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With regard to teeth and their treatment, these vary from their hygiene to the operations relating to them.

With regard to dental hygiene, the Muslims innovated with the miswak, certainly the first cleansing tooth-brush in history [93]. Gustav Nachtigal, the famous 19^th century traveller and explorer of the Sahara and Sudan, relates that the women of Wadai, a region in the Sudan, rarely go out without their toothbrushes in the corner of their mouths [94]. These toothbrushes are, as he says, prepared from the wood of the siwäk (Salvadora portico L.) which has been made fibrous at the end, and as soon as they sit down they use these brushes diligently [95]. Reporting in an article in 1915 the information of Max Meyerhof, an ophthalmologist who had practiced for many years in Cairo, Wiedemann declares that the Nubians always carry with them a wooden stick of about 15 to 20 cm, called siwak, to which they probably owe their shiny white teeth [96]. It is not something only common to these Nubians, but widespread amongst Muslims, and even nowadays some Muslims belonging to a religious movement called Jamaat al-Tabligh can often be seen wearing the siwak in their breast pockets, which they use on every suitable occasion [97]. In this way, all these Muslims follow the example of the Prophet who according to the Hadith, was a fervent supporter of its use [98]. The siwak was, according to him, a purgative for the mouth and a pleasure for Allah. When the Prophet came into his house, he first of all used the siwak. When he woke during the night, he cleansed his mouth with it, then washed himself and prayed [99]. The extent to which the use of the siwak in the Muslim mind is associated with the Prophet may be illustrated by the fact that the tree from which the siwak was prepared was called siwak al-nabi or "siwak of the Prophet" in Algeria [100].

The kind of wood recommended for the preparation of the toothbrush called siwak or miswak [101] is that of the arak tree. Abu Hanifa al-Dinawari, for instance, states that this tree is best known for the preparation of the miswak from its roots, branches and suru [102]. Nachtigal informs us that this kind of wood has the quality of making the breadth of the women of wadai sweet smelling [103]. Wiedemann states that the toothbrush used in Egypt is exclusively prepared from this wood [104], whilst al-Dinawari lists a number of other kinds of trees [105].

Al-Washsha (d. 936) in his kitab al-muwashsha, and handbook for good manners and etiquette is a good window on the subject [106]. He formulates certain rules for its proper use:

`For the cleaning of the teeth with the miswak definite times of the day and places have been prescribed. One should not use it at improper times nor should one go beyond the times fixed for it. One may use it in the morning and evening, during the afternoon, before daybreak and after prayer. It is also permitted to use the miswak on an empty stomach, before going to sleep and during the daytime when fasting. Fine, well-educated people are not allowed to use the siwak in certain places as, for instance, in the toilet, in the bath, in the middle of the street, and among many people. None of them cleans his teeth when standing, reclining upon his side, or lying down. Neither does he clean them when everyone is looking at him, or when he is speaking. To use the siwak on the toilet and in the bath belongs to the bad habits of the low and common people for such an abuse weakens the gums and worsens the breath of the mouth. Well-educated, respectable and fine people never behave in that way [107]."

A century or so earlier, Hunayn B. Ishaq (809-873) wrote a work on dentistry, kitab hifz al-Asnan wa al-litha (On the Preservation of the Teeth and Gums) which is till in manuscript form [108]. Fragments, however, are cited by al-Razi in his al-Hawi (Liber Continens) [109]. Quoting Hunayn, he remarks:

`and if anyone wants his teeth and gums to stay healthy… they should beware of pieces of food left between the teeth, and clean their teeth painstakingly without unsettling them and without wounding the gums. And excessive use of the toothpick (idman al-Khilal) and playing with it wounds the gums [110]."

Hunayn also warns against too much use of the miswak, for it ends up weakening the teeth and make them go rotten [111]. It is obvious that Hunayn treated patients who suffered from diseases of the teeth caused by an excessive use of toothbrush and toothpick, whilst he recognises their wholesome effect when used moderately [112].

Muslim dentistry had another aspect, the surgical aspects. Here are one or two examples from Al-Zahrawi's contribution to such an aspect of dentistry:

`When, in extracting a tooth, the broken-off root remains behind, you should apply cotton-wool soaked in butter for one or two days to soften it, then insert the tongs with stork-billed jaws. The points should be made like a file or rasp on the inside. If this does not work, dig down over the root and remove all the flesh, then insert the instrument resembling a small crowbar (‘atala). If the root comes out, well and good; if not, try the other instruments here depicted [113].

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Figure 9: Medical prescription issued by the director of the Bimaristan Qalawun dating from the 9^th century H/15^th century CE, Mamluk period. © Museum of Islamic Art in Cairo. (Source).

After describing and illustrating a whole series of picks and probes - with triangular points, forked, hooked - he says:

"You should know that dental instruments are very numerous, as are the other instruments, almost countless. And the experienced worker with a knowledge of his craft may devise fresh instruments as his work on actual cases suggests them to him. For there are certain ailments for which the Ancients did not mention any instrument, because of the variety of their types [114]."

He describes how to cut down projecting teeth, prefacing his remarks with "When teeth grow in other than their natural place, the appearance is very bad, especially when it occurs in women or slaves." His account of how to secure loose teeth (292) is particularly interesting:

"When the front teeth are loosened by some blow or fall and the patient cannot bite his food lest they fall out, and you have tried, unsuccessfully, treating them with styptics, the technique is to bind the teeth with gold or silver wire. Gold is the better, for silver oxidizes and corrodes after some days, but gold remains for ever in its state [115]."

The wire should be of moderate thickness, in keeping with the distance between the teeth. Take the wire and run it doubled between two sound teeth then, with the two ends of the wire, weave between the loose teeth, one or several, until you bring your weaving to a sound tooth on the other side. Then repeat the weaving, back to the side where you began; tighten it gently and judiciously till they do not move at all. Then cut off the ends of wire, bring them together and twist them with forceps and hide them between a sound tooth and a loose tooth so as not to hurt the tongue. But if it comes undone or breaks, bind them with another wire; so may he have the use of them all his life [116].

After one or two teeth have fallen out, they may be restored to their place and bound in as instructed, and become permanent. Sometimes a piece of ox-bone may be carved and made into the shape of a tooth. . . and fastened as we have said, and it will last and he will get long service from it [117].

Hygiene and prevention played major roles in Islamic medicine. It was a cardinal principle of Islamic pathology that overtaxing the digestive organs was the cause of a multitude of disorders [118]. The abstentious and temperate habits which characterised the 1ife of the desert were impressively inculcated by the Qur'an and the entire body of Muslem tradition [119].

Muslims also adopted other techniques for healing, such as cautery as seen here with al-Zahrawi with the following instances. He refers to the common saying that the cautery is the end of medicine, "al-kayy akhir al-tibb." Which is true, he says, but not in the way they mean:

"For they believe that after the cautery no treatment. . . will help. It means precisely the opposite: after various treatments have been applied. . . then last of all we apply cauterisation and this proves effective, whence the saying that the cautery is the end of medicine; not in the sense in which it is held by the laity and many ignorant doctors [120]."

So he prescribes cauterisation for headache, epilepsy, incipient hunchback, cataract - not on the eye itself but on the middle of the head and on the temple - warts, dropsy, diarrhoea, and almost anything you can think of [121].

". . . Mark the place of the swelling with ink, then heat in the fire the cautery that resembles a probe, and make one cauterisation until the whole thickness of the skin is burnt through, finishing up at the capsule so that all the purulent matter comes out. Then apply the treatment for wounds. But in my opinion it would be better to pass it by [122]."

The text of his treatise does not make it clear but an illustration in the manuscripts does, that what he calls the cautery resembling a probe is in fact a trocar together with a cannula, a tube through which it passes so as not to hurt the patient more than necessary: this seems to be original with Al-Zahrawi [123].

For some ailments he advises cauterisation with various caustic materials, not with the actual cautery. One such is non-chronic migraine:

"Take one clove of garlic, peel it and cut both ends off. Then cut open the site of the pain in the temple with a broad scalpel till there is room to contain the clove under the skin, then introduce it under the skin till it is completely hidden. Then bind up the wound tightly and leave for 15 hours, then unbind it, remove the garlic and leave the wound open for two or three days; then apply cotton wool soaked in butter until it suppurates. Then dress with ointment until it heals [124]."

"You should know, my sons, that . . . fire is a simple substance having no action except upon the part cauterised; nor does it do more than slightly hurt any adjacent part. But the effect of cauterisation with caustic may spread to parts at a distance. Fire, on the other hand . . . has no such effect unless it is overdone [125]."

Nevertheless he does not rush blindly on, brandishing his cautery. Here is what he says about cauterisation for cancer (al- kayy fil-saratan: I, 28, p. 151):

"When the cancer is in its initial stage, burn all round it with the circular cautery. Some doctors have said it may be cauterised with one extensive cauterisation in the middle. This hardly seems right to me, for I should expect it to ulcerate out, which I have seen several times [126]."

Even in that remote age there were specialists who wrote with signal ability on the morbid anatomy of the different portions of the body [127]. Affections of the eye, obstetrics, eruptive fevers, were exhaustively treated, the book of Al-Razi on the diseases of children being the first on that topic known to exist [128]. The various topical applications used at present by the profession—such as unguents, plasters, counter-irritants, and pomades—originated in Muslim Spain [129]. Al-Zahrawi, once more, played a great part in this. In the 19th volume of Al-Tasrif by al-Zahrawi, a chapter was devoted completely to cosmetics, and is the first original Muslim work in cosmetology. He described the care and beautification of hair, skin, teeth and other parts of the body, perfumes, scented aromatics and incense. He includes under-arm deodorants, hair removing sticks and hand lotions. Towards the medicaments, he recommend Ghawali and Lafayfe for epileptic fits and Muthallaathat, prepared from camphor, musk and honey, in fact very much like Vicks Vapour Rub, for the treatment of cold relief. Other utilities which we tend to consider as part of the 20^th century but which were present in Muslim Spain and which are described by Al-Zahrawi include nasal sprays, mouth washes and hand creams [130].

One difficulty unlikely to confront most modern doctors appears in Al-Zahrawi's Book II, Chapter 61 (421), on extracting a stone from females.

"It is very uncommon for women to have stones, but if it should happen the treatment is indeed difficult and is hindered by a number of things. One is that the woman may be a virgin. Another is that you will not find a woman who will expose herself to a male doctor if she be chaste or married. A third is that you will not find a woman competent in this art, particularly not in surgery. If necessity compels you, you should take with you a competent woman doctor. As these are scarce (qalil), if you are without one, then seek a eunuch doctor as a colleague, or bring a midwife or a woman to whom you may give some instruction in this art. Have her with you and bid her do all that you tell her to do [131]."

"In the polished capitals of Damascus and Cairo numbers of splendidly appointed medical institutions—colleges, hospitals, dispensaries, laboratories—arose. The services of the most distinguished physicians were gratuitously rendered to the inmates of the hospitals. The hygienic arrangements of the latter were, in many respects, superior even to those dictated by the spirit of modern scientific progress. They were larger, better arranged, and more commodious. Purity of air was assured by a system of thorough ventilation. There were fountains everywhere,—in the courts, in the halls, in the gardens. Wards placed under the direction of competent specialists were appointed for the treatment and study of every disease. Insane patients were prescribed for like the others, and had their attendants, their baths, and their amusements. For them, as well as for the unfortunate victim of insomnia and the convalescent, there were the diverting mirth of the story-teller and the soothing powers of music [132]."

We know of thirty-four hospitals established in Islam in this period. The most famous hospital in Islam was founded in Damascus in 706; in 978 it had a staff of twenty-four physicians. Medical instruction was given chiefly at the hospitals [133]. Early were hospitals constructed in the land of Islam, the work of both Tulunids of Egypt and Aghlabids of Tunisia. The Aghlabid ruler, Ziyadat Allah I (817-838), built a hospital in the city in 830, one of the most pioneering of its genre, called ad-Dimnah hospital, being built in ad-Dimnah quarter near the great mosque of al-Qayrawan [134]. The hospital of Ibn Tulun established at al-Fustat in 872 was situated between the mosque of Ibn-Tulun and the hill of al-Gareh, in one of the most heavily populated quarters of Fustat. In both construction and management it absorbed vast resources; and also included a library of 100,000 books [135]. Its financing came chiefly from the bazaar and from other waqfs; the patients were given a special garment and beds, and were served meals and medications; physicians attended to the patients every day; and every Friday Ibn-Tulun visited the hospital, inspected the supplies, conferred with the physicians and visited the patients [136].

By the 12^th century, the hospital in Islam had reached very advanced standards. Thus, in Damascus the largest hospital built in 1156 by Nur al-Din Zangi: The Al-Nuri Hospital, was placed under the direction of the physician al-Bahili. It was well supplied with food and medication, and had a well stocked library for teaching [137]. Ibn Jubayr admired, most particularly, the way in which the administrator of the hospital kept a register of patients [138], probably the earliest of its kind [139]. In Morocco, in 1190, Al-Mansur Ya'qub Ibn Yusuf built a hospital in Marrakech in a spacious area surrounded by fruit trees, flowers, herbs, and vegetables [140]. `Water, the historian al-Marrakuchi said, "was brought in aqueducts to all its sections, besides four pools in the centre thereof, of which one was built of white marble." The daily endowment was thirty golden Dinars for the purchase of food supplies, un-stocked medication, and unpredicted expenses. Physicians cared for the sick and prescribed diet and medications, while appointed pharmacists specialised in the compounding and preparing of drugs. Here too, patients were provided with special apparel for the summer and winter seasons. In Cairo, in 1285, Sultan Qalawun began the construction of al-Mansuri Hospital; the largest of all. It attended 4000 patients daily, had different wards catering for diverse diseases, and even applied music therapy on mentally ill patients [141]. Al-Mansuri hospital is described by Durant:

"Within a spacious quadrangular enclosure four buildings rose around a courtyard adorned with arcades and cooled with fountains and brooks. There were separate wards for diverse diseases and for convalescents; laboratories, a dispensary, out-patient clinics, diet kitchens, baths, a library, a chapel, a lecture hall, and particularly pleasant accommodations for the insane. Treatment was given gratis to men and women, rich and poor, slave and free; and a sum of money was dispersed to each convalescent on his departure, so that he need not at once return to work. The sleepless were provided with soft music, professional story-tellers, and perhaps books of history [142]."

All these institutions were supported by the government, and placed under the supervision of the court physician, the head of his profession, who was held to a strict accountability for their proper management [143]. For this important and responsible employment belief in Islam was by no means essential; honesty, skill, and industry were the sole recommendations to imperial favor, and the medical advisers of the Successors of the Prophet were frequently Christians and Jews [144]. In all hospitals registers of cases were opened and preserved, and far more importance was attached to the observations made at the bedside of the patient than to the information obtained by the perusal of books [145].

Likewise, Muslim Spain also shined thanks to its hospital institutions. The hospital service of that country has received little attention from historians, but it is highly improbable that, in the general advance of civilisation, this important auxiliary to medicine should have been at all neglected [146]. It is a singular fact that the only detailed notice of a Moorish hospital in the Peninsula is of that of Algeziras, which was founded in the 12^th century, but there are reports that many public institutions of this kind existed at one time at Cordova [147]. The Hispano-Muslim practitioners held consultations at the bedside of the patient; some, employed by the government, visited the sick of remote localities at regular intervals; for the poor there was generous attendance and treatment [148].

In many of the hospitals prescribed lectures were given in the large hall of the hospital. These consisted of the reading of a medical manuscript by the so-called "Reading out Physician," for these texts in manuscript form were scarce and seldom owned by the medical student [149]. Following the reading, the chief physician or surgeon asked and answered questions of the students. Bedside teaching was considered the most important part of the training [150]. The students in groups followed the attending physician or surgeon in his ward rounds; the more advanced students observed the doctor, later in the day, taking the history and making an examination of the patients, and prescribed for them in the Out-Patient Department of the hospital. The exact time for training the medical students must have varied at different times and places [151].

It is worth ending this outline by stressing the role of Islamic medicine and its impact. Al-Razi's Kitab al-Hawvi (Comprehensive Book), for instance, covered in twenty volumes every branch of medicine. Translated into Latin as Liber continens, it was probably the most highly respected and frequently used medical textbook in the Western world for several centuries; it was one of the nine books that composed the whole library of the medical faculty at the University of Paris in 1395 [152].

Another concluding point is how Muslim scholars viewed their profession, and how they regarded their social milieu. Al Zahrawi, as a scrap of information in the form of a note by the scribe of the Veliuddin manuscript (fol. 228b), written 250 years after his death, says:

"I have been told that he was extremely ascetic; that half of his work every day he did without fee, as charity, and that he wrote this compendium over a period of forty years [153]."

And best to conclude this outline on Muslim medicine with these words from al-Zahrawi to his "sons" (his students):

"Show then caution and care for yourselves, and gentleness and perseverance for your patients. Take the best road that leads to health and a happy outcome. Purify yourselves of anything which you fear may cause doubt as to your religious life and your worldly life, for this will perpetuate your good name and will elevate your fortunes in this world and the next [154]."

[93] See the excellent article by G. Bos, "The Miswak: An Aspect of Dental Care in Islam", in Medical History, vol. 37, 1993, pp. 68-79.

[94] G. Nachtigal, Sahara and Sudan, Leipzig, 1889; reprint Graz: Akademische Verlagsantast, 1967, vol 3, p. 261.

[96] E. Wiedemann, "Zanarzliches bei den Muslimen", Aufsatze zur arabischen wissenschats-geschichte, Heidelsheim-New York, 1970, vol. 2, p. 181.

[98] See J. Wensinck, A Handbook of early Mohammedan Tradition, alphabetically arranged, Leiden: Brill, 1927, p. 280.

[101] R. Dozy, Supplément aux dictionaries arabes, 2^nd edition, 2 vols. Leiden/Paris: 1927, vol. 1, p. 707.

[102] Abu Hanifa al-Dinawari, Kitab al-Nabat, edited by B. Lewis. Wiesbaden: Franz Steiner Verlag, 1974, p. 225.

[106] Abu Tayyib al-Washsha, Kitab al-Muwashsha, ed. R.E. Brunnow, Leiden: Brill, 1886; German translation by D. Bellman (Leipzig, 1984).

[107] Abu Tayyib al-Washsha, Kitab al-Muwashsha, op. cit., pp. 141-142; German translation by D. Bellman, op. cit., pp. 101-102.

[109] Al-Razi, Kitab al-Hawi (Hydrebad: Osmania Oriental Publication Bureau), 1952-1974, 23 vols.

[130] Mainly derived from S.K Hamarneh and G. Sonnedecker, A Pharmaceutical View of Albucassis Al-Zahrawi in Moorish Spain, Leiden, 1963; and M. Levey, Early Arabic pharmacology, op. cit.

[134] S. K. Hamarneh, Health Sciences in Early Islam, Noor Foundation and Zahra Publications, Texas, 1983, p. 102.

[135] F.S. Haddad, in I.B. Syyed, "Medicine and Medical Education in Islamic History", in Islamic Perspectives, edited by S. Athar, pp. 45-56; p. 48.

[136] A. Issa Bey, Histoire des hopitaux en Islam, Beirut: Dar ar ra'id al-'arabi, 1981, pp. 112-115.

[138] Ibn Jubayr, Al-Rihla. The Travels of Ibn Jubayr, translated by R. J. C. Broadhurst, Jonathan Cape, 1952, pp 283-4.

[140] Abd al-Wahid al-Marrakushi, Al-Mu'jib fi talkhis akhbar al-Maghrib, edited by R. Dozy (Leiden, 1881), pp. 208-10 (quoted in S. K. Hamarneh, Health Sciences, op. cit., p. 103).

[141] F. S. Haddad in I.B. Syyed, "Medicine and Medical Education", op. cit., p. 48.

[143] S.P. Scott, History of the Moorish Empire, op. cit., vol. 3, pp. 508-509.

[149] A. Whipple, The Role of the Nestorians and Muslims in the History of Medicine, op. cit., p. 59.