HISTORY OF MEDICINE

Background material by Professor Omar Hasan Kasule Sr. for Year 1 Semester 1 Medical PPSD session on 13^th August 2008

PRE-ISLAMIC ROOTS OF MEDICINE

The roots of modern medicine can be traced to ancient civilizations of Egypt, Babylon, China, India, Persia, Greece, and Rome. There were also contributions from traditional medicine of many societies including the Pre-Islamic Arabian peninsula.

The practice of embalming the dead gave Egyptians a lot of knowledge about anatomy. They also developed various medical and surgical modalities. The Babylonians knew nasal tamponade for bleeding, cataract couching. They used blood-letting as a treatment. They knew circumcision

Ancient Chinese medicine was well developed. The Chinese developed acupuncture and castration of males who became eunuchs. Chang Chon-Ching, who lived in the 2^nd century M, was the most famous Chinese physician. He had famous medical writings and spread medical knowledge to Japan. In the 3^rd century M the Chinese surgeon Hua Chu wrote about physiology, anatomy, pathology, anesthetics. After him Huang wrote about acupuncture. Tao Hung Ching (454-536 M) used acupuncture and had interests in internal medicine, anatomy, children and women diseases, obstetrics, dietetics, and drugs. Chao Yuan Fang (550-630 M) wrote a medical encyclopedia. Sa’ad Ibn Abi Waqqaas the commander of the conquest of Qadisiyyat (13H) and the founder of the city of Kufa (18H) was sent by Othman Ibn Affan on a diplomatic mission to China 620-640 M and is reported to have lived in the Chinese city of Canton. Thereafter contacts between Muslims and Chinese increased. A Chinese physician came to Al Razi (d. 313 AH/925 M) and requested to study under him for 1 year. He learned Arabic and translated medical books into Chinese. Muslims were in contact with Chinese physicians who visited Central Asia such as Yuan Chwang 630-645 M and I Tsung 675-685 M.

Surgical knowledge in India was very advanced and many surgical instruments were developed. The following operations were carried out by Indian surgeons: tonsillectomy, amputation, tumor excision, hernia repair, repair of harelips, removal of bladder stones, couching cataracts, nose repair, ceserian section. Indians knew the washing and bandaging of wounds. Hyoscamus (Henbane) and cannabis indica were used as anesthetics. In some cases hypnosis was used as anesthesia. The period 6-12^th centuries M witnessed development of Indian medicine especially in the field of toxicology. Indian medicine reached Baghdad both directly and indirectly, through Persia. Muslims entered Sindh in 15H/637M led by the Omayyad military leader Muhammad Ibn al Qasim; a long period of contact with Indian medicine, trade and cultural exchange ensued. In the Abassid era the ruling Barmaki family were interested in Indian culture especially its medicine. Yahya bin Khalid al Barmaki, vizier of Harun al Rashiid, sent missions to India to learn its medical knowledge. He also invited Indian physicians to Baghdad. Some Indian medical texts were translated into Arabic in Baghdad. The physician Abi al hasan Ali Bin Sahal al Tabari in his book ‘Firdaus al Hikmat’ completed in 236H / 850M wrote about Indian medicine covering topics such as: importance of spiritual cures, treatment of metal disorders, importance of specialization, women diseases, obstetrics, internal medicine, dietary treatment, looking at the patient as one entity, diagnosis, preventive medicine, anatomy, surgery, surgical instruments, and medical training. The Indian physician Kankah treated Harun al Rashiid and translated a book on poisons. The Indian physician Salih bin Baghlat was famous at the Abassid court. Urnda, Siddhayogar, and Ibn Dahn al Hindi were Indian physicians who served the Abassids and all worked at the Baghdad Hospital built in 187H/ 803M in the era of Harun al Rashid. Zantah was an Indian physician who wrote about poisons and their treatment. Ibn al Nadiim in his book ‘Al Fihrist’ mentioned Indian medical books that were translated into Arabic. Abubakr al Razi in his book ‘al Hawi’ depended a lot on Indian medical knowledge. Abi al Rayhan Muhammad bin Ahmad al Bairuni wrote about Indian medicine. He traveled in India and was very familiar with its people and culture.

Persian interest in Greek medicine was demonstrated when the King of Persia invited the famous Greek physician Hippocrates (460-377 BC) to help deal with diseases and epidemics in Persia. Hippocrates did not agree. When Alexander of Macedonia defeated Persia, he spread Hellenic civilization including its medicine. Greek knowledge was translated first into Persian then into Arabic. Hereafter many translations of medical works were made from Persian to Arabic especially at the time of the Abassids. Persian influence was very strong at the Abassid court in many areas including medicine.

Greek medical knowledge was picked up by the Romans and was spread in West Asia by the Byzantines. The famous Roman physician Galen closely followed Hippocrates. He in turn had a major impact on Byzantine medicine. Muslims learned a lot from Galen but also had access to other Greek sources. Complete reliance on Galen was not possible because Galen was selective in his copying from Hippocrates and other Greek physicians. Muslims played a big role in preserving early Greek medical knowledge, improving and enhancing it, and eventually passing it on to Europe during the renaissance. The Greek physician and father of European medicine, Hippocrates son of Heraclides (460-377 or 370 BC), introduced rational/scientific medicine. He introduced the theory of the 4 humors and the 4 elements of the body. The Hippocratic corpus consists of his writings and those of his students. Romans learned from the Greeks and developed advanced military hospitals called valetudinaria that were used to treat wounded soldiers on the battle-field. Three Roman physicians became famous: Celsus, Rofus, and Galen. Celsus described the cardinal signs of inflammation: rubor, tumor, calore, and dolore; provided details of surgical procedures; and described ligation of blood vessels. He encouraged dissection. Rofus wrote 42 titles and made contributions to anatomy, surgery, and urinary tract disease. Claudius Galen (130-201 BC), a skilled Roman military surgeon, had great impact on Arab medicine. His writings were compiled by the Byzantines and were eventually translated into Arabic.

The Greek-speaking multi-national Byzantine Empire, with its capital at Constantinople in West Asia, lasted over 1000 years after the fall of Rome and acted as a bridge to transfer Greek knowledge to West Asia and North Africa. The Byzantines compiled Greek knowledge from Hellenic and Roman books. The University of Alexandria was the center of this activity. It continued functioning after the Muslim conquest of 642M and lasted until 719M. Johns Philoponus, the grammarian, was an Egyptian scholar in Alexandria who met Amre bin al ‘Aas. He wrote commentaries on the books of Aristotle and Galen. Palladius and Asclepius wrote commentaries on Hippocrate’s writings in the 6^th century M. Paulinus, an expert in women diseases and obstetrics, was another Byzantine physician in Alexandria.

Medical knowledge in the Arabian peninsular before Islam was the folk medicine found in all human communities. We know a lot about the nature of this medicine from the many authentic hadiths on Tibb al nabawi. The prophet’s medicine was in most cases the medicine practised in Hejaz at that time. Pre-Islamic Arabs used cupping, hijamat; cautery, kayy, and branding with fire, wasm. They used a wide variety of herbal medicine. Among medical practitioners in the pre-Islamic era were: Ibn Huzeem, Nadr Ibn Harith, and Ramtha al Tamiimi. The harsh environment, isolation in the desert, the nomadic Bedouin life, and general illiteracy explain the low level of medical knowledge among Arabs before Islam. They sometimes confused medical practice with sorcery and magic.

MUSLIM CONTRIBUTIONS TO MEDICINE

BASIC MEDICAL SCIENCES

Anatomy: Muslims largely depended on the writings of Galen. They however made their own observations and corrected many mistakes made by Galen. Al Razi encouraged dissection and study of physiology. Al Zahrawi insisted on knowledge of anatomy before any surgery. 

Physiology: Muslim physiological knowledge was influenced a lot by the Greek theories of the 4 elements, al asqaat: hot, cold, wet, and dry; the 4 humors: blood, phlegm, yellow bile, and black bile; the 9 temparaments: 1 balanced and 8 out of balance. They also described the faculties: natural faculties, animal faculties, psychic faculties, and procreative faculties. These Greek ideas had one very important and true concept, the idea of balance which is the forerunner of the modern physiological concept of homeostasis. Most of the details were however found by later research to be untrue and were discarded. The heart and circulation were described by Muslims as a mechanical pump. Ideas of food digestion were also known.

MEDICAL DISCIPLINES

Infectious diseases: Al Razi was aware of air-borne infection when he made an experiment to determine the site of a new hospital in Baghdad by putting meat in the air and waiting to see the site where it putrified soonest. Al Razi in his book, Kitaab al judri wa al hisbat described the symptoms of smallpox and measles. The concept of contagion was known as early as the time of the prophet. Al Majuusi described contagious diseases like leprosy, elephantiasis, phrenitis, and trachoma. Ibn al Khatib and Ibn Khatimat described the symptoms of plague. Ibn Khatima had mentioned minute bodies causing disease in the 14^th century CE.

Blood circulation:  Ibn Nafees al Nafees described pulmonary circulation centuries before its ‘discovery’ by William Harvey.

Psychiatry: depression melancholia was related to organic factors. It was also realized that it could be caused solely by psychological factors. The symptoms of depression were described very well.

Metabolic/endocrine diseases: The symptoms of diabetes mellitus were described well. Urine examination was a very advanced art.

Allergy: Al Razi described rhinitis due to plant exposure centuries before similar descriptions by Europeans.

Dietetics: Muslims knew that diet is a method of treatment.

PHARMACEUTICALS

Muslims knew both simple and compound drugs.

SURGICAL DISCIPLINES

Ophthalmology: Ibn Hytham (965-1040 CE) in his book 'Kitaab al Manadhir' disproved the extromission theories of Euclid and Ptolmey and instead advocated an intromission view. He described the optic pathways and the point-to-point projection of the visual world into the  brain. He described how eye movements helped in visual perception. He also realized that several processes were involved in conscious visual experience. Jurjani (5^th century H) wrote about ophthalmology in his book 'Nur al ‘Uyuun'. Al Zahrawi described many extra-ocular operations. Al Zahrawi described the posterior displacement of the lens in cataracts. He also discovered many instruments such as: hooks, eye speculum, conjuctival scissors for removal of panus, perforator and depressing needles for cataract surgery. Al Razi recommended tearing the capsule of the lens if it cannot be displaced and Ibn Sina described various needles that can be used for this. Ali Ibn Isa was another ophthalmologist who wrote the book 'Tadhkirat al Kahaliin'. Both Al Razi and Ibn Sina described a procedure for operative decompression of glaucoma.

Anesthesiology: Al Zahrawi performed many of his operations under anesthesia: opium or mandragora.

Obstetrics: Al Baladi (circa 380 H) wrote a complete discourse on midwifery called ' Kitaab Tadbir al Habala'. Al Zahrawi described normal and abnormal presentations and described instruments for craniotomy to deliver a dead fetus in case of obstruction. He also developed a vaginal speculum.

General surgery: The main contributors were: Ibn Zuhr, al Shirazi, Ibn Dhahabi, and al Zahrawi. The book al Tasrif By Al Zahrawi took 30 years to compile in 30 volumes. The last volume deals with surgery and is one fifth of the whole book. The volume on surgery is divided into three sections: (a) cauterization in 56 chapters (b) incisions, perforations, wounds & wound healing in 93 chapters (c) bones setting and joints in 36 chapters. The book contains anatomical details. It covered all branches of surgery. The book was used as a standard text in Europe and was translated into Latin in the 12^th century M. Al Zahrawi performed thyroidectomy in 952 M. Al Razi was the first to use gut sutures for intestinal repair. Al Zahrawi is also reported to have used catgut and cotton sutures. Al Zahrawi recognized pain as a symptom and not a disease. Among operations performed by Al Zahrawi and described in his writings were: tracheostomy as an elective procedure and bandaging techniques. Al Zahrawi has 11 inventions credited to his name such as use of the syringe for bladder irrigation, the vaginal speculum, and plaster for bone setting. Al Jurjani (d. 1136 M) described the relation between goiter and exophthalmos

Traumatology & orthopedics: Al Zahrawi and al Quff described treatment of bone and joint trauma. Zahrawi wrote about osteomyelitis, amputations, and osteotomies for un-united fractures. He cautioned against above-knee and above-elbow amputations.

Wound treatment: The main contributors were: Ibn Sina, Al Zahrawi, Ibn Rushd, and Al Razi. Al Zahrawi taught the following methods of arresting hemorrhage: digital pressure, tourniquet, sponges, cauterization, hypothermia, ligation of bleeding vessels by sutures of thread. He also advised against tight bandaging. Al Zahrawi emphasied the imoortance of cleanliness in would treatment. Ibn Sina mentioned dry dressing. Al Zahrawi wrote about the drainage of abscesses describing in detail the site and shape of the incision, packing of the wound, excision of the skin edges, use of slow decompression of large cavities, dependent and counter drainage.  

Urology: Al Zahrawi described bladder irrigation. He also developed original methods of lithotromy for impacted stones. He introduced a fine drill into the urethra and was rotated gently to break up the stone into small pieces that could be washed away by the urine. He also wrote about using a bladder sound to locate bladder calculi, control of post-operative hemorrhage, and removal of clots from the bladder.

Gastro-enterology: Al Zahrawi used stomach tubes. He described paracentesis for ascites and intra-peritoneal abscesses. He mentioned use of trocar and cannula to drain liver abscesses. He also described the use a heated cautery to open liver abscesses. Ibn Zuhr (1113-1162 M) was the first to describe in detail the distinction between gastric ulcer and gastric malignancy. Ibn Sina wrote about colitis and its management by diet, drugs, and enema. Abu Imran Musa bin Maymun (1135-1204 M) wrote about hemorrhoids and the role of diet and surgery in their treatment. Mohammad bin Mahmood Al-Qusum (circa 1525 M) in his book ' Zad al Masir fi 'Ilaj Bawasir' wrote about treatment of piles. Ibn al Quff wrote about complications of hemorrhoidectomy and post-operative anal stricture. Al Zahrawi originated cauterization treatment of fistula-in-ano and was aware of the complications of this treatment.

Plastic surgery: Al Zahrawi described the cauterization treatment of harelip. He wrote that the edges must be freshened first before cautery.

Ear, Nose, and Throat: Al Zahrawi discovered the guillotine method of tonsillectomy as well as the complications of the operation. He described the tumors of the tonsil. Among discoveries attributed to al Zahrawi are: use of special osteotomies for nasal operations and polypectomy, use of a marine sponge with an attached string for removal of foreign bodied from the throat, removal of foreign bodies from ears, treatment of nasopharyngeal tumors by repeated excision and cauterization.

Dentistry: Ibn al Quff described making artificial teeth from bone. A Zahrawi described several dental operations: wiring of loose teeth, extraction of roots of broken teeth and broken pieces of the mandible by use of special forceps.

Thermal and chemical cauterization for syphilitic lesions were described by Ibn Sina

Tumors: The main contributor was Abdul Malik Ibn Zuhr (d. 484 H). Al Zahrawi and Ibn Sina recommended wide excision including healthy tissue in removal of tumors. Use of cautery and drugs in treatment of tumors was also described. 

Neuro-surgery: Both al Zahrawi and Ibn Quff described in detail the various intra-cranial and extra-cranial hemorrhages due to arrow wounds and their respective treatments. Al Zahrawi described symptoms and signs of skull fracture. He also described the depressed fracture in children and recommended treatment by removal of a bone. In cranial operations, the drill may accidentally perfotate the delicate intra-cranial structure; Al Zahrawi developed an instrument to prevent this accidental penetration. Al Zahrawi's craniotomy operations were remarkably like modern ones; using burr holes with a linking cut between them allowing to raise part of the cranial vault. Al Zahrawi described paralysis due to injury of the spinal cord. Haly Abbas described several types pof fractures: simple, comminuted, displaced, and hairline. Ibn Sina classified fractures of the skull into two types: closed fractures and open fractures. He described treatment of skull wounds by relieving hematomas or removing pieces of bone that could hurt the brain. Al Baghdadi described the depression fracture found in children. He also described meningoceles that remained after skull surgery and appeared during coughing. Samarkandi described treatment of brain edema following skull trauma and its relief using dehydration, venesection, and enema.

HOSPITALS

The Persian word bimaristan was used to refer to hospitals and is literally translated as the house of the sick. The first hospital in Islam was the hospital tent that the prophet ordered erected in the mosque of Madina during the battle of the confederates and Rufaidat used it to treat the wounded. The complete bimaristan was established in 88H for the lepers and the blind by the Omayyad Khalifat al Waliid bin ‘Abd al Malik. There were general bimaristans as well as specialized ones for prisons and schools. There were bimaristans for isolating patients who mad or those with chronic diseases like leprosy. The army has mobile bimaristans.

Hospitals were built in Baghdad, Cairo, Andalusia, and Damascus. Bimaristan al Adudi al Kabir was opened in Baghdad in 982 M. Bimaristan al Nuri al Kabir was established in Cairo in 160 M. The Salahi and Mansuri hospitals were built in Cairo and the Nuri hospital was built in Damascus. Muslim hospitals had separate sections for each type of disease. They had gardens. Fans were used to cool the hospital. Cleanliness was observed by workers in all areas of the hospital especially the kitchen and the pharmacy. Daily clinical rounds were carried out. Patients were given some money on discharge.

MEDICAL COLLEGES

Mosques were first used for medical education for example Omar bin al Mansur (d. 824H) taught medicine at the Tulinid mosque, al jami’u al taaluuni, in Egypt. Abu Ja’afar al Mansur established Bayt al Hikmat in Baghdad that had become by the time of Ma amuun a research center in which medical books were translated. Among schools of medicine was the school of Abu Bakar bin Fuwruk al Asbahani (d. 406H). The Wazir Nidhaam al Mulk (408-486H) established medical schools in Iraq and Khurraasaan. Medical schools were also established at bimaristans such as the school of the al Muqtadiri Bimaristan in Baghdad established in 306H. Out of concern for proper medical education, Khalifah al Muqtadiri ordered in 319H that nobody would be allowed to practice medicine unless examined by Sinan bin Thaabit bin Qurra.

GROWTH OF EUROPEAN MEDICINE

Post-renaissance: The growth of medical knowledge post-renaissance was phenomenal. Ocver the past 600 years medical knowledge has spread from Europe to all over the world. The European medical system has become the dominant form of medicine world wide because of its rational scientific and empirical basis. It is almost impossible to trace the development of this medicine because of voluminous information. We shall use surgery as an example.

The renaissance witnessed rapid progress in surgical knowledge and practice. Leonardo da Vinci (1452-1519 M) dissected and described human bodies. Andreas Vesalius (1513-1564 M) dissected bodies and published De Humani Corporis Fabrica Libri Setem which corrected many anatomical mistakes. Ambrose Pare (1510-1590 M) was an army surgeon who stopped use of hot oil to treat gunshot wounds, invented surgical instruments, used ligatures instead of cauterisation of blood vessels in amputations, developed artificial limbs, and invented surgical instruments. Jean Baptiste Denis carried out the first successful blood transfusion in 1667 M using blood from a lamb. Obstetric forceps were developed by Peter Chamberlain in England in 1630 M. Santorio Santorio (1561-1636 M) developed the thermometer and measured body weight. Milliam Harvey (1578-1657 CE) rediscovered blood circulation that had been described centuries before by the Muslim physician Ibn Nafis. Marcello Malphigi (1628-1694 M) described capillary circulation. Athansius Kircher (1602-1680 M) and Anton Van Leewenhook (1632-1723 M) described micro-organisms seen under the microscope. Fransesco redi (1626-1697 M) disproved the theory of spontaneous generation. 

18^th-19^th Centuries M: Daniel Fahrenheit (1686-1736 M) developed the mercury thermometer. Stephen Hales (1677-1761 M) was the first to measure blood pressure. William Hunter (1718-1783 M) and his brother John Hunter (1728-1793 M) dissected bodies and taught anatomy and surgery. Rene TH Laennec (1781-1826 M) discovered the stethiscope. Claude Benard (1813-1878 M) introduced the scientific method in medicine. Herman Von Helmholtz (1821-1894 M) invented the ophthalmoscope. Joseph Priestly discovered nitrous oxide in 1776 M and it was later used as an anesthetic in operative surgery. Ignas Semmelweiss (1818-1865 M) insisted on hand-washing in obstetric practice to prevent spread of infection. Oliver Wendell Holmes (1809-1894 M) also wrote treatises on infections. Louis Pasteur (1822-1895 M) laid the foundations of modern bacteriology but Robert Koch (1843-1910 M) is considered the father of this discipline. William Roengten (1845-1922 M) discovered x-rays in 1895 M. Madame Curie and her husband Peter discovered radium and its ability to destroy malignant cells in 1898 M.

20^th century: Paul Erlich (1854-1915 M) discovered Salvarsan in 1910 M. Alexander Fleming (1881-1955 M) discovered penicillin in 1929 M. In 1901 M Karl Landsteiner discovered blood grouping. In 1948 M Dr Papanicoulus discovered the PAP smear.