in the attitudes of patients. In a
series of short monographs on the doctor-patient relationship, he
described principles that are still taught a millennium later:
Doctors and patients need to establish a mutual bond of trust, he
wrote; positive comments from doctors encourage patients, make them
feel better and speed their recovery; and, he warned, changing from
one doctor to another wastes patients' health, wealth and
time.
Not long
after Al-Razi's death, Abu 'Ali al-Husayn ibn 'Abd Allah ibn Sina
(980-1037) was born in Bukhara, in what today is Uzbekistan. Later
translators Latinized his name to Avicenna. It is hard to describe
Ibn Sina in anything other than superlatives. He was to the Arab
world what Aristotle was to Greece, Leonardo da Vinci to the
Renaissance and Goethe to Germany. His preeminence embraced not only
medicine, but also the fields of philosophy, science, music, poetry
and statecraft. His contemporaries called him "the prince of
physicians."
Ibn Sina's
life was in fact the stuff of legend. The son of a tax collector, he
was so precocious that he had completely memorized the Qur'an by age
10. Then he studied law, mathematics, physics, and philosophy.
Confronted by a difficult problem in Aristotle's Metaphysics, Ibn
Sina re-read the book 40 times in his successful search for a
solution. At 16 he turned to the study of medicine, which he said he
found "not difficult." By 18, his fame as a physician was so great
that he was summoned to treat the Samanid prince Nuh ibn Mansur. His
success with that patient won him access to the Samanid royal
library, one of the greatest of Bukhara's many storehouses of
learning.
At 20, Ibn
Sina was appointed court physician, and twice served as vizier, to
Shams al-Dawlah, the Buyid prince of Hamadan, in western Persia. His
remaining years were crowded with adventure and hard work, yet he
somehow found time to write 20 books on theology, metaphysics,
astronomy, philology and poetry and 20 more on medicine - including
Kitab al-Shifa', or The Book of Healing, a medical and philosophical
encyclopedia.
His supreme
work, however, is the monumental Al-Qanun fi al-Tibb, The Canon of
medicine. Over one million words long, it was nothing less than a
codification of all existing medical knowledge. Summarizing the
Hippocratic and Galenic traditions, describing Syro-Arab and
Indo-Persian practice and including notes on his own observations,
Ibn Sina strove to fit each bit of anatomy, physiology, diagnosis
and treatment into its proper niche.
The Canon
stressed the importance of diet and the influence of climate and
environment on health. It included discussions of rabies, hydrocele,
breast cancer, tumors, labor and poisons and their treatment. Ibn
Sina differentiated meningitis from the meningismus of other acute
diseases; and described chronic nephritis, facial paralysis, ulcer
of the stomach and the various types of hepatitis and their causes.
He also expounded the dilation and contraction of the pupils and
their diagnostic value, described the six motor muscles of the eye
and discussed the functions of the tear ducts, and he noted the
contagious nature of some diseases, which he attributed to "traces"
left in the air by a sick person.
The Canon
also included a description of some 760 medicinal plants and the
drugs that could be derived from them. At the same time Ibn Sina
laid out the basic rules of clinical drug trials, principles that
are still followed today .
Not
surprisingly, The Canon rapidly became the standard medical
reference work of the Islamic world. Nizami-i Arudi of Samarkand
spoke for generations of physicians when he wrote, in the early 12th
century, "From him who manages the first volume (of The Canon),
nothing will be hidden concerning the general theory and principles
of medicine." The Canon was used as a reference, a teaching guide
and a medical textbook until well into the l9th century, longer than
any other medical work.
During the
10th century, when Arab astronomical texts were first translated in
Catalonia, Europe began to reap the intellectual riches of the Arabs
and, in so doing, to seek out its own classical heritage. The
medical works of Galen and Hippocrates returned to the West by way
of the Middle East and North Africa, recovered through Latin
translations of what had become the Arab medical classics. Through
the intellectual ferment of the Islamic present, Europe recovered
some of its past.
The two main
translators of classical material from Arabic into Latin were
Constantinus (also known as Leo) Africanus (1020-1087), who worked
at Salerno and in the cloister of Monte Cassino, and Gerard of
Cremona (1140-1187), who worked in Toledo. It was no accident that
both translators lived in the Arab-Christian transition zone, where
the two cultures fructified each other. And it was no coincidence
that Salerno, Europe's first great medical faculty of the Middle
Ages, was close to Arab Sicily, nor that the second, Montpellier,
was founded in 1221 in southern France, near the Andalusian
border.
Ibn Sina's
Canon made its first appearance in Europe by the end of the 12th
century, and its impact was dramatic. Copied and recopied, it
quickly became the standard European medical reference work. In the
last 30 years of the l5th century, just before the European
invention of printing, it was issued in 16 editions; in the century
that followed more than 20 further editions were printed. From the
12th to the 17th century, its materia medica was the pharmacopoeia
of Europe, and as late as 1537 The Canon was still a required
textbook at the University of Vienna.
Translations
of Al-Razi's Al-Kitab al-Hawi and other works followed rapidly.
Printed while printing was still in its infancy, all of Al-Razi's
works gained widespread acceptance. The ninth book of Al-Kitab
al-Mansuri ("Concerning Diseases from the Head to the Foot")
remained part of the medical curriculum at the University of
Tubingen until the end of the l5th century.
Contemporary
Europeans regarded Ibn Sina and Al-Razi as the greatest authorities
on medical matters, and portraits of both men still adorn the great
hall of the School of Medicine at the University of Paris. In The
Inferno, Dante placed Ibn Sina side by side with antiquity's two
greatest physicians, Hippocrates and Galen. Roger Bacon consulted
Ibn Sina to further his own inquiries into
vision.
But it was
not only Al-Razi and Ibn Sina who influenced Europe. Translations of
more than 400 Arab authors, writing on such varied topics as
ophthalmology, surgery, pharmaceuticals, child care and public
health, deeply influenced the rebirth of European
science.
Despite
their belief in now superseded theories such as humors and miasmas,
the medicine of Ibn Sina, Al- Razi and their contemporaries is the
basis of much of what we take for granted today. It was those Arab
physicians who made accurate diagnoses of plague, diphtheria,
leprosy, rabies, diabetes, gout, cancer and epilepsy. Ibn Sina's
theory of infection by "traces" led to the introduction of
quarantine as a means of limiting the spread of infectious diseases.
Arab doctors laid down the principles of clinical investigation and
drug trials, and they uncovered the secret of sight. They mastered
operations for hernia and cataract, filled teeth with gold leaf and
prescribed spectacles for defective eyesight. And they passed on
rules of health, diet and hygiene that are still largely valid
today.
Thus the
Islamic world not only provided a slender but ultimately successful
line of transmission for the medical knowledge of ancient Greece and
the Hellenic world, it also corrected and enormously expanded that
knowledge before passing it on to a Europe that had abandoned
observation, experimentation and the very concept of earthly
progress centuries before. Physicians of different languages and
religions had cooperated in building a sturdy structure whose
outlines are still visible in the medical practices of our own
time.
