Detail from a folio based on the 1375 “Catalan Atlas” by Abraham Cresques.
In 1120, a Muslim doctor was on his way to see his patient, the
Almoravid ruler of Seville. By the side of the road he saw an emaciated
man holding a water jug. The man’s belly was swollen, and he was in
obvious distress.
“Are you sick?” the doctor asked. The man nodded.
“What have you been eating?”
“Only a few crusts of bread and the water from this jug.”
“Bread won’t hurt you,” said the doctor. “It could be the water. Where are you getting it?”
“From the well in town.”
The doctor pondered a moment. “The well is clean. It must be the jug. Break it and find a new one.”
“I can’t,” whined the man, “This is my only jug.”
“And that thing bulging out there,” replied the doctor, pointing
to the man’s midsection, “is your only stomach. It is easier to find a
new jug than a new stomach.”
The man continued to protest, but one of the doctor’s servants
picked up a stone and smashed the jug. A dead frog spilled out with the
foul water.
“My friend,” the doctor said to the patient, “look what you have
been drinking. That frog would have taken you with him. Here, take this
coin and go buy a new jug.”
When the doctor passed by a few days later, he saw the same man
sitting by the side of the road. His stomach had shrunk, he had gained
weight, and his color was back. Seeing the doctor, the man heaped praise
on him.
—attributed to Ibn Abi Usaybi’a, 13th century
While this demonstration of clear reasoning was taking place in
Muslim Spain, medical practice in Christian Europe, hobbled by a mindset
that would have seen the doctor’s work as a challenge to divine will,
offered the sick little more than prayers and comfort, rather than
medicine or treatments.
In the East, the spread of Islam, beginning in the seventh century
ce, sparked the assimilation of existing knowledge and its development
in all branches of learning, including medicine. Arab conquerors rapidly
absorbed much from their new subjects. Arabic became to the East what
Latin and Greek had been to the West—the language of literature and of
the arts and sciences, the common tongue of learned men from the Rann of
Kutch to the French border—and the Hajj, or pilgrimage to Makkah,
brought hundreds of thousands of pilgrims together each year,
facilitating the exchange of ideas, knowledge and books.
Recognizing the importance of translating Greek works into Arabic to
make them more widely available, the Abbasid caliphs Harun al-Rashid and
his son, al-Ma’mun, sponsored a translation bureau in Baghdad—the Bayt
al-Hikmah, or House of Wisdom—starting in the late eighth century, that
sent agents throughout Muslim and non-Muslim lands in search of
scholarly manuscripts in every language. Rendered into Arabic, these
precious documents established a solid foundation for the Muslim
sciences, not the least of which was medicine.
Illustrations of surgical instruments from a 13th-century Arabic copy of al-Zahrawi’s On Surgery.
As in Greece, medicine in the Muslim world was based on the theory of
the four humors that had been advanced by the second-century Greek
physician Galen. Each of the four universal elements that comprised the
world—earth, air, fire and water—was associated with one of the
humors—blood, phlegm, black bile and yellow bile—whose various mixtures
defined the different temperaments. When the body’s humors were in
correct alignment, a person was healthy; when out of balance, he was
sick. The task of the doctor, Galen wrote, was to restore this alignment
by prescribing changes in diet, exercise or certain activities, or by
taking other measures. For example, fever was caused by too much blood,
and thus he prescribed bloodletting to remove the excess.
However incorrect, Galen’s essentially rationalist view of health and
disease found favor in the East, where the Qur’an assured that “for
every disease there is a cure.” Thus Muslim physicians saw themselves as
healers and preservers of health rather than passive witnesses to
events with supernatural causes.
While the translators in the House of Wisdom toiled, Muslim doctors
developed the bimaristan—later simply maristan—the forerunner of today’s
hospital. Open to all, it welcomed patients to be treated for, and
recover from, a variety of ailments and injuries, including mental
illness. The larger maristans were attached to medical schools and
libraries, where prospective physicians were taught, examined and, as
today, licensed. The maristan became the cradle of Islamic medicine and
the means of its dissemination throughout the empire.
Like the hospital, pharmacy as a profession is also an Islamic
innovation. In the maristans, trained pharmacists prepared and dispensed
remedies that more often than not had some positive effects. Their
extensive pharmacopeias detailed the geographical origins, physical
properties and methods of application of everything found useful in the
curing of disease. By al-Ma’mun’s time, the pharmacists (saydalani)
were, like doctors, licensed professionals required to pass demanding
examinations, and to protect the public from errors and incompetence,
government inspectors monitored the purity of their ointments, pills,
elixirs, confections, tinctures, suppositories and inhalants. In the
maristan, the chief pharmacist held a rank equal to that of the chief of
medicine.
But while Abbasid Baghdad, with the House of Wisdom and the first
maristans, may have begun the golden age of Islamic medicine, the center
of learning and progress began to shift westward in the eighth century,
to al-Andalus, today’s southern Spain.
The Abbasids had taken power from the Damascus-based Umayyad dynasty.
Abdulrahman, grandson of the 10th Umayyad caliph, escaped the massacre
of his relatives and in 758 ce took asylum in Spain. Within a few years,
this intrepid ruler had carved out a rival caliphate with its capital
at Córdoba, and by the late 10th century Córdoba had surpassed Baghdad
as the center of intellectual activity in the Islamic world.
Córdoba’s 70 libraries, 900 public baths, 300 mosques and 50
maristans were available to all of its one million residents. Córdoba’s
university, founded in the eighth century, was a premier center of
learning, and its library held at least 225,000 volumes. (At that time,
the library of the University of Paris held some 400 volumes.) It drew
scholars from all over Europe—one of them, Gerbert of Aurillac, later
became Pope Sylvester ii, who replaced cumbersome Roman numerals with
today’s “Arabic” numbers. Al-Andalus was soon home to accomplished and
innovative philosophers, geographers, engineers, architects and
physicians.
In the western caliphate, doctors differed from their eastern
counterparts. Although Córdoba and Baghdad were in close contact
intellectually, the western physicians exhibited more independence of
thought than their more classics-bound eastern colleagues, offering no
blind obedience to either Galen or the Canon of Ibn Sina, the
10th-century Bukhara-born physician who was the Arab world’s equivalent
of Aristotle and Leonardo. Instead, they challenged and rejected both
when their own experience justified it. Their writings and research
showed their preference for the concise, the brief and the exact, as
contrasted with the discursive, often hair-splitting, subtleties
preferred by the savants of the East.
While the western Islamic world produced hundreds of insightful and
even brilliant medical men between the ninth and 15th centuries, five
stand at the pinnacle of medicine during their eras, and their
influences reverberate even now, more than a millennium later.
”The Father of Surgery”
Born in 938 ce just north of Córdoba in Al Zahra, the royal city of
Abdulrahman iii, Abu al-Qasim Khalaf ibn al-’Abbas was known to
contemporaries as al-Zahrawi, and his name was Latinized to Albucasis.
While little is known for certain about his personal life, his surgical
acumen was unprecedented.
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| Al-Zahrawi’s annotated illustrations of
surgical instruments were circulating in Europe in Latin translation in
the 14th century. |
Al-Zahrawi only wrote one book, Kitab al-Tasrif li-man ‘Ajizja ‘an
al-Ta’lif (The Arrangement [of Medical Knowledge] for One Who is Unable
to Compile [a Manual for Himself]), a compendium of 30 volumes on
medicine, surgery, pharmacy and other health topics compiled during a
50-year career. Its last volume, the 300-page On Surgery, was the first
book to treat surgery as a separate subject and the first illustrated
surgical treatise. Covering ophthalmology, obstetrics, gynecology,
military medicine, urology, orthopedics and more, it remained a standard
surgical reference in Europe until the late 16th century.
Al-Zahrawi described a vast repertoire (see “On the Cutting Edge,” at
left) of procedures, inventions and techniques, including
thyroidectomy, extraction of cataracts and an innovative method of
removing kidney stones by diversion through the rectum that dramatically
reduced the mortality rate for the procedure, compared to the method
Galen recommended.
The Arrangement of Medical Knowledge was the earliest text to deal
with dental surgery in detail, including reimplantation of dislodged
teeth. It also described the carving of false teeth from animal bone, as
well as how to correct non-aligned or deformed teeth. Al-Zahrawi also
detailed procedures still used by today’s dental hygienists to remove
calculus deposits from teeth.
More prosaically, al-Zahrawi used ink preoperatively to mark the
incisions on his patients’ skin, now a standard procedure worldwide. He
was the first to use catgut for internal sutures, silk for cosmetic
surgery and cotton as a surgical dressing. He described, and probably
invented, the plaster cast for fractures—a practice not widely adopted
in Europe until the 19th century. He produced annotated diagrams of more
than 200 surgical instruments, many of which he devised himself. His
meticulous illustrations, intended as both teaching tools and
manufacturing guides, are the earliest known and possibly the first ever
such published diagrams. His best-known inventions were the syringe,
the obstetrical forceps, the surgical hook and needle, the bone saw and
the lithotomy scalpel—all items in use today in much the same forms.
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Image via Wikipedia
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The Doctor of Seville
The doctor who observed, diagnosed and cured the man by the side of
the road at the beginning of this article was Abu Marwan ‘Abd al-Malik
ibn Zuhr, later Latinized to Avenzoar, who was born in 1091 ce in
Seville. Since the Banu Zuhr, as his family was known, had already
produced two generations of physicians (and would produce five more),
there was no question about his career.
Ibn Zuhr, however, did not merely follow in his ancestors’ footsteps.
He became the first Muslim scientist to devote himself exclusively to
medicine, and his several major discoveries were chronicled in his books
Kitab al-Taysir fi ‘l-Mudawat wa ‘l-Tadbir (Practical Manual of
Treatments and Diets) and a treatise on psychology whose title
translates Book of the Middle Course Concerning the Reformation of Souls
and Bodies, as well as Kitab al Aghdiya (Book on Foods) that describes
the health effects of diets, condiments and drinks.
In this body of work, one of his smaller but most effective
accomplishments was proof that scabies is caused by the itch mite, and
that it can be cured by removing the parasite from the patient’s body
without purging, bleeding or any other (often painful) treatments
associated with the four humors. This discovery sent a shudder through
medical science, for it unshackled medicine from strict reliance on the
theory of humors and, with that, blind acceptance of Galen and Ibn Sina.
Ibn Zuhr also wrote about how diet and lifestyle can help a person
avoid developing kidney stones. He gave the first accurate descriptions
of neurological disorders, including meningitis, intracranial
thrombophlebitis and mediastinal tumors, and he made some of the first
contributions to what became modern neuropharmacology. He provided the
first detailed report of cancer of the colon. Ibn Zuhr was the first to
explain how to provide direct feeding through the gullet or rectum in
cases where normal feeding was not possible—a technique now known as
parenteral feeding.
Ibn Zuhr introduced the experimental method into surgery, using
animals as test subjects—using, for example, a goat to prove the safety
of a tracheotomy procedure he devised. He also performed post-mortems on
sheep while doing clinical research on how to treat ulcerating diseases
of the lungs. Ibn Zuhr is the first physician known to have performed
human dissection and to use autopsies to enhance his understanding of
surgical techniques.
Ibn Zuhr established surgery as an independent field by introducing a
training course designed specifically for future surgeons before
allowing them to perform operations independently. He differentiated the
roles of a general practitioner and a surgeon, drawing the metaphorical
“red lines” at which a physician should stop during his management of a
surgical condition, thus further helping define surgery as a medical
specialty. He was also among the first to use anesthesia, performing
hundreds of surgeries after placing sponges soaked in a mixture of
cannabis, opium and hyoscyamus (henbane) over the patient’s face.
Not least, by seeing to it that both his daughter and his
granddaughter went into medicine, he became a pioneer in a different
way. Though largely limited to obstetrics, these women began a tradition
in the Muslim world that accepted females as medical doctors 700 years
before Johns Hopkins University graduated the first American female
physician.
Doctor and Philosopher
Born in Córdoba in 1126 and at one time a student of Ibn Zuhr, Abu
‘l-Walid Muhammad ibn Ahmed ibn Muhammad ibn Rushd was in many respects
to the western caliphate what Ibn Sina was to the eastern one. Known in
Europe as Averroës, he became known mainly for his works on philosophy.
Ibn Rushd’s principal medical work, a slender volume called Kitab
al-Kulliyat fi al-Tibb (General Rules of Medicine) became an important
précis of medicine. Beginning with a brief anatomical survey of the
human body, the book continues with sections on the functions of the
various organs, systemic diseases, diet, drugs, poisons, baths and the
role of exercise in maintaining health. The sections on surgery briefly
cover the treatment of abscesses and the use of styptics, cauterization
and ligatures. Perhaps most notably of all, he observed that smallpox
“is a disease (that) attacks the patient only once”—the first known
reference to acquired immunity.
Doctor in Exile
Musa ibn Maymun (Latinized to Maimonides) was a Renaissance man
before there was a Renaissance. He too was born in Córdoba, just 12
years after Ibn Rushd, to a family that had produced eight generations
of scholars. The towering genius of his era, a Jew living in a Muslim
world, his achievements covered law, philosophy and medicine. At an
early age, he developed an interest in science and philosophy. In
addition to reading the works of Muslim scholars, he also read those of
the Greek philosophers made accessible through Arabic translations. His
great work on Jewish law was written in Arabic using the Hebrew
alphabet, and as a religious scholar he opposed the mingling of religion
and medicine. He was the only intellectual of the Middle Ages who truly
personified the confluence of four cultures: Greco-Roman, Arab, Jewish
and European.
When he was 10 years old, the less-than-tolerant Almohads conquered
Córdoba. They offered the city’s Jews and Christians the choice of
conversion to Islam, exile or death. Maimonides’s family chose exile,
and they eventually settled near Cairo. When family tragedy reduced them
to penury, he took up the practice of medicine.
Maimonides wrote 10 known medical works in Arabic. They describe,
among much else, conditions including asthma, diabetes, hepatitis and
pneumonia. They emphasize moderation and a healthy lifestyle. A doctor,
he wrote, must be knowledgeable in many disciplines, treat the whole
patient and not just the disease, heal both the body and the soul, and
must himself be imbued with human and spiritual values, the foremost of
which is compassion.
Throughout his medical works Maimonides often challenged what he
called Galen’s “arrogant presumption” when it differed from his own
experiences, leading to one of his key contributions: the idea that, in
medicine, personal empirical experience trumps written authority.
Nonetheless, his passion for order and learning led him to abridge the
Roman physician’s massive literary output to a single book of key
extracts that a physician could carry in his pocket. Though he was also a
Talmudic rabbi, when it came to the understanding of disease,
Maimonides was what today we would call a “natural scientist”—a strict
empiricist—and he strove to clearly divorce medicine from religion. At a
time when magic, superstition and astrology were all widespread in
medical practice, his writings contain no references to these, nor to
Talmudic medicine. That which is correct, he argued, is that which
works.
One of Maimonides’s key contributions was the idea that, in medicine, personal empirical experience trumps wirtten authority.
Maimonides taught that individuals should look after their own health
by avoiding bad habits and seeking medical attention promptly when ill.
“One’s attention,” he wrote, “should first focus on the maintenance of
natural [body] warmth, before anything else. That which best insures
this is [the performance of] moderate physical exercise, which is good
both for the body and soul.” He then goes on to prescribe a daily
regimen of walking for elderly patients, something with a distinctly
modern ring to it. He also discusses the benefits of massage and touch
as a means of stimulating the innate “heat” of the body, insofar as it
rejuvenates the body naturally.
He recognized furthermore the medical benefits of positive thinking,
leading to an early form of psychosomatic medicine. Whether certain
amulets or trinkets were anathema to his rational world view was
unimportant compared to the needs of the patient. If they made the
patient feel better, he wrote, then having them present was best “lest
the mind of the patient be too greatly disturbed.”
Secrets of the Heart
B y the time Ala al-Din Abu al-Hassan Ali ibn Abi-Hazm al-Qurashi al
Dimashqi —far more easily known as Ibn al-Nafis—was born in 1213 in
Damascus, the intellectual center of the Islamic world had become
Ayyubid-ruled Cairo. While in his early 20′s, Ibn al-Nafis moved there
and eventually became chief physician at the 8000-bed Al-Mansouri
Hospital.
At 29, he published the Sharh Tashrih al-Qanun Ibn Sina (Commentary
on Anatomy in the Canon of Ibn Sina). The book described a number of his
anatomical discoveries, including the earliest explanation of the
pulmonary circulation of blood.
This modern gouache illustration depicting
Ibn al-Nafis is titled “Discovery of the ‘Small Circulation’”—the
movement of blood from the right ventricle of the heart to the lungs and
back to the left atrium. It was Ibn al-Nafis who first correctly
described the interaction of the heart and lungs in circulation and
oxygenation of blood.
Ibn al-Nafis went on to show that the wall between the right and left
ventricles of the heart is solid and without pores, thus disproving
Galen’s teaching that the blood passes directly from the right to the
left side of the heart. Ibn al-Nafis then correctly stated that the
blood must pass from the right ventricle to the lungs, where its lighter
parts filter into the pulmonary vein to mix with air and then to the
left atrium and finally onward to the rest of the body. It was the first
time anyone was able to explain how air entered the blood.
Ibn al-Nafis also hinted at the existence of capillary circulation,
arguing “there must be small communications or pores [manafidh] between
the pulmonary artery and vein.” Though his hypothesis was limited to
blood transit in the lungs, it would be confirmed for the entire body
400 years later when Marcello Malpighi described the action of
capillaries. Moreover, after the 14th century, Ibn al-Nafis’s discovery
was lost, and it was not until 1924, when Egyptian physician Muhyo
al-Deen Altawi found a copy of the Commentary in Berlin’s Prussian State
Library, that the full extent of Ibn al-Nafis’s work was
understood—showing that it was he, and not William Harvey some four
centuries later, who had discovered the circulatory system.
Unfortunately, Ibn al-Nafis’s fall into undeserved obscurity was not
unique or even particularly unusual. Over those medieval centuries
Muslim physicians by the tens of thousands, the great and the ordinary,
lived and worked mostly outside centers of medical science. While they
toiled, small groups of Christian and Jewish scholars also labored,
filling for a coming era the roles of translators and disseminators that
their Muslim predecessors had once filled for al-Ma’mun in Baghdad.
Many were located along the porous, shifting, multicultural frontier
with Spain where Toledo, Barcelona and Segovia offered them support;
others gathered in the cities of France, Italy and Sicily that were
touched by Islam. They too became cultural bridges, returning to a
reawakening West both the intellectual foundations it had foregone
nearly a millennium earlier and a rich legacy of discovery upon which
today’s western medicine is founded.
The physicians who produced this legacy of discovery in the Muslim
world devised techniques and further unraveled enduring mysteries of the
human body and mind. They established hospitals and the professions of
surgery, medicine and pharmacy, invented surgical instruments and
applied empirical methods to test hypotheses. They separated religion
from science and opened a door for women. Many of their precepts of
personal health, diet and hygiene are common sense today. Perhaps most
important of all, they re-taught European physicians that sickness is
only a deviation from health, and that the role of medicine is to cure
disease.
If any of this seems too easily self-evident to us, that is because
progress turns yesterday’s discoveries into today’s everyday knowledge.
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