Medicine in the Middle Ages: New Insights and a Call for Further Research

[Proceedings of the conference 1001 Inventions: Muslim Heritage in Our World organised by FSTC, London, 25-26 May 2010].

Aiming at restoring historical continuity to the currently available knowledge on medicine in the Middle Ages, the article summarizes some results from Prof. Abdel-Halim's extensive primary-source studies of the original Arabic works of ten medieval Islamic medical scholars who lived and practiced between the 9th and 13th centuries and whose works represented original contributions to the progress of anatomy, physiology, clinical medicine and surgery. The article also highlights the importance of continuing research in this field, for the reason that the investigation about the transmission and translation movements that occurred during the Middle Ages are bound to emphasize the universality of knowledge and unity of mankind. Such an assumption will certainly boost cultural inter-appreciation around the world and help to strengthen mutual understandings between the West and the East and, thus, nurture the interaction between different faiths and various civilisations.

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Professor Rabie E Abdel-Halim

Figure 1-2: Professor Rabie E Abdel-Halim presenting his lecture in the "1001 Inventions" conference. © FSTC 2010.

Abstract

In this presentation, in order to restore historical continuity to the currently available knowledge on medicine in the Middle Ages, the author summarizes some results from his extensive primary-source studies of the original Arabic works of ten medieval Islamic medical scholars who lived and practiced between the 9th and 13th centuries. The results thus obtained documented some of the original contributions to the progress of anatomy, physiology, clinical medicine and surgery during the medieval Islamic era. They also gave support to the new trend arising from recent studies, establishing later dates for the beginnings of decline of Islamic sciences as well as earlier dates for the onset of European Renaissance. Moreover, the author highlights the importance of continuing research in this field, for the reason that the investigation about the transmission and translation movements that occurred during the Middle Ages are bound to emphasize the universality of knowledge and unity of mankind. Such an assumption will certainly boost cultural inter-appreciation around the world and help to strengthen mutual understandings between the West and the East and, thus, nurture the interaction between different faiths and various civilisations.

Introduction

As wisely stated by George Sarton, "we shall not be able to understand our science of to-day, if we do not succeed in penetrating its genesis and its evolution." [1]

To get the benefit of penetrating the genesis and evolution of the medicine of today, historians should always endeavour for a chronologically continuous and uninterrupted knowledge of its progress. This is particularly necessary for the study of the medieval phase of the history of medicine.

The Term Middle Ages and the Fragmented Look at History of Science

Because the term "Middle Ages" was first used by European scholars during the Italian Renaissance to describe their own history, and as the study of the era has evolved, that focus has remained fundamentally the same. Accordingly, the field of medieval studies is, by its very nature, "Eurocentric [2]." This does not mean that medievalists deny or ignore the significance of events that took place elsewhere. Yet, the entire concept of a "medieval era" remains a European one and, consequently, little light is shed on the medieval medicine and science in the East.

Figure 3: Diagrammatic representation of the gradual expansion of scientific knowledge from ancient times up till now.

This fragmented look at the history of science resulted in obscuring the geographic diffusion, the gradual expansion and circulation of scientific knowledge that occurred around the world and across cultures, not only during the medieval and early modern periods, but also throughout time, from ancient times up till now (Figure 3). This has broken an important link in the globally continuous line of progress and evolution of world civilizations [3] (Figure 4).

Figure 4: Diagrammatic representation of the broken link in the globally continuous line of progress and evolution of world civilizations.

Furthermore, despite the recent trend to subdivide the European Middle Ages on the basis of scientific progress into early, high and late periods, the tendency to apply the term Dark Ages to the whole era still exists and continues to be globally applied (Figure 5). This is well illustrated by Al-Hassani [4] in Figure 6.

Figure 5: Diagrammatic representation of the tendency to apply the term dark ages to the whole era of Middle Ages.

Figure 6: A timeline graph showing the thousand years missing history during the Middle Ages (Courtesy of The Foundation for Science, Technology, and Civilization (FSTC, UK).

Therefore, it is noticeable that, in any contemporary article on medicine, the more than 1000 years between Greco-Roman times and the modern era are commonly overlooked. The same holds true with respect to mass media resources and curricula, at schools and colleges.

An Example of the Current Knowledge Gap in the History of Medicine

An example of this gap is found in the well-known textbook Clinical Methods and Laboratory Examination [5].

Kenneth Walker in the chapter on "The origins of the history taking and physical examination" named "ten individuals as responsible for the development of modern physical diagnosis: Hippocrates then Vesalius, followed by 8 others. The author described their accomplishments, as forming a ‘golden thread' [that runs] throughout the history of the world, consecutive and continuous, the work of the best men in successive ages" [5].

Figure 7: Timeline (CE) of the origins of clinical medicine created from data reported in Chapter 1 of Clinical Methods and Laboratory Examination published by Butterworth's in 1990.

Figure 8: The timeline in Figure 7 with highlights of the more than 1000 years gap in the chain of clinical knowledge between Hippocrates and Vesalius.

Figure 7 shows the timelines of those ten mentioned successive individuals throughout world history. This more than 1000 years gap shown in Figure 8, the missing link in this golden chain between Hippocrates and the 16th-century Vesalius, gives the impression that no progress in clinical medicine occurred during the Islamic era, the period between the Greco-Roman civilization and the European Renaissance.

Table 1: Original Works of Some Medieval Islamic Scholars Studied by the Author.

Contrary to Kenneth Walker's statement, our primary-source studies documented many important original contributions to the development of modern clinical methods by the Islamic scholars shown in Table 1, who lived and practiced during that same period. Full text of the already published results of the study can be found on: http://www.rabieabdelhalim.com.

Figure 9: Title and a manuscript page of Kitab Ma Al-Fariq: Kalamun Fi Al-Furuq Bayn Al-Amradh (A discourse on differential diagnosis) by Al-Razi (Rhazes), published by the Aleppo University Institute for Arabic Scientific Heritage, 1978.

We have shown the supreme abilities of the 9th century Abu Bakr Muhammad ibn Zakariya Al-Razi as a clinician, and documented his original additions to this field, such as his book Kalamun fi al-furuq bayn al-amradh (A Discourse on differentiating diseases) (Figure 9), the first ever independent book to be written on differential diagnosis, and a landmark in the development of modern clinical methods.

Accordingly, we have disproved the erroneous belief that in the Middle Ages, physicians never examined or came in contact with their patients, but made their diagnoses from looking only at their urine flasks [6]. We have shown that this was not the case in the East where, coinciding with the spread of Islam, the study of medicine and other branches of science revived and acquired a scientific basis during the same period [7,8,9,10].

Figure 10: Title page of the 10th volume of Kitab Al-Hawi Fi Al-Tibb (The Continens) of Al-Razi edited and published by The Osmania Oriental Bureau Publications, Hyderabad, 1961.

Under this influence, in his book Al-Hawi fi al tibb (Figure 10), Al-Razi opposed every form of charlatanism and combated the exaggerated importance that was given to the examination of urine. His appraisal and classification of findings on urine examination was based on an emerging scientific method relying on accurate observation and careful clinico-pathological correlation [11,[12],13].

Figure 11: Title page of Kitab Al Taysir Fi Al-Mudawat Wa Al-Tadbir of Ibn Zuhr (Avenzoar), published by Darul Fikr Press, Damascus for the Arab Educational Scientific and Cultural Organization, 1983.

Figure 12: Title page of Kitab Al-Mukhtar Fi Al-Tibb of Muhadhdhabul Deen Al-Baghdadi, edited and published by The Osmania Oriental Bureau Publications, Hyderabad, 1942.

Scholars who came after Al-Razi, like ibn Sina, Al-Zahrawi, Ibn Zuhr (Figure 11) [14] and Al Baghdadi (Figure 12) [15], continued to follow and enrich his pioneering school in giving prime importance to clinical observations and differential diagnosis.

Figure 13: The timeline shown in Figure 7 after bridging the missing link by some of the medieval Islamic scholars whose works have been studied.

These findings not only fill the wide gap in Kenneth Walker's statement about the landmarks in the progress of clinical methods (Figure 13), but also prove the originality of the scholars of the Islamic era.

Another Example of the Current Knowledge Gap in History of Medicine

Another example of the missing link in the chain of scientific knowledge, is found in the history of medieval Anatomy and Physiology. Garrison and many contemporary medical historians stated that: "The anatomy written and compiled, in the second century, by the eminent Roman physician Galen, remained unquestioned until the sixteenth century, the time of the great anatomist Andreas Vesalius" [16].

Figure 14: Timeline created from several encyclopedias and references on history of renaissance stating that Galen's anatomy remained unquestioned until the time of the 16th century great anatomist Vesalius; the more than 1000 years knowledge gap is highlighted.

This statement gives the impression that no progress was made in human anatomy, and consequently in surgery, during the Medieval Islamic era, the period between Galen and Vesalius (Figure 14).

Figure 15: Early anatomical scene from a manuscript authored by the 15th century Ottoman surgeon and physician Serefeddin Sabuncuoglu.

However, this is again disproved by the published results of our ongoing study of the original works of the medieval Islamic Scholars. We have shown that Al-Razi, Ibn Sina, Muhadhdhabul al-Din Al-Baghdadi, Ibn Zuhr and Ibn Rushd emphasized the value of dissection and knowledge of anatomy in medical education and practice (Figure 15).

Figure 16: The title page of Kitab Sharh Tashrih Al-Qanun (Commentary on [ibn Sina's] Canon) authored by Ibn Al-Nafis, edited by Salman Qattaya and published by The Egyptian Manuscript Editing Bureau, Cairo, 1988.

Also a similar view was held by the 13th-century Muslim physician Ibn al-Nafis, the discoverer of the coronary and pulmonary circulations, in his book Sharh tashrih al-Qanun (Figure 16).

Figure 17: The drawing of the cross section of the brain and the eyes made by the 13th century Khalifa ibn Abi Al Mahasin Al Halaby (from Aleppo) in his book Al Kafi Fi Al-Kuhl (The Book of Sufficient Knowledge in ophthalmology). From: The Arabian Ophthalmologists, compiled from original texts by J. Hirchberg, J. Lippert and E. Mittwoch, translated into English by F. C. Bildi et al., edited by Z. Wafai and published by King Abdel-Aziz City for Science and Technology, Riyadh, 1993.

Furthermore, the presence of anatomical drawings within the textbooks authored by the Muslim scholars is a trend that started and flourished in the Islamic era reflecting the role of direct observations and experience (Figure 17). From the days of Al Razi and onward, the medical scholars of the Islamic era were keen on direct observation and experimentation.

Therefore, more than 600 years before the time of Vesalius, the interest and experience of the Muslim scholars in the study of anatomy led them to contribute to the advance of this important medical science, by correcting many of Galen's erroneous anatomical concepts (Table 2). Moreover, all those eminent physicians stated that knowledge of anatomy leads to a deeper appreciation of God's wisdom and omniscience [17].

Table 2: List of some areas where the medieval Islamic scholars challenged the anatomy of Galen and proved its fallacy.

Ibn Rushd's statement that "anyone who practices anatomy will increase his faith in Allah" [18] is of particular significance because he was, at the same time, the Grand Qadi (Chief Magistrate) of Cordova and a well known authority on Islamic jurisprudence. Similarly, as documented by Emilie Savage-Smith, the 9th-century religious scholar Imam Al-Gazali made a strong statement in support of anatomy and dissection. This was influential in the rise of anatomy and dissections carried out in the 12th and 13th centuries [19].

Islamic Faith and Medicine

This also shows how Islamic faith and medicine were closely integrated in the minds and hearts of the medical scholars of Islam. They had no conflict at all in their minds between religion and science. Indeed many of them were also pioneers in religious sciences.

The human body was looked upon by them as a source of appreciation, as it is created by the Almighty God. Hence, all activities contributing to the well-being and preservation of health, as well as the relief of sufferings of individuals and societies, are virtuous acts of worship, and essential religious duties.

Furthermore, health education and preventive medicine have always been an integral element of Islamic teaching, and its spread was inextricably linked with the spread of Islam itself [20].

Moreover, as documented by George Saliba [21,22,23], in the field of astronomy, and by others in the field of medicine [15,32], it is becoming more and more apparent that the scientists who were responsible for the production of original scientific discoveries in Medieval Islamic medicine and science were mostly religious men at the same time, and religious scholars in their own right.

Accordingly, works exploring the relationship between science and religion and between Arabic science and Western science have to be rewritten in light of these new findings.

Transmission of Medieval Islamic Medicine to Europe

Figure 18: Two latin editions of the Colliget (Al-Kulliyyat fi al-tibb) of Ibn Rushd and the Taysir of Ibn Zuhr; the first ever example of joint authorship of a medical textbook. Printed in Venice in 1542 and 1553. Courtesy of Biblioteca Histórica de la Universidad Complutense de Madrid.

Figure 19: Two Latin editions of Ibn Sina's Canon of Medicine printed in Venice (1520) and in Rome (1593). Courtesy of Biblioteca Histórica de la Universidad Complutense de Madrid.

The Latinized works of the Medieval Islamic scholars we studied, were available in Europe, as early as the 12th century (Figures 16-18), with their influence lasting until the 18th century, as documented by several Western authorities [7,9,24,25,26,27].

Figure 20: Another Latin edition of Ibn Sina's Canon of Medicine printed in Louvain in 1658. Courtesy of the Koraes collection, Koraes Central Library of Chios.

Therefore, our results lend further support to the conclusions of Charles Homer Haskins (Figure 14). In his book The Renaissance of the Twelfth Century published in 1927, he stated that: "the continuity of history rejects violent contrasts between successive periods…[and] modern research shows the Middle Ages: less dark and less static; the Renaissance: less bright and less sudden, than was once supposed." [28]. This is also in agreement with results of other more recent new studies [29,30].

The Date of Decline of Medieval Islamic Medicine

Our studies helped, as well, to push forward the date for the beginning of decline in Islamic medicine, commonly believed to be at the end of the 11th century. We have documented plenty of original contributions in several fields by Ibn Zuhr, Ibn Rushd , the two Al-Baghdadis, Ibn Abi Usaybi'a and and Ibn al-Nafis, who lived and practiced during the 12th and the 13th centuries as shown in Figure 21 [14,15,31,32]. Moreover, recent studies by Nil Sari 33 and others, uncovering important works by the medieval Ottoman physician Serafeddin Sabuncuoglu, documented continued contributions of Islamic medicine in the second half of the 15th century.

Figure 21: Timeline (AD) of some of medieval Islamic scholars in relation to the end of the eleventh century (green = before; red = after).

The Need for More Efforts

Much more efforts are still needed to fully restore the missing continuity in the evolutionary line of medieval medicine. A great deal of potentially important material lies unexamined.

Individual efforts, though of help, are not enough. The role of universities, research centers, foundations and institutions is vital in order to restore the universality and continuity of medical knowledge in the Middle Ages.

The outcome of these efforts will be rewarding, not only at academic, scientific and educational levels, but also in the social and cultural environments. The thoughtful study and documentation of the transmission and translation movements will highlight the universality of knowledge and unity of mankind. This will boost cultural inter-appreciation around the world and help to strengthen mutual understandings between the West and the East and, thus, nurture the interaction between different faiths and various civilizations.

References

[1] Sarton, G. (1936), The Study of the History of Science. Harvard: Harvard University Press, p. 5.

[2] Snell Melissa. Defining the Middle Ages, Part 5: Europe, About.com, Medieval History.

[3] Abdel-Halim RE. The missing link in the history of urology: A call for more efforts to bridge the gap. Urol Ann 2009; 1:2-8. Also available at: http://www.rabieabdelhalim.com/TheMissingLinkInHistoryOfUrology.pdf.

[4] Al-Hassani, Salim S. T., A Thousand Years of Missing History. Manchester, UK: Foundation for Science Technology and Civilization, Publication ID: 4060 (published in 2004).

[5] Kenneth Walker H. (1990), "The Origins of the History and Physical Examination", in: Clinical Methods: The History, Physical and Laboratory Examination. H Kenneth Walker, W Dallas Hall and J Willis Hurst (eds.), Boston and London: Butterworths (3rd edition), chapter 1.

[6] Fischer, Josef E., "On the Uniqueness of Surgery", The American Journal of Surgery, 2005, vol. 189, 259-263.

[7] Cumston, C. G., "Islamic Medicine", in: Cumston C. G., editor, An Introduction to the History of Medicine from the Time of the Pharaohs to the End of the XVIIIth Century. London (UK): Kegan Paul, Trench, Trumbner and Co / New York: Alfred A. Knopf, 1926; pp. 185-211.

[8] Dickinson, E. H., The Medicine of the Ancients, Liverpool (UK): Holden, 1875, pp. 37-39.

[9] Sarton, G., Introduction to the History of Science. Carnejie Institution of Washington. Baltimore: Williams & Wilkins Company, 1927-1931. Reprinted in New York: Robert E. Krieger Publishing, 1975, vol. 1, vol. 2, Part 1.

[10] Margotta, R., "The Dark Ages, the Decline of Rome", in An Illustrated History of Medicine, edited by P. Lewis. Feltham, Middlesex: Paul Hamlyn, 1968, pp. 100-105.

[11] Abdel-Halim, Rabie E., "Pediatric Urology 1000 Years Ago", Prog. Pediatr. Surg., 1986; 20: 256-64.

[12] Abdel-Halim, R. E., "Clinical Methods and Team Work: 1,000 Years Ago", Am. J. Surg., 2006; 191: 289-90.

[13] Abdel-Halim, R. E., " Obesity: 1000 years ago", Lancet, 2005, Jul 16-22; 366 (9481): 204.

[14] Abdel-Halim, R. E., "Contributions of Ibn Zuhr (Avenzoar) to the Progress of Surgery: A Study and Translations from his Book Al-Taisir", Saudi Med J., 2005;26: 1333-9.

[15] Abdel-Halim, R. E., "Contributions of Muhadhdhab Al-Deen Al-Baghdadi to the Progress of Medicine and Urology. A Study and Translations from his Book Al-Mukhtar", Saudi Med J., 2006; 27: 1631-41.

[16] Garrison, F. H., An Introduction to the History of Medicine with Medical Chronology, Suggestions for Study and Bibliographic Data. Fourth edition, reprinted. Philadelphia, London : WB Saunders Company; 1976, pp. 115-116.

[17] Abdel-Halim, R. E., Abdel-Maguid Thoraya, E., "The Functional Anatomy of the Ureterovesical Junction: A Historical Review", Saudi Med. J., 2003; vol. 24 (8): 815-819.

[18] Ibn abi Usaybi'a, 'Uyun al-Anba' Fi-Tabaqat AI-Atiba' (The sources of the knowledge of classes of doctors). Reda N., editor. Beirut: Dar Maktabat al Hayat, 1965, pp. 530-533.

[19] Savage-Smith, Emilie (1995), "Attitudes Toward Dissection in Medieval Islam", Journal of the History of Medicine and Allied Sciences vol. 50 (1): pp. 67–110.

[20] Abdel-Halim, R. E., "Health Education during the Islamic Era: A Historical Review", Saudi Med. J. 2003: 24(9): 188-195 (Arabic Section), 927 (English summary).

[21] Savage-Smith, Emilie (1988), "Gleanings from an Arabist's Workshop: Current Trends in the Study of Medieval Islamic Science and Medicine", Isis, vol. 79-2 (June 1988), pp. 246-266.

[22] Saliba, G., Whose Science is Arabic Science in Renaissance Europe? In: Visions of Islam in Renaissance Europe. Columbia University.

[23] Saliba, G., Islamic Science and the Making of the European Renaissance, Cambridge, Ma.: The MIT Press, 2007.

[24] Campbell, D. C. (1974), Arabian Medicine and its Influence on the Middle Ages, reprint Amsterdam (NL): Philo Press.

[25] Friend, J., Histoire de la médecine depuis Galien jusqu'au commencement du seizième siècle, Pt. 3. Leiden: Langerak, pp. 1-80.

[26] Radbill, S. X., "The First Treatise on Pediatrics", American Journal of Diseases of Children, 1971; 122: 369-376.

[27] Ullmann, M. (1978), Islamic Medicine. Islamic surveys No.11. Edinburgh: Edinburgh University Press.

[28] Haskins, C. H. (1927), The Renaissance of the Twelfth Century. Cambridge, Ma./London: Harvard University Press; reprinted 1955, p. v.

[29] Sabra, A. I ., "The Appropriation and Subsequent Naturalization of Greek Science in Medieval Islam: A Preliminary Statement." History of Science, 1987, 25:223-243.

[30] Hogendijk J. P., Sabra, A. I., The Enterprise of Science in Islam: New Perspectives. Cambridge Ma.,: The MIT Press, 2003.

[31] Abdel-Halim, R. E., Al-Faqih, S. R., "Pericardial Pathology 900 Years Ago: A Study and Translation from an Arabic Medical Textbook", Saudi Med. J., 2007: Mar; 28(3): 323-5.

[32] Abdel-Halim, R. E., "Contributions of Ibn Al-Nafis (1210-1288) to the Progress of Medicine and Urology: A Study and Translation from his Medical Works", Saudi Med J., 2008; 29: 13-22.

[33] Büyükünal, S. N., Sari, N., "Serafeddin Sabuncuoglu, the Author of the Earliest Pediatric Surgical Atlas: Cerrahiye-i Ilhaniye", J. Pediatr Surg., 1991; 26: 1148-51.

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