A SHORT HISTORY OF NEUROLOGY The Arab & Muslim Contribution 500-1516 A.D

A SHORT HISTORY OF NEUROLOGYThe Arab & Muslim Contribution 500-1516 A.D Regional and 21st International Conference of Alzheimer's Disease 28th Sep -1st Oct 2005 Ashraf Kurdi FRCP (G) FRCP (London) Amman,JORDAN

Introduction • The language of science at the time was Arabic. • Many scientists and physicians throughout the Muslim Empire taught and wrote in Arabic. • Many scientists were born all over the Muslim Empire from Central Asia to Andalusia with various ethnic and religious backgrounds, but what united all of them was the Arabic language which they all used in their work. The political and cultural stability coupled with religious tolerance was paramount in allowing their work to flourish. • One should not restrict the term of Arab Medicine to those born in what is now an "Arab" country, but think more globally without ethnic, religious or social restraints.

Introduction ... • In the history of Arab medicine, we can easily identify several consecutive periods: • Pre-Islamic and early Islamic medicine from 500 - 750 A.D, the end of the Umayyad caliphate in Damascus. • The expansion of Arab medicine started when the Arabs conquered Syria, Mesopotamia, Persia and Egypt and came in contact with an established medical science and tradition. This period coincided with the rise of the Abassid caliphate from 750 - 900 A.D, and the expansion of translation from the Greco-Roman medicine into Arabic with addition of personal commentaries and experiences to the original text.

Introduction ... • The flourishing period of pure Arab medicine, which started during the Abassid Caliphate around 900 A.D and spanned through to the Andalusian era up to 1300 AD. • The fourth period from 1300 - 1516 AD. This was exemplified by the reverse wave of translations from Arabic into Latin starting in the western countries of the Arab domain, and the propagation of Arab medicine from the schools of Southern Italy and Spain into the north, especially Northern Italy, France and Germany. Although at the same time another direct translation from Greek into Latin was provided to the physicians of Europe, the Arabic translations, due to their rich and encyclopedic material remained to be the basic textbooks to those physicians and thus became the main stimuli for the renaissance in the West

Pre-Islamic and early Islamic period (500 - 750 A.D) • This period can be further broken down into two distinct periods: • Pre-Islamic period (500 – 621 AD), including the Late Greek and Roman periods. • The early Islamic period which included the rise of Islam (621 - 661 A.D), which was during the prophet's time and the Orthodox Caliphate and the Umayyad period (661 - 750 A.D).

The Abassid period (750 - 900 A.D) • Center of power moved from Damascus to Baghdad • Translators • Bakhtyashoo Family (730 – 1058 AD) • Yohanna bin Masawaiyah (778 – 856 AD) • Hunain bin Ishaq (809 – 873 AD) • Costa bin Luqa (Died 912 AD) • Thabet Bin Qurra (836 – 901 AD)

Ali Bin Rabban Al-Tabari(838-870 AD)

Ali Bin Rabban Al-Tabari (838-870 AD) • Author of the first Arabic Medical Encyclopedia (The Paradise of Wisdom) • Born and educated in Tabaristan before moving to Baghdad • The most important characteristic of Al-Tabari was his reliance on his personal experience and the clinical cases he treated or heard of from reliable sources. One of the last chapters of his book is devoted to psychotherapy where he cites several examples of the effectiveness of this treatment in psychosis

Ali Bin Rabban Al-Tabari (838-870 AD) • In neurology • He wrote about anatomy and physiology of the Central Nervous System • first to mention the internal sensations, which are called "common sensations” • first among the Arab authors to write on Epilepsy, headache, Effect of psychological states in disease occurrence • Described tetanus as a disease and predicted the death of the patient within four days • Described hemiplegia, facial palsy and speech difficulties associated with hemiplegia.

The Flourishing Period (900 - 1300 AD) • During this period the Islamic Empire extended from China in the East to its Western Domain in the Iberian Peninsula (Andalusia and Portugal).

The Flourishing Period (900 - 1300 AD) ... • The Arabic Language was by far the language of science in that era • Since the empire was so wide spread, the contribution was not necessarily made just by Muslims. Many Christians and Jews had major contributions and only through the tolerance of Islam did these scientists and physicians find the freedom to study, practice, write and teach. Their contributions were accepted and highly respected

The Flourishing Period (900 - 1300 AD) ... • The relationship between the eastern and western part of the Empire was never interrupted. Physicians and scientists made several trips from one part to another carrying with them books, knowledge and experience. • In the East, Centers of Medical excellence were already established and flourishing. Hospitals, as both, centers of education, training and treatment were widely spread. Libraries attached to these institutions contained treasures of medical books. • Among the most famous physicians of the time were Ar-Razi (Rhazes), Al-Majusi (Haly Abbas) and Ibn Sina (Avicenna).

The Flourishing Period (900 - 1300 AD) ... • In Andalusia, the Arabs established a highly sophisticated civilization and many physicians and philosophers appeared throughout this period. • The most famous were: Ibn Rushd (Averroes), Musa bin Maimun (Maimunedes) and several physicians from the family of Ibn Zuhr (Avenzoar). • The most famous surgeon of the era was Abu al-Qasim al Zahrawi (Abulcasis). His book on surgery “Al-Tasrif”, in which he described the surgical tools used at that time, remained to be a reference for several centuries.

Abu Bakr Mohammed Bin Zakariya Ar-Razi (Rhazes) (841–925 AD)

Rhazes • Rhazes is considered to be one of the greatest doctors known to humanity • Princeton University in the U.S. set aside the best suite in its most beautiful building to the achievements of Rhazes and established a center to teach the Arabic language and translate his manuscripts into English. • Six hundred years ago, the school of medicine in Paris had the smallest library in the world. It contained only one book, Al-Hawi (the Container) in medicine by Rhazes. He also excelled in many fields including philosophy, Botany, zoology, mathematics, physics and music.

Rhazes ... • Rhazes was born in Ray, near modern-day Tehran in Persia. • He learned his anatomy from Galen’s books and from his teacher Bin Masawaiyah. • In Baghdad he dissected animals, particularly monkeys, and also made many anatomical quotes, such as “knowing the anatomy of that organ you will understand its functions, then the illnesses that might attack that organ”. • He established a new tradition assimilating Greek and other medical cultures. He wrote more than two hundred books and articles, half of which relate to medicine.

Rhazes ... • His work was translated from Latin and soon became the standard textbooks in most of the medical schools of Europe. • He emphasized in his writings and lectures, that doctors should take note of the medical history as told by patients, emphasized doctor patient relationship and advised patients not to change doctors, except when necessary. • Rhazes was the first to treat patients who were considered incurable. He went against what Hippocrates advocated in keeping one’s distance from incurable patients. He strongly committed himself to treat these patients and continuously encouraged them and helped them in facing their ailments.

Rhazes ... • He also was sympathetic and firm in trying to treat patients with neurologically incurable diseases unlike Medieval Europe and the church where such patients used to be imprisoned and degraded. To that effect he was a true humanitarian • He was most noted in dealing with the question of epilepsy. He was the first to distinguish between Hereditary and Acquired Epilepsy.

Rhazes ... • He says: “epilepsy is a convulsion that affects the whole body. Yet it is not permanent, since its illness disappears quickly. The ill effects that are caused to the head and body organs indicate that the illness emanates from the brain”. • Rhazes was also the first to describe the recurrent laryngeal nerve and thought it originated near the trachea. He studied the function of nerves. He said “ if the nerve was cut longitudinally nothing will happen to that nerve, but if cut transversely, both sensations and motor power will be lost and it will be out of hand, no use for treatment”.

Rhazes ... • He went against Galen as related to Hemiplegia when he identified that the source of the paralysis is in the brain whereas Galen related it to the ventricles. • Al- Hawi (the Container) his most famous medical encyclopedia was written in 25 volumes. The first volume was dedicated to Head illnesses and contained 11 chapters dealing with most of the neurological diseases such as stroke, paralysis, numbness, convulsions, cognition, facial weakness, epilepsy, nightmares, spasticity, tetanus, meningitis and encephalitis, headache, migraine and confusion

Ali Bin Abbas Al-Majusi (Haly Abbas) (?-995 AD) • Haly Abbas was born in the town of Ahwaz near Jundishapur. • The name “Al-Majusi” is said to indicate that he was a Persian of Zoroastrian ancestry. • He reached his greatest eminence about 50 years after the death of Rhazes. • He wrote “Kamil Al-Sina’ah al-Tibbiya”, also known as Al-Kitab Al-Malaki, the Royal Book (Liber Regius).

Haly Abbas ... • Haly Abbas considered that nerves originate in the brain, which is the center of sensory and motor action. • This action is mediated in the brain through the cranial nerves and to the rest of the body through the spinal cord. • He identified that nerves originating from the brain are bundled in 7 pairs and that each nerve prior to emerging from the skull is covered with two layers referring to the Pia matter and the Dura matter.

Haly Abbas ... • Haly Abbas described the pathophysiology of certain disorders that affect the brain and the spinal cord. • Examples of Brain disorders include headache, trauma, parasthesia, confusional states, meningitis, apoplexy, epilepsy, hemiplegia, melancholy, obsession, memory loss, mania and coma. He also described different types of skull fractures • Examples of Spinal cord disorders include paralysis of flaccid and spastic type, clonus and parasthesia.

Abu Ali Al-Hussein Bin Abdallah ibn Sina (Avicenna) (980-1037 AD)

Avicenna • Avicenna was born near Bukhara (Central Asia) and was called the Sheik, the Chief and the second teacher, after Aristotle. • He is highly respected for his contribution to the field of medicine, both as a transmitter of the knowledge of men like Hippocrates, Aristotle and Galen, and as an original thinker on the subject. • His energy and intelligence were all embracing, and he also studied and wrote widely on philosophy, astronomy, mathematics, the Arabic Language, music and several other domains of knowledge, thus producing over 276 books in all branches of knowledge. He was an encyclopedic thinker

Avicenna ... • He was the first to identify Meningitis thus refuting the sayings of the ancients that the soft and hard tissues such as the brain and bones are not affected by inflammation, he was the first to differentiate paralysis based on primary and secondary etiological factors related to the brain. • He described stroke resulting from bleeding, contrary to common belief of the era based on Greek medicine. He differentiated central and peripheral facial weakness. • Avicenna was the first to use oral anesthesia and deduced that Opium was the strongest anesthetic.

Avicenna ... • Avicenna also described a fundamental scientific fact in the fractures of the skull. The skull bones contrary to other bones in the body do not heal after fracture in the same way as other bones in the body. The skull is connected by fibrous tissues and only through these does the skull heals and broken segments reconnect. • He further broke down skull fractures into two types, closed and open fractures and ascertained that deep broken fragments of skull fractures should be removed to avoid further complications.

Avicenna ... • Avicenna also divided headache into three types; Ordinary Headache, Headache caused by brain damage and Migraine (Al-Shaqiqa). • He was the first to formulate a mature idea about the underlying pathophysiology of Migraine: “migraine is due to hyper excitability of brain tissue which causes the brain to react unusually to noises and to light stimuli”. • He also described several effective medications for headaches.

Avicenna ... • Avicenna differentiated between two types of epilepsy, Grand Mal and Petit Mal. In his description of Grand Mal epilepsy he identified three stages of the attack as follows: • Aura • Clonic phase • Relaxation • He also differentiated between apoplexy and Coma. Moreover, Avicenna introduced novel methods of treatment such as the use of ice packs in the treatment of various neurological illnesses and more dramatically the use of swimming in tanks with Electric eels for the treatment of Epilepsy (Electrotherapy)

Avicenna ... • His book (Al-Kanoon) was the most famous and contained the essence of Greek and Arab medicine. • It comprises five volumes among which are neurological diseases. • It was printed twenty times in Latin in the sixteenth century alone and was the principal medical text in the Arab World and Europe for about eight centuries. • Avicenna summarized all medical knowledge in a poem of 1326 verses.

Avicenna ... • The first topic in the third volume in Al-Kanoon deals with the diseases of the head and the brain. It contains five articles: • The First covers the overall provisions of the diseases of the head and thebrain. • The Second deals with the aches and pain of the head • The Third deals with head tumors • The Fourth deals with the illnesses of the head that mostly affect the sensory and management actions • The Fifth deals with brain diseases that strongly affect voluntary movement • The second topic in the third Volume of Al-Kanoon deals with nerve diseases.

Abu Al-Qassim Bin Abbas Bin Khalaf Al-Zahrawi (Abulcasis) (936-1010 AD)

Abulcasis • Abulcasis was born in the city of Al-Zahraa, to the west of Qurtubah (Cordoba). • He placed his knowledge and expertise in a single book called “Al-Tasreef” (practical guide for those who cannot be authors). • It is composed of 30 articles divided into two parts, medical and surgical, with the surgical part divided into three sections. The last one is devoted to brain and Neurosurgery, particularly ailments resulting from head and brain injuries, skull fractures and the use of skull trepanation.

Abulcasis ... • John Shaning did the first modern Latin translation in Oxford in 1778. • Lucien de Clerq did the first French translation in 1861. • In 1908, Loco published an Arabic illustrated edition. In 1974, Loco printed an English edition together with the Arabic original and the illustrating instruments. • Al-Tasreef gained world fame and was the basic book for surgery in Europe for five centuries. • The Europeans adopted and developed a lot of its Contents.

Contributions to Neurosurgery • General Scientific contributions • Abulcasis compiled all that pertained to Neurosurgery and added a more developed type of surgery based on anatomy. • He used anesthesia during surgical operations to alleviate the pain of patients • He was the first to • describe skull fractures and their complications and also the first to describe depressed skull fractures in children. • to call on surgeons to familiarize themselves with the anatomy of the body parts they were about to operate on

Contributions to Neurosurgery ... • He understood and realized that pain should not be considered as an illness, but as a symptom. Accordingly the root cause of the pain, not pain itself should be treated • He considered hygiene as basic in the treatment of wounds. • He called for the sterilization of wounds and used Alcohol for this purpose contrary to the ideas of his contemporaries • He described head injuries including bleeding inside/outside the skull

Contributions to Neurosurgery ... • Technical Contributions • Abulcasis invented an instrument that prevents involuntary penetration of the skull of the patient during the process of trepanation, and this modification is still in existence today. • Described and performed a cranium fissure in the same manner performed nowadays. He made several holes in the skull and then connected them.

Contributions to Neurosurgery ...

Contributions to Neurosurgery ... • Stressed the need for utmost care before brain surgery to remove bones and coarseness resulting from injuries. He stressed the need to have these areas clean and sterile. • Called for the readiness of surgical instruments for emergencies. (i.e. to be kept sterile and clean) • Advised the use of female assistants and nurses when operating on women to ensure calmness and peace of mind of woman patients • Used instruments for the stretching of the neck and prolapsed Disc.

… And other Contributions • Abulcasis had also numerous contributions not only in Neurosurgery but also in the field of neurology in the areas of Apoplexy, hemiplegia, Facial Paralysis, Convulsions and Tonic Spasms, Flaccidity and Anosmia. • Professor Garcia Palestero of Granada University in Spain stated: “Abu Al-Qasim Al-Zahrawi was the greatest Muslim surgeon in the whole of the middle ages. He was the point of departure for all types of brain and skull surgeries in Spain and Western Europe”.

Concluding Remarks on the Arab Contributions to Medical Sciences • The Arabic language was the world language (Lingua Franca) of science. Until the sixteenth and seventeenth centuries, every medical student had to master the Arabic language. Between 850-1350 AD, there were 4000 medical books written in the Arabic language. • During that time, students headed towards Baghdad, Alexandria, Damascus and Andalusia to study medicine. • Translating from various pre-Arab civilizations like the Babylonian , Egyptian, Greek, Indian and Persian cultures

Concluding Remarks on the Contribution in Medical Sciences … • Polishing, developing, expanding and adding to the neurological sciences • Writing encyclopedic books on medicine and pharmacology • The first to introduce illustrations and tables in the study of medicine and the first to write medical sciences in poetical form to make it easy for students to memorize • Established various types of hospitals (called Bimaristan) including a new residency system for doctors and specialized wards for psychiatric patients. • Attached hospitals to the schools of medicine with large libraries of medical books.

Concluding Remarks on the Contribution in Medical Sciences … • Introduced examinations and prohibited unlicensed or unqualified persons from practicing medicine. • Emphasized ethical standards that were based on • Hippocrates • Christian values and principles • Islamic values and principles • Played an important and prominent role in the study of anatomy, physiology, diagnosis and treatment of various neurological disorders.

Concluding Remarks on the Contribution in Medical Sciences … • Described Neurosurgical operations, instruments and sutures. • Played a large role in discovering anesthesia and sterilization by alcohol. • The West built on this foundation and embarked on its modern renaissance that came in the wake of the stillness of themiddle ages, and took off at the beginning of the seventeenth century.

A SHORT HISTORY OF NEUROLOGY The Arab & Muslim Contribution 500-1516 A.D