Medicine and Medical Education in Islamic History

MEDICAL EDUCATION
In 636 A.D., the Persian City of Jundi-Shapur, which originally meant beautiful garden, was
conquered by the Muslims. Its great university and hospital were left intact. Later other Islamic
medical schools were built according to the Jundi-Shapur pattern. Medical education was serious
and systematic. Lectures and clinical sessions included in teaching were based on the apprentice
system. The advice given by Ali ibnul-Abbas (Haly Abbas: - 994 A.D.) to medical students is as
timely today as it was then2. "And of those things which were incumbent on the student of this
art (medicine) are that he should constantly attend the hospitals and sick houses: pay unremitting
attention to the conditions and circumstances of their inmates, stay in company with the most
astute professors of medicine, and inquire frequently as to the state of the patients and symptoms
apparent in them, bearing in mind what he has read about these variations, and what they indicate
of good or evil."
Razi (Razes: 841-926 A.D.) advised the medical students that while they examine a
patient, they should bear in mind the classic symptoms of a disease as given in textbooks
and compare them with what they found".
The ablest physicians such as Razi (Al-Razes), Ibn-Sina (Avicenna: $80-1037 A.D.) and
Ibn Zuhr (Avenzoar: 116 A.D.) worked both as the directors and the deans of medical
schools. They studied patients and prepared them for student presentation. Clinical
reports of cases were written and preserved for teaching," and regular registers were
maintained.
Training in Basic Science
Only Jundi-Shapur or Baghdad had separate schools for studying basic sciences.
Candidates for medical study received basic preparation from private tutors through
private lectures and self study. in Baghdad anatomy was taught by dissecting the apes,
observing skeletal studies, and studying didactics. Other medical schools taught anatomy
through lectures and illustrations. Alchemy was one of the prerequisites for admission to
a medical school. The study of medicinal herbs and pharmacognosy rounded off the basic
training. A number of hospitals maintained herbal gardens as a source of drugs for the
patients and a means of instruction for the students.
Upon completion of the basic training, a candidate was admitted as an apprentice to a
hospital where, along with a large group, he was assigned to a young physician for
indoctrination, preliminary lectures, and familiarization with library procedures and uses.
During this preclinical period, most of the lectures were on pharmacology and toxicology
and the use of antidotes.
Clinical training
The next step was to give the student full clinical training. During this period students
were assigned in small groups to famous physicians and experienced instructors, for ward
rounds, discussions, lectures, and reviews. Early in this period therapeutics and pathology
were taught. There was a strong emphasis on clinical instruction and some Muslim
physicians contributed brilliant observations that have stood the test of time. As the
students progressed in their studies they were exposed more and more to the subjects of
diagnosis and judgment. Clinical observation and physical examination were stressed.
Students (or clinical clerks) were asked to examine a patient and make a diagnosis of the
ailment. Only after all else had failed would the professor make the diagnosis himself.
While performing physical examination, the students were asked to examine and report
six major factors: the patients' actions, excreta, the nature.and location of pain, and
swelling and effluvia of the body. Also noted was color and feel of the skin-whether hot,
cool, moist, dry, flabby. Yellowness in the whites of the eye (jaundice) and whether or
not the patient could bend his back (lung disease) was also considered important.'
After a period of ward instructions, students were assigned to outpatient areas. After
examining the patients, they reported their findings to the Instructors. After discussion,
treatment was decided and prescribed. Patients who were too ill were admitted as
inpatients. The maintenance of records for every patient was the responsibility of the
students.
Curriculum
Different medical schools pursued different clinical curriculum and offered separate
courses of studies, but the mainstay was usually internal medicine. Emphasis was placed
on clarity and brevity in describing a disease and the separation of each eAtity. Until the
time of Ibn Sina the description of meningitis was confused with acute infection
accompanied by delirium. Ibn Sina described the symptoms of meningitis with such
clarity and brevity that there is very little that can be added to it even after a thousand
years(6). Surgery was also a part of the curriculum. After completing the prescribed
course of studies, some students specialized under famous specialists, while others
specialized during their clinical training. According to Elgood,6 knowledge of many
surgical procedures such as amputation, excision of varicose veins, and hemorrhoids was
essential. Orthopedics was widely taught, and the use of plaster of paris for casts after
reduction of fractures was routinely shown to students. This method of treating fractures
was rediscovered in the West in 1852. Although ophthalmology was practiced widely, it
was not taught regularly in medical schools. Apprenticeship to an eye doctor was the
preferred way of specializing in ophthalmology. Surgical treatment of cataract was very
common. Obstetrics was left to midwives. Medical practioners consulted among
themselves and with specialists Ibn Sina and Hazi both widely practiced and taught
psychotherapy. After completing his medical training, every medical graduate was
required to pass a licensing examination before starting his medical practice. It is
important to note that there existed a Scientific Association which was formed in the
hospital of Mayyafariqin to discuss the conditions and diseases of the patients.'
Licensing of Physicians
In Baghdad in 931 A.D., Caliph Al-Muqtadir learned that a patient had died as the result
of a physician's error. Thereupon he ordered his chief physician, Sinan ibn Thabit bin
Qurrah to examine all those who practiced the art of healing. In the first year of the
decree more than 860 were examined in Baghdad alone. From that time on, licensing
examinations required and administered in various places. Licensing Boards were under a
government Official called Muhtasib or inspector general. Muhtasib also inspected
weights and measures of traders and pharmacists. Pharmacists were employed as
inspectors to inspect drugs and maintain quality control for drugs sold in a pharmacy or
apothecary. The chief physician gave oral and practical examination, and if the young
physician was successful, the Muhtasib administered the Hippocratic oath and Issued a
license. After a thousand years, licensing Of physicians has been implemented in the
West, particularly in America by the State Licensing Board Specialties such as in
Medicine, Surgery, Radiology, etc. European medical schools followed the pattern set by
the Islamic medical schools and even in the early nineteenth century, students at the
Sorbonne could not graduate without reading Ibn Sina's Qanun (Canon). According to
Razi a physician had to satisfy two conditions for selection: firstly, he was to be fully
conversant with the new and the old medical literature, and secondly, he must have
worked in a hospital as house physician.
HOSPITALS
The development of efficient hospitals was an outstanding contribution of Islamic
medicine (7). The hospitals served all citizens free and without any regard to their color,
religion, sex, age or social status. The hospitals Were run by government and their
directors were physicians.
Hospitals had separate wards for male and female patients and were staffed with nursing
and other ancillary staff of the same sex.Diffrent diseases such as fever, wounds,
infections, mania, eye conditions, cold diseases, diarrhea, and female disorder were
allocated diffeient wards. Convalescence centers were divided into separate sections.
Hospitals provided patients with unlimited water supply and bathing facilities. Only
qualified and licensed physicians were allowed by law to practice medicine. The
hospitals were teaching hospitals to educate and train medical students. They had housing
for students and house-staff,g and contained pharmacies dispensing free drugs to patients.
All hospitals had their conference rooms and expensive libranes containing the most up-to-date books. According to Haddad"'· the library of the Tulum Hospital which Was
founded in Cairo in 872 A.D. (1100 years ago) bad 100,000 books. Universities, cities
and hospitals acquired large libraries, physicians had their own extensive personal book
collections, at a time when printing was unknown and book editing was done by skilled
and specialized scribes putting in long hours of manual labor. Mustansiriyya University
in Baghdad contained 80,000 volumes; the library of Cordova 600,000 volumes: that of
Cairo 2,000,000 and that of Tripoli 3,000,000 books.
These hospitals kept records of all their patients and their medical care, something done
for the first time in medical history.
For considerations of treatment, the hospital was divided into two main departments, out-patient and in-patient departments. The in-patient depart ment differed only slightly from
any modern in-patient department. At the Tulum hospital, on admission the patients were
given special apparel while their clothes, money, and valuables were stored away, and
returned to them at the time of their discharge. On discharge, they also received five gold
pieces each to tide them over until they could support themselves.
The hospital and medical school at Damascus had elegant rooms and an extensive library.
Healthy people are said to have feigned illness in order to enjoy its cuisine. There was a
separate hospital in Damascus for lepers, while, in Europe, even six centuries later, lepers
were condemned and burned to death by royal decree.
The Qayrawan Hospital (built in 830 A.D. in Tunisia) was character ized by its spacious
wards, waiting rooms for visitors and patients, and female nurses from Sudan, the first
account of nursing in Arab history. The hospital also provided facilities for performing
prayers.
The Al-Adudi hospital (built in 981 A.D. in Baghdad) was furnished with the latest
equipment and supplies available at the time. It had interns, residents, and 24 consultants
attending its professional activities. An Abbasid minister, Ali ibn Isa, requested the court
physician, Sinan ibn Thabit, to organize regular visiting of prisons by medical officers.''
At a time when Paris and London were mud streets and hovels, Baghdad, Cairo, and
Cordova had hospitals which incorporated innovations which sound amazingly modern.
It was chiefly in the humaneness of patient care that the Muslim hospitals excelled. Near
the wards of those : afflicted with fever, fountains cooled the air; the insane were treated
with gentleness; and at night music and storytelling soothed the patients."
The Bimaristans (hospitals) were of two types - the fixed and the mobile. The mobile
hospitals were transported upon beasts of burden and were erected from time to time as
required. The physicians in the mobile were of the same standing as those who served the
regular in the hospitals. Similar mobile hospitals accompanied the armies in the field. The
field hospitals were well equipped with medicaments, instruments, tents and a staff of
doctors, nurses, and orderlies. The travelling clinics served the totally disabled, the
disadvantaged and those in remote areas. These hospitals were also used by prisoners,
and by the general public, particularly in times of epidemics.
BACTERIOLOGY
Al-Razi was asked to choose a site for a new hospital when he came to Baghdad. In order
to choose the most hygienic area, he hung pieces of meat in different parts of the city and
observed where they decomposed the least.
Ibn Sina stated explicitly that the bodily secretion is contaminated by foul earthly body
before getting infected. Ibn Khatima stated that man Is surrounded by minute bodies
whichenter the human system and cause disease.
In the middle of the fourteenth century when the "black plague" ravaged Europe and
Christians stood helpless, considering it an act of God, Ibn al Khatib of Granada
composed a treatise in the defense of the theory of infection in the following way.
To those who say, "How can we admit the possibility of infection while the religious law
denies it?" we reply that the existence of contagion is established by experience,
investigation, the evidence of the senses and trustworthy reports. These facts constitute a
sound argument. The fact of infection becomes clear to the investigator who notices how
he who establishes contact with the aftlicted gets the disease, whereas he who is not in
contact remains safe, and how transmission is affected through garments, vessels and
earrings.
Al-Razi wrote the first medical description of smallpox and measles two important
infectious diseases He described the clinical difference between the two diseases so
vividly that nothing since has been added.'" Ibn Sina suggested the communicable nature
of tuberculosis. He is said to have been the first to describe the preparation and properties
of sulfuric acid and alcohol. His recommendation of wine as the best dressing for wounds
was very popular in medieval practice.(8) However Razi was the first to use silk sutures
and alcohol for hemostasis.l5 He was also the first to use alcohol as an antiseptic.(2)
ANESTHESIA
Ibn Sina originated the idea of the use of oral anesthetics.(l7) He recognized opium as the
most powerful mukhadir (intoxicant or drug). Less powerful anesthetics known at the
time were mandragora, poppy, hemlock, hyoscyamus, deadly nightshade (belladonna),
lettuce seed, and snow or ice cold water. The Arabs invented the soporific sponge which
was the precursor of modern anesthesia. It was a sponge soaked with aromatics and
narcotics and held to the patient's nostrils.(l7)
The use of anesthesia in Islam was one of the reasons why surgery rose to the level of an
honorable profession, while in Europe, surgery was belittled and practiced by barbers and
quacks. The Council of Tours in 1163 A.D. declared "Surgery is to be abandoned by the
schools of medicine and by all decent physicians"(l2). Burton'" stated that "anesthetics
have been used in surgery throughout the East for centuries before ether and chloroform
became the fashion in civilized West."
SURGERY
Al-Razi is the first to use the seton in surgery and animal gut for sutures. Abu alQasim
Khalaf Ibn Abbas Al-Zahrawi (930-1013 A.D.), known to the west as Abulcasis, Bucasis
or Alzahravius, is considered to be the most famous surgeon in Islamic medicine. In his
book Al- Tasrif, he described hemophilia for the first time in medical history. The book
contains the description and illustration of about 200 surgical instruments many of which
were devised by Zahrawi himself" In it Zahrawi stresses the importance of the study of
Anatomy as a fundamental prerequisite to surgery.(l2) He advocates the reimplantation of
a fallen tooth and the use of dental prosthesis carved from cow's bone, a better alternative
to the wooden dentures worn by the first President of America, George Washington seven
centuries later.(l5) Zahrawi appears to be the first surgeon in history to use cotton (Arabic
word) in surgical dressings in the control of hemorrhage, as padding in the splinting of
fractures, as a vaginal padding in the tearing of the pubis and in dentistry. He introduced
the method for the removal of kidney stones by cutting into the urinary bladder. He was
the first to teach the lithotomy position for vaginal operations. He described tracheotomy,
distinguished between goiter 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, sounds almost like modern surgery." In orthopedic
surgery he introduced what is called today Kocher's method of reduction of shoulder
dislocation and patellectomy, thousand years before Brooke reintroduced it in 1937.(13)
Ibn Sina's description of the surgical treatment of cancer holds true even today after 1,000
years. He says the excision must be wide and bold; all veins running to the tumor must be
included in the amputation. Even if this is not sufficient, then the area affected should be
cauterized.(9)
The Muslim surgeons performed three types of surgery: vascular, general, and
orthopedic. Ophthalmic surgery was a specialty which was quite distinct both from
medicine and surgery. They freely opened the abdomen and drained the peritoneal cavity
in the approved modern style. To an unnamed surgeon of Shiraz is attributed the first
colostomy operation. Liver abscesses were treated by puncture and exploration. Today
surgeons all over the world practice and use several surgical procedures first introduced
by Zahrawi a thousand years ago.(25)
MEDICINE
One of the most brilliant contribution to medicine was made by AlRazi who
differentiated between smallpox and measles, two diseases that were hitherto thought to
be one single disease.'" He is credited with many contributions: he was the first to
describe true distillation, glass retorts and luting, corrosive sublimate, arsenic, copper
sulfate, iron sulfate, saltpeter, and borax in the treatment of diseases." 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.(28) He described hay-fever
or allergic rhinitis.
Among other Arab contributions to medicine are included the discovery of itch mite of
scabies (Ibn Zuhr), anthrax, ankylostoma and the guineaworm by Ibn Sina, and sleeping
sickness by Qalqashandy.(l3) They described abscess of the mediastinum. They also
understood tuberculosis and pericarditis.(7)
Al Ash'ath demonstrated gastric physiology by pouring water into the mouth of an
anesthetized lion and showed the distensibility and movements of the stomach, preceding
Beaumont by about a thousand years(l3). Abu Sahl al-Masihi explained that the
absorption of food takes place more through the intestines than the stomach.(l0) Ibn Zuhr
introduced artificial feeding either by gastric tube or by nutrient enema.(l3) Using the
stomach tube, the Arab physicians performed gastric lavage in case of poisoning.(l0) Ibn
Al-Nafis was the first to discover pulmonary circulation.
Ibn Sina in his masterpiece Al-Qanun (Canon), containing over a million words,
described complete studies of physiology, pathology and hygiene. He specifically
discoursed upon breast cancer, poisons, diseases of the skin, rabies, insomnia, childbirth
and the use of obstetrical forceps, meningitis, amnesia, stomach ulcers, tuberculosis as a
contagious dixax, facial ties, phlebotomy, tumors, kidney diseases and geriatric care. He
defined love as a mental disease.
OPHTHALMOLOGY
The Arab physicians exhibited a high degree of proficiency and certainly were foremost
in the treatment of eye diseases. Words such as retina and cataract are of Arabic origin. In
ophthalmology and optics Ibn al Haytham (965-1039 A.D.) known to the West as
Alhazen 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
#urface in a darkened room through a small aperture, thus conclusively qroving that
vision happens when light rays pass from objects towards the eye and not from the eye
towards the object as thought by the Greeks. He 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 All of Mosul, who introduced a
hollow metallic needle through the sclerotic and extracted the lens by suction. Europe
rediscovered this in the nineteenth century.
PHARMACOLOGY
Pharmacology took roots in Islam during the 9th century. Yuhanna bin Masawayh (777-857 A.D.) started scientific and systematic applications of therapeutics in the Abbasid
capital. His student Hunayn bin Ishaq al-Ibadi (809-874 A.D.) and his associates
established solid foundations of Arabic medicine and therapeutics in the ninth century. In
his book al-Masail Hunayn outlined methods for confirming the pharmacological
effectiveness of drugs by experimenting \vith them on humans. He also explained the
Importance of prognosis and diagnosis of diseases for better and more effective
treatment.
Pharmacy became an independent and separate profession from medicine and alchemy.)"
With the wild sprouting of apothecary shops, regulations became necessar~ and were
imposed to maintain quality control.(ll) The Arabian apothecary shops were regularly
inspected by a syndic (Muhtasib) who threatened the merehants with humiliating corporal
punishments if they adulterated drugs." As early as the days of al-Mamun and alMutasim
pharmacists had to pass examinations to become licensed professionals and were pledged
to follow the physician's prescriptions. Also by this decree, restrictive measures were
legally placed upon doctors, preventing them from owning or holding stock in a
pharmacy.
Methods of extracting and preparing medicines were brought to a high art, and their
techniques of distillation, crystallization, solution, sublimation, reduction and calcination
became the 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, nux vomlca, cubebs, aconite, ambergris and mercury.(g) The important role of
the Muslims in developing modern pharmacy and chemistry 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. They invented flavoring extracts made of rose water, orange blossom water,
orange and lemon peel, tragacanth and otheraromatic ingredients. Space does not permit
me to list the contributions to pharmacology and therapeutics, made by Razi, Zahrawi,
Biruni, Ibn Butlan, and Tamimi.
PSYCHOTHERAPY
From freckle lotion to psychotherapy - such was the range of treatment practiced by the
physicians ofIslam. Though freckles continue to sprinkle the skin of 20th century man, in
the realm of psychosomatic disorders, both Al-Razi and Ibn Sina achieved dramatic
results, antedating Freud and Jung by at least a thousand years.(l5) When Razi was
appointed physician- inchief to the Baghdad Hospital, he devoted a ward exclusively for
the mentally ill making it the first hospital ever to have such a ward."
Al-Razi combined psychological methods and physiological explanations, and he used
psychotherapy in a dynamic fashion. Al-Razi was once called in to treat a famous caliph
who had severe arthritis. He advised a hot bath, and while the caliph was bathing, Razi
threatened him with a knife, saying he was going to kill him. This deliberate provocation
increased the natural caloric, enhanced its strength, and consequently dissolved the
already softened humors, so that the caliph stood up in the bath and ran after A1-Razi.
The Arabs brought a refreshing spirit of dispassionate clarity into psychiatry. They were
free from the demonological theories which swept over the Christian world and were
therefore able to make clearcut clinical observations about the mental diseases."
Najab ud din Muhammad," a contemporary of Al-Razi, has left many excellent
descriptions of various mental diseases. His carefully compiled observations about the
patients made up the most complete classification of mental diseases theretofore
known.(39) Najab described agitated depression, obsessional types of neurosis, Nafkhae
hrlalikholia (combined priapism and sexual impotence). Kutrib (a form of persecutory
psychosis), Dual-Kulb (a form of mania).(40)
Ibn Sina recognized 'physiological psychology' in treating illnesses involving emotions.
From the clinical perspective Ibn Sina developed a system for associating changes in the
pulse rate with inner feelings which has been viewed as predating the word association
test of Jung. He is said to have treated a seriously ill patient by feeling the patient's pulse
and reciting aloud to him the names of provinces, districts, towns, streets, and people. By
noticing how the patient's pulse quickened when names were mentioned. Ibn Sina
deduced that the patient was in love with a girl whose home Ibn Sina was able to locate
by the digital examination. The man took Ibn Sina's advice, married the girl, and
recovered from his illness.
It is not surprising to know that at Fez, Morocco, an asylum for the mentally ill had been
built early in the 8th century, and mental asylums were also built by the Arabs in
Baghdad in 705 A.D., in Cairo in 800 A.D., and in Damascus and Aleppo in 1270 A.D.40
I, addition to baths, drugs, kind and benevolent treatment given to the mentally ill,
musico-therapy and occupational therapy were also employed. These therapies were
highly developed. Special choirs and live music bands played daily to entertain the

patients by singing, music, and other light-hearted performances.(l3)