Some would say that we are living in interesting times, particularly as another US-Iraq confrontation at this stage seems almost inevitable. Such is the present power of the United States that only a few voices in the rest of the world suggest that the United Nations should be the only party to be involved in any future decisions about the coming conflict. Nobody in the West is brave enough any longer to take a moral stance against the imposed economic sanctions, which by now have killed more than 1.6 million Iraqis, mostly children, according to the UN’s own statistics.
On the eve of the Eid-Al-Fiter (the most widely observed Islamic festival marking the end of the fasting month of Ramadan), the well-respected Qatar-based Arabic news network Aljazeera reported that in the past three months (from September to November 2001), more than 31 thousand Iraqis (including 21 thousand children under the age of 5) died due to the UN-imposed economic sanctions against Iraq, a figure even higher than the 1999 UNICEF estimate of an average 5200 Iraqi child deaths per month. This comes at the same time as warnings from Iraqi physicians about an escalating crisis of increased cancer cases in the southern part of the country. The report adds that the fear of having babies with birth defects is so great that many pregnant women choose to have abortions. I myself must accept some blame for not reorting this, having recently turning down an opportunity to visit the suffering patients in the hospitals in Baghdad in the interests of personal safety.
So what brought us to the point of the precipice, this point where two belligerent nations want to draw swords against each other in the region once known as the cradle of civilisation. This was the land of the Sumerians, the Assyrians, and the Babylonians where advanced civilizations flourished long before that of Egypt, Greece, and Rome. This Garden of Eden, this land of Abraham, where the Hanging Gardens on the River Euphrates were once considered amongst the Seven Wonders of the World and where the origins of our medicine once flourished. There is little doubt that any historian would say that the Mongol invasion of Mesopotamia was one of the turning points in the history of this region. Its long shadow and memory has left formidable imprints that are still discernible in thought formation of Iraqi political leaders right into this century. The destruction of many centuries of learning, being ruled for a period by barbarians, Ottoman Turks and later the British has left a lasting stamp on these proud people who want to protect their recently found freedom.
I would like to take time for a moment to consider life in this part of the world before the sack of Baghdad by the Mongols. I would like to identify the influence of the Baghdad School of Medicine on the medicine we practise today in the Western world. This influence has been neglected and unjustifiably overpassed by scholars in the West and this article is written to allow us for a while to acknowledge that fact and try and restore this missing part of our history. We must remember that medicine, as we know it today did not develop overnight and this knowledge over the centuries has been handed from one country to the other. Between the ancient civilizations of Egyptians, Greek, Roman, and the Renaissance era in Europe, there was a gap, commonly called “the dark ages”, during which the flames of the knowledge of medicine was hosted, not by the West, but by the Arabs or Moslems.
The nomenclature, “the dark ages” reflects the civilization in Europe between the 7th and 13th centuries, but by no means it expresses the state of affairs in the Arab world or the Islamic Empire at that time. By the ninth century, Islamic medical practice began to advance beyond the talisman and the people of Mesopotamia became avid for the wisdom of Galen, Hippocrates, and Paul of Aegina. By the tenth century, their zeal and enthusiasm for learning resulted in all essential Greek medical writings being translated into Arabic in Baghdad. The Islamic Empire continued to grow and extended its influence from the Atlantic Ocean on the West to the borders of China on the East. Arabic became the International Language of learning and diplomacy and the centre of medical knowledge and activity shifted eastward as Baghdad emerged as the capital of the scientific world.
This era also saw the introduction of hospitals with wards, the introduction of medical terminology and the regulation of medical students who by now had to pass rigorous examinations. Baghdad General Hospital soon became the envy of the Islamic world and incorporated innovations, many of which still sound modern by today’s standards. The hospital used fountains to cool the air near the wards of those afflicted with fever; it was the first hospital to have a ward exclusively devoted to the mentally ill. The Baghdad School brought a refreshing spirit of dispassionate clarity into psychiatry, which was free from the demonological theories that swept over the Christian world. It is known that Najab ud din Muhammad, a contemporary of Razi, carefully compiled observation on actual patients made up the most complete classification of mental diseases theretofore known. He described agitated depression, obsessional neurosis, Nafkhae Malikholia (combined priapism and sexual impotence). Kutrib (a form of persecutory psychosis), Dual-Kulb (a form of mania). At night, the pain of the restless in Baghdad General Hospital was soothed by soft music and storytelling. I still remember the open courtyard of the Ibn ‘al Bitar still being used in this fashion, just before the Gulf War, by the patient’s relatives at night as I strolled back from my night rounds.
There were also social policies introduced by the governing regime to Baghdad General Hospital, which assured that the prince and pauper received identical attention and the destitute received five gold pieces upon discharge to sustain them during convalescence. We must remember that this was at a time when the streets of Paris and London were still paved with mud and open sewers. Baghdad General Hospital was amongst the first to introduce separate wards for male and female patients and these were staffed by attendants of both sexes. This medical centre of excellence contained both a library and a pharmacy and it is known that medical staff attended outreach clinics to attend to the disabled or the disadvantaged who lived in remote areas.
Baghdad also introduced regulations to maintain quality control on drugs, they advocated that pharmacists became licensed, and legal measures were taken to prevent doctors from owning or holding stock in a pharmacy. Methods of extracting and preparing medicines were brought to a high art in Mesopotamia and techniques of distillation, crystallization, solution, sublimation, reduction and calcination became essential processes of pharmacy and chemistry. With the help of these techniques, the Saydalanis (pharmacists) introduced new drugs such as camphor, senna, sandalwood, rhubarb, musk, myrrh, cassia, tamarind, nutmeg, alum, aloes, cloves, coconut, nuxvomica, cubebs, aconite, ambergris, and mercury to the world. The important role of the Baghdad School and others in developing modern pharmacy is memorialized in the significant number of current pharmaceutical and chemical terms derived from Arabic: drug, alkali, alcohol, aldehydes, alembic, and elixir among others, not to mention syrups and juleps.
In 636 A.D., the Muslims conquered the Persian City of Jundi-Shapur, and after this period, Islamic medical schools mostly developed on the Jundi-Shapur pattern. In the late seventh century, only Baghdad and Jundi-Shapur had separate schools for studying basic sciences. In Baghdad Medical School, doctors learned anatomy by dissecting apes, skeletal studies and didactics while other schools only taught anatomy through illustrations and lectures. During the eight century, the study of medicinal herbs and pharmacognosy was added to the basic training and a number of hospitals in Baghdad maintained barbel gardens as a source of drugs for the patients and a means of instruction for the students.
Surgery was also included in the Baghdad curriculum many surgical procedures such as amputation, excision of varicose veins and haemorrhoids were required knowledge. Orthopaedics was also widely taught in Baghdad and doctors routinely used plaster of Paris for casts in the reduction of fractures. Interestingly, this method of treating fractures was only rediscovered in the West in 1852. Ophthalmology was practiced in Baghdad, but it was not taught as part of the curriculum in medical schools, rather an apprenticeship to an eye doctor was the preferred way of specialisation. The ophthalmologists of Baghdad exhibited a high degree of proficiency and it should be remembered that medical words such as retina and cataract are of Arabic origin. lbn al Haytham (965-1039 A.D.) wrote the Optical Thesaurus from which such worthies as Roger Bacon, Leonardo da Vinci and Johannes Kepler drew theories for their own writings.
In his Thesaurus he showed that light falls on the retina in the same manner as it falls on a surface in a darkened room through a small aperture, thus conclusively proving that vision happens when light rays pass from objects towards the eye and not from the eye towards the objects as thought by the Greeks. He presents experiments for testing the angles of incidence and reflection, and a theoretical proposal for magnifying lens (made in Italy three centuries later). He also taught that the image made on the retina is conveyed along the optic nerve to the brain. Razi was the first to recognize the reaction of the pupil to light and Ibn Sina was the first to describe the exact number of extrinsic muscles of the eyeball, namely six. The greatest contribution of Islamic medicine in practical ophthalmology was in the matter of cataract. The most significant development in the extraction of cataract was developed by Ammar bin Ali of Mosul, who introduced a hollow metallic needle through the sclerotic and extracted the lens by suction. Europe rediscovered this in the nineteenth century.
In 931 A.D. Caliph Al-Muqtadir learned that a patient in Baghdad had died as the result of a physician’s error and he ordered his chief physician, Sinan-ibn Thabit bin Qurrah to regulate all those who practiced medicine in Mesopotamia. In the first year of the decree, more than 860 doctors were examined in Baghdad alone. This led to the introduction of new examinations and a Licensing Board was established under a government official called Muhtasib. European medical schools followed the Baghdad pattern and even in the early nineteenth century, students at the Sorbonne could not graduate without reading Ibn Sina’s Qanun (Cannon).
During this period, Al-Razi moved to Baghdad where he became the Chief Physician of the Baghdad Hospital and the Court-Physician of the Caliph. He published several medical books, which were translated into Latin, French, Italian, Hebrew, and Greek including the differentiating between smallpox and measles, two diseases that were hitherto thought to be one single disease. It is also written that when he was asked to choose a site for a new hospital in Baghdad, he deduced which was the most hygienic area by observing where the fresh pieces of meat he had hung in various parts of the city decomposed least quickly.
He also published a book called “Al-Murshid, in which he described the different types of fever including continuous, relapsing, and hectic. He stated that fever can be a symptom of a disease or a disease in itself. He introduced mercury as a therapeutic drug for the first time in history, which was later adopted in Europe. Al-Razi is attributed to be the first to use animal gut for sutures. He is credited with many contributions, which include being the first to describe true distillation, corrosive sublimate, arsenic, copper sulphate, iron sulphate, saltpetre, and borax in the treatment of disease. He introduced mercury compounds as purgatives (after testing them on monkeys); mercurial ointments and lead ointment.”
His interest in urology focused on problems involving urination, venereal disease, renal abscess, and renal and vesical calculi. He described hay fever or allergic rhinitis. He stressed the continued medical education of the physician advising him to record his own observations and encouraging him to meet with other physicians to discuss medical problems. The new Al-Adudi hospital in Baghdad was built in 981 A.D. and had interns, residents, and 24 consultants. An Abbasid minister, Ali ibn Isa, requested the court physician, Sinan ibn Thabit, to organise regular visiting of prisons by medical officers.
Many other Islamic physicians and surgeons of the period influenced the Baghdad School. In 930 A.D., Al-Zahrawi was born in Al-Zahra, a suburb of Cordova and later attended the University of Cordova, which had a long tradition of excellence. At that time, Cordova had a population of one million. Al-Zahrawi became an eminent surgeon being appointed as the Court-Physician of King Abdel-Rahman III. He was to influence the Baghdad School of Medicine through his four books, one of which “Al-Tastif Liman Ajiz’an Al-Ta’lif’ is still considered the best medieval surgical encyclopaedia and was used in medical schools in Europe until the 17th century. Al-Zahrawi described the ligature of arteries long before Ambrose Pare and he also used cautery to control bleeding. Interestingly, he also used wax and alcohol to stop bleeding from the skull during cranial surgery long before Sir Victor Horsley used it to effect in the late eighteen hundreds. His preparation made up of seven parts beeswax and one part almond oil is still known today as Horsley’s Wax.
Al-Zahrawi was also the first to in history to use cotton (Arabic word) in surgical dressings in the control of haemorrhage, as padding in the splinting of fractures, teach the lithotomy position for vaginal operations, to describe and use alcohol as a surgical preparation. He distinguished between goitre and cancer of the thyroid and explained his invention of a cauterizing iron, which he also used to control bleeding. His description of varicose veins stripping, even after ten centuries, is almost like modern surgery. In orthopaedic surgery he introduced what is called today Kocher’s method of reduction of shoulder dislocation and patelectomy, 1,000 years before Brooke reintroduced it in 1937. He described tracheotomy, orthodontia and described the different types of fracture before the introduction of X Rays.
In the rest of the Islamic world, the Iranian Ibn Sina (Avicenna 980-1037 A.D) suggested the communicable nature of tuberculosis long before the infectious nature of the pathogen was discovered. He was also the first to describe the use silk sutures for haemostasis and the first to use alcohol as an antiseptic. Ibn Sina originated the idea of the use of oral anaesthetics and he recognised opium as the most powerful mukhadir (an intoxicant or drug). He also used less powerful anaesthetics such as mandragora, poppy, hemlock, hyoscyamus, deadly nightshade (belladonna), lettuce seed, and snow or ice cold water. He introduced the soporific sponge, soaked with aromatics and narcotics, which was the precursor of modem anaesthesia. In his masterpiece Al-Quanun (Canon), he described complete studies of physiology, pathology, and hygiene.
However, the turning point in the great age of Islam’s contribution to medicine came when a confederation of nomadic tribes led by Genghis Khan, first conquered China, and then spread out to attack the rest of the Muslim Empire. By 1220, they had conquered Samarkand and Bukhara and by the mid-century, they had taken Russia, Central Europe, northern Iran, and the Caucuses. In 1258, Hulagu Khan invaded Baghdad and destroyed the ancient systems of irrigation with such extensive devastation that even today agricultural recovery in this nation is still incomplete. While in Baghdad, Hulagu made a pyramid of the skulls of Baghdad’s scholars, religious leaders, and poets, and he deliberately destroyed what remained of Iraq’s canal headworks. The medical knowledge of centuries was swept away and Mesopotamia became a neglected frontier province ruled from the Mongol capital of Tabriz in Iran.
In 1380, another Turko-Mongol confederation was organised by Tamerlane the Great, who claimed descent from Genghis Khan. They swept down on Baghdad again destroyed the hospitals and burnt the libraries with their irreplaceable works. It is said that the waters of the Tigris ran blue with the ink of the medical and scientific works destroyed by these barbarians. The result was to wipe out much of the priceless cultural, scientific, and medical legacy that Muslim scholars had been preserving and enlarging for some five hundred years. A minor scion of the Mamluk dynasty took refuge in Egypt and the ‘Abbasid caliphate continued the practice of medicine there late into the sixteenth century. In 1401, he sacked Baghdad and massacred many thousands of its inhabitants. Like Hulagu, Tamerlane had a penchant for building pyramids of skulls. His rule virtually extinguished Islamic dominance of medicine and Baghdad, long a centre of trade suffered severe economic depression. The medico-social innovations of the Baghdad scholars totally disintegrated.
To make matters worse, the southern province of Basra, which had been a key transit point for seaborne commerce was circumvented after the Portuguese discovered a shorter route around the Cape of Good Hope. Mesopotamia’s once-extensive irrigation system fell into disrepair, creating swamps and marshes at the edge of the delta. The rapid deterioration of settled agriculture led to the growth of tribally based pastoral nomadism. By the end of the Mongol period, the medical knowledge of the people of Mesopotamia had shifted from the urban-based Abbasid culture to the tribes of the river valleys, where it has remained well into the twentieth century.
Maybe, for a moment if we considered Baghdad’s great contribution to the world of Western medicine, we would not be so quick to see this nation as radically demonic and possibly even learn to respect the descendants of these original scholars who today still die suffering along the shores of the Tigris, sacrificed on yet another altar of human indifference.
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