Medicine
East to West: The Golden/Dark Ages of Islam and
The beginnings of medicine have been obscured by time and lack of evidence, but perspectives on medicine from different times and places are known, by the discovery of paintings and hieroglyphics in Egypt, ancient Sanskrit documents from India, the Greek records of Hippocrates and others, the books written by Galen at the end of the Roman Empire, and many more historical artifacts from all over the world. What we know of medicine in the western part of the world is the result of brilliant scholarship and ingenuity of many different times and cultures; however, if not for the study, preservation, research, clinical advances, and dissemination of knowledge by physicians in the Islamic world from the 8th through the 14th centuries CE, much of ancient medical knowledge would have been lost. Furthermore, many medical treatments established by Muslim physicians during this “Golden Age of Islam” were well-documented, and have formed the base of much of our medical knowledge today. (Abouleish, p.1).
The Dark Ages of
medieval Europe occurred after the fall of the
in the 5th century CE. For almost 1000 years, the Roman Catholic Church basically determined priorities throughout Europe. Most Europeans did not read or write unless they were ordained into Holy Orders; books were produced only in monasteries, and focused mainly on the Gospels. The origin of illness was believed to be sin, not only of the individual, but of mankind as a whole. Suffering was seen as just and due punishment for sin, and knowledge of how disease was spread was faulty and very limited; for instance, it was commonly believed that disease was spread through odors.
Treatment, too, was limited and generally involved prayer and/or pilgrimage; medical methods were risky, and treatment was often given by practitioners with little or no education. Pregnancy and childbirth were the provinces of midwives, who had great skill in assisting normal deliveries; however, women with difficulties often died, along with their babies. There were no treatments for eye diseases, and no dentistry; hospitals existed mainly as wards established and maintained by monks and nuns, which offered charitable care for the sick and dying, but no medical treatment. Surgery (usually bloodletting), often done by barbers, was for many years performed without anesthesia, and herbal treatments were offered by village practitioners who relied on generational data passed down to them by their parents and grandparents (proprietary data). While some of these treatments were effective, they were limited in scope, historical knowledge, and clinical and epistemological research (Annenberg 2004).
In the Islamic world of the Middle East, this period was not “The Dark Ages,” but rather an age of enlightenment, progress, and discovery. “The first word revealed to the Moslems’ prophet Mohammed was ‘Read’” (Abouleish, p. 2). This respect for learning, along with the encouragement of cleanliness and hygiene, contributed to a culture of medical innovation and knowledge. The Prophet Muhammad himself said, “Make use of medical treatment, for Allah has not made a disease without appointing a remedy for it, with the exception of one disease, namely old age” (Medieval Medicine, Health and Hygiene, p. 1). Because the religion of Islam spread quickly and “repeatedly instructs human beings to use their powers of intelligence and observation” (The Spread of Islam, p. 1), Muslim scholars availed themselves of the libraries of Egypt, Persia, and Greece. They translated works from Greek, Syrian, Pahlevi, Sanskrit, and other languages into Arabic, thus preserving these texts and continuing to explore and extend the knowledge within them. This was made easier through the acquisition of Asia’s paper-making technology. The world of Islam expanded west from the Middle East to Northern Africa, east to India and China, and north through Turkey and into Spain and southern Italy. From Egypt to Syria (the seat of Eastern Christian knowledge) to India and China, scholars worked to absorb and share the knowledge of earlier medical geniuses. These studies served as the fertilizing period for the explosion of medical brilliance that soon followed. The two biggest influences on Arabic (here used to describe Moslems of the Middle East by the language most utilized) physicians were Hippocrates (of ancient Greece) and Galen (a physician of Greek birth who lived and practiced medicine in the last years of the Roman Empire). Most of these texts were discovered upon the conquering of Syria in the 7th century. Nestorian Christians had brought the Greek texts to Edessa, and some had been translated into Pahlevi (a Persian language) already. Hippocratic treatises were widely studied for general knowledge, and Galen, who presented monotheistic philosophies along with medicine in ways that Muslim physicians could accept, was presented as a great medical teacher and writer (U.S. National Library of Medicine, Islamic Culture and the Medical Arts, 1998, p. 2). Unhampered by the sin and suffering tradition of contemporaneous Christians, Muslims were free, even obliged, to explore medical treatments and cures, and they did so with a passion.
Upon this foundation of scholarship, the Islamic world then built a palatial structure of medical practice and research. The Islamic capitals of Baghdad (in the east) and Cordova (in the west) became seats of learning, research, and clinical practice. One of the first true hospitals (according to current facts in evidence) was built in Baghdad in the 9th century, although it was based on an earlier encounter by Muslims in the 7th century in Jundi-Shapur, a Persian city conquered by the Muslims. Jundi-Shapur, as well as Syrian Edessa, had a university and hospital, which formed the basic pattern of Islamic hospitals/medical schools. Although it is true that the concept of a hospital can be dated back to ancient Greece and Rome (the temples of Aesculapius), it is also true that, in medieval Europe, hospitals as places of genuine treatment of the sick did not exist. European monasteries had “healing gardens,” which contained some herbs, but in general, the monks and nuns did little but nurse and pray for the sick. In contrast, the Nestorian Christians of Edessa and the Persians of Jundi-Shapur were models for the crucial Islamic advancement that has influenced the modern world. An Islamic hospital, called a bimaristan or maristan, “served several purposes: a center of medical treatment, a convalescent home for those recovering from illness or accidents, an insane asylum, and a retirement home giving basic maintenance needs for the aged and inform who lacked a family to care for them” (USLM, Islamic Culture and the Medieval Arts, 1998, p.3). In areas where there were no permanent hospitals, mobile hospitals traveled between villages (Medicine and Health: Muslim Hospitals, p. 2). It is important to note that medical care was free to patients; the third pillar of Islam is charity. Although hospitals were run by the government rather than the mosque, government leaders were expected to be faithful to the tenets of Islam. “The rulers set aside generous funds to run these hospitals. Also the philanthropists gave generously, thus following their religious beliefs and imitating their rulers” (Abouleish, p. 5). Islamic hospitals had several important characteristics, many of which were passed along to later European hospitals:
1. Baths and water supplies: Before praying, Muslims must wash the face, head and hands, if possible; sometimes a bath is required. Hospitals routinely provided water and bathing facilities to patients, which helped to prevent the spread of bacterial infections that were so prevalent in European society.
2. Practicing physicians: In 931 CE, the Caliph Al-Mugtadir from the Abbasid dynasty ordered the Chief Court-Physician to screen the 860 physicians of Baghdad; only those qualified were granted license to practice. The same process was completed in Damascus, Mecca, and Medina. This is in contrast to Europe, where there was very little accreditation in the medical profession at this time.
3. Medical school: Hospitals were used for educating medical students, exchanging medical knowledge, and research. Many hospitals included libraries, which contained the most current books, auditoria for meetings and lectures, and housing for students and staff.
4. Records: Hospitals kept records of patients and their care, for the first time in history.
5. Pharmacy: Pharmacology developed hand-in-hand with other medical practices in the Islamic golden age; since Moslems had contact with a huge part of the world, either through conquest or trade, they had access to chemicals and plants from all over the world, from which they developed new drugs and compounds (Abouleish, p. 4).
The discoveries and advances made by “Arabic” physicians were varied and multitudinous; surgery, anesthesia, antiseptics, hygiene, treatment of eye conditions, dentistry, pharmacology, and childbirth were all areas of great progress. Fortunately, the great physicians of Islam’s Golden Age were also prolific and systematic writers, and their records have survived.
Anesthesia was an area of great interest to the “Arabian” physicians, and one of their greatest contributions; they knew of anesthesia by inhalation thanks to their familiarity with India (Garrison, p. 137). Hemp fumes, hashish, and the “soporific sponge,” a sponge soaked with aromatics and narcotics, were all used by the “Arab” doctors; thanks to the great physician Ibn Sina, opium and other less powerful oral anesthetics were introduced and developed. While surgery among Westerners was not practiced by reputable physicians, in the world of Islam it was an “honorable specialty,” thanks to the use of anesthesia (Syed, p. 6).
It is important, while examining the advances of medieval Islamic medicine, to examine also the great physicians who introduced, developed, tested, practiced, and documented these discoveries. To do so, it must be understood that the magnificence of Islamic medicine had three major phases:
1) Acquisition, study, translation, assimilation, and dissemination of the knowledge of other times and cultures;
2) Development, research, clinical practice, and teaching of new techniques and discoveries;
3) The dissemination of this additional knowledge, compiled with previous knowledge, to other cultures actively (through travel and education) and passively (through time).
One of the greatest physicians from the first phase was Jurjis ibn Bakhtishu Jibril Yuhanna ibn Masawayh, who lived in Baghdad in the 8th century. He is responsible for translating the works of Hippocrates, Galen and Aristotle.
From the second and third phases, there are a plethora of great physicians, whose contributions must be mentioned:
Al-Razi (known in Europe as Razes or Rhazes), lived in Kharasan (Iran) and Baghdad from 841-926 CE, and was in charge of Baghdad Hospital. He is particularly famous for studying and differentiating between smallpox, measles, and chicken-pox. He was the first physician known to use opium during surgery, and the first to introduce the use of alcohol as an antiseptic. Al-Razi also is the first to have made the connection between bacteria and infection, the foundation of antibiotic research. He also emphasized the importance of psychological factors, believing that “if a patient does not have the will or the desire to get well, the physician’s hands are tied and cannot help him” (Abouleish, p. 10, and Medieval Medicine, Health, and Hygiene, p.2). His books, one of which was “Al-Hawi,” a compendium of Greek-Arab medical knowledge and the largest medical encyclopedia ever written, were translated into Latin and many European languages; they were used in European medical schools throughout the Renaissance and up to the 19th century.
Abbas al-Majusi (known in the West as Haly ben Abbas or Haly Abbas) was a Persian physician (? – 994 CE) who wrote The Royal Book of All Medicine; this was the primary book on medicine until Ibn-Sina’s Canon. Its anatomical section, translated into Latin in the late 11th century by Constantinus Africanus and known as Pantegni, was the sole source of anatomical knowledge at Salerno and other medical schools from 1070-1170 CE.
Abul Qasim al-Zahrawi (known in Europe as Abulcasis), was born in Cordova and lived from 930-1013 CE. He is known as the “father of surgery,” and was the court surgeon of Caliph al-Hakam II in Baghdad. “He wrote a medical encyclopedia which contained 30 sections...and illustrations of 200 surgical instruments, most of which he designed himself” (Medieval Medicine, Health, and Hygiene, p. 5). He was the first to stitch wounds with silk thread, practiced and wrote about different kinds of skull fractures, and saved countless lives by performing, describing, and teaching caesarean sections for difficult births. Descendants of his surgical instruments, surgical clamps and forceps for example, are still in use today. He was also an accomplished dentist, who created artificial teeth from animal bone and wrote treatises on dental extraction, re-implantation, and orthodontia.
Ibn-Sina (known as Avicenna in the West), was born in Bukhara (now part of Russia), and lived from 980 to 1037 CE. He was an accomplished scholar by the age of ten, having become proficient in the Qur’an and other Arabic classic literature. By the age of 16, he was a lawyer, a philosopher, and a mathematician; he completed his medical studies by 18. He became the Vizier and Court-Physician of the ruler of Bukbara, and wrote his first book at the age of 21. He served several rulers in several different places, and established a medical practice in Ray, Iran. He eventually became Prime Minister of Hamadan (in Persia) when he cured the amir’s renal colic. Imprisoned due to a military rebellion against him, he was released when the amir became sick; he was given back his position when he cured the amir once again. He lived a very stressful life, and died at the relatively young age of 57, but left behind him a multitude of writings; his most important contribution was the Al-Qanon fi al-Tibb (Canon of Medicine), which was the primer of European and Asian medical knowledge until the 17th century. His discovery that diseases could be spread through water and soil influenced bacteriology and contagion research for centuries. The only negative result from Ibn-Sina’s Canon was that he discouraged surgical operations; this set surgery back in Europe several hundred years, as many medical schools did not “re-discover” al-Zahrawi until the 15th-17th centuries. (Bettmann, 1956, p.59; Doolin, 1949, p. 165; Garrison, 1929, pp. 130-131; Saghir, 1999, p. 2).
Ibn-Zuhr (Avenzoar in the West) was born in Seville, Spain, in 1091 CE and graduated from the respected medical school in Cordova. He visited Baghdad and Cairo, but returned to Spain as a court physician. He was a proponent of clinical observation rather than blind obedience to Galen and Hippocrates, and was one of very few physicians in the Islamic Empire to dissect dead human bodies; this allowed him to correct mistaken conclusions in Galenic anatomy. He was one of the earliest known parasitologists in the world, and discovered the “itch-mite,” known today as scabies. One of his most important contributions was the invention of the feeding tube for patients with occluded throats or other conditions that interfered with nutrition. In his writings, translated into Latin and Hebrew and used in Europe until the late 18th century, he described the tracheotomy (he was the first to do so), middle ear infection, and several types of tumors (Bettmann, 1972, p. 64; Garrison, 1929, p. 131; Medieval Medicine, Health and Hygiene, p. 6).
Ibn-Al-Nafis, who was born in Damascus in 1208 CE and spent most of his professional life in Cairo, was the first chief of the great Al-Mansuri Hospital in Cairo. He was the first to understand pulmonary circulation and the circulation of blood to the heart, although several Europeans, among them Michael Servetus, took credit for this discovery over 300 years later (Abouleish, p. 15-16).
Not all physicians, writers, and philosophers in the medieval Islamic world were Moslem. Syrian Christians were among the first to translate Greek works into Arabic, and Jews were allowed to live their lives and hold their property in peace in Islamic Caliphates, as were Christians. One of the greatest Jewish physicians in the Islamic world was Musa Ibn-Maimon (Moses Maimonides), who was born in Cordova in 1135 CE. As a young man, he emigrated to Fas, in North Africa, where he studied medicine. He lived most of the rest of his life in Egypt, becoming the court physician of King Salah-El-Din (Saladin) and his elder son. During the Crusades, when King Richard of England became ill, Saladin sent Maimonides to treat him. Upon being cured, Richard invited Maimonides to join his court, but Maimonides preferred to return to Saladin. Maimonides’ most important contribution was the translation of many Arabic books, particularly the Canon of Avicenna, into Hebrew – this allowed for later translation into Latin and other European languages. He also wrote an important book on poisons and antidotes (Abouleish, p. 14).
An essential contribution to the world’s store of medical knowledge was the study of ophthalmology; the doctors of Islam were the innovators of many treatments, and their detailed and illustrated texts were the source of great knowledge to geniuses of the European Renaissance – Roger Bacon, Leonardo da Vinci, and Johannes Kepler, to name a few. Ibn al Haytham (Known as Alhazen in the West), a physician who lived in the late 10th-early 11th centuries, wrote the Optical Thesaurus, a brilliant compendium of knowledge. He proved that vision happens when light travels from objects to the eye, not from the eye to objects (as believed by the Greeks). He also was the first to theorize that the retina’s image travels to the brain through the optic nerve. Al-Razi, the first physician to discover the pupil’s reactions to light, and Ibn-Sina, the first to illustrate the exact number of eyeball muscles, also contributed to European knowledge of the human eye. The most significant treatment, developed by Ammar bin Ali, was the removal of the cataract; Europe did not rediscover this until the nineteenth century, to the detriment of centuries of European citizens blinded by cataracts. It is interesting to note that the words “retina” and “cataract” are, in fact, of Arabic origin (Syed, p. 7).
Pharmacology was a discipline that became independent from medicine early in the Islamic world. Apothecaries were regularly inspected, and pharmacists were punished corporally if they “adulterated drugs” (Syed, p. 10). Physicians were not allowed to own pharmacies, and pharmacists were not allowed to practice medicine; this tradition has been passed down to our own pharmaceutical system. The following terms, used in pharmacy today, are derived from Arabic: drug, alkali, alcohol, aldehydes, alembic, elixir, syrup, and julep (Syed, p. 8). “Arabic” pharmacists invented flavoring to make drugs more palatable, including “rose water, orange blossom water, orange and lemon peel...” (Syed, p. 8).
Treatment of mental illness was far more advanced in medieval Caliphates than it was even 900 years later in Europe. In the 8th and 9th centuries, there were already insane asylums in Morocco, Baghdad, and Cairo; by the 13th century Damascus and Aleppo also had institutions for the mentally ill. Therapies were far more humane than in Europe: “In addition to baths, drugs, kind and benevolent treatment given to the mentally ill, musico-therapy and occupational therapy were also employed. These therapies were highly developed. Special choirs and live music bands were brought daily to entertain the patients by providing singing and musical performances and comic performers as well” (Syed, p. 9).
The sharing of medical knowledge with Europeans occurred because of several factors. The first was the conquering of European regions by the Muslims, the most important being Spain, which underwent a vital sequent occupation during which Islamic cultures were deeply imprinted. Cordova was the capital of Moorish Spain, and developed one of the greatest major medical universities. Adventurous students came from Greece, Italy, and many other countries to study there (similarly, the great hospital and medical school in Baghdad was the source of training for many Asian medical practitioners). Jews, who flourished in Islamic Spain (and many of whom became great physicians in the Western Caliphate), were ejected from the country in 1492. Many of these Jewish physicians then taught at the medical school of Salerno, which was the state-of-the-art medical school in late-medieval, early-renaissance Europe. Salerno was located just north of Sicily, another Islamic territory.
The second factor that influenced the spread of Islamic medical knowledge and clinical practice to Europe was, in fact, the School of Salerno, established in the 11th century. Its origins are a mystery, but legends abound; some say it was established by Charlemagne (Clendening, 1942, p. 76), but a more interesting and credible version is that it was “founded by four doctors: a Greek, a Jew, an Arab and a Christian” (Bettmann, 1972, p. 66). However it was established, there is absolutely no doubt that it was influenced by “Arabic” medicine; Constantinus Africanus, who taught briefly at Salerno, devoted himself to translating Arabic medical texts, as well as Arabic translation of Greek medical texts, into Latin. Thus, Greek classic texts and, notably, Haly Abbas’ The Royal Book of All Medicine (also known as The Perfect Book of the Art of Medicine) shared essential medical information with the first secular institution of higher learning in Europe (Bettmann, 1972, pp. 66-67).
Yet another contributing factor in the spread of medical knowledge was the trade routes. Trade was a very important part of the Islamic Empire, and many travelers to and from Islamic Caliphates benefited, over centuries, from the medical knowledge located there, largely in Spain: “...these Moslems of Spain gladly threw open to the Christian stranger the portals of medical science, making them free of the intellectual treasures of antiquity which they had so carefully preserved through the centuries. The contribution of Arab Spain has been an important and an honourable link in our scientific evolution” (Doolin, 1949, pp. 32-33). From Moorish Spain in the West, to the 30 hospitals founded in Asia Minor, the passing of pharmaceutical products, medical treatment, and experiential medical knowledge was spread from Europe to India and China along the caravan routes. Pharmacopeias compiled in apothecaries in Granada, Almeria, and Seville, “...under the dual stimulus of the profitable trade in spices and the study of botany were amongst the first books to come off the Venetian printing presses in the 15th century....The abundance of valuable drugs in the East found a ready market in Western ports...and, chiefly through the Spanish Moors, European chemistry was born” (Doolin, 1949, pp. 29-30).
The Crusades were also an important factor in the dissemination of medicine from the world of Islam. It is no coincidence that the first medieval hospital established by Europeans was established by the order of St. John, a group of Crusaders who fought their way to, and founded a hospital in, Jerusalem in 1099. The Teutonic Order of Knights, more Crusaders, founded a field hospital outside Acre in 1191. Both of these groups must have been influenced by the great hospitals of the Islamic Caliphates, although European scholars have been curiously reluctant to acknowledge this: “The chief glory of medieval medicine was undoubtedly in the organization of hospitals and sick-nursing, which had its origins in the teachings of Christ. For while the germ of the hospital idea may have existed in the ancient Babylonian custom of bringing the sick into the market-place for consultation...the credit of ministering to human suffering on an extended scale belongs to Christianity. The Arabian hospitals, large and liberal as were their endowments and capacity, came long after the beginning of the Christian era, and the Mohammedans probably got the idea from India or from the Christians” (Garrison, 1929, p. 176). With all due respect to Dr. Garrison, this does not appear to be quite accurate. As previously stated, following the decline of the Roman Empire, European scientific knowledge and medical practices rapidly declined, and hospitals that actually treated the sick were virtually unknown. If, by Christian hospitals, Garrison is talking about the Nestorian Christians in Edessa, Syria, it is important here to note that these “Christians” were persecuted and driven out of Europe – this is why they were in Edessa in the first place. They certainly were Christian, and this particular hospital may be of Christian origin, but it was the only one of its kind for many hundreds of years, and in fact formed the base on which Muslim hospitals were modeled, from which much advancement was made in terms of actual medical care and research. There is also no doubt in the minds of most scholars that, while Indian hospitals may have existed, most records point to the hospitals of Syria and Persia as the “germ” of the Muslim idea for health care centers. The description of the Babylonian “marketplace” hospital is nowhere near the reality of the great medical center the Muslims discovered and improved upon in Jundi-Shapur; Garrison seems in this instance to be suffering from a racist perspective, and his claims of Christian dominance in the area of hospitals therefore seem unfounded. The factor of the Crusades, of course, also affected the Islamic world in an enormous way; Spain and Sicily became parts of Europe once again, and Turkey was taken, retaken, and taken yet again. Constant war takes a toll on an empire, and the Islamic empire was no exception. But political and religious boundaries did not erase the knowledge gained by Islamic physicians.
As previously stated, the massive translation efforts of Islamic scholars was a major factor in the preservation of classic medical knowledge; later translation of the Arabic texts, by such scholars as Constantinus Africanus, Simon Cordo, Abraham ben Shemtob, and many others, ensured that Arabic advances in medicine and the essential classical texts would not be lost. Maimonides and other Jewish physicians were the primary translators of Arabic into Hebrew and, often, Latin; a great number of Jewish physicians of the 13th, 14th, and 15th centuries brought these texts into Central Europe.
Fittingly, the most important factors in the spread of medical wisdom over Europe were the genius, the scholarship, the relentless clinical efforts, the meticulous records, and the devotion to education and knowledge that characterized physicians in the Golden Age of Islam. Without them, great knowledge would have been lost, and great advances would have been delayed hundreds of years. “They not only preserved, but also added to earlier achievements in medicine. They have fostered the flame of civilization, made it brighter, and handed it over to Europe in the best possible condition. Europe, in turn, passed it to the United States of America, and the cycle continues” (Abouleish, p. 18).
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