The Greatest Benefit to Mankind

Rabbi Moshe ben Maimun (1135–1204: Moses Maimonides or Abu ’Imran ibn ’Ubdaidalla Musa ibn Maimun) was another scholar who testifies to the intellectual pre-eminence of Spain at this time. The ascendancy of a fanatic Muslim ruling group forced the Jewish Maimonides, like Averroës, to flee Cordova in 1148, and he spent the next ten years in exile. In 1158, he settled in Fez, but moved on a few years later to Cairo where he stayed until his death. His medical practice earned him celebrity; in 1174 he was appointed court physician to Saladin, sultan of Egypt and Syria, and he became the head of the Jewish community in Egypt.

Paralleling the Islamic intellectuals of his day, Maimonides was a polymath, combining philosophy, logic, theology, astronomy and medicine. Apart from his major fourteen-volume religious work, the Mishneh Torah, which is in Hebrew, his books were written in Arabic. His ten medical works, all surviving, mostly in Arabic but some only in Hebrew translation, include the Extracts from Galen, a collection of Galen’s writings, and a Commentary on the Hippocratic Aphorisms. His Medical Aphorisms is of particular interest because of its criticism of Galen for preferring Aristotelian over biblical cosmology. He emphasized the duties of physicians: ‘may I never see in the patient anything but a fellow creature in pain.’

There are various treatises on individual topics (on haemorrhoids, asthma, poisons and their antidotes, and so forth), but Maimonides’ most famous medical book was his Regimen of Health – short, much reproduced, often translated, and full of solid advice:

How can a person heal his intestines if they are slightly constipated? If he is a young boy, he should eat salty foods, cooked and spiced with olive oil, fish brine and salt, without bread, every morning; or he should drink the liquid of boiled spinach or cabbage in olive oil and fish brine and salt. If he is an old man, he should drink honey mixed with warm water in the morning and wait approximately four hours, and then he should eat his meal. He should do this for one day or three or four days if it is necessary, until his intestines soften.

While not adding anything original to Graeco – Arabic medicine, Maimonides’ considerable literary output earned him respect, and, like other contemporaries, he was widely cited by leading European authorities such as Henri de Mondeville, Arnald of Villanova and Guy de Chauliac.

An original aspect of Arab – Islamic medicine was its contribution to pharmacology. The lands overrun by Arab warriors yielded an abundance of plants, animals and minerals; hence, whereas Dioscorides’ materia medica had included less than a thousand plants, animals and minerals, that of Ibn al-Baytar (d. 1248) astonishingly listed over 3000 items, including 800 botanical drugs, 145 mineral drugs, and 130 animal drugs. The medical formulary of al-Kindi (Yaqub ibn-Ishaq al-Kindi, c. 800–870) served as a source for Arabic treatises on pharmacology, botany, zoology and mineralogy. His writings contained many Persian, Indian or Oriental drugs unknown to the Greeks, including camphor, cassia, senna, nutmegs and mace, tamarind and manna.

In the eleventh century, al-Biruni described more than a thousand simples in his Kitab al-Saydanah fi al Tibb [Book of Pharmacy in the Healing Art]. The Minhaj al-Dukkan via Dustur al-’yan [Handbook for the Apothecary Shop], written in Cairo in 1259 by the Jewish pharmacist Abu al-Muna Kohen al-’Attar, was much more than a mere formulary of the materia medica. Intended to provide instruction for his son, it included drug synonyms, recipes for syrups, remedies to aid digestion, fumigations and liniments and pharmaceutical weights – and also covered the duties and shop practices of the pharmacist.

The word ‘drug’ is of Arabic origin, as are alcohol (it then referred to a sulphurous powder), alkali, syrup, sugar, jujube and spinach; and many new drugs were introduced by the Arabs – benzoin, camphor, myrrh, musk, laudanum, naphtha, senna and alcohol. From the time of the ‘father’ of Arabic alchemy, Jabir ibn Hayyan (Jebir or Geber), who lived in the tenth century, they developed the alchemical techniques of crystallization, filtration, distillation and sublimation, alongside investigations into the properties of things contained in a ‘secrets of nature’ tradition paralleling that in the West. They created the first pharmacies, which also served as rendezvous for the exchange and discussion of information.

Overall, the value of Arab contributions to medicine lies not in their novelty but in the thoroughness with which they preserved and systematized existing knowledge. Great effort was devoted to its dissemination and medical texts were repeatedly copied. Over 5000 medical manuscripts in Arabic, Turkish, and Persian survive in libraries in Turkey alone, with more than fifty copies of Ibn Sina’s Qanun, and still more transcripts of the many later commentaries on it. And though the era of the great Arabic medical compendia ended with the Qanun, such works long continued as foci of scholarly attention, commentaries in turn becoming the bases for super-commentaries, such as that of ’Ala’ al-Din ibn al-Nafis (1200–88).

Growing up in Damascus, Ibn al-Nafis studied at the famous Nuri hospital there. As with so many Arabic physicians, his interests were wide: medicine, logic, grammar and theology; he also wrote numerous commentaries on Hippocrates and Ibn Sina. His Mujiz al-Qanun, an epitome of Ibn Sina’s Canon, was vastly popular, but the work for which he is best known today is the commentary on the anatomy of Ibn Sina, the Sharh Tashrih al-Qanun, since one passage contains the first description of the pulmonary circulation.

Contrary to the Galenic description of the passage of blood from the right ventricle directly through ‘invisible pores’ to the left ventricle, Ibn al-Nafis states that no blood could pass through the interventricular septum, ‘the substance of the heart there being impermeable … therefore, the blood must pass only through the lungs’. He thus proposed for the first time the pulmonary circuit of the blood:

This is the right cavity of the two cavities of the heart. When the blood in this cavity has become thin, it must be transferred into the left cavity, where the pneuma is generated. But there is no passage between these two cavities; the substance of the heart there seems impermeable. It neither contains a visible passage, as some people have thought, nor does it contain an invisible passage which would permit the passage of blood, as Galen thought.… It must, therefore, be that when the blood has become thin, it is passed into the arterial vein [pulmonary artery] to the lung, in order to be dispersed inside the substance of the lung, and to mix with the air. The finest parts of the lung are then strained, passing into the venous artery [pulmonary vein] reaching the left of the two cavities of the heart.

His description, however, seems to have fallen into obscurity. A similar description of the pulmonary circuit appeared in 1553 by the Spaniard Michael Servetus, and then in 1559 by the Italian, Realdo Colombo, but there is no evidence that either had access to his work.

HEALTH CARE

What of health care in general in Islam? Damascus and Cairo were no dirtier or cleaner than Naples, Paris, or any other pre-modern cities. Livestock was kept at home, waste left in the streets, and epidemics wrought havoc. Medieval sources frequently refer to ‘pestilence’, sometimes smallpox, though the greatest scourge was bubonic plague, which devastated the region in wave after wave between 541 and 749, returning as the Black Death in 1347–9. Cairo, the world’s second largest city with half a million people, lost half its population.

To serve the sick, a range of medical practitioners and services was on offer. The formative period was marked by the predominance of Christian doctors, with lesser numbers of Jews and pagans. Many physicians had several occupations, and sidelines in trade were common. Healing remained more flexible and unregulated than in Christendom: there were no licensing requirements, no fixed curricula or sites for learning medicine, and no laws defining the profession. Islamic society tolerated a spectrum of practitioners and remedies, partly because popular lore was upheld by custom and the approval of the Prophet. In any case, learned medicine was often unavailable in the countryside, and within the cities it was beyond most people’s pockets.

There were various ways to prepare for a medical career. Some doctors were self-taught, like Ibn Sina. Others underwent formal study under a teacher. Muslims sometimes taught in mosques, and hospitals were natural places for instruction, since patients were to hand and many hospitals had libraries. Teaching methods and curricula varied according to the master, though instruction often focused on the key Galenic works. Mathematics and logic were also studied, and the novice had an array of manuals, later supplemented by the cribs generated around Ibn Sina’s Qanun. Textual mastery was paramount; texts were usually read aloud and learnt by heart, and classwork meant sitting with a mentor who posed questions and glossed obscurities. Anatomy was not taught in a hands-on manner, since dissection was abhorrent to Muslim sensibilities: the dead were believed to feel pain, and dissection was desecration. Clinical experience was obtained in hospitals: physicians used patients to illustrate maladies and problems to students who trailed them on their rounds. Pupils probably shouldered certain basic duties, such as venesection.

Physicians had certain public duties to fulfil, some quite bureaucratic. Doctors were frequently called upon to make official statements – for example, when a leper was seeking public assistance. Jewish physicians were often leaders of their communities, and Muslims found themselves in administrative positions such as army physician or hospital medical superintendent.

The hospital, though not part of a wider ‘health policy’, was a centre of Islamic medical practice. These institutions (the greatest were in Baghdad, Damascus, Cairo and Cordova) were initially inspired by the precedent of sick-relief services offered at Christian monasteries, although the Islamic hospital became a more elaborate medical institution. The first was apparently founded in Baghdad around 805 on the initiative of Harun al-Rashid, and this was followed by others. The movement spread to Persia, and by the twelfth century a hospital graced every large Islamic town; thirty-four have been identified in Muslim cities from Spain to Moghul India. One of the best known was built in Cairo in 1283 by al-Mansur Qalawun, who dedicated it to all who needed care – rich and poor, old and young, male and female, of all faiths. It had special wards for physical and mental diseases, a surgery, pharmacy, dispensary, library and lecture rooms, and a chapel for Christians as well as a mosque; it was still in use when Napoleon invaded Egypt.

Separate hospitals for the insane were also set up. The Qur’an required humane care of the mad, and the first institutions created primarily for mental cases appeared in Muslim lands. Called maristans, these had a good reputation, and European travellers marvelled at the humanity shown to the insane. The Islamic tradition had some impact, the first European mental hospitals being built in former Muslim Spain, beginning with Granada in 1365.

Nevertheless, the role of hospitals in medieval Islam should not be exaggerated. They were a drop in the ocean for the vast size of the populations they had to serve, and their true function lay in highlighting ideals of compassion and bringing together the activities of the medical profession.

With Cordoba falling to the Christians in 1236 and Baghdad sacked by the Mongols in 1258, Arab civilization was beginning to decline after 1300. The Ottoman Turks who dominated the Levant in the succeeding centuries did not inspire new intellectual glories. Nevertheless, the medical system described flourished in the Muslim world until the nineteenth century, when it gradually receded before the tide of modern western medicine. It continues in India and Pakistan as Yunani medicine.

CHAPTER V THE MEDIEVAL WEST

BARBARIAN INVASIONS, the collapse of the western Roman empire, and the rise of warrior fiefdoms spelt catastrophe for civilization and its amenities – including the teaching and practice of learned medicine. City life collapsed in Europe into a landscape dominated by castles and cathedrals, with literate men and women confined to monastic cloisters. The medical thread was, however, unbroken, even if it frayed and threatened to snap. Through what are known as the Dark Ages medical manuscripts were at least preserved, copied and studied within the sanctuaries provided by abbeys and cathedral schools. The medicine they kept alive was, however, but a shadow of its brilliance in Galen’s day: a basic survival kit when book-learning itself was under threat.

The revival of formal medicine took place centuries later in the backward West than in the Islamic world – not until around 1100, emerging first in Salerno in southern Italy, thirty miles south of Naples and seventy miles from the glorious Benedictine monastery of Monte Cassino. And it had to be imported and replanted.

THE WEST COMES TO LIFE AGAIN

The Salerno medical school was supposedly founded by four scholars – a Latin teacher, a Jew, an Arab and a Greek who had brought to the West the writings of Hippocrates. This legend carries a figurative truth. Sited in mid-Mediterranean and protected by the modernizing Norman dukes of Sicily, Salerno lay at a crossroads – cultural, economic and ethnic. In 1063, Alphanus (d. 1085), a Benedictine monk of Monte Cassino who had become archbishop of Salerno, travelled to Constantinople where he became acquainted with Greek medical texts. His Premnon Physicon introduced into the Latin-speaking world a Christianized Galenism, while his writings on the humours and the pulse reflected Byzantine medicine. Together Alphanus’s works amount to a more philosophical approach to medicine than that hitherto available in the West, hellenizing it and enabling the physician to set himself above the workaday healer.

Later Salernitan teaching texts continued the latinization of Greek writings, and Salerno channelled Arabic medicine into the West, under the stimulus of Constantinus Africanus (c. 1020–87). A native of Carthage (in modern Tunisia) who became a monk of Monte Cassino, Constantine relayed texts of Arabic and Greek medicine, the most important of his translations being the Pantegni [The Whole Art] of Haly Abbas (d. 994). Many Greek texts which had been translated into Arabic were now latinized by Constantine, notably Galen’s Method of Healing, his commentaries on Hippocrates’ Aphorisms, his Regimen in Acute Diseases, Prognostic and the Art of Medicine. Constantine also made a version of Hunayn’s (Johannitius’) Medical Questions, known as the Liber Ysagogarum [Isagogue or Introduction]. By the mid-twelfth century these texts were seeping beyond Italy.

Constantinc’s translations were crucial, providing as they did the means whereby Latin Christendom gained access to the tradition of Hippocratic learning rationalized by Galen and digested by the Arabs. For the first time since the sixth century, Latin speakers could share in contemporary medical thinking. Providing a framework for medical teaching on diagnosis and therapy, the Liber Ysagogarum became a foundation text in the medical schools which sprang up in Italy and France, forming the basis of the Articella (see below).

The Liber Ysagogarum also broadened and gave greater prominence to the Galenic idea of the ‘six non-naturals’ – food and drink, environment, sleep, exercise, evacuations (including sexual) and state of mind; by regulating these, natural body balance could be preserved in the medical analogue to monastic rule. Stressing regimen, the non-naturals set the mould for medieval therapeutics, particularly in popular health books emanating from Salerno. The Regimen sanitatis salernitanum [Salernitan Regime of Health], a book of verses probably compiled in the thirteenth century and sometimes credited to Arnald of Villanova (1240–1311), supplied tips for healthy living from youth to old age, highlighting hygiene, exercise, diet and temperance. The first of the home health manuals, its enduring popularity is shown by the number of later printed editions: some 240 versions in Latin and other European languages, as well as Hebrew and Persian. And no wonder, since it was simple and even entertaining in its advocacy, alongside Galenic venesection, of Drs Quiet, Diet and Merryman.^*

Salernitan translations and teachings created a new canon of medical authority known as the Articella [Little Art of Medicine], which included the Liber Ysagogarum and Hippocrates’ Aphorisms and Prognostic, supplemented by Galen’s Tegni and the Hippocratic On Regimen in Acute Diseases in a translation by Gerard of Cremona (fl. 1150–87). Rapidly becoming canonical, the Articella or Ars medicinae marked a turning point in the revival of medicine in the West. It combined translations from Greek and Arabic; it was concerned with theory, providing a basis of philosophical knowledge organized around key themes; its discussions set medicine within a wider conception of nature; and its Aristotelian orientation appealed to university scholastics. Not least, the Articella gave medicine a distinctly Galenic complexion. Pre-Salernitan compendia had included texts drawn from the Methodist as well as the Hippocratic tradition; Galen had not eclipsed all others. But the Articella texts were wholly Galenic: a proper doctor could thenceforth be defined as a man who knew his Galen.

Learned medicine continued to develop, thanks to the rise of universities (discussed below) and further access to scholarship via translation. The business of Latin translation proceeded through several stages. The first, the Salernitan, involved both Greek and Arabic texts. From the 1140s, there was a great outpouring of Latin translations from Arabic made in Muslim Spain, sometimes by way of Hebrew intermediaries. This development, which included philosophical texts, especially Aristotle, as well as medical, was led by Gerard of Cremona. Settling in Toledo, he translated an incredible quantity of material from Arabic – twenty-four works on medicine alone, including the Qanun of Avicenna, the Liber Almansorius of Rhazes (al-Razi), the last part of Albucasis’ De cirurgia, the Ars parva and other works of Galen, and the Commentary on Galen’s Art of Medicine by Haly Rodoan (Ali-ibn Ridwan). The Qanun or Canon of Medicine became the cornerstone of the medical curriculum at the University of Montpellier, remaining a textbook there until 1650! These translations created a richer terminology for learned medicine in Latin and provided Galenic medicine with a logical backbone. Medicine could now speak the language of scholasticism.

A century later there came a further burst of translations, mainly in Spain and Italy, latinizing other major works of Arabic science. These included the Continens [All-Embracing Book] of al-Razi (trans. 1282); and the Colliget [The Book of Universals] of Ibn Rushd, translated in Padua in 1283. The key figure in this drive was Arnald of Villanova. After studying medicine at Montpellier, he became a teacher and a polymath. Not only a translator of medical works, he was physician to the popes and the Aragonese royal family in Spain; later in life, he pored over theology, propounding heterodox ideas – his astrological computations predicted the world would end in 1378. As a theoretician, Arnaud aspired to rationalize Galenic medical theory with mathematical precision, by drawing on Arabic writers, notably al-Kindi and Averroës.

His Italian contemporary Pietro d’Abano (1257-c. 1315) made versions directly from Greek manuscripts he had carried back from Constantinople, including the beginning of a translation of Galen’s On the Use of the Parts of the Body. Niccolò da Reggio (fl. 1315–48) translated over fifty Galenic writings, many for the first time, including the entire text of that work. There was also translation from Latin into the vernacular, in growing demand when town life was reviving and courts and burghers were hungry for knowledge. The Surgery of John of Arderne (c. 1307–70), discussed below, exists in both Latin and English versions, and Bartholomew the Englishman’s (d. 1260) De proprietatibus rerum (1246) [On the Properties of Things] also enjoyed wide circulation in both tongues. Parts of the Articella were made available in French and English, and even in Welsh and Gaelic. For a couple of centuries, the translation movement had no less momentous consequences in Europe than in Islam, bolstering the prestige of antiquity and canonizing a Galenic medicine set in an arabized Aristotelian framework. Medical knowledge was buttressed not just by its classical heritage but by its place within the divine scheme of Christianity.