Introduction: The Birth of Medicine
Excellencies, Ladies and Gentlemen,
It is with great humility that I accept the great honor you bestow upon me today. Thank you from the bottom of my heart.
In coming here, I reflected upon the nobility of the medical profession, healers and researchers all, and how proud I am to be included in your company. But I also looked back at my forbears and I am also proud of the legacy that I am heir to as I come to stand in the midst of this august company.
I come from Egypt where medicine was born and where the brain was given a name and its components studied. Egypt, home of the earliest students of physical disease and mental health, the healers of millennia ago, who wanted to assist their fellow humans out of their misery by the application of that special combination of art and science that medicine remains to this day.
Egypt has a unique time scale. The Stela of King Narmer – dating from over 5100 years ago – recorded the unification of northern and southern Egypt, thereby creating the longest continuous human society with a central government within boundaries that have remained approximately unchanged, and have been recognized as “the land of Egypt” ever since. The vastness of that time scale is worthy of reflection. When Alexander the great came to Egypt, there was more distance in time between Alexander and the pyramid builders than there is between Alexander and us today!
So from the mists of time, there emerges the majestic figure of the ancient Egyptian Polymath Imhotep, known for having been the architect/engineer of the stepped Pyramid of Saqqara, precursor to all the great Egyptian pyramids that were to follow. But Imhotep was also a medical doctor of great ability, and he was also deified by the ancients as the Egyptian God of Medicine. So it was in that land, as old as time itself, that something miraculous happened: Imhotep was the first recorded case of advancement based on intellectual merit rather than by birth or conquest. I would invite all who believe in the virtue of a merit based system to reflect on the time scale and on the significance of that advancement based on merit.
Imhotep who flourished almost 5000 years ago, is considered to be the author of a medical treatise which was handed down through the generations, and survives in a copy– the so-called Edwin Smith papyrus – which is between 3500 and 4000 years old. That document is remarkable for containing anatomical observations, diagnoses of ailments, and recommendations for cures, all of which are based on empirical observation and devoid of magical interpretations.
Thus, Imhotep should deservedly be considered the father of Medicine for having established that humans can study and understand both trauma and disease and can intervene to deal with it by surgery and herbs. It was under his tutelage that the exquisite combination of art and science that medicine represents was born. The study and understanding of both trauma and disease and the designation of treatment by surgery or herbs – the science part – was added to the skill of talking with the patient, the agility in handling the broken limbs and the dexterity of suturing – the art part. It is also interesting to note that in this earliest catalogue of interventions, the recommendations also include the cases where it is recommended not to intervene
However, the Edwin Smith Papyrus is also remarkable for something else. It is the first time that the word ‘brain’ appears in any language. Further, the papyrus describes realistic anatomical, physiological and pathological observations. It contains the first known descriptions of the cranial structures, the meninges, the external surface of the brain, the cerebrospinal fluid, and the intracranial pulsations.
The procedures described in the Edwin Smith papyrus demonstrate that the Egyptian level of knowledge of medicine surpassed that of Hippocrates, who lived 1000 years later than the papyrus, not to mention the original and much older text from which it was copied.
But that is not to say of course that the ancient Egyptians did not also believe in magic and resorted to incantations and other such formulae to complement what their empirical studies and clinical observations had allowed them to diagnose as diseases and what to recommend as treatments. Again, in another very famous ancient medical Papyrus – the so-called Ebers Papyrus – we have a much larger document, and it is considered the single most voluminous record of ancient Egyptian medicine known. The scroll contains some 700 remedies and magical formulas. But it is striking also for reflecting evidence of a long tradition of empiricism. For example, the Ebers papyrus suggested treatment for asthma to be a mixture of herbs heated on a brick so that the sufferer could inhale their fumes.
Also worthy of note is that the ancient Egyptians conceived of mental and physical diseases in much the same way. Disorders such as depression and dementia are covered not as spiritual conditions to be treated by magic only, but also as diseases to be treated by Doctors. These Mental disorders are detailed in a section or chapter of the Ebers Papyrus called the Book of Hearts. The descriptions of these disorders suggest that there was serious empirical observation that had gone in the study of these diseases.
Alexandria: From Greece to Rome and Beyond
Leaving aside the evolution of medicine in non-western cultures such as Asia and particularly China – which deserves a separate lecture – we can trace the next chapters of the evolution of medicine to the Golden Greeks who flourished in the first millennium BC and who still dazzle us with their philosophy, science and art.
In ancient Greece, Asclepius was the god of medicine, combining religion and mythology. The staff of Asclepius, a snake-entwined staff, remains a symbol of medicine today.
Asclepius and his daughters represent the best about being and remaining healthy. His daughters are:
- Hygieia ("Hygiene", the goddess/personification of health, cleanliness, and sanitation),
- Iaso (the goddess of recuperation from illness),
- Aceso (the goddess of the healing process),
- Aglæa/Ægle (the goddess of beauty, splendor, glory, magnificence, and adornment), and
- Panacea (the goddess of universal remedy).
What a lovely household.
But it is from the most famous practicing physician of the Age of Pericles, Hippocrates of Kos, who was born in 460 BC, and died in 370 BC, that we trace the ethical oath that all doctors repeat to this day.
But that brings us back to the land of Egypt. For less than half a century after the death of Hippocrates, Alexander the Great (356 BC- 323 BC), pupil of Aristotle, would conquer the known world of his time and found the city of Alexandria. His successors the Ptolemies would turn it into the intellectual capital of the world.
So between the decline of splendid Greece and the rise of mighty Rome, there is the glorious period of the dazzling new capital of learning and knowledge on the shores of the Mediterranean: Hellenistic Alexandria, with its magnificent lighthouse and its famous ancient library. Alexandrian medicine would bring the best of the Egyptian and Greek traditions together to create a very important school of medicine.
Herophilus, who was one of the greatest figures in Alexandrian medicine and who established his own school of medicine, was a pioneer of functional physiology, and produced a very large amount of anatomical writings. He correctly identified that it is the brain that is the controlling organ of the body, and not the heart as Aristotle had said. He carried out pioneering work on the anatomy of the brain and nervous system, and is credited with the identification of the dura mater and pia mater, two of the brain's membranes; and with tracing the connections between the spinal cord, nerves, and the brain.
So important was the Alexandrian school, that even long after it had started its gradual decline, Galen, the famous Roman physician, came to study for a while in Alexandria before practicing in Rome. His teachings and writings – which incorporated much of the Alexandrian Knowledge – survived well into the sixteenth century and formed the basis of more modern medical practices during the Renaissance.
The Golden Ages and the Dark Ages:
Europe was to sink into the so-called dark ages of the medieval period where learning remained confined to a few beacons among the monasteries with an emergence of some universities and learned societies in the later middle ages. But in the east, the golden Ages of Islam were to flourish.
The sun of Islam burst out of Arabia and soon covered the world from Andalusia in Spain through Morocco to Egypt and eastward to parts of India while stretching north to Central Asia and south to Sudan and eastern and western Africa. The Arabs who carried Islam into the world were very soon a minority among Muslims of all ethnicities and races. In those vast lands, under a largely tolerant and open system of governance, Science would flourish. In fact, after the destruction of the ancient Library of Alexandria, and the murder of Hypathia at the hands of a zealot Christian mob in 415 CE, it was in the early 9th century that much of the knowledge of the ancient world was re-collected in Baghdad’s House of Wisdom and translated into Arabic.
Indeed, throughout the dark ages it was the Muslims who held up the torch of rationality and reason, while Europe was in the throes of bigotry and intolerance. And here all of you, scholars and medical practitioners alike may be interested in this amazing story:
We are at the beginning of the ninth century and the Abbasid Empire stretches from Morocco to India, and from central Asia to the Sudan. The capital is Baghdad. The new Caliph Al-Maamoun, son of the legendary Caliph Haroun Al-Rasheed of Arabian Nights fame, would give a big push to the project of the House of Wisdom. He actually offered that anyone who would translate an ancient manuscript into Arabic would receive its weight in gold. Soon, from all over the vast empire manuscripts were being collected and translated. Soon the Vizier, Al-Maamoun’s minister of Finance, said that: “The scholars are cheating: they are using big letters and thick paper in order to increase the gold they will receive”. To which Al-Maamoun replied: “let them be, for what they give us is infinitely more valuable than the gold we give them”…. All scholars must aspire to have rulers with such priorities!
As a result of that enormous program of translation Arabic became the language of knowledge and science within less than a century. But the program also helped gather the remnants of all the copies of manuscripts from the Great Ancient Library of Alexandria that remained anywhere in the vast Abbasid empire. These were gathered back into the house of Wisdom in Baghdad as their owners rushed to have them translated and get their weight in gold. The Arabic translations were copied many times over and they traveled far and wide in the Empire and found their way to Europe through Spain and Sicily and other points.
Ah! But not all societies in the middle ages were so sympathetic to learning and books. Baghdad, with its fabulous House of Wisdom, was destroyed by Hulagu and his Mongol armies in 1258 CE. But the talents of Muslim scientists would still shine on for another 400 years as they had in the preceding 400 years, spread throughout the lands under Muslim control from Andalusia to India and from Central Asia to Sudan.
In Cairo, we can name Ibn al-Haytham (965-1040), Latinized as Alhazen, who was born in Basra but practiced in Egypt. He is the true founder of the modern empirical scientific method. Listen to how Ibn Al-Haytham described that method, centuries before Bacon, Descartes and Galileo, and how he laid down the rules of the empirical approach, describing how the scientific method should operate through observation, measurement, experiment and conclusion:
“We start by observing reality … We then proceed by increasing our research and measurement, subjecting premises to criticism, and being cautious in drawing conclusions… In all we do, our purpose should be … the search for truth, not support of opinions”.
From the land of Spain, we can name Abū al-Qāsim Al-Zahrawi (936-1013), Latinized as Abulcasis, a brilliant Arab Muslim physician and surgeon who designed many surgical instruments that have proven very useful over the centuries, as has his book Al-Tasrif.
From Persia, or modern day Iran, we can cite Abū Bakr al-Rāzī (854-925), Latinized as Razes, was a Persian polymath, physician, alchemist, philosopher, and a major contributor to medicine. And also from Persia, we have Ibn Sina (980-1037), Latinized as Avicenna, who was one of the greatest figures of the middle ages, another polymath who produced much in many fields. He is said to have written 450 work of which around 250 have survived, including 150 on philosophy and 40 on medicine. Of his medical works, Al-Qanun, or the Canon would remain one of the most influential medical references throughout the middle ages.
But getting back to Egypt, we must also cite the great Ibn al-Nafis (1213-1288), a physician mostly famous for being the first to describe the pulmonary circulation of the blood, but whom I admire mostly for his advocacy of openness to unusual and contrarian views, and accepting opinions only subject to evidence and argument. Listen to the voice of Ibn Al-Nafis (13th C) on accepting the contrarian view, subject only to the test of evidence and rational analysis.
“When hearing something unusual, do not preemptively reject it, for that would be folly. Indeed, horrible things may be true, and familiar and praised things may prove to be lies.”
This was the practice in these golden years of Islam, while Europe mostly suffered in the dark ages, the inquisition was still to come, and Galileo, four centuries after ibn Al Nafis would be put on trial in 1633.
Likewise, you all know the difficulties that confronted Darwin and the supporters of the theory of evolution in western societies even as late as the 19th century. Well, listen to the words of one of the most respected scientists of islam, father of sociology, and important historian, judge and diplomat, listen to how Ibn Khaldun reflected on the world and arrived at his own theory of evolution in the 14th century, some 500 years before Darwin and he was not attacked nor vilified for his having sidestepped the story of Adam and Eve :
One should then take a look at the world of creation. It started out from the minerals and progressed, in an ingenious, gradual manner, to plants and animals. The last stage of minerals is connected with the first stage of plants, such as herbs and seedless plants. The last stage of plants, such as palms and vines, is connected with the first stage of animals, such as snails and shellfish which have only the power of touch.
The word 'connection' with regard to these created things means that the last stage of each group is fully prepared to become the first stage of the newest group.
The animal world then widens, its species become numerous, and, in a gradual process of creation, it finally leads to man, who is able to think and reflect. The higher stage of man is reached from the world of power, in which both sagacity and perception are found, but which has not reached the stage of actual reflection and thinking. At this point we come to the first stage of man.
This is as far as our (physical) observation extends.
-- Ibn Khaldun (1332 – 1406)
This is the Muslim tradition that must be revived if the Arab World, Muslim and non-Muslim alike, will indeed join the ranks of the advanced societies of our time. Rejecting politicized religiosity, and reviving these traditions would promote the values of science in our societies… but that is for another discussion another day. Suffice to say that after the early years of the Ottoman Empire it quickly became an ossified structure and the gradual decline of the Muslim and Arab lands was to begin, while the torch would now pass to Europe.
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A Special Case: Mental Diseases:
Excellencies, ladies and gentlemen,
I would like to add one more aspect to this discussion of Medieval Medicine as it was practiced in the Muslim empires of the time, namely, how mental disorders were addressed.
We can cite among the most famous authors who wrote on mental disorders and/or proposed treatments during this period: Al-Balkhi, Al-Razi, Al-Farabi, Ibn-Sina, Al-Majusi, Abu al-Qasim al-Zahrawi, and Ibn Rushd (Averroes). They wrote about fear and anxiety, anger and aggression, sadness and depression, and obsessions. Arab medical texts from this period contain detailed discussions of melancholia, mania, hallucinations, delusions, and other mental disorders. They were concerned with the links between the brain and disorders, while they also searched for spiritual/mystical meaning of the disorders.
Mental disorder was generally connected to loss of reason. And in the Islamic tradition, the mentally ill were considered incapable of running their own affairs, but fully deserving of humane treatment and protection.
Muslims built the first psychiatric treatment hospital in the World. Within the first century of Islam, by order of the Umayyad Caliph Al-Walid ibn Abd al-Malik, such a hospital was founded in Baghdad in 705. Insane asylums were built in Fes in the early 8th century, Cairo in 800 and in Damascus and Aleppo in 1270. Insane patients were treated with baths, drugs, music and activities. In fact by some accounts, the physicians of the Islamic world would invent and use a variety of treatments, including occupational therapy, music therapy, as well as medication.
In the centuries to come, Latin translations of many scientific Islamic texts would play a major role in Europe. But these Muslim progressive concepts to dealing with mental disorders would not come to Europe until the 19th century. By that time, the eastern lands of Islam had fallen behind, and Europe had become the dominant civilization on the planet.
Before the 19th century, conditions in the so-called lunatic asylums of the West were basically beastly places of confinement and mistreatment, not to say outright abuse. Some of the more famous inmates of such facilities as Charenton, included the Marquis de Sade, whose visions were romanticized in such literary works as Peter Wiess’ play and Peter Brooks’ film Marat/Sade and Kaufmann’s film Quills.
Improvement finally came in the West from the beginning of the 19th century when under the impetus of great reformers like Phillipe Pinel (1745- 1826) in France and William Tuke (1732-1822) in the United Kingdom, both advocates of Moral treatment of the insane, brought about a more humane and scientific outlook. Very gradually throughout the 19th and 20th centuries, western concepts of mental health and the humane and scientific treatment of patients suffering from mental disorders would evolve towards its contemporary configurations.
In the meantime, Medicine also improved in the west by such breakthroughs as the introduction of anesthesia, nursing and better understanding through the work of such giants as Pasteur and Koch who gave us the germ theory of disease, Darwin who gave us evolution and Freud who invited us to look into the inner self. They and others helped pave the way for the giant strides that western medicine made in the 20th century, a time when Europe was practically ruling the world, and medicine and mental health would transform themselves in the 20th century.
Europe Ascendant, America Dominant
Following the European Renaissance and the scientific revolution, Europe would rule the world. The values of the Enlightenment would appear mostly from the 17th and the 18th century and bring their fruits in the American and French revolutions and the subsequent reforms that would cover England and the rest of Europe. The 19th century would see the full emergence of the modern state, whose seeds were found in the treaty of Westphalia.
I will not go over that history which you know only too well, and which covers the establishment of your profession, with its many disciplines and its evolving standards of practice. Rather let me skip to a few observations about the challenges of the new Century. The emergence of the new genetics, the much expanded understanding of the human body, and the new technologies that will allow nano-scale interventions, all herald a new golden age of medicine for the treatment of all diseases, much expanded life expectancies, and healthier lives for all. But that rapidly expanding knowledge base also reminds us to be humble, for it also underlines how much more we still have to learn.
But from those who treat the individuals, we need to build bridges to those who want to treat entire societies. For when I see the failures of our political discourse, the shallowness of our vaunted new domains of social connectivity, and the complete collapse of once-vibrant societies, I can only hope that other professions will be as effective as medical doctors in developing their domains of knowledge and insights, so that we will be able to better understand and cope with the transformations that we are living through, and that we will also be able to better diagnose the social pathologies that societies like our own are being subjected to.
In Egypt, as in other parts of the Muslim and Arab Worlds, we the intellectuals who produce art and science must hold up mirrors to ourselves and to our societies and ask why is it that our societies have become such fertile ground for extremism and violence? We must overcome fear and open windows onto the rest of the world and seek out different and more open relations with the “other”. We must promote pluralism, dialogue and understanding, and cherish diversity and the enrichment it brings. We must help move the values of our societies to embrace not only the new technologies but also a vision of a more desirable future.
Thank you.