During the first five centuries of the Christian era, barbarian invasions of the West, recurrent disasters and pestilences, and the zealous anti-Hellenism of the Christian Church led to the physical loss of much of the Greek and Roman writings that were the basis of Western civilization. However, in the seventh century the new evangelical religion of Islam was moved to preserve the classical learning still extant and later to yield it back to the European world.
Based on the role of Islam, many have characterized Arabic contributions to medicine as principally preservation and compilation. As one historian commented, "Certainly they contributed no original or novel ideas to develop Hippocratic thought, but in a period of unrest they were preservers of tradition; they disseminated lay medical culture, they gave medical studies an honored place in their civilization, and they were intermediaries from whom the Western world retrieved a precious heritage." But this sweeping statement fails to recognize the lasting, original contributions of the Islamic thinkers and the Christians, Persians, Jews, and others who resided in Muslim countries. Together they are sometimes called "Arabists," for their writings were mostly in Arabic.
It was their respect for learning that caused the Arab conquerors to become the fountainhead of Greco-Roman knowledge during those many centuries that Latin Europe had little contact with ancient writings. Through translations, studies, and elaborations of Greek and Roman works, the world of Islam assembled an enormous body of information in virtually all fields of endeavor, especially philosophy, mathematics, and science—on which the intellectual development of the West depended.
The Arabic world had had previous contact with Greek culture, including medical theory, well before Muhammad's founding of Islam. In the year 489, Nestorian Christians (supporters of the Patriarch Nestorius who had been expelled from Constantinople for heresy in 431) were in turn driven away from Edessa in Mesopotamia (where St. Ephraem had established a hospital) and subsequently founded another hospital at Gundishapur in Persia. There they had also found Greek physicians whose forebears had been in the East since the time of Alexander's empire in the fourth century B.C. Greek philosophers had also gone to Gundishapur when Justinian closed the Academy in Athens in the fifth century A.D. Even earlier, when Jerusalem was destroyed by the Romans in A.D. 76, Jews had fled to Arabia bringing with them much Greco-Roman knowledge. Thus by the time of Muhammad (570-632), Greek ideas were not unknown among the Arabs.
The Spread of Islam
Over the next hundred years, Islam swept through the Near and Middle East into Africa, Spain, and part of France. The extent of this dispersion led to the emergence of three principal dynastic caliphates: in Persian Baghdad, the Abbasids (750-1258); in the Spanish West, particularly at Cordova, the Umayyads (756-1031); in Egyptian Cairo, the Fatimids (909-1171).
The earliest dominant center of Islam was Baghdad, where two of the most famous Muslim leaders reigned, al-Mansur (712?-75) and Harun al-Rashid (764?-809), caliph of the Arabian Nights. With encouragement and support from the caliphs, cultural richness rivaled the magnificent buildings and general opulence. Greek and Roman writings were rendered into Arabic from earlier translations into the Syriac of the Nestorians and the Hebrew of the Jews; in later centuries these works were translated again, this time into Latin by compilers in the West. In medicine and science the works of Aristotle, Hippocrates, and Galen were the most frequently translated. Some treatises, including several by Galen, had been completely lost in the original Greek and came down to subsequent generations only in Arabic. Among the early well-known translators were Hunain ibn-Is-haq (d. 767?) and al-Kindi (796-c. 874). Philosopher-commentators of influence were al-Farabi (870?-950) and al-Biruni (973-1048). Rhazes (850-932) and Avicenna (980-1037) became the most famous of the Persian Muslim writers.
Cordova in the West became more prominent in Islam as the caliphate in Baghdad lost influence. The same intellectual ferment that had been shown in the East was also a characteristic of the western caliphate, where Averroes (1126-98), Avenzoar (1091?-1162), and Maimonides (1135-1204) were outstanding physician-philosophers.
In the sultanate of Egypt, where science was an important concern, the hospital in Cairo was a jewel in the crown of Muslim medical care; it was probably far better developed, more efficient, and more progressive than any similar institution elsewhere in the Christian or Muslim worlds. The cultured ruler Saladin (1138-93) held court in Cairo, impressing the West with his learning and the Crusaders with his military skill.
The Arabists (which included Nestorian Christians, Persians, and Jews, who were not ethnic Arabs) did much more than merely hold safe the traditions of the past. They were also responsible for the establishment of pharmacy and chemistry as sciences. Many drugs heretofore unknown or little appreciated became part of the materia medica. Methods of extracting and preparing medicines were brought to a high art, and Arabist techniques of distillation, crystallization, solution, sublimation, reduction, and calcination were to become the essential processes of pharmacy and chemistry. Although physicians often continued to prepare their own medications, pharmacy as a separate profession became established under Arabic rulers. The important role of the Arabists in developing modern chemistry is memorialized in the significant number of current chemical terms derived from Arabic: alkali, alcohol, alembic, and elixir, among others, not to mention syrup and julep.
There was a strong emphasis on clinical instruction, and some Arabic physicians contributed brilliant observations that have stood the test of time. They described diseases that had hardly been perceived as such by the Greeks, among them scabies (itch-mite skin disease) and abscess of the mediastinum (a central area of the chest). They understood tuberculosis and pericarditis (inflammation of the membrane surrounding the heart) better than their predecessors. Avicenna even suggested the communicable nature of tuberculosis.
The development of efficient hospitals was an outstanding Arabic contribution to medicine. The Roman military valetudinaria and the occasional Christian hospital, such as the one founded by the benefactress Fabiola, were but crude prototypes compared to the number, organization, and excellence of the Arabic hospitals after the time of Muhammad. The medical center at Gundishapur in Sassanian Persia founded by Nestorian Christians in the fifth century A.D. may have been a model, but even that complex reached its zenith under Muslim rule.
In some respects the attitude of Islam toward the origin of disease was similar to the Judaeo-Christian idea in that Allah caused illness as punishment for a person's sins, or for reasons beyond man's ken, but sickness was usually borne without moral stigma. Although one might hope for curative miracles through prayer, one could also seek divine help through the agency of a physician. Giving aid and succor to the sick was good work—counting toward self-redemption, as in the Christian world—but Muslims also valued compassion for its own sake.
The Islamic religion held that there was an afterlife: the vital spark that remained in the human body after death was reawakened and rewarded appropriately in paradise. So as not to interfere with this, dissection of the human body was forbidden. Speculation on the nature of the internal organs and on blood flow led to perceptive reasonings. For example, al-Quff suspected a connection between the smaller arteries and veins through small pores, and ibn-Nafis hypothesized such a connection in the lungs. But since there were no attempts to verify these theories through dissection, Arabic physicians relied on Galen for their anatomical knowledge.
Methodology and Treatment
Arabist practitioners used essentially the same methods as the Greeks and Romans. Diagnosis was based on six criteria: the patient's behavior; the excreta; the other effluvia from the body; swellings; the character of pain; and the location of pain. The properties of the pulse were also carefully noted. Even astrology had a role, for the influence of the stars over health and disease was considered a part of natural science. Because of the emphasis placed on examining urine (uroscopy), the half-filled urine flask became a symbol of the physician. The urine's color, consistency, sediment, smell, and taste helped to determine what was wrong with a patient, to predict his prognosis, and to guide treatment.
Since surgery was held in low regard, much of the cutting, cauterizing, bandaging, bleeding, and cupping was done by untrained folk doctors, laymen, and charlatans. Nevertheless some outstanding physicians practiced surgery and wrote about it. Lithotomy (removal of stones from the urinary bladder) continued to be condemned as it had in Greco-Roman times, probably because of bad results.
The most common surgical technique of the Arabic physician was cauterization, which he used for both internal and external diseases. Anesthesia by means of a sponge saturated in a narcotic acid (or other soporific drug) held to the nose and mouth was widespread enough to have been imparted to Theodoric (454-526) in the Latin West. Galen's writings were interpreted to advocate formation of pus in wounds in order to induce healing, and salves were therefore commonly applied. This unfortunate doctrine of "laudable pus" influenced surgical thinking throughout all areas of Christendom as well as Islam.
The special characteristic of Arabist therapy was the wide employment of drugs of all kinds. The herbal De Materia Medica of Dioscorides (1st century A.D.) was studied closely. New medications, including mineral as well as vegetable and animal substances, were added to make up a voluminous Arabist materia medica. Ambergris, camphor, cloves, myrrh, and senna were introduced, and also preparations of syrups, juleps, elixirs, and many other concoctions of the apothecary. Some of these substances may have originated in China or India.
In the early years of Islam, medical practice was still carried on by Christian and Jewish physicians. There was little prejudice against non-Muslims, and Muhammad himself was treated by a nonbeliever. Muslim physicians came upon the scene when Alexandria, Gundishapur, and other cities became centers of Muslim intellectual life.
A physician acquired his training in a teaching center or unaffiliated hospital, and he received certification from his teachers. However, untrained and self-proclaimed healers practiced unmolested until the early tenth century when the caliph of Baghdad required all who wished to practice, except those of unchallenged reputation, to take an examination. The western caliphate later followed suit.
Although women occupied a secondary place in Muslim society, midwives were permitted to practice. The reluctance of Arabic physicians to violate social taboo and touch the genitals of female strangers ceded much of obstetrics and gynecologic practice to midwives. As in Greek and Roman times, however, the seriously ill were treated by physicians.
Academies, schools, and libraries as separate institutions or attached to mosques or to hospitals were found throughout the world of Islam. Medicine was usually only one of the disciplines taught. Philosophy and the sciences were combined. Gundishapur was a fusion of Arabic, Nestorian, Byzantine, Indian, and Jewish medicine. There, in the eighth century A.D., the Bachtishua family, who were Nestorian' Christians, became prominent physicians. Other influential Nestorians were translators and teachers, among them Ben Mesue the Elder (also called Janus Damascenus) and Johannitus (Hunain ibn-Is-haq).
Among the many outstanding physicians we can single out a few. In the eastern caliphate were Rhazes, Avicenna, Haly Abbas, and Isaac Judaeus (850-950). In the western, Spanish area of Islam were Abul Qasim (Albucasis in Latin), Avenzoar, and Maimonides.
One of the most appealing healers from a modern vantage point was the Persian Razi, called Rhazes in the West (abu-Bakr Muhammad ibn-Zakariya al-Razi, 850-c. 923). He was outstanding in his generosity and always willing to treat and help the poor. Students and practitioners thronged to his lectures, and apparently he was also a brilliant bedside teacher. A man of his time, he revered learning and based his knowledge on the books of authorities. But he was also an independent thinker, not afraid to rely on his own observations when they contradicted the past; he counseled others that "all that is written in books is worth much less than the experience of a wise doctor."
Rhazes became blind in his last years (some say as the result of a brutal beating ordered by a caliph angered by his candor). Despite the large fees and honors he received, his generosity to the less fortunate left him poor at the time of his death. Of his 237 books on many subjects—including alchemy, anatomy, physiology, and ethics—much has been lost. A large part of his work was a compilation of the theories of Hippocrates, Galen, and others. Through the clarity of his writing and his influence over students and contemporary physicians he brought much of Greek medicine to the Arabic world. His most celebrated work, Al-Hawi (Liter Continens), summarized the medical and surgical knowledge of his time.
Rhazes's fame rested on clear-cut clinical descriptions of illness, original observations, and a pragmatic approach to treatment. However, he followed Galen's humoral pathology, practiced bloodletting, saw a place for precious stones in medication, and believed that the wrinkles of a pregnant woman could foretell the number of her children. On the other hand, he gave the first accurate descriptions of smallpox and measles, advised proper food in preference to drugs in treatment, opposed employment of the abstruse mathematical formulas of al-Kindi in therapy, and recommended simple rather than complex remedies.
The most widely influential Arabic contributor to medicine was Avicenna (abu-Ali al-Husayn ibn-Sina, 980-1037), whose standing in both Islam and Christendom was equal to that of Galen. Born near Bokhara, Persia, he was a boy prodigy and is said to have mastered the Koran by the age of ten. Aristotle's ideas intrigued him, and he also studied the commentators, such as al-Farabi. The Nestorians at Baghdad were Avicenna's principal teachers, and the entire gamut of human knowledge was within his purview: grammar, poetry, geometry, astronomy, anatomy, physiology, materia medica, surgery. When only twenty-one, he wrote a scientific encyclopedia.
Although he may at times have practiced medicine, his principal contribution was as a compiler and commentator. The most renowned of his approximately one hundred books was The Canon (Al-Qanun), upon which untold numbers of translators, teachers, students, and practitioners based their medical ideas and procedures for hundreds of years. In fact, until the mid-seventeenth century, the medical curriculum of the Christian universities, including those in the British Isles, was based on Avicenna's writings.
Haly Abbas (Ali ibn' ul-Abbas, d. 994), also from the eastern caliphate, in the late tenth century wrote highly popular and perceptive commentaries on Hippocrates, Galen, Oribasius, Paul of Aegina, and Rhazes, which were standard Arabic texts before Avicenna's Canon came upon the scene. Early Christian translators introduced Haly Abbas's works to the West, especially his surgical writings.
The name of Isaac Judaeus (Abu Ya'qub Is-haq Sulayman al-Israili) is linked with Haly Abbas because the translator Constantinus Africanus erroneously attributed to Isaac Judaeus some texts that may have been written by Haly Abbas. Among the genuine contributions of Judaeus, a physician of high repute in Egypt, was a collection of aphorisms in Hebrew, some of which were probably inspired by Rhazes. Examples are worth repeating:
Albucasis (Abul Qasim al-Zahrawi, 936-1013), the major Muslim writer on surgery, greatly influenced the Christian West. His al-Tasrif contained a section on surgery which was the first illustrated, systematic text on this subject. Most of the content was a repetition with modifications of the earlier contributions of Paul of Aegina and others, but Albucasis's careful descriptions and pragmatic advice revealed a cautious, ethical, thoughtful approach. The Arabic reliance on the cautery, cupping, and bleeding was part of his practice too, but his embrace of surgery as a worthy art and his emphasis on anatomy (even though it was based on Galen) were in contradiction to the tendency of Arabic medicine to relegate both surgery and anatomy to an inferior position.
Avenzoar (abu-Marwan ibn-Zohr, 1091?-1162) was an Arabist physician born in Seville. The son of a Jewish physician, he rejected much of Aristotle and Avicenna, condemned astrology and mysticism in medicine, and disagreed strongly with some of Galen's teachings. His clinical acumen led to accurate descriptions of scabies and pericarditis, a disease from which he himself suffered. He wrote on the preparation of drugs, on the practical uses of diet, and on alchemy. His reports on tracheotomy (cutting into the windpipe) suggest that he may have practiced surgery. Avenzoar recommended reliance on one's own experience rather than traditional doctrines. Through translations of his works into Hebrew and Latin he exercised great influence over the medical and alchemical teachings of medieval Europe.
Averroes (abul-al-Walid Muhammad ibn-Ahmad ibn-Rushd, 1126-98), a pupil of Avenzoar, was primarily a philosopher, but he also studied law and medicine. He wrote a medical compendium based on Aristotelian theory, but he is best known for his criticism of established religion and authority. Both Avicenna and Averroes were admirers and followers of Aristotle. But while Avicenna reconciled Aristotelianism with accepted religious views, Averroes held that religion should not be a branch of knowledge and that there was no personal immortality but rather a merging of the soul with nature and the universe. This interpretation of Aristotle was condemned by both Islam and the Christian Church.
Averroes held high political positions in Cordova and Morocco for many years, but eventually his pantheistic, irreverent views forced him to drop out of sight. Aided by his pupil Maimonides, he went into hiding among the Jews. His philosophy was spread throughout Europe by Jewish intellectuals after their expulsion from Spain.
The most famous Jewish physician in Arabic medicine was Maimonides (Moses ben Maimon, 1135-1204). Born in Cordova, he fled in 1160 with other Jews to Fez in Morocco when the strictly orthodox Muslim dynasty of the Almohades began to harass nonbelievers. He later migrated to Palestine and then to Cairo, where financial needs prompted him to enter medicine as a career. He rose rapidly, finally becoming physician to the sultan Saladin.
Maimonides's writings contained sage advice on diet, hygiene, first aid, poisons, and general medical problems, but his primary focus was on philosophy. He tried to reconcile scientific reasoning and religious faith, and he advanced the "heresies" of Averroes. Orthodox Jews of his time were sometimes hostile to his views, and wholehearted acceptance of Maimonides by Jewish intellectuals as a great medical and philosophical sage came only after his death.
Although he was a proponent of the ancient Galenic doctrine of the four humors and followed the general methods of Arabic medicine, Maimonides aimed at practical therapeutics. He translated the voluminous Canon of Avicenna into Hebrew, but his collection of the aphorisms of Hippocrates and Galen was written in Arabic, as was his popular Book of Precepts, which was composed as a collection of letters to Saladin. Translations of the writings of Maimonides into Hebrew and Latin were widely read throughout Christian Europe. Although the Morning Prayer of the Physician is attributed to him by some, he was probably not the author. However, the principles expressed in this prayer were in keeping with his philosophy and behavior. A section of one of the many versions is often quoted:
O God, let my mind be ever clear and enlightened. By the bedside of the patient let no alien thought deflect it. Let everything that experience and scholarship have taught it be present in it and hinder it not in its tranquil work. For great and noble are those scientific judgments that serve the purpose of preserving the health and lives of Thy creatures.
Keep far from me the delusion that I can accomplish all things. Give me the strength, the will, and the opportunity to amplify my knowledge more and more. Today I can disclose things in my knowledge which yesterday I would not yet have dreamt of, for the Art is great, but the human mind presses on untiringly.
In the patient let me ever see only the man. Thou, All-Bountiful One, hast chosen me to watch over the life and death of Thy creatures. I prepare myself now for my calling. Stand Thou by me in this great task, so that it may prosper. For without Thine aid man prospers not even in the smallest things.
Public Health and Hospitals
In medieval times, the general health of the populace and its hygienic conditions probably were essentially the same in Latin Europe and in the Muslim world. Medical treatises of the era reveal a concern with the same diseases, acute and chronic. A special interest in eye treatments suggests that ocular afflictions were common. The excellent Arabic descriptions of epidemics marked by skin eruptions may indicate that such pestilences were as prevalent in the world of Islam as in Christian lands. Orthodox Muslims apparently accepted epidemics as inherent in the lot of man.
The streets and homes doubtless were as filthy in Islam as in Christendom. In some cities sewers probably existed, but they often emptied into the local streams from which people got their drinking water. The rich frequently chose to live upstream from the city; in Cairo, for example, relatively unpolluted water was available above the point where the Nile entered the city and became sullied with sewage and garbage.
Medical care by reputable physicians was mainly limited to the rich and noble. The repeated praises of kindly Rhazes who treated the sick poor free of charge makes one suspect that such generosity was not a common practice. Hosts of lay healers, mountebanks, and magicians plied their trades. But even when medical care was available, the deeply devout often resented the ministrations of physicians as an infringement on the province of Allah.
General health care under Islam outshone Christian society in at least one respect—the hospital system. Although Christian hospitals existed in the West, they were few, rudimentary, and greatly inferior in terms of sanitation, care, facilities, and medication to the centers in Muslim cities. Moreover Christians emphasized salvation of the soul rather than restoration of the body. Although the famous school and hospital at Gundishapur had been established by Nestorian Christians, its later support by Muslim rulers stamped it as a hospital of Arabic medicine.
The best-known of the great hospitals in the Middle Ages were at Baghdad, Damascus, and Cairo. Although hospitals had existed in Baghdad in the ninth century, the most ambitious was founded in the tenth century. In keeping with the principles enunciated by Rhazes, who taught and practiced there, clinical reports of cases were collected and preserved for teaching. The hospital and medical school at Damascus had elegant rooms and an extensive library. Healthy people are said to have feigned illness in order to enjoy its cuisine. Probably the largest and most magnificent was the Mansur Hospital in Cairo, founded in the thirteenth century and built by workers and artisans who were ordered by the sultan to give all their time to its construction. Even the sultan himself took a physical part in the project. Separate wards were set aside for different diseases, such as fevers, eye conditions, diarrhea, wounds, and female disorders. Convalescents had separate sections within them. On discharge, each patient received five gold pieces to support himself until he could return to work.
Jews as Translators
Jewish translators occupied a special place in bridging Arabic and Latin learning. The open atmosphere of tolerance fostered by Islamic rulers (with a few exceptions) permitted and even encouraged scholars of all races and religions to pursue their studies. The contributions of non-Muslims to learning were eagerly absorbed and incorporated into the rich cultural heritage of Islam.
There was always some interchange between the Muslim and Christian worlds—during the supremacy of Muslim civilization and also during its decline. The familiarity of the Jews with Syriac, Hebrew, and Arabic gave them the opportunity to bring Greek writings (much of which had been translated into Syriac by the Nestorian Christians) into the Arabic orbit. And, later, Jewish writers were instrumental in returning Greek works to the Christian West through their translations. Especially in Spain, contacts between the Muslim and Christian cultures occurred. When Jews at the time of Maimonides fled persecution by the Almohades dynasty in Cordova, they dispersed to European centers of learning, among them Salerno and Montpellier, to which they brought Arabic science and medicine.