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Volume 20, Number 1January/February 1969

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Medicine From The Middle East

Written by Leslie Farmer
Photographed by Khalil Abou El Nasr

Two hundred years after the Arabians swept out of the peninsula on an irresistible Islamic tide, the medicine they practiced was the most advanced in the world. With the breakup of the Islamic world after the devastating invasions of the Mongols, Arab medicine sank into a deathlike sleep, to be awakened, after 600 years, by an emperor's sword.

The first trained Arab physician was Al-Harith ibn Kaladah, who shortly before the advent of Islam had traveled to the school of Jundi Shapur in Persia to study medicine, then returned to the peninsula to practice. The Persian wars had brought Greek physicians captive to Persia; Alexander's conquest had made Greek its official language, so educated Persians were brought in contact with Greek scientific literature. The school was already flourishing when Nestorian Christians from Edessa, near modern Aleppo, sought refuge in Persia after the East Roman emperor Zeno in Constantinople ordered Edessa's university closed for supporting the Nestorian heresy. The university had taught a pure Hippocratic medicine; the native Christians, learning Greek so as to be able to read the Scriptures, had also come in contact with Greek medical writings. The coming of the Nestorians to Jundi Shapur strengthened the Greek element there—the scientific method of close observation and carefully preserved notes on symptoms, treatment and results that made the medicine of Greece the first essentially modern medicine.

In A.D. 630 Jundi Shapur surrendered peacefully to the armies of Islam. It was to remain the greatest center of medicine in Islam until Baghdad, under the Abbasids, drained it first of its best teachers then, inevitably, of students.

The record of medicine among the Arabs between Ibn Kaladah and the Abbasids is patchy. With the Abbasids, the scientific approach of Greek medicine, as taught by the physicians of Jundi Shapur who were attracted to the great capital, was elaborated and extended by Arab intellect to bring forth the golden age of Arab medicine.

It was the time of the Arab world's greatest physicians, Rhazes and Avicenna, whose portraits hang in the great hall of the School of Medicine at the University of Paris. Rhazes' 141 works established his reputation as one of the keenest thinkers and greatest clinicians of the Middle Ages, during which his Kitab al-Asrar (Book of Secrets) was a chief source of clinical knowledge in Europe. Second only to Rhazes was Avicenna; his Al-Qanun fil-Tibb (The Canon) was the textbook in medical schools of Europe for 500 years. Brilliant though lesser physicians of the Abbasid period described some 130 eye diseases and also contributed a clear conception of the pulmonary circulation of the blood (some 500 years before the Portuguese Servetus, Who was credited with the discovery). Some were so confident in their surgical skill that they did not hesitate to operate for cataract on a one-eyed man. The Abbasid caliphs, in the impetus of the day's almost Renaissance-like thirst for knowledge, dispensed money lavishly on translations from Greek, Syriac and Indian scientific writings, a practice reaching its peak when Al-Ma'mun, the son of Harun al-Rashid, founded a state college of translators.

The period saw some remarkable advances: the world's first apothecary shops and pharmacopoeia; as. early as 931 some examination required for all practicing physicians to test their qualifications; a staff of doctors that made visits to outlying towns and to prisons. Harun al-Rashid built the first hospital of Islam in Baghdad; before the end of the Abbasid empire there were hospitals—some with special libraries and courses for medical students—in every major city of the realm. They were divided into separate sections for men and women, each with a complex of wards—for internal medicine, surgery, orthopedics, diseases of the eye and convalescent rooms—and a hierarchy of chief physicians, heads of the various departments, orderlies and nurses.

But before the disintegration of the Abbasid empire Arab science had made its last significant advances. The indiscriminate reverence for past authorities, in science as well as in philosophy, that was to be the curse of medieval Europe, was stifling Arab intellect, and the brilliant light of scientific medicine among the Arabs was going out.

Europe, meanwhile, had long since entered her dark ages. The monasteries, the few centers of learning, preserved some of the classical writings and dispensed a strange mixture of alchemy, remedies embalmed in the classical texts and, in cases of dire need, fervent prayers. In addition, in scattered spots in Europe a spark of science, lit from the sinking light of the East, smoldered on.

One was Salerno, near Naples, whose embryo medical school, influenced at first by a few classical texts, was revolutionized by the coming of Constantine the African. An Arab physician born in Carthage, he eventually came to Salerno under the patronage of the Norman con-querer Robert Guiscard, and settled down to translate his Greek and Arabic medical manuscripts. Later writings from Salerno clearly show Constantine's influence in their attempts to learn from nature rather than from past authorities and in their stress on careful and collected notes.

Another was Montpellier in southern France, a cosmopolitan and tolerant university town on the road between Spain and Italy, a natural refuge for the Spanish Arabs and Arabized Spaniards driven out by the growing intolerance of Spain's Christian rulers. Some were physicians, many bilingual in Arabic and Spanish and some also knowing Latin; in short, they had access to, and could pass on, both the Arab medical writings and Arabic translations from Greek. By the 14th century there was a medical school at Montpellier whose curriculum included Hippocrates and Avicenna, and which was turning out translators, teachers, medical writers and practitioners of the first order.

With the Renaissance came the great revival of interest in classical learning. The Greek writings revived interest in science; an efficient thermometer, the microscope, taking the pulse, clinical teaching of medicine, even reasonably sophisticated facial plastic surgery were some of the contributions of the age.

The era of the Industrial Revolution saw improvements in public health such as the licensing of midwives, increased interest in the health of mothers and children, the compulsory registration of births, deaths and cases of contagious disease. By the 19th century the existence of bacteria had finally found credence, laying the foundation for the knowledge of the nature of infection, and other revolutionary developments in medicine took place. One was the use of anesthesia, which reduced the necessity for speed in operations and permitted more careful work. Another was the discovery of the nature of sepsis—then the rule, not the exception, in hospitals—and of effective antiseptics. Before, surgeons had hesitated to operate even with anesthesia, for fear of a fatal infection. The last of the 19th and the beginning of the 20th century brought in immunizations against disease, surgery of the brain and heart, improved plastic surgery, the use of X rays, the "miracle drugs," more specialization and great government interest in public health. Scientists now talk of an artificial liver, stomach, pancreas and intestines of new plastics and metals, even an artificial brain of miniature computers, and researchers already are working on an artificial skin to cover extensive burns.

After the Abbasids—first under the Mamelukes, then under the Ottoman Turks, who defeated the Mamelukes-Arab science had suffered a quick decline and a long stagnation. On July 1, 1798, Napoleon landed at Alexandria in a bid to cut the British lifeline to India, He failed, but in the attempt he brought the East and the West face to face. Among the troops that the Ottoman Turks sent to repel him was the illiterate son of an Albanian tobacco merchant, Muhammad Ali, risen to officer on the staff of the Turkish governor of Egypt. When the governor left, Muhammad Ali stayed—with a picked regiment of Albanian guards under him. In two years, he was master of Egypt.

He built canals, schools and factories; he founded a ministry of education, a civil service and a navy; he introduced cotton from the Sudan, imported an army of foreign advisers, military and professional and educational, and sent Egyptians out to England, Italy, Austria and France to be educated. And last but not least, with the help of Dr. Antoine Clot—better known as "Clot Bey"—he founded the Arab world's first modern school of medicine in Cairo, Abu Za'bal, later known as Qasr al-Ayni, in 1827.

Lebanon, meanwhile, was ruled by a man friendly to Muhammad Ali, the Emir Bashir al-Shihabi. Tolerant and open to new ideas, in 1806, he had himself and his family vaccinated against smallpox and encouraged others to do likewise. In 1813-1816 the plague raged through Lebanon. Bashir ordered a special fund set aside for isolation of the sick in special quarters set up outside the towns, set up roadblocks and prohibited the holding of markets and fairs.

Once when Bashir became seriously ill. Muhammad Ali sent Clot to care for him. On his return, Clot took with him five promising Lebanese youths to study at Qasr al-Ayni; they returned to be Lebanon's first modern doctors. It was also the repercussions of Muhammad Ali's modernization in Egypt that introduced modern medicine into Syria; while campaigning there his son, Ibrahim Pasha, sent back some bright Syrian boys to study at the medical school and they also returned to practice in their country.

Lebanon began her first school of medicine in 1867 under the auspices of the Syrian Protestant College, later the American University of Beirut; a second one opened in 1883 at the French University of St. Joseph. The Sudan's school of medicine opened in 1924, and Iraq's Royal Medical School in 1927, both under British auspices. Tunisia, Morocco and Algeria have opened medical schools in the last decade, and in Saudi Arabia contractors are working on the country's first medical school now.

Egypt now has five more medical schools, Syria and Iraq each another. Hospitals, dispensaries, mobile medical units for the more remote areas, mother and child health centers, school health centers, nursing schools, special hospitals for the particular, medical needs of the area are, it seems, springing up in the Arab world as fast as the money is available for them. In the peninsula, with the gush of oil wealth, developments have been particularly spectacular. Saudi Arabia now has some 73 hospitals, 167 dispensaries and 250 health centers; Kuwait's medical services, that started in 1949 with one 50-bed hospital, now include 10 hospitals and sanatoriums.

Bahrain spent 55% of her 1967 budget on health and education. Qatar, which in 1945 had one hospital with one resident doctor, now has five hospitals, one with 600 beds and 15 specialists. The Trucial States have their de facto medical centers in Abu Dhabi and Dubai, the richest two; the Sultanate of Muscat and Oman, that shipped out its first shipload of oil in 1966, has begun to construct health facilities. The two Yemens are building respectively on the health facilities left by the British and on aid from Kuwait.

And other statistics tell their story. In the mid-19th century there was one medical journal in the Arab world; now there are over 50. The doctor-patient ratio of Kuwait, highest in the area at 1780, compares favorably with Sweden's 1960, Switzerland's 1680, Great Britain's 1830 and the United States' 1700. Infant mortality is down all over the area. And in the wake of the heart-transplantation operations came rumors that such an operation would be performed at the hospital of the American University of Beirut, by the same Lebanese surgeon who performed the Middle East's first open heart operation. The press descended on the university, the doctor refused to talk, the director of the hospital denied that such an operation was contemplated—for the present. But even the necessity of such a denial underscores the level of competence available to the area.

It is difficult to evaluate completely the quality and the quantity of Arab work in medicine. Many doctors can be cited who have' brilliant promise but who are still comparatively young, in their late 30's or early 40's. Many are siphoned off by the brain drain, lured not only by higher salaries but by more prestige or greater facilities for research—notably post-graduate students abroad who simply don't return. In 1966, statistics show, the Middle Eastern graduates licensed to practice in the United States alone came to 10 per cent of the area's yearly crop. Once established abroad they melt into the landscape; Arab names crop up, unnoticeable unless one knows how to look, metamorphosed into unrecognizability: a Khoury into a Corey, a Dabaghi into a DeBakey, an al-Hawa into a Howard.

And medical skill is difficult for a lay-man to measure in medical values—both from secular ignorance and, not less confusing, the differences of doctors themselves in evaluating colleagues. But two names are inevitably mentioned first, those of two men both of Lebanese origin.

Michael Ellis DeBakey was born in Lake Charles, Louisiana, in 1908, of Lebanese-American parents. • He graduated from Tulane University, New Orleans, and studied also in Europe, eventually becoming professor and chairman of the department of surgery at Baylor University's college of medicine in Houston, Texas. He is editor, co-editor or member of the editorial board of some 16 medical and scientific journals and has served on several advisory committees to the United States government. He made many contributions to thoracic, cardiac and vascular surgery before, with the help of engineers, he designed the "auxiliary heart", an air-driven pump of plastic and synthetic fabric, to take over part of the work of the heart's main "pump", the left ventricle. In 1966 the "heart" took over most of the work for a victim of rheumatic heart disease after a corrective operation, allowing her damaged heart slowly to recover. Newspapers carried articles for several weeks running, and DeBakey's photograph was plastered over the front pages of the world press. Last autumn, Dr. DeBakey and his Methodist Hospital colleagues again made history when five surgical teams (about 70 persons) headed by DeBakey transplanted for the first time four organs—the heart, one lung and two kidneys—from a single donor into four recipients during simultaneous operations.

Sir Peter Medawer was born in 1915 in Rio de Janeiro, son of a British subject of Lebanese origin. Educated at Marlborough and Magdalen colleges in England, he took a bachelor's degree in zoology and then became interested in research on those fields of biology related to medicine. A series of prizes, professorates and fellowships, including the Royal Medal, have culminated in his appointment to the position of Director of the National Institute for Medical Research in 1962.

During the Second World War the Medical Research Council asked Medawer and another researcher, Burnet, to investigate why skin grafts from one person to another will not take, as the British government was much interested in developing improved methods of grafting—an operation used in the treatment of extensive burns suffered by troops and civilian bomb victims. This was the work which enabled Medawer to formulate the theories of transplantation immunity which would form the basis for his later work—in brief, that there must exist a mechanism enabling the organism to distinguish "self" from "nonself." Medawer was able to show that a homograft, a skin graft from another person, is at first rejected rather slowly. But the second time it is tried, the patient's body has acquired an immunity to it, and the graft is rejected quickly.

In the 1940's in Birmingham, in collaboration with R. Billingham, Medawer studied the problem of skin grafts in cattle. Together they concluded that the phenomenon they called "actively acquired tolerance of homo-graft" could be artificially produced. Medawer continued to work with Billingham and L. Brent in London, and their work began to cause great excitement in the transplant field. In 1953 they published a paper on their experiments.

They had proved that the full I capacity to produce immunity is only reached several weeks after birth. Burnet had early theorized that the capacity to recognize self-substance is not inherited, but acquired in fetal life. During the constant contact with self-substance, the developing immunity-producing tissue must learn to recognize and "remember" its pattern. If this assumption were correct, a foreign pattern could also impress itself on the immunological memory if it were introduced into the fetus at the right time. Burnet predicted the possibility of experimental preparation of an individual so as to make him later able to accept a foreign substance as his own.

Medawer, Billingham and Brent, working on this hypothesis, inoculated unborn mice with tissue from another variety of mice. Then after the mice had been born and reached immunological maturity, grafts of the same immunological pattern were performed. They were not rejected. Further, it was discovered, the injection of white blood cells from the lymphatic system could confer tolerance for grafts of skin, tissue, ovaries, kidneys, thyroid or adrenal glands.

In March, 1960, Medawer delivered the Dunham Lectures at Harvard. The large amphitheater of the medical school was packed and loudspeakers in other auditoriums broadcast to the overflow audience. In December, 1960, Medawer and Burnet were jointly awarded the Nobel Prize in medicine.

Their observations now have been further expanded. The recent heart transplant operations have raised a host of questions as to how long the recipient's immunity can be suppressed. Experiments now being carried on, based on the work of Burnet and Medawer, may provide the answers.

There are many others not so famous, well known, nationally or internationally, in their fields. One is Dr. Victor Najjar, Professor of Microbiology at Vanderbilt University in Nashville, Tennessee. His name appears in a variety of common medical terms, such as the Najjar Solution and the Crigler-Najjar Syndrome.

The Najjar Solution is the solution now widely used by UNRWA to rehydrate badly dehydrated babies, victims of a combination of intestinal disorders, intense heat and improper care. The Crigler-Najjar Syndrome, the description and analysis of which made Najjar world-famous in his specialty, the metabolic diseases of children, is a condition that causes newly born babies to look extremely jaundiced, and which eventually fatally affects the brain. Najjar discovered that the condition was due to a congenital absence of the enzyme that clears the body of bilirubin.

A graduate who left and came back was Dr. Khalil Wakim, who emigrated from Lebanon to the United States with a Mayo Foundation fellowship to become Professor of Physiology and consultant at the University of Minnesota. He returned in 1950 at the request of the Syrian government to help reorganize the medical college and modernize the hospitals of Damascus. For this he was awarded the Gold Medal of the Highest Order of Merit by both Syria and Lebanon.

One of the most notable representatives of women in medicine is Dr. Rosalie Nemir Audi, past president of the American Medical Women's Association—the highest position a woman can hold in United States medical organizations. Born in Waco, Texas, in 1905—the same year that Anastase Barakat, the first Lebanese woman doctor, graduated from Harvard's medical school—she graduated from Johns Hopkins Medical School and now is Professor of Pediatrics at New York University and director of the Children's Chest Clinic at Bellevue. She is well known for her many articles on pneumonia and tuberculosis. Married, with two sons and a daughter, she has a strong interest in all aspects of Lebanese culture which makes her Brooklyn home a magnet for Lebanese in the United States. Last autumn Dr. Audi was awarded the Order of the Cedars by the Lebanese government.

It can be asked what now is Arab in the medicine taught, learned, practiced and researched by Arabs. A distinguished Lebanese doctor, in a passion of logic, told me, "There are no Arab doctors," and spent a good half-hour enlarging on his statement. Arab medical students are taught techniques developed in Russia, Britain, the United States, sometimes by foreign teachers, in foreign-built universities. Many pursue graduate studies abroad, and some become foreign citizens. (My own doctor, in a slight reversal of the usual procedure, was born of Lebanese-American parents, studied medicine in the United States, then returned to practice in Lebanon with an American wife.)

And, in a positive way, the doctor is right. There are, except by the criterion of blood, no "Arab doctors" practicing "Arab medicine". But neither now, is there American medicine, or British medicine, or Russian medicine. Perhaps it is one slightly hopeful sign in a world of splintering disputes that the sick are not victims of the more depressing forms of nationalism; medical discoveries of Communists and capitalists, Asians and Europeans flow freely back and forth, in the medical journals, in conferences and forums. South Africa saw, without much of a quiver,, a white Jewish South African receive the heart of a racially-mixed Christian South African at the hands of a South African of Dutch origin, the success of whose work may depend on the experiment of two British citizens, one of Scottish, one of Lebanese descent. In medicine, at least, there are no national boundaries. There is one medicine, a structure to which no nation has not contributed a stone, the symbol not of confusion but of comprehension.

Leslie Farmer, a free-lance writer who specializes in the Middle East, is also a feature writer for Beirut's Daily Star.

This article appeared on pages 2-7 of the January/February 1969 print edition of Saudi Aramco World.


Check the Public Affairs Digital Image Archive for January/February 1969 images.