Introduction

Medicine, as it stands today, did not develop overnight. It is the culmination of efforts of millions of people, some we know and others we do not. The flame of civilization, including medicine, started thousands of years ago. The flame has been handed over from one generation to another, and from one country to the other. Depending on who took the sacred responsibility of hosting it, sometimes it got brighter and sometimes it got dimmer. However, it never died away, because if it did, it would have been too hard to start all over again.

Between the ancient civilizations, namely the Egyptians, Greek, Roman, Persian, Indian, and Chinese, and the Renaissance era in Europe, there was a gap, commonly called "the dark ages", during which the flame was hosted, not by the West, but by another culture and people called the Arabs or the 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 when an and science were as bright as the midday sun. That era, unjustifiably, has been commonly neglected and overpassed, as if nothing happened. This paper is an effort to elude to the important events which took place and the significant physicians who lived during that period.

The Spread of Islam

In order to understand how medicine developed in the middle ages, we have to look back at the history and find out the important things that happened during the Seventh Century.

In 570 A.D., a man was born in a small city in the Arabian peninsula, called Mecca (Haykal 1976), his name was Mohammed. In 610 A.D. he declared a new religion, Islam. In 632 A.D., he died after uniting the Arab tribes who had been torn by revenge, rivalry, and internal fights. Out of these mostly illiterate nomadic people, he produced a strong nation that encountered and conquered, simultaneously, the two known empires at that time, namely, the Persian and Byzantine Empires. In a man's life-time, the Islamic Empire extended from the Atlantic Ocean on the West, to the borders of China on the East. In 711 A.D., only 80 years after the death of their prophet, the Arabs crossed to Europe to rule Spain for more than 700 years. In 732 A.D., they threatened Paris and their thrust was stopped at Tours and Poiter (Eigeland 1976). In 831 A.D., the Moslems of North Africa invaded Sicily and ruled it for 200 years. By 846 A.D., they controlled the southern part of Italy and encountered Rome (Hitti 1977). The hold of the Moslems over Italy remained so firm that Pope John VIII (872-882 A.D.) deemed it prudent to pay tribute for two years (Hitti 1977) In 869 A.D., the Arabs captured Malta (Ibn-Khaldun). In the tenth century, from Italy and Spain, the Arabs extended their raids through the Alpine passages into mid-Europe. In the Alps, there are a number of castles and walls which tourists guides attribute to the invasion of the Moslems of Sicily. In the southern part of Italy and in Sicily, a great civilization was established and through which the torch of knowledge spread to Europe, mainly through the University of Salerno in the southern part of Italy (Hitti 1977, Parente 1967).

The expansion of the Moslems in Europe was not limited to those from North Africa and Spain. The Moslems, under the Ottoman Empire, invaded Europe from the East. They occupied a good part of Middle Europe and besieged Vienna twice, once during the reign of Sulayman 1 (1520-1566 A.D.) and the other during the reign of Mohammed IV (1648-1687 A.D.) (Hitti 1977).

Islam and the Promotion of Culture and Science

As the Moslems challenged the civilized world at that time, they preserved the cultures of the conquered countries. On the other hand, when the Islamic Empire became weak, most of the Islamic contributions in art and science were destroyed. This was done by the Mongols who, out of barbarism, burnt Baghdad (1258 A.D.), and by the Spaniards, who out of hatred, demolished most of the Arabic heritage in Spain. The difference between the Arabs and these was the teachings of Islam which:

1. Stressed the importance and respect of learning. For example, the first word revealed to the Moslems' prophet Mohammed was "Read". In Mohammed's era, a captured enemy was freed if he paid a ransom or taught ten Moslems writing and reading. In their holy book, the Qur'an, the importance of knowledge has been repeatedly stressed as it says "Those who know and those who do not are not equal." The prophet Mohammed stressed learning by saying. "One hour of teaching is better than a night of praying." One of the early princes, Khalid fbn Yazid (end of the 7th century), gave up his treasure for the study of medicine and chemistry. He studied medicine under John the Grammarian of Alexandria, and chemistry under Merrinos the Greek (Haddad 1942). He also encouraged several Greek and Coptic medical books to be translated into Arabic.

2. Forbade destruction. On conquering Mecca, the prophet Mohammed strongly stated that no homes, animals, or trees should be destroyed. His followers abided with these principles when conquering other countries.

3. Encouraged cleanliness and personal hygiene. Islam instructed them to approach God in their prayers five times a day with bodies and clothes spotlessly clean.

4. Developed in them the respect of authority and discipline. For example, realizing the scourges and terror of plague, their prophet Mohammed (p.b.u.h.) decreed that "no man may enter or leave a town in which plague broke out." And to make this law all the more binding and effective, he promised the blessing of heaven to those who die of plague by stating that if a man died of plague he would be considered a martyr (Haddad 1942). Thus Mohammed (p.b.u.h.) laid for the Moslems the laws governing corden and quarantine for the first time in history and made it work.

5. Tolerated other religions. The Islamic religion recognizes Christianity and Judaism and considers their followers to be people with holy books like Moslems. Moreover, they candidly treated the Jews at an era when the latter were persecuted in Europe. Dr. Jacob Minkin, a reputable Rabbi and scholar says "It was Mohammadan Spain, the only land of freedom the Jews knew in nearly a thousand years of their dispersion... While during the Crusades, the armored Knights of the Cross spread death and devastation in the Jewish communities of the countries through which they passed, Jews were safe under the sign of the Crescent. They were not only safe in life and possessions, but were given the opportunity to live their own lives and develop a culture so unique and striking that it went down in history as the 'Golden Ages'. The Moors, the Muslim conquerors of Spain in 711, were not religious fanatics. They were strong in their faith but generous with regard to the religious convictions of others.... "The Ranaissance of Art in Italy, says George A. Dorsey, has blinded us to the Renaissance of Science in Spain, which fostered science, promoted culture, encouraged learning, and set a premium on intellectual pursuits, no matter whether the intellect was Moslem, Christian or Jew. Not since the days of Greece had the world known such thirst for knowledge, such passion for learning, such spirit shared by the prince and the courtien alike" (Minkin 1968).

The Arabs were assimilated by the vast new countries they reached. From this marriage of genuine characters and righteousness with the ancient and well established civilizations, a great new nation was born. It is difficult to identify this new breed as Arabs, because although the language was Arabic, all the scientists were not necessarily from the Arabian Peninsula. It is also equally difficult to describe it as Islamic, because although the majority of the scientists were Moslems, sponsored by Moslem rulers, and governed by the Islamic law, yet some scientists were Christians or Jews, especially at the early phase of the lslamic civilization: the translation period to Arabic, and the decline part: the translation period to Latin and Hebrew. Therefore, in this article, the adjectives Arabic or Islamic will be used as synonyms.

Medicine Before Islam

In order to comprehend the contributions of Arabs to medicine,we must have in our minds a picture of the condition of medicine before they arrived to the scene. Generally speaking, two elements are required for medical practice:

Manpower and hospitals

A. Manpower before Islam:

There were medical centers in different parts of the world which were later either under control of the Arabs or in touch with them. For example, in Syria, medicine was advanced and was greatly influenced by the Byzantine civilization which affected also the economic and administrative systems (Hammameh 1962). From the fifth century on, the Greek was the language of learning in Syria. The knowledge of the Arabs of the Greek civilization was mainly through the Syrian scholars who translated it into Arabic. In Egypt, Alexandria was another center for culture. The Arabs got in touch with both the ancient Egyptian and Greek civilizations through the Egyptian scholars. In Persia, there was a medical school in a city called Jundi-Shapur in which medicine was highly developed. The Abbasi Caliphs during the 8th century encouraged the Persian physicians to translate into Arabic the medical knowledge therein, to build medical centers in Baghdad, the capital of their empire, and to run newly built hospitals. With further expansion east, the Arabs through contacts with India and China, brought ideas and methods, not only in medicine, but also in mathematics, chemistry, philosophy, etc.

B. Hospitals Before Islam:

Hospitals as we know them now probably were not present. True, there were places for the sick to stay, but these were mainly temples or annexes to temples that were run by priests. Gods were supposed to play a major role in the art of healing. For example, the Goddess Toueris was the Egyptian symbol of fecundity and protectress of the pregnant and parturient. She was shown as a standing pregnant hippopotamus carrying the hicroglyph meaning protection in one paw, and the sign of life in the other. Small figures of Toucris were popular as amulets (Speert 1973). In those days, sanctuary, prayers, inactation, and hypnosis were integral parts of the therapy.

During the Islamic civilization, hospitals had much developed and attained specific characteristics:

1. Secular: Hospitals served all peoples irrespective of color, religion, or background. They were run by the government rather than by the church, and their Directors were commonly physicians assisted by persons who had no religious color. In hospitals, physicians of all faiths worked together with one aim in common: the well-being of patients.

2. Separate wards: Patients of different sexes occupied separate wards. Also different diseases especially infectious ones, were allocated different wards.

3. Separate nurses: Male nurses were to take care of male patients, and vice versa.

4. Baths and water supplies: Praying five times a day is an important pillar of Islam. Sick or healthy, it is an Islamic obligation; of course physical performance depends on one's health, even he can pray while laying in bed. Before praying, washing of face, head, hands, and feet must be done, if possible. For certain conditions, a bath is obligatory. Therefore, these hospitals had to provide the patients and employees with plentiful water supply and with bathing facilities.

5. Practicing physicians: Only qualified physicians were allowed by law to practice medicine. In 931 A.D., the Caliph Al-Mugtadir from the Abbasid dynasty, ordered the Chief Court-Physician Sinan Ibn-Thabit to screen the 860 physicians-of Baghdad, and only those qualified were granted license to practice (Hamarneh 1962). The counterpart of Ibn- Tbabit, Abu-Osman Sai'd Ibn-Yaqub was ordered to do the same in Damascus, Mecca, and Medina. The latter two cities were in need for such an act because of hundreds of thousands of pilgrims visiting them every year. This was to prevent taking advantage of these pilgrims and to curb the spread of diseases among them.

6. Rather medical schools: The hospital was not only a place for treating patients, but also for educating medical students, interchanging medical knowledge, and developing medicine as a whole. To the main hospitals, there were attached expensive libraries containing the most up-to-date books, auditoria for meetings and lectures, and housing for students and house-staff.

7.Proper records of patients: For the first time in history, these hospitals kept records of patients and their medical care.

8. Pharmacy: During the Islamic era, the science and the profession of pharmacy had developed to an outstanding degree. The Arabic materia medica became so rich and new drugs and compounds were introduced because the Muslims had contact with almost all the known world at that time, either through control or trade. Their ships sailed to China and the Philippines, and their convoys made trades with black Africa, Europe and Asia. Chemistry became an advanced science, and there were means and need for a specialization called pharmacy.

Thus, the main Arabian hospitals were models for medieval hospitals built later in Europe. They were rather medical schools to which those seeking advanced medical knowledge, from the East or West, attended.

In the Islamic Empire, the hospitals attained a golden era unsurpassed in previous history. The reasons behind such a high standard include:

1. Being part of a civilization as a whole:The people were prosperous; thus, they were capable of taking care of their health and of seeking the best available treatment. Also, lslam stresses the necessity of seeking treatment of every disease; the Prophet says "For every disease, God created a cure." The required sciences for good medical care were at a high standard e.g. the Arabs were advanced in chemistry, mathematics, administration, pharmacy, medicine, etc. They gave the world the system of numbering which have replaced the cumbersome Roman numerals. The world owes to them the knowledge of the following chemical reactions, namely sublimation, precipitation, filtration, distillation, etc. The great Arab chemist Jabir Ibn- Hayan discovered sulphuric and nitric acids. According to Webster Dictionary, the words sugar, alcohol, alkali, syrup, coffee, cotton, all are Arabic words. Fielding H. Garrison, the author of the well-known work on the "History of Medicine" said: "...The Saracens themselves were the originators not only of algebra, chemistry, and geology, but of many of the so- called improvements or refinements of civilization, such as street lamps, window-panes, firework, stringed instruments, cultivated fruits, perfumes, spices, etc... "

2. High prestige of physicians: The physicians in this era earned a high prestige. Although anyone, irrespective of his social status, can study medicine, yet the route was long and tedious. He had to finish Islamic studies, philosophy, astronomy, art, chemistry, etc. before being accepted as a medical student. Therefore, the physician was a cultured person who had wisdom and knowledge. In fact, the Arabic translation of a physician is "Hakim" which means sage. In the 9th and 10th century, the Court- Physician was in the protocol ahead of the Chief-Justice. Many eminent physicians, as we will discuss later, showed enough talent, social knowledge, political capabilities, and wisdom to be appointed by the Caliphs as prime ministers (Visiers). Owing to the high prestige and connections of physicians, generous funds for hospitals were easily obtained.

3. Rulers' involvement in public services: The Caliphs of the Islamic empire built magnificent hospitals for one or more of the following reasons:

a. Religion: Their religion stated that money spent on charity is a good investment for Judgment Day.

b. Eternity: The Pharoahs of Ancient Egypt sought eternity by building pyramids, the rulers of Islam sought the same thing by building mosques, hospitals, and schools carrying their names.

c. Politics: To show their people that they cared, and were interested in them, the rulers built hospitals.
Whatever the motive of the ruler, the population benefited and good hospitals were erected.

4. Adequate financing to run the hospitals:The rulers set aside generous funds to run these hospitals. Also the philanthropists gave generously, thus following their religious beliefs and imitating their rulers. In Islam, there is a special system called Al-Waqf. A person can donate part or all of this wealth to charity. The government takes care of such a donation, and its revenues help to maintain and build mosques, hospitals, and schools. Another source of funds and an important pillar of Islam is alms-giving (2 1/2% of property value). Collected alms goes to the state treasury which takes care of charitable organizations. Very few hospitals in the Islamic era were private. Thus, patients fees constituted an unimportant source of funding.

The capital of the Islamic empire kept changing from one dynasty to the other. In each capital, an important medical center developed. Thus, by the end of the 13th century, there were many medical centers spread throughout the Arab world. Space does not allow the description of all the hospitals built throughout these centuries. We, therefore, chose some of the important ones which will be described according to the region where they were developed.

1. In El-Sham
El-Sham at that time included what is known now as Syria, Lebanon, Jordan, and Palestine, Damascus and Jerusalem were the important cities.

a. In Damascus: The first known hospital in Islam was built in Damascus in 706 A.D. by the Umayyad Caliph, Al-Walid (Hamarneh 1962). The most important hospital built in Damascus in the middle ages was named Al-Nuri Hospital, after King Nur Al-Din Zinki, in 1 156. This hospital was built during the Crusade Wars to fulfill a need for a well-equipped and well-staffed hospital. It turned out to be not only a first class hospital, but also a first class medical school. The king donated to the hospital a whole library rich in medical books. It is important to understand why books were expensive and limited in number in the middle ages. This was because they were hand-written as printing was not used until the middle of the fifteenth century. The hospital adopted medical records, probably the first first in history. From its medical school, many eminent physicians graduated, an example is Ibn Al-Nafis, the scholar who discovered the pulmonary circulation as will be discussed. The hospital served the people for seven centuries and parts of it still exist.

b. In Jerusalem: In 1055 A.D., the Crusaders built Saint John Hospital. By the end of the eleventh century, it grew to such an extent to include a hospital, a palace for knights, and a convent for the nursing sisters. The medical activities of the hospital were tremendous because of the large number of daily admissions of patients, pilgrims, and wounded soldiers. After the liberation of Jerusalem by Salah Al-Din in 1187 A.D., the hospital name was changed into Al-Salahani Hopital. He expanded the hospital which continued to serve the people until its destruction by an earthquake in 1458 A.D.

2. In Iraq and Persia: In 750 A.D., Baghdad was built to be the capital of the Abbasid dynasty by the Calip Abu-Gaifar Al- Mansur. In 766 A.D., he assigned the dean of the medical school of Jindi Shapur, Judis Ibn-Babtishu', to be the Court- Physician and to establish hospitals proportionate to the glory and prosperity of Baghdad.

When Harun Al-Rashid followed (786-809 A.D.), he ordered the grandson of Ibn-Bahtishu and his Court-Physician, Jibril, to build a special hospital named Baghdad Hospital. This hospital developed into an important medic center. One of its chiefs was Al-Razi, the eminent Internist.

In 918 A.D., the Caliph Al-Mugtadir built two hospitals in Baghdad. One was on the east side of the city which he named Al-Sayyidah Hospital, after his mother. The other was on the west side which he named, Al- Mugtadiri Hospital, after himself.

Another important hospital was named Al-Adudi Hospital. It was built in 981 A.D. after King Adud Al-Dawlah. It was the most magnificent hospital built in Baghdad before modern time. The Caliph wanted to outdo his predecessors. It was furnished with the best equipment and supplies known at the time. It had interns, residents, and 24 consultants attending its professional activities. Haly Abbas, who wrote the famous book "Liber Regius (Al-Malaki)", was one of the staff. It was destroyed in 1258 when the Mongols, led by Holagu the grandson of Ghingiz Khan, invaded Baghdad.

3. In Egypt:

In 872 A.D., Ahmed Ibn-Tulun built a hospital called Al-Fusta Hospital in the City Al-Fustat which is now in old Cairo. It served the growing Cairo population for six centuries. It was divided into separate wards. On admission, the patients were given special apparel while their clothes, money, and valuables were stored until the time of their discharge.

In 1284 A.D., King Al-Mansur Qalawun built an important hospital named Al-MansuriHospital . The story behind its construction is interesting. King Al-Mansur Qalawun was an officer in the Arabian army fighting the Crusaders. While in the Holy Land, he fell sick and was admitted to Al- Nuri Hospital. On recovery, he vowed that if he ever became the ruler of Egypt, he would build a great hospital in Cairo even more magnificent than Al-Nuri Hospital for, the sick. poor, and rich alike. At the dedication ceremony, he asked for a cup of wine from the pharmacy. After drinking it he declared that by taking that portion as a medication, he was signifying that the hospital was serving all people. from the king to the least of his subjects (Hamarneh 1962).

e. It was the best hospital built then as reported by the contemporary historians such as Ibn-Battota and El-Kalkashandi. It had different sections for different diseases. Music therapy was used as a line of treatment for psychiatric patients. It served 4,000 patients daily. The patient's stay in the hospital was free moreover on his discharge, the patient was given food and money for compensation for being out of work during his hospital stay. Al-Mansuri Hospital has served Cairo for seven centuries since it has been built. It is now used for ophthalmology and called Mustashfa Qalawun. Its ancient door is preserved in the Islamic Museum of Cairo.

4. In North Africa (Al-Maghrib Al-Arabi):

a. Tunisia: In 830 A.D., Prince Ziyadat Allah I, built Al-Qayrawan Hospital in a district of the Qayrawan city called Al-Dimnah. Subsequently all hospitals in Tunisia were called Dimnah instead of Bimaristan as they were called in the East, which is a Persian word meaning a hospital. The Qayrawan Hospital was characterized by spacious separate wards waiting rooms for visitors and patients, and female nurses from Sudan, an event representing the first use of nursing in Arabic history. The hospital also included a chapel for prayers.

b. Morocco: In 1190 A.D., the king Al-Mansur Ya'qub Ibn-Yusuf, built a hospital in the capital city, Marakesh, named it the Marakesh Hospital. It was a huge hospital beautifully landscaped with fruit trees and flowers. Water was brought by aqueducts to all sections. Patients were provided with special apparel: one for winter and another for summer. The pharmacy was taken care of by specialists called the Sayadlah. There was an expensive private section where a patient was charged what is equivalent to $ 1501 day. One thousand years ago, this fee was quite expensive.

5. Al-Andalus (Spain):

In 1366 A.D., Prince Muhammed Ibn-Yusuf Ibn Nasr, built the Granada Hospital in the city of Granada which had expanded to half a million population. The hospital represented the beauty of the Arabic architecture in Spain and served the people until the fall of Granada in 1492 A.D.

The patients were treated through a scheme starting with physiotherapy and diet; if this failed, drugs were used, and at last, surgery would be resorted to. The physiotherapy included exercises and water baths. The Arabs had an elaborate system of dieting and were aware of food deficiencies. Proper nutrition was an important item of treatment.

Drugs were divided into two groups: simple and compound drugs. They were aware of the interaction between drugs; thus, they used simple drugs first. If these failed, compound drugs were used which are made from two or more compounds. If these conservative measures failed, surgery was undertaken.

The medical profession was a well respected specialty and its Ieaders kept it this way by laying down proper ethics. Al-Tabari, the chief physician in 970 A.D., described the Islamic code of ethics as follows (Hamamch 1971, Levy 1967):

I. Personal characters of the physician:

The Physician ought to be modest, virtuous, merciful, and un addicted to liquor. He should wear clean clothes, be dignified, and have well- groomed hair and beard. He should not join the ungodly and scaffers, nor sit at their table. He should select his company to be persons of good reputation. He should be careful of what he says and should not hesitate to ask forgiveness if he has made an error. He should be forgiving and never seek revenge. He should be friendly and peacemaker. He should not make jokes or laugh at the improper time or place.

II. His obligation towards patients:

He should avoid predicting whether a patient will live or die, only God (Allah) knows. He ought not loose his temper when his patient keeps asking questions, but should answer gently and compassionately. He should treat alike the rich and the poor, the master and the servant, the powerful and the powerless, the elite and the illiterate. God will reward him if he helps the needy. The physician should not be late for his rounds or his house calls. He should be punctual and reliable. He should not wrangle about his fees. If the patient is very ill or in an emergency, he should be thankful, no matter how much he is paid. He should not give drugs to a pregnant woman for an abortion unless necessary for the mother's health. If the physician prescribes a drug orally, he should make sure that the patient understands the name correctly, in case he would ask for the wrong drug and get worse instead of better. He should be decent towards women and should not divulge the secrets of his patients.

III. His obligation towards the community:

The physician should speak no evil of reputable men of the community or be critical of any one's religious belief.

IV. His obligations towards his colleagues:

The physician should speak well of his acquaintances and colleagues. He should not honor himself by shaming others. If another physician has been called to treat his patient, the family doctor should not criticize his colleague even if the diagnosis and the recommendations of the latter differ from his own. However, be has the obligation to explain what each point of view may lead to since his duty is to counsel the patient as best as he can. He must warn him that combining different types of therapy may be dangerous because the actions of different drugs may be incompatible and injurious.

V. His obligations towards his assistants:

If his subordinate does wrong, the physician should not rebuke him in front of others, but privately and cordially.