CONTRIBUTION OF ISLAM TO MEDICINE

By  Ezzat Abouleish, M.B., CH.B., D.A., D.M., M.D.

Medicine, as it stands today, did not develop overnight. It is the culmination of efforts of millions of people, some we know and other we do not. The flame of civilization,including medicine, started thousands of years ago, was passed on from one generation to another, and from one country to the other. Depending on who took the sacred responsibility of hosting it,sometime it glowed brighter and sometimes dimmer: it never died away, because if it did, it wouldhave been impossible to re-kindle it.

Between the ancient civilization, namely the Egyptians, Greek,Roman,Persian,Indian,and Chinese, and the Renaissance era in Europe, there was a gap, commonly called "the darkages", during which the flame was hosted, not by the West, but by another group of people called the Arabs or the Moslems. The term "the dark ages" reflects the civilization in Europe between the 7th and 13th centuries, but by no means does it express the state of affairs in the Arab world or the Islamic Empire at that time when the position of art and science were as bright as the middaysun. That era, unjustifiably, has been commonly neglected and passed over, as if it never existed. This paper is an effort to focus on some of the important events which took place during this period, including the accomplishments ofthe prominent physicians who lived at that time.

The Spread of Islam

In order to understand how medicine developed in the middle ages, we have to look at history and find out the important things that happened during the seventh century.

In 570 A.D., a man was born in a small city called Makkah in the Arabian Peninsula (Haykal 1976); his name was Mohammed. In 610 A.D. he started preaching a new religion, Islam. In 632 A.D., he died after uniting the Arab tribes who had been torn by incessant feuds, cycles of revenge, rivalries, and internecine fights. He transformed these mostly illitcrate nomadic people into a strong nation that encountered and conquered, simultaneously, the two known powers of the time, namely, the Persian and Byzantine Empires. Within a comparatively short space oftime, the Islamic Empire extended from the Atlantic Ocean on the west, to the borders of China on the east. In 71 1 A.D.. only 80 years after the death of the prophet, the Arabs had crossed over to Europe where they ruled Spain for more than 700 years. In 732 A.D., they threatened Paris before their thrust was stopped at Tours and Poiter (Eigeland 1976). In 831 A.D., the Muslims of North Africa invaded Sicily and ruled there for 200 years. By 846 A.D., they controlled the southern part of Italy and encountered Pome (Hitti 1977). The hold of the Moslems over Italy remained so firm that Pope John VIII (872-882 A.D.) deemed it prudent to pay tribute for two years (Hitti 1977). In 869 A.D., the Arabs captured Malta (ibn-Khaldun). In the tenth century, from Italy and Spain, the Arabs extended their raids through the Alpine passages into mid-Europe. In the Alps, ruins of a number of castles and walls which tourists' guides trace back to the invasion of the Moslems from Sicily still exist. In the southern part ofItaly and in Sicily, a great civilization prospered and through it, the torch of knowledge passed on to Europe, mainly through the University of Salerno in the southern part of Italy (Hitti 1977, Parente 1967).

The expansion of the Muslims in Europe was not limited to those from North Africa and Spain. The Moslems, under the Ottoman Empire, invaded Europe from the East. They occupied a large part of Middle Europe and besieged Vienna twice: during the reign of Sulayman I (1520-1566 A.D.), and during the reign of Mohammed IV (1648-1687 A.D.) (Hitti 1977).

Islam and the Promotion of Culture and Science

As the Muslims challenged the civilized world at that time, they pre served the cultures of the conquered countries. On the other hand, when the Islamic Empire became weak, most of the Islamic contributions in art and science were destroyed. The barbarous hordes of Mongols burnt down Baghdad (1258 A.D.), and later the Spaniards, in their hatred, destroyed most of the Arabicheritage in Spain. What distinguished the Arabs from their enemies was their beliefin Islam which:

1. Stressed the importance and respect for learning. In fact, the very first word revealed to the Prophet ofIslam was "Read". The Prophet freed an enemy captured in battle if he paid a ransom or taught writing and reading to ten Muslims. In their holy book, the Qur'an, the importance of knowledge has been repeatedly stressed: "Those who know and those who do not are not equal." The Prophet Mohammed stressed learning by saying, "One hour of teaching is better than a night of praying." One of the early princes, Khalid Ibn Yazid (end of the 7th century), gave up his treasure for the study of medicine and chemistry. He studied medicine under John the Grammarian of Alexandria, and chemistry under Merrinos the Greek (Haddad 1942). He also encouraged several Greek and Coptic medical books to be translated into Arabic.
2. Forbade destruction. On conquering Mecca, the Prophet Mohammed strongly forbade destruction of homes, animals, or trees. His followers faithfully followed these principles when they conquered other countries.
3. Encouraged cleanliness and personal hygiene. Islam instructed them to approach God in their prayers five times a day with bodies and clothes spotlessly clean.
4. Developed in them respect of authority and discipline. For example, realizing the scourges of plague, their Prophet Mohammed (p.b.u.h.) decreed that "no man may enter or leave a town in which a plague has broken out." And to make it all the more binding and effective, he promised heaven for those who die of plague, saying that such a death was that of a martyr (Haddad 1942). Thus Mohammed (p.b.u.h.) laid for the Muslims the laws governing cordon and quarantine for the first time in history and made them work.
5. Tolerated other religions. Islam recognizes Christianity and Judaism and considers their followers to be people with holy books like Muslims. In fact, they generously sheltered the Jews at an era when the latter were persecuted in Europe. Dr. Jacob Minkin, a reputable rabbi and scholar says "It was Mohammadan Spain, the only land of freedom the Jews knew in nearly a thousand years of their dispersion...while during the Crusades, the armored knights of the crossspread death and devastation in the Jewish communities of the countries through which they passed, Jews were safe under the sign of the Crescent. They were not only safe in life and possessions, but were given the opportunity to live their own lives and develop a culture so unique and striking that it went down in history as the 'Golden Age'. The Moors, the Muslim conquerors of Spain in 711, were not religious fanatics. They were strong in their faith but generous with regard to the religious convictions of others ... The Renaissance of Art in Italy, says George A. Dorsey, has blinded us to the Renaissance of Science in Spain, which fostered science, promoted culture, encouraged learning, and set a premium on intellectual pursuits, no matter whether the intellect was Moslem, Christian or Jew. Not since the days of Greece had the world kHown such thirst for knowledge, such passion for learning, such spirit shared by the prince and the courtier alike" (Minkin 1968).

The Arabs were assimilated by the vast new countries they reached. From this marriageof genuine character and righteousness with the ancient and well established civilizations, a great new nation was born. It is difficult to identify this new breed as Arabs, because although the language was Arabic, all the scientists were not necessarily from the Arabian Peninsula. It is also equally difficult to describe it as Islamic, because although the majority of the scientists were Moslems, sponsored by Moslem rulers, and governed by Islamic law, yet some scientists were Christians or Jews, especially during the early phase of the Islamic civilization: the period when works in foreign languages were translated into Arabic, and the period of its decline, when the Arabic books were translated into Latin and Hebrew. Therefore, in this article, the adjectives Arabic and Islamic will be used as synonyms.

Medicine Before Islam

In order to comprehend the contributions of the Arabs to medicine, we must have in our minds a picture of the condition of medicine before they arrived on the scene. Generally speaking, two elements are required for medical practice: manpower and hospitals.

A. Manpower before Islam. There were medical centers in different parts of the world which were later either underthe control of the Arabs or inluenced by them. For exampie, in Syria, medicine was advanced and was greatly influenced by the Byzantine civilization which affected also the economic and administrative systems (Hammarneh 1962). From the fifth century on, Greek was the language of learning in Syria. The knowledge of the Arabs of the Greek civilization was mainly through the Syrian scholars who translated it into Arabic. In Egypt, Alexandria was another center for culture. The Arabs came into contact with both the ancient Egyptian and Greek civilizations through the Egyptian scholars. In Persia, there was a medical school in a city called Jundi-Shapur in which medicine was highly developed (Fig. 1). The Abbasi Caliphs during the 8th century encouraged the Persian physicians to translate medical literature from the Persian language into Arabic, to build medical centers in Baghdad, the capital of their empire, and to run newly built hospitals. With further expansion east, the Arabs through contacts with India and China, obtained ideas and methods, not only in medicine, but also in mathematics, chemistry, philosophy, etc.

B. Hospitals before Islam. Hospitals, as we now know them, were probably not present. True, there were places forthe sick to stay, but these were mainly temples or buildings adjoining temples that were run by priests. Gods were supposed to play a major role in the art of healing. For example, the Goddess Toueris was the Egyptian symbol of fecundity who was the protectress of the pregnant and parturient. She was shown as a standing pregnant hippopotamus carrying the hieroglyph meaning protection in one paw and the sign of life in the other. Small figures of Toueris were popular as amulets (Speert 1973). In those days, sanctuary, prayers, incantation, and hypnosis were integral parts of the therapy.

Characteristic Feature of Hospitals in the Islamic Civilization

During the Islamic civilization, hospitals had developed and attained specific characteristics:

1. Secular: Hospitals served all peoples irrespective of color, religion, or background. They were run by the government rather than by the church, and their directors were commonly physicians assisted by persons who had no special religious color. In hospitals, physicians of all faiths worked together with one aim in common: the well-being of patients.
2. Separate wards: Patients of different sexes occupied separate wards. Also different diseases especially infectious ones, were allocated different wards.
3. Separate nurses: Male nurses were to take care of male patients, and vice-versa.
4. Baths and water supplies: Praying five times a day is an important pillar of Islam. Sick or healthy, it is an Islamic obligation. In either case one must offer prayer, but if one is sick one may pray lying in bed. Before praying, one must, however, wash the face, the head, the hands,and the feet, if possible. For certain conditions, a full bath is obligatory. Therefore, these hospitals had to provide the patients and employees with plenty of water and adequate bathing facilities.
5. Practicing physicians: Only qualified physicians were allowed by law to practice medicine. In 931 A.D., the Abbasid Caliph Al-Muqtadir, ordered his Chief Court- Physician SinanIbn-Thabit to screen the 860 physicians of Baghdad and to grant licenses to practice only to the ones who were qualified (Hamarneh 1962). The counterpart of Ibn-Thabit, AbuOsman Sai'd Ibn-Yaqub, was ordered to do the same in Damascus, Mecca, and Medina. The latter two cities werein need of such a screening because of the hundreds of thousands of pilgrims visiting them everyyear.
6. Medical schools: The hospital was not only a place for treating patients, but it also served as a school to educate and train medical students, imparting medical knowledge, and developing medicine as a whole. To the main hospitals, there were attached expensive libraries containing the most up-to-date books, auditoria for meetings and lectures, and housing for students and staff of the hospital.
7. Proper records of patients: These hospitals were the first in history that kept regular records of patients and their medical treatment.
8. Pharmacy: During the Islamic era, the science and the profession of pharmacy had developed to an outstanding degree. The Arabic materia medica became rich and many new drugs and compounds were added to it as the Muslims had access to all parts of the known world, either through control or trade. Their ships sailed to China and the Philippines, and their convoys exchanged trade with Africa, Europe and Asia. Chemistry became an advanced science, and a new specialization called pharmacy developed.

The hospitals built in medieval Europe were modeled after these Arabian hospitals. They also served as centers for medical education and students from all parts of the south and the west thronged to them in search forknowledge.

The Reasons for the High Standard of Islamic Hospitals

In the Islamic Empire, the hospitals reached their golden era unsurpassed in previous history. The reasons for this unprecedented progress may briefly be summed up as follows

1. Bring part of an ascendent civilization : The people were prosperous, and they were capable of taking care of their health seeking the best available treatment. Islam stresses the necessity of seeking treatment of every disease. The Prophet says "For every disease God has created a cure." The sciences related to a good medical care system were fairly advanced, e.g., the Arabs were very advanced in chemistry, mathematics, administration, pharmacy, medicine, etc. They gave the world a counting system which replaced the cumbersome Roman numerals. The world also owes to them the knowledge of many important chemical processes and reactions, namely, sublimation, precipitation, filtration, distillation, etc. The great Arab chemist Jabir Ibn- Hayan discovered sulphuric and nitric acids. According to Webster's Dictionary, words such as sugar, alcohol, alkali, syrup, coffee, cotton, are all Arabic in origin. Fielding H. Garrison, the author of the well-known work on the "History of Medicine" said:,..."The Saracens themselves were the originators not only of algebra, chemistry, and geology, but of many of the so-called improvements or refinements of civilization, such as street lamps, window-panes, firework, stringed instruments, cultivated fruits, perfumes, spices, etc..."
   
   
2. High prestige of physicians: The physicians in this era enjoyed high prestige. Although anyone, irrespective of his social status, could study medicine, the route was long and tedious. Before embarking upon his medical studies a student first had to study Islamics, philosophy, astronomy, art, chemistry. Only then was he admitted into a medical school. A physician was thus a highly cultured person who had wisdom and knowledge. In fact, the Arabic term for a physician is hakim or a sage. In the 9th and IOth centuries, the Court Physician was placed above the Chief Justice. Many eminent physicians, as we will see later, had enough talent, social knowledge, political ability and wisdom to be appointed by the caliphs as their prime minister (viziers). With their high position and social connections physicians could easily obtain generous funds for their hospitals.
   
   
3. Rulers involvement in public services: The caliphs of the Islamic empire built magnificent hospitals for one or more of the following reasons: 
   
   • Religion: Their religion stated that money spent on charity is a good investment for life in the Hereafter.
   
   
   • Eternity: The Pharaohs of Ancient Egypt sought eternity by building pyramids, the rulers oflslam sought the same by building mosques, hospitals, and schools carrying their names.
   
   
   • Politics: To show their people that they cared, and were interested in them, the rulers built hospitals. Whatever the motive of the ruler, the population benefitted and good hospital were erected.
4. Adequate financing to run the hospitals. The rulers set aside generous funds for running these hospitals. Also there were many philanthropists, who like their rulers, followed their religious beliefs and spent generously on charitable causes like building hospitals, etc. In Islam, there is a special system called Al-Waqf or endowments. One may donate part or all of his wealth to an endowment for any charitable cause. Usually the government takes care of such endowments, and the resultant revenues are used in maintaining and building mosques, hospitals, and schools. Another important source of funds and an important pillar oflslam is what is known as zakah or poor-due which is collected annually from prosperous people at a rate of two and a half percent of their surplus wealth. All funds thus collected go to the state treasury which uses them for well-defined charitable purposes. Very few hospitals in the Islamic era were private. In other words, income from patients' fees constituted a relatively unimportant source of funding.

Specific Hospitals 
The capital of the Islamic empire kept changing with the change of rulers and dynasties. One result of this was that in all these capital cities important medical centers developed. By the end of the 13th century, there were many such medical centers throughout the Arab world. Because of the limitation of space and scope of this paper, we will confine ourselves to some of the important hospitals established in various regions.

1. In El-Sham

El-Sham included what is known now as Syria, Lebanon, Jordan and Palestine. Damascus and Jcrusalern were its important cities.

1. In Damascus. The first known hospital in Islam was built in Damascus in 706 A.D by the Umayyad caliph, AI-Walid (Hamarneh 1962). The most important hospiral built in Damascus in the Middle Ages was named Al-Nuri Hospital, after King Nur Al-Din Zinki, in 1156. This hospital was built during the Crusades to fulfill a need for a well-equipped and well-staffed hospital. It turned out to be not only a first class hospital, but also a first class medical school. The king donated to the hospital a whole library rich in medical books. Books were expensive and limited In number in the Middle Ages because they were hand-written as printing was not used until the middle of the fifteenth century. The hospital adopted medical records, probably for the first time in history. Many eminent physicians graduated from its medical school. An example is Ibn Al - Nafis, the eminent Scholar who discovered the pulmonary circulation. This hospital served the people fol+ seven cenhlries and parts of it are still extant.
   
   
2. In Jerusalem : In 1055 A.D., the Crusaders built Saint John Hospital. By the end of the eleventh century, it had grown quite large and included a hospital, a palace for large number of daily admissions of patients, pilgrims, and wounded soldiers. After the liberation of Jerusalem by Salah AI-Din in 1187 A.D., the hospital was renamed as Al- Salahani Hospital Salah Al-Din expanded the hospital and it continued to serve the people until its destruction by an earthquake in 1458 A.D.

2. In Iraq and Persia.

In 750 A.D., Baghdad was built as the capital of the new Abbasid dynasty by the Caliph Abu-Gaifar AI-Mansur. in 766 A.L)., he appointed the dean of the medical school of Jindi Shapur, Jurjis Ibn-Bakhtishu', as his Court Physician and instructed him to build more hospitals reflecting the true glory and prosperity of Baghdad. Later the caliph Harun AI-Rashid (786-809 A.D.) ordered his Court Physician, Jibril, the grandson of Ibn Bakhtishu, to build a special hospital called Baghdad Hospital. This hospital developed into an important medical center. One of its chiefs was Al-Razi, the eminent Internist.

In 918 A.D., the Caliph Al-Mugtadir built two hospitals in Daghdad. One was on the east side ofthe city which he named Al-Sayyidah Hospital, after his mother, and the other was on the west side which he named after himself, Al-Mugtadiri Hospital. Another important hospital was AI- Adudi Hospital. It was built in 981 A.D. and was named after King Adud AlDawlah. It was the most magnificent hospital built in Baghdad before modern times. The caliph wanted to outdo his predecessors. The hospital was furnished with the best equipment and supplies available at the time. It had Interns, residents, and twenty four consultants to care and look after the patients. Haly Abbas, the author of the famous book "Liber Regius (AlMalaki)", was one of its staff physicians. It was destroyed in 1258 when Holagu. the grandson of Chengiz Khan, invaded Baghdad.

3. In Egypt.

In 872 A.D., Ahmed Ibn-Tulun built a hospital called Al-Fustat Hospital in the City of AI- Fustat, now a part of old Cairo. It served the growing Cairo population for six centuries. It was divided into separate wards. On admission, the patients were given special apparel while their clothes, money, and valuables were stored away and returned to them at the time of their discharge.

In 1284 A.D., King Al-Mansur Qalawun built an important hospital, named Al-Mansuri Hospital. The story behind its construction is interesting. King Al-Mansur Qalawun was an officer in the Muslim army fighting the Crusaders. While in the Holy Land, he fell sick and was admitted to AlNuri Hospital. On recovery, he vowed that if he ever became the ruler of Egypt, he would build a hospital in Cairo even larger and more magnificent than Al-Nuri Hospital for the sick, poor, and rich alike.

It was the best hospital built then as reported by the contemporary historians such as Ibn- Battuta and El-Kalkashandi. It had different departments for different diseases. Music therapy was used as a line of treatment for psychiatric patients. It served four thousand patients daily. Not only was the patient's stay in the hospital free, but on his discharge, the patient was given food and money in compensation for being out of work during his stay in hospital. Al-Mansuri Hospital has continued to serve Cairo for the past seven centuries. Today it is used for ophthalmology and is called Mustashfa Qalawun. Its ancient door is preserved in the Islamic Museum of Cairo.

4. In North Africa (A I-Maghrib Al-Arabi):

1. Tunisia. In 830 A.D., Prince Ziyadat Allah I, built Al-Qayrawan Hospital in a district of the Qayrawan city called Al-Dimnah. Subsequently all hospitals in Tunisia were called Dimnah instead of Bimaristan as they were called in the East, which is a Persian word meaning a hospital. The Qayrawan Hospital was characterized by spacious separate wards, waiting rooms for visitors and patients, and female nurses from Sudan, an event representing the first use of nursing in Arabic history. The hospital also included a mosque for prayers.
2. Morocco: In 1190 A.D., the King Al-Mansur Ya'qub Ibn-Yusuf, built a hospital in the capital city, Marakesh, and named it Marakesh Hospital. It was a huge hospital beautifully landscaped with fruit trees and flowers. Water was carried by aqueducts to all sections. Patients were provided with special apparel: one for winter and another for summer. The pharmacy was taken care of by specialists called the Sayadlah. There was an expensive private section where a patient was charged what is equivalent to $150/day. One thousand years ago, this fee was quite expensive.

5. Al-Andalus (Spain).

In 1366 A.D., Prince Muhammed Ibn-Yusuf Ibn Nasr built the Granu~lrr HospitLII in the city of Granada which had a population of half a million. The hospital represented the beauty of the Arabic architecture in Spain and served the people until the fall of Granada in 1492 A.D.

Method of Therapy in Islamic Medicine

The patients were treated according to a well-defined treatment plan. It began with physiotherapy and diet; if this failed, drugs were used. Only as a last resort was surgery used. The physiotherapy included exercises and water baths. The Arabs had an elaborate system of dieting and were aware of food deficiencies. Proper nutrition was an important part of treatment plan.

Drugs were divided into two groups: simple and compound drugs. The Arabs were aware of the interaction between drugs. They used simple drugs first. If these failed, compound drugs made from two or more compounds were used. When all these conservative measures failed, surgery was performed.

Medical Ethics in Islam

The medical profession was a well respected area, and by laying down its own code of ethics it maintained its position of importance. Al-Tabari, the chief physician in 970 A.D., described the Islamic code of medical ethics as follows (Hamarneh 1971, Levy 1967):

1. Personal characters of`the physician:

The physician ought to be modest, virtuous, merciful, and unaddicted to liquor. He should wear clean clothes, be dignified, and have wellgroomed hair and beard. He should not join the ungodly and scoffers of truth, nor sit at their table. He should select his company from among persons of good reputation. He should be careful of what he says and should not hesitate to ask forgiveness ifhe makes an error. He should be forgiving and never seek revenge. He should be friendly person and a peacemaker.

He should not make jokes or laugh at the improper time or place.

II. His obligation towards patients:

He should avoid predicting whether a patient will live or die, only God (Allah) knows that. He ought not lose his temper when his patient keeps asking questions, but should answer them gently and compassionately. He should treat the rich and the poor, the master and the servant, the powerful and the powerless, the elite and the illiterate alike. God will reward him if he helps the needy. The physician should not be late for his rounds or his house calls. He should be punctual and reliable. He should not wrangle about his fees. If the patient is very ill or has an emergency, he should be thankful for what he is paid. He should not give drugs to a pregnant woman to induce an abortion unless it is necessary for the mother's health. If the physician prescribes a drug orally, he should make sure that the patient knows the name of the drug in case he asks for the wrong drug and get sicker. He should be decent towards women. He should not divulge the secrets of his patients.

III. His obligation towards the communitv:

The physician should speak no evil of reputable men of the community or be critical of any one's religious beliefs.

IV. His obligations towards his colleagues.

The physician should speak well of his acquaintances and colleagues. He should not honor himself by shaming others. If another physician has been called to treat his patient, he (family doctor) should not criticize his colleague even if the diagnosis and the recommendations of the latter differ from his own. However, he has the obligation of explaining the consequences of each method of treatment, since it is his duty to counsel the patient as best he can. He must warn him that combining different types of therapy may be dangerous because the actions of different drugs may be incompatible and injurious.

V. His obligations towards his assistants. 
If his subordinate makes a mistake, the physician should not rebuke him in front of others, but correct him privately and cordially.