Islamic Civilization

Dominant Aspects of Muslim Medicine 

Under the Muslims, medicine departed from the narrow focus of its predecessors, a few individuals such as Galen and Hippocrates, to become a universal science, attracting the interest of hundreds, not to say thousands of scholars.[1] The authors of repute alone numbered over 400.[2] The fame of the medical colleges of the Orient spread rapidly throughout the world, and attracted the ambitious of every creed, Christian, Hebrew and Muslim.[3] In the 11^th century there were more than six thousand students of medicine in the schools of Baghdad  alone,[4] possibly an exaggerated figure, but even if by ten times, it still expresses the mass interest and spread of medical learning and practice in the Islamic world. In the city of Baghdad, in the year 931, a board for the medical practitioners was established by royal decree, and all those who practised medicine had to pass the examination. 860 candidates appeared for the examination, indicating at least 1000 practising physicians in Baghdad.[5] The population, whether rich or poor, also found in the hospitals places and means for healing.[6] The Mansuri hospital in Cairo , founded in 1284, accommodated 8000 people in its separate wards for different illnesses and for both men and women. It had also a large administrative staff, a dispensary, a mosque, a library and facilities for teaching.[7] And more appropriately, its constitution read:

‘Its duty is to give care to the ill, poor men and women until they recover. It is at the service of the powerful and the weak, the poor and the rich, of the subject and the prince, of the citizen and the brigand, without demand for any form of payment, but only for the sake of God, the provider.’[8]

That Muslim medicine was flourishing is obvious in the countless works on the subject, and also in their size and impact. Ibn Sina 's Qanun (Canon of Medicine) is one of the most voluminous works ever published; but also, according to Meyerhof, a masterpiece of  systematisation.[9] Al-Razi  wrote more than 100 books covering a variety of diseases and medical subjects.[10] His al-Hawi (the Comprehensive Book) or Continens as known by its Latin  name, is an encyclopaedic work on medicine and surgery in 25 volumes.[11] No complete Manuscript of it exists, but it can be found split in many parts in libraries world-wide: three volumes in the British Museum, three in the Bodleian, four or five in the Escurial (Madrid), others at Munich and Petrograd and some abridgments in Berlin.[12] Ibn al-Nafis (1210-1288) wrote among others Kitab al-Shamil fi Sina’at al-Tibiyya (Comprehensive Book on the  Art of Medicine), a book intended to be in three hundred volumes, of which he only managed to publish eighty.[13] Manuscripts of this work can be found in Cambridge University Library, the Bodleian (Oxford), and al-Muthaf al-Iraqi (Iraq ). Equally huge and richly diverse are the works of Ibn Zuhr, Ibn Rushd, and many others.

The impact of these works is obvious in their lengthy use and repeated editions. The Canon of Ibn Sina , for instance, first translated into Latin  in the 12th century, remained taught in Europe until the 17th century. In the last thirty years of the 15^th century, it was issued sixteen times: fifteen in Latin and one in Hebrew.[14] In the 16^th century, it was edited 21 times; on top of commentaries in both Latin and Hebrew.[15] Al-Razi ’s Al-Hawi was translated on the order of Charles of Anjou in the 13^th century by Faraj Ibn Salim (Faragut), and was propagated in numerous manuscripts in the following centuries.[16] Latin versions of Al-Razi were published at Milan in 1481, at Venice in 1483, 1490, 1493; Bergamo 1497; 1498; 1500; 1506; 1509; and 1510, and at Lyons in 1510. Other Latin versions appeared in Basle (1529; 1544); Strasbourg (1549); Basle London (1747), Gottingen (1781), and elsewhere. In addition his works were translated into Greek (Paris, 1548), French (Paris, 1763), Italian (Venice); and English (1848).[17] The last cited translation into English being of his treatise On Small pox and Measles, undertaken for the Sydenham Society by Greenhill, appearing in 1848.[18] Al-Zahrawi’s tasrif, translated as Liber Servitoris by Gerard of Cremona (in the 12^th century), had many editions in Venice (1497), Basel (1541) and Oxford (1778), and for centuries, it was the manual of surgery in Salerno, Montpelier and other early medical schools of Europe.[19]

It is of little value to discuss even the most important subjects addressed by Muslim authors, a whole encyclopaedia being necessary for this. But briefly, here, the most succinct outline looking at some subjects, by some authors, will illustrate for us how the Muslim scholars, by their works, created the first proper medical textbooks, in a format which would be recognisable to medical students anywhere in the world today,[20] and how Islamic medicine covered many subjects hardly, if ever considered by the Greeks, beginning with Al-Madjusi (d. 994), who, in his Kitab al-Malaki (Liber Regalis), describes eczema, scabies, miliaria rubra, miliaria alba, favus, pediculosis, seborrhoeic dermatitis, alopecia areata, lupus vulgaris, leprosy, filariasis, smallpox, chickenpox, measles and erysipelas, giving the differential diagnosis of each with the appropriate treatment.[21] The second Ibn Zuhr (the Latin  Avenzoar) (b. ca. 1091- 1094) wrote  Kitab al-taysir fi-l-mudawat wal-tadbir (Book of Simplification Concerning Therapeutics and Diet), which contains an elaborate study of pathological conditions and relevant therapeutics, the whole followed by an antidotary or formulary called Jami' (Collected Recipes), which is sometimes mentioned as a separate work.[22] The Taysir dealt with specific medical conditions such as pericarditis, pharangeal paralysis, inflammation of the middle ear, and recommended tracheotomy for laryngeal obstruction.[23] Ibn Zuhr is said to have been the first to suggest that  patients suffering from oesophageal stricture might be fed by nutrient enemata.[24] Ibn Sina ’s Canon discusses mineral, animal and vegetable poisons, rabies, venesection, cancer of the breast, hydrocele, tumours, skin diseases, labour.[25] In the Canon, pulmonary tuberculosis is for the first time regarded as a contagious disease.[26] Ibn Sina also gives an excellent clinical account of meningitis, differentiating from the meningismus of other acute diseases; he describes chronic nephritis, facial paralysis; pyloric senosis, ulcer of the stomach, and much else.[27] In describing difficult labour, he says, after mentioning several procedures, ‘when this fails, the forceps are to be applied and the child is to be extracted by them,’ a passage, which Major insists, supplies unmistakable proof that the Muslim physicians were familiar with obstetrical forceps.[28] Ibn Sina also notes the effect upon health of water supply, climate, the seasons, bathing, sleep, and emotional disturbance.[29]

The Islamic scholars completely reshaped medical writing and learning in comparison with their Greek predecessors, putting together a whole new methodology. Al-Razi , for instance, observes how Hippocrates' Aphorisms was disorganised, ambiguous, and unnecessarily brief.[30] Hence, his larger, more encompassing, and more importantly, systematically constructed work, Al-Hawi. Islamic scholars strove to bring order to the subject, on theoretical and practical levels, the first including body matters, and the second embracing all forms of therapeutics: surgery, physical exercise, drug therapy, etc. Medicine was further subdivided into various disciplines: ophthalmology, dentistry, psychiatry, gynaecology, paediatrics, etc.[31] In Al-Razi’s al-Mansuri, a treatise on anatomy, each bone, muscle, or organ is described in the light of its function and purpose.[32] Al-Madjusi’s  Kitab al-Maliki (The Royal Book) consists of twenty sections, ten on the theoretical principles of medicine and ten on its practice. It was the first comprehensive and methodical presentation of medicine as a whole-something which the Greeks had not attempted.[33] Al-Qumri (fl end 10^th century), and the teacher of Ibn Sina , wrote Kitab ghina wa mana (The Book of Life and Death) divided into three parts: internal diseases, external diseases, and fevers.[34] Al-Zahrawi, Al-Madjusi, Ibn Zuhr, and others also make classifications of their subjects, and from the writing of Ibn Zuhr it can be seen that in his day the professions of physician, surgeon and apothecary were separated.[35]

The training of doctors, although hardly given its due in the literature on the subject, played a crucial role in the advance of medicine. It was carried out by the apprenticeship method, and in the hospitals, where the school, if it were called that, was a part of the hospital, much as it is still done in London at the present time.[36] In many of these hospitals, prescribed lectures were given in the large hall of the hospital. These lectures consisted of the reading of a medical manuscript, and following the reading, the chief physician or surgeon asked and answered questions from the students.[37] Al-Razi , for instance, called for high professional standards for practioners, and urged physicians to continue their education by studying medical treatises, attending lectures, and training at hospitals.[38] He boasted that his knowledge had been acquired in hospitals and not from libraries.[39] Bedside teaching was considered to be the most important part of the training, the students in groups following the attending physician or surgeon in his ward rounds, the more advanced students observing the doctor, then later in the day, taking the history and making an examination of the patients, and prescribing for them in the Out-Patient Department of the hospital.[40] Only those professionals who had undertaken the required training, such as in Cairo , at the madrasa al-Barquqia, and who had submitted to examinations, which generally consisted in a commentary on an ancient medical treatise, could undertake the profession of physician.[41] They obtained a licence to practise (ijaza), delivered by the head of the medical profession.[42] Women, too, could join the profession.[43] But all medical doctors submitted to the supervisory authority of the Muhtasib (the State Inspector), who also made them swear their professional oaths.[44] All the writings on hisba, city policing, cover the rigorous inspection of doctors, bone-setters, oculists, and veterinary surgeons.[45] The prefect was empowered to investigate the competence of the practitioners, who were expected to know certain manuals by heart, and to demand to see their medical instruments, lists of which were given in the manuals.[46]

Ethics took a central role in Muslim medical practice. Al-Zahrawi  (b.936. d.1013), recommending to his sons (i.e his students) the trade of surgeon, says:

‘Show caution and care for yourselves and gentleness and perseverance for your patients. Purify yourselves of anything which you fear may cause doubt as to your religious life and your secular life; for this will perpetuate your good name and will elevate your fortunes in this world and the next.’[47]

And:

‘I warn you against undertaking any case in which there is any element of doubt to you; for in the exercise of the art, you will be mobbed by all kinds of persons with all manners of afflictions... let your caution be stronger than your greed and desire for gains, and do not embark upon anything of this kind unless you have positive knowledge, which you judge adequate, about the way of bringing the patient a good outcome. In treating every patient be prescient and foretell the means whereby health may be restored to him.... may God inspire you my sons, with His guidance, and grant you that you hit the mark and succeed; for it is in His hand. There is no God but He.’[48]

The best account we have in English on the ethics of the physician is by Ishaq bin Rahawi ‘Adab al-Tabib,' (On the Good Manners of the Physician) a substantial part of which was translated by Levey.[49] The treatise has twenty chapters, which include matters such as 1. What the physician must avoid and beware of; 2. Manners of the visitors; 3. Care of remedies by the physician; 4. Dignity of the medical profession; 5. Examination of physicians; 6. Removal of corrupt physicians.[50]

Islamic medical care was an all encompassing practice, Muslim physicians seeing their patients regularly, and even associating with them socially. They looked at all aspects of the patient's life, physical and mental, and were aware of the latter's influence on the general well being.[51] Al-Razi , thus, called for consultation and mutual trust between skilled physicians, and favoured a family doctor practice, besides warning patients that changing doctors would waste their wealth, health, and time.[52] He promoted psychotherapy, pointing out that hopeful comments from doctors encouraged patients and made them feel better.[53]

The equilibrium of the body had the most important role, though.[54] As Levey notes, when a person became ill, the Muslim physician’s tendency was to tip the balance the other way gently by means of nutritive drugs, and when these were not effective, simple drugs were then employed.[55] Treatment took into account the patient’s temperament, diet and previous illnesses.[56] Ibn Jazla’s (b.1074) Taqwim al-Abdan fi tadbir al-Insan (Tables of the Body With Regard to the Physical Management of Man), for instance, is a thorough study of the very structure of the body, how its diverse parts impacted and inter-related. Health depended on ‘an equilibrium of the humours,’ an equilibrium which varied with the individual.[57]

The emphasis is more on health than on disease, and near the beginning of Ibn Sina 's Canon of Medicine was this:

"I say that medicine is the science by which the dispositions of the human body are known, in order that customary health may be preserved or, being lost, may be recovered."[58]

Ibn Massawayh (Mesue Senior) (777-857) in his aphorisms,[59] advises the following:

‘The constitution of living bodies is made up of numerous factors. Do not use brutal procedures which undermine the organism and attack, weaken and shake the body, so that its constitution becomes changed.’ (Aphorism 26)

‘Whenever possible, we must treat each organ with remedies resembling the organ’s natural food; if the cure is a change of diet, so much the better.’ (Aphorism 35).

‘Patients whose main organs are impaired must not be given hot medicaments; you must control their diet until equilibrium is restored.’ (Aphorism 61)

            ‘The physician must copy the action of nature.’ (Aphorism 64)

‘In their treatment of diseases, physicians must aim to restore the body to its normal state of health, and not to perfect equilibrium.’ (Aphorism 68) 

Ibn Butlan's (d.ca 1068) Taqwim as-sihha (Latin : Tacuinum Sanitatis,) retaining the Arabic word with the translation "regimen", begins:

‘On the six things that are necessary to any man for the daily conservation of his health, with its corrections and operations.’ These are immediately listed:

"The first care of health is the preparation of the air, which affects the heart. The second is the regulation of food and drink. The third is the regulation of movement and rest. The fourth is the restraint of the body from sleep and from much watching. The fifth is the regulation of the relaxation and constriction of the humours. The sixth is regulation of the person to moderate joy, anger, fear and anxiety. So the preservation of health will be in these methods of balance, and the removal of these six from that balance makes illness, God the Glorious, the Almighty, permitting. And under each of these kinds there are many types, and many things necessary of which, God willing, we will describe the natures ... Let us invoke the help of God that He may make straight our mind, for human nature can scarcely be prevented from error…’’[60]

Diet was central in Islamic medicine, and early Islamic scholars followed the Prophet’s stance that all health predicaments have their origin in diet. Abu 'Abdallah Mutammad al-Tamimi al-Muqaddasi (fl. c. 970) wrote several medical books, and most interestingly Kitab al-murshid ila jawahir al-aghdhiya wa quwa-l-mufradat; which, as the title suggests, is a guide toward the understanding of the substances of food-stuffs and (of) the simple drugs, on how diet affects well being.[61] Ibn al-Wafid in his On the Powers of Medicines and Foods, among others, states:

"I have put together this book on the virtues of medicines and foods, from the books of the ancients; for long have I wearied my mind with it . . . I have poured forth prayers on it that it may come near to God, the Exalted, the Glorious . . . The object of medicine is health, and according to two modes. The first is the knowledge of the complexions of the bodies of men. The second is the knowledge of medicines and foods, by the knowledge of which health is maintained in the healthy man and restored in the sick man.’[62]

Ibn Zuhr of Seville  in his Teisir also describes the methods of preparing medicines and diet.[63] Al-Razi , too, advised his colleagues to allow patients to eat foods they preferred; and also stressed the importance of a balanced diet for the preservation or restoration of good health.[64]

Good, appetising food was also deemed, under special circumstances, to help recovery as well captured in this anecdote narrated by Al-Zahiri who told about his visit to Damascus  :

‘I was accompanied by a distinguished and affable Persian. When he visited the al-Nuri hospital (named after the ruler Nur Eddin Zangi (d. 1173) and saw the diets, the utilities and the comforts to be found there, he decided to see for himself what being a patient was like in that hospital. He pretended illness and was admitted to the hospital. There the medical chief visited him every day and took his pulse and prescribed his diet, consisting of a variety of meats, fat chickens, candies and drinks and fresh fruits. On the third day the doctor told him that such patients were not allowed to stay more than three days, and asked him to leave.’[65] 

Just as, in its generalised form, Islamic medicine formed the foundation of modern medicine, in some specific areas it still constitutes the most powerful basis for many modern breakthroughs in the subject.