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HISTORY OF ANCIENT MEDICINE

HISTORY OF ANCIENT MEDICINE IN MESOPOTAMIA & IRAN

Massoume Price, October 2001

 

Science including medicine has a long history in Middle and Near East and goes back to the ancient Mesopotamian period (Beginning with Sumer 3000BC). There are many cuneiform tablets from cities as ancient as Uruk (2500 BC). The bulk of the tablets that do mention medical practices have survived from the library of Asshurbanipal at Nineveh (668BC) Assyria. So far 660 medical tablets from this library and 420 tablets from the library of a medical practitioner from Neo-Assyrian period, as well as Middle Assyrian and Middle Babylonian texts have been published. The vast majority of these tablets are prescriptions, but there are a few series of tablets that have been labeled “treatises”. One of the oldest and the largest collections is known as “Treatise of Medical Diagnosis and Prognoses.” The text consists of 40 tablets collected and studied by the French scholar R. Labat. Although the oldest surviving copy of this treatise dates to around 1600 BC, the information contained in the text is an amalgamation of several centuries of Mesopotamian medical knowledge. The diagnostic treatise is organized in head to toe order with separate subsections covering convulsive disorders, gynecology and pediatrics. To the non-specialist they sound like magic and sorcery. However, the descriptions of diseases demonstrate accurate observation skills. Virtually all expected diseases exist, they are described and cover neurology, fevers, worms and flukes, venereal disease and skin lesions. The medical texts are essentially rational, and some of the treatments, (such as excessive bleeding) are essentially the same as modern treatments for the same condition.

Mesopotamian diseases are often blamed on pre-existing spirits: gods, ghosts, etc., and each spirit was held responsible for only one disease in any one part of the body. Ancient mythologies tell stories of diseases that were put in the world by supernatural forces. One such figure was Lamashtu the daughter of the supreme god Anu, a terrible she-demon of disease and death. It was also recognized that various organs could simply malfunction, causing illness. Medicinal remedies used as cures were specifically used to treat the symptoms of the disease, and are clearly distinguished from mixes or plants used as offerings to such spirits. There were two distinct types of professional medical practitioners in ancient Mesopotamia. The first type of practitioner is called ashipu, who in older texts is identified as a sorcerer or the witch doctor. One of the most important roles of the ashipu was to diagnose the ailment. In the case of internal diseases or difficult cases the ashipu determined which god or demon was causing the illness. He also attempted to determine if the disease was the result of some error or sin on the part of the patient. He pre- scribed charms and spells that were designed to drive out the spirit causing the disease. The ashipu could also refer the patient

to a different type of healer called an asu. He was a specialist in herbal remedies, and in texts is frequently called “physician” because he dealt with empirical applications of medication. For example in case of wounds the asu applied washing, bandaging, and making plasters. The knowledge of the asu in making plasters is of particular interest.

Many of the ancient plasters (a mixture of medicinal ingredients applied to a wound often held on by a bandage) seem to have had some helpful benefits. For instance, some of the more complicated plasters called for the heating of plant resin or animal fat with alkali. This particular mixture when heated yields soap which would have helped to ward off bacterial infection. The two practitioners worked together and at times could function in both capacities.

Another textual source of evidence concerning the skills of Mesopotamian physicians comes from the Law Code of Hammurabi (1700 BC). There are several texts showing the liability of physicians who performed surgery. These laws state that a doctor was to be held responsible for surgical errors and failures. Since the laws only mention liability in connection with “the use of a knife,” it can be assumed that doctors were not liable for any non-surgical mistakes or failed attempts to cure an ailment. According to these laws, both the successful surgeon’s compensation and the failed surgeon’s liability were determined by the status of his patient. Therefore, if a surgeon operated and saved the life of a person of high status, the patient was to pay a lot more as compared to saving the life of a slave. However, if a person of high status died as a result of surgery, the surgeon risked having his hand cut off. If a slave died the surgeon only had to pay enough to replace the slave. At least four clay tablets have survived

that describe a specific surgical procedure. Three are readable, one seems to describe a procedure in which the asu cuts into the chest of the patient in order to drain pus from the pleura. The other two surgical texts belong to the collection of tablets entitled “Prescriptions for Diseases of the Head.” One of these texts mentions the knife of the asu scraping the skull of the patient. The final surgical tablet mentions the postoperative care of a surgical wound. This tablet recommends the application of a dressing consisting mainly of sesame oil, which acted as an anti-bacterial agent.

It is hard to identify some of the drugs mentioned in the tablets. Often the asu used metaphorical names for common drugs, such as “lion’s fat” (much as we use the terms “tiger Lilly” or “baby’s breath”). Of the drugs that have been identified, most were plant extracts, resins, or spices. Many of the plants incorporated into the asu medicinal repertoire had antibiotic properties, while several resins and many spices have some antiseptic value, and would mask the smell of a malodorous wound. Beyond these benefits, it is important to keep in mind that both the pharmaceuticals and the actions of the ancient physicians must have carried a strong placebo effect. Patients undoubtedly believed that the doctors were capable of healing them. Therefore, visiting the doctor psychologically could reinforce the notion of health and wellness. Temples belonging to gods and goddesses of healing were also used for health care. Gula was one of the more significant gods of healing. The excavations of such temples do not show signs that patients were housed at the temple while they were treated (as was the case with the later temples of Asclepius in Greece). However these temples were sites for the diagnosis of illness and contained libraries that held many useful medical texts. The primary center for health care was the home. The majority of health care was provided at the patient’s own house, with the family acting as care givers. Outside of the home, other important sites for religious healing were nearby rivers. These people believed that the rivers had the power to care away evil substances and forces that were causing the illness. Sometimes a small hut was set up either near the home or the river to aid the patient and their families.

While many of the basic tenants of medicine, such as bandaging and the collection of medical texts, began in Mesopotamia, other cultures developed these practices independently. In Mesopotamia many of the ancient techniques became extinct after surviving for thousands of years. It was Egyptian medicine that seems to have had the most lasting influence on the later development of medicine, through the medium of the Greeks. In the fifth century BC the Greek historian and traveler Herodotus commented on current medical practices in Egypt; “the art of healing is with them divided up, so that each physician treats one ailment and no more. Egypt is full of physicians, some treating diseases of the eyes, others the head, others the teeth, others the stomach and others unspecified diseases”.

 

 

ANCIENT EGYPT

 

Physicians in ancient Egypt devoted their care to disorders of individual organs. Notable among the specialties was gastroenterology, a subject matter that occupied a major portion of the surviving medical papyri. Although they did not name diseases as we know them, Pharaonic physicians described a host of gastroenterological symptoms for which an extensive array of therapeutics was prescribed. Their clinical accounts indicated an impressive knowledge of gastric and anorectal conditions. In their thinking on disease mechanism, the circulating materia peccans absorbed from feces represented a major cause of medical symptoms and disorders. This served as the rationale for the popular practice of self-purgation with enemas.

 

CANOPIC JARS

 

In the University of Stanford collection of ancient Egyptian artefacts are two alabaster canopic jars dating from the 18th dynasty (1539–1295 BC) at the time of the New Kingdom. One had a head stopper shaped like a falcon (fig 1) representing Kebeh-senu-ef, one of the four sons of Horus acting as a guardian god of the embalmed guts of the deceased. A very similar name is given at the British Museum for the same god, namely Qebhsenuef. These four sons of Horus were the genii who guarded the north, south, east, and west. Remarkably, the ancient Maya of central America also had four deities upholding heaven at the four points of the compass. The Maya also used funerary jars called after these gods.

Nunn,1 in his remarkable account of ancient Egyptian medicine, states that the embalmers showed great technical expertise removing those internal organs, most likely to putrefy through a relatively small incision. These organs could not be discarded as they could be used to cast spells against the deceased. Furthermore, they had to be adjacent to the body when, as they believed, resurrection occurred in the afterlife. The organs removed were the liver, lungs, stomach, and intestines. Each had a son of Horus as a protector as well as a protective goddess. The goddess for the intestines was Serqet. From the 18th dynasty of Egypt each canopic jar had a head. For the intestines it was described as the falcon (see above) or hawk. The internal organs were dried in natron (sodium chloride, sulphate, carbonate, and bicarbonate) and placed in the canopic jars. Interestingly, by 700 BC the organs were dried and placed back in the body. Yet canopic jars remained, in fact these were now solid wood and were only there as they had become vital to the funerary assemblage (British Museum exhibit 2001).

 

The ancient Egyptian texts of the Old Kingdom (2635-2155 BC) contain at least 50 physicians, mainly from their names on tombs. The later periods also give detailed information about physicians and their practice. Though most physicians were men, female physicians existed as well. The title ‘Lady Director of Lady Physicians’ proves the existence of a group of women who practiced as doctors. Physicians were literate, some were scribes and others were priests at the same time. Most inherited the profession from their fathers but needed to be trained in the field. The profession was organized hierarchically with the Chief Physician at the top and lesser titles following, such as Master of Physicians, Director of Physicians, Inspector of Physicians, Plain Physicians and auxiliaries such as Bandage personnel etc. Texts deal with diagnosis, treatments and prescriptions. Surgery and mummification processes used by ancient Egyptians still amazes the modern experts. All major and expected diseases are known and treated, ailments are attributed to spirits, ghosts and revenge by gods and goddesses. Texts dealing with gynecology cover fertility, sterility, pregnancy, contraception and abortion. Women were tested to decide whether they could conceive or not. However the Egyptians were behind Babylonian doctors who had gone further and designed the first pregnancy tests known in history. This test involved placing in the women’s vagina a tampon impregnated with the juice of various plants in a solution of alum. This was left in position either overnight or for three days. Pregnancy or non-pregnancy was indicated by color changes between red and green. The test used the pH value of the woman’s secretions in vagina to determine pregnancy. Rational thinking and sound medical observation were used alongside magic and sorcery. Magic was based on the assumption that an object with certain qualities, or an action of a certain kind, could be used to create sympathetic action (healing) or to repel something evil. Magical elements were included in medical texts and were added to the prescriptions and medicines appropriate for treatment of diseases. Some conditions like sterility and impotence in men used magic extensively while other easier ailments relied mainly on medicinal treatments. Heart was extensively studied with arteries however it is not clear if they fully understood the circulation of blood. In fact heart was considered to be the organ of reason instead of the brain though this later organ was extensively studied as well. Anatomy was well understood and dissection was a common procedure.

There are many medical papyri providing detailed descriptions of surgical procedures and other topics related to medicine. The collections are massive and medical knowledge is organized and detailed. Such organization of knowledge is a prerequisite for major advances in science. Indeed Greeks made extensive use of Egyptian science and medicine and created their own school of medicine that dominated the ancient civilizations for centuries to come.

 

ANCIENT GREECE AND ROME

 

By the time Hippocrates began his scientific medicine in his native city Cos, the city was already the headquarters of the Asclepiadae, a professional association of physicians under the patronage of Asclepius, the god of healing. They were all familiar with Mesopotamian and Egyptian medical knowledge and used such texts extensively. However the Greeks based medicine on empirical knowledge and separated the supernatural from the scientific information.

The Ancient Greeks and Romans assigned the liver a more “authoritative” role relative to the other organs in the human body. And in Eastern cultures, the liver was endowed with almost noble and prophetic qualities. Indeed, descriptions of jaundice, a clearly observable symptom of liver disease, are found in a number of ancient texts on medicine. In fact, Hippocrates, in his description of diseases, recorded what is believed to be an epidemic form of jaundice. The liver may no longer be considered magically supreme, but its importance in health -- and disease -- is no less appreciated.

After the breakup of the Roman Empire the tradition of Greek medicine continued in the universities of the Arab world. Many of the original Greek manuscripts were preserved at these centers and were used in formal medical studies. Since the Near East abounded with plants from which drugs could be extracted, Arab physicians used them extensively.

In today’s gastroenterology practice, the diagnosis and management of diseases of the liver remains a significant focus. The discipline of hepatology (generally viewed as part of the field of clinical gastroenterology) broadly encompasses the structure, function, and diseases of the liver and biliary tract, and includes topics as diverse as viral hepatitis, alcoholic liver disease, nonalcoholic

fatty liver disease, complications of portal hypertension, hepatocellular carcinoma, and postoperative management of liver trans- plant recipients, among others.

 

IRAN

 

The first major Iranian dynasty Achaemenid (550 BC) promoted the development of culture and science extensively. The great scholars such as the philosopher Heraclitus of Ephesus, the Babylonian astronomer Kidinnu and even the historian Herodotus were Persian subjects. The ancient cultures of the Egyptians, Babylonians, Elamites, and others continued to exist and develop. Babylonian Physicians were all over the territories and served all people including Persians. Xenophon relates that when the Greek soldiers who served under Cyrus the younger passed through the territory of Babylonia, they found sufficient number of physicians even in the villages to treat the wounded warriors. Texts describe how physicians used medicine, prayers and magic, they would often model images of evil spirits out of clay and shatter them, in order to restore the invalid to health.

Achaemenid made Babylon one of their major capitals and extensively used the texts at the temple libraries. The library and museum at the Persepolis was built to rival the Babylonian archives famous in the ancient world. Greek and Egyptian physicians were invited to join the Achaemenid court and served the royal household. Persians also adopted the tradition of paying the physicians according to the rank and gender. The archives at Persepolis indicate that physicians and midwives who delivered boys were paid double the amount they got when the baby delivered was a girl. The records do not indicate severe punishments if the sick person died, as was the case under Hammurabi. Texts also show lists of plants, herbs and other substances used for medicinal purposes. Drugs are taken internally; mercury, antimony, arsenic, sulfur and animal fats are also prescribed. All are basically the same as Babylonian medicine and prescriptions.

At one point Darius orders a representative to return to Egypt in order to restore the department of the ruined house of life dealing with medicine; “ While his majesty was in Elam he ordered me (Udjahorresne) to return to Egypt. I gave them every useful thing and all their instruments indicated by the writings, as they had been before. His majesty did this because he knew the virtue of this art to make every sick man recover”. The subsequent Seleucid and Parthian dynasties followed the same trends with more Greek influence science and art due to massive presence of Greeks in the area. However the flourishing of science and technology happened in the Sassanian period with major centers of learning and the famous university Jundaishapur.

The Sassanian king, Khosrow Anoshirvan is mentioned by many historians and biographers to have been a major promoter of all sciences including philosophy and medicine. In a Pahlavi text (Karnamag) he is quoted the following; “We have made inquiries about the rules of the inhabitants of the Roman Empire and the Indian states. We have never rejected anybody because of their different religion or origin. We have not jealously kept away from them what we affirm. And at the same time we have not disdained to learn what they stand for. For it is a fact that to have knowledge of the truth and of sciences and to study them is the high- est thing with which a king can adorn himself. And the most disgraceful thing for kings is to disdain learning and be ashamed of exploring the sciences. He who does not learn is not wise”.

Greek Philosophers Syriac speaking Christians and Nestorian Christians fleeing persecution by Byzantine rulers were received by Anoshirvan and were commissioned to translate Greek and Syriac texts into Pahlavi. Paul the Persian dedicated Works of logic to the king. The Greek philosopher Priscianus Lydus wrote a book in response to the king’s questions on a number of subjects in Aristotelian physics, theory of the soul, meteorology and biology. The Sassanian religious text, Dinkard shows familiarity with all these topics, especially Aristotelian physics. It is apparent from the text that Aristotle’s famous article ‘On Coming to be and Passing away’ was well known by the compilers of Dinkard. Becoming, decay and transformation the three fundamental concepts in the article are mentioned and discussed. Pahlavi texts also indicate that the doctors were paid according to the rank of the patient. Books in medicine, astronomy, Almagest (by Ptolemy), Aristotle’s Organon and a number of texts in crafts and skills were translated from Greek. Syrian Christians in particular played a significant part in communicating Greek sciences and knowledge to the Persians.

The famous university and the hospital at Jundaishapur built earlier reached its peak at Anoshirvan’s time. The Muslim historian Qifiti (12/13th century AD) in his book ‘History of Learned Men’ quotes the following; “In the twentieth year of the reign of Khosrow II (Anoshirvan) the physicians of Jundaishapur assembled for a scientific symposium by order of the king. Their debates were recorded. This memorable session took place under the presidency of Jibril Durustabad, the physician in ordinary to Khosrow, in the presence of Sufista’i and his colleagues, together with Yuhanna and a large number of other medical men”. It is likely that the medical teaching resembled those at Alexandria with some influence from Antioch. This hospital and the medical center were to become the model on which all-later Islamic Medical Schools and hospitals were to be built. Earlier Muslim historians such as Maqdisi (10th century) mention the medical school in Khuzistan and name it’s famous associates and practitioners. The famous writer and translator, Burzoy who translated the Indian book of fables the Panchatantra (later, Kalila wa-Dimna) for Anoshirvan was also a well-known physician from Nishapur. The first recorded Muslim Physician Harith bin Kalada had studied at Jundaishapur Medical School. In Jundaishapur Greek, Indian and Persian scientific traditions were assimilated. Indian scientific material in astronomy, astrology, mathematics and medicine were also translated into Pahlavi along with Chinese Herbal medicine and reli- gion. The books were kept at the university and the royal libraries and Greek medicine based on works by Hippocrates and Galen dominated the discipline.

The later Muslim historians refer to the Sassanian Imperial library as the House of Knowledge (Bayt al Hikmat). The library functioned as both a place where accounts of Iranian history and literature were transcribed and preserved. At the same time it was a place where qualified hired translators, bookbinders and others worked to preserve, purchase, copy, illustrate, write and translate books. It was such texts that made their way into the Islamic period. Many books in sciences and philosophy were translated by the Persians, Greeks, Syriac and Aramaic-speaking scholars into Arabic and eventually made their way into Muslim Spain and Western Europe. Persia and Byzantium dominated the area before Islam. The later was a continuation of the Eastern Roman Empire and the seat of Greco-Roman art, culture and civilization. Alexandria and Constantinople were major centers of intellectual activities with theaters, libraries and universities. In addition to Major cities like Alexandria Constantinople and Jerusalem, intellectuals and scientists moved and carried ideas from Edessa in the west, through Nisbis and Mosul (Iraq) to Marv and Jundaishapur in Western Persia.

The conquest of Islam in 7th century united east and west, improved trade and boasted book publishing by introducing advanced paper making techniques from China. This started the formation of a dynamic and significant translation movement for almost two hundred years till 10th century. The movement started in Damascus in Umayyad times and flourished in Abbasid Baghdad (754 AD). All major surviving Greek, Syriac, Persian and Indian texts were translated into Arabic and Neo Persian. Pre-Abbasid transla- tions from Pahlavi included major religious, literary, scientific and historical texts. Nawbakht the court astrologer and his son Abu Sahl and other colleagues Farazi and Tabari and many others sponsored by the Barmakid family (the chief ministers to the early Abbasids who were murdered later) translated and promoted Pahlavi texts into Arabic and Neo-Persian. They were all Iranians and aimed to incorporate Sassanian culture into Abbasid ideology and guarantee the continuity of the Iranian heritage. Christian and Jewish learned families of Sassanian Persia such as Bukhtishu and Hunyan families were also great translators of Syriac Greek Pahlavi and other texts into Arabic. Both families had served at Jundaishapur University for generations and were instrumental in founding the Adudi Hospital and Medical School in Baghdad.

The Nestorian physician, Jabrail ibn Bakhtishu was the head of the Jundaishapur University when he was called to Baghdad in 148 AD as the court physician to Caliph al-Mansur. He was later charged with building the first hospital (Bimarestan or Maristan) in the city based on the Syro-Persian model already established at Jundaishapur. He went back to Iran but many members of his family served the Abbasids for a long time.

Baghdad, a suburb of Ctesiphon was built in 762 by al-Mansur. The Royal library at Baghdad was based on the Sassanian model and was also called the house of knowledge (Bayt al-Hikmat) and like the Persian royal library became a center of learning and attracted scientists and intellectuals alike and many of its’ directors were either Iranian or from Iranian descent. Baghdad itself became hire to the Alexandrian and Persian scientific traditions and thought. The ‘Adudi’ hospital was built under the instructions of the great Iranian Physician Razi (Latin Rhazes, he was from Ray) and resembled the great hospital in Jundaishapur. It is said that in order to select the best site for the hospital he had pieces of meat hung in various quarters of the city and watched their putrefaction and chose the site where the putrefaction was the slowest and the least. At its inception it had 24 physicians on staff including specialists categorized as Physiologists, oculists, surgeons and bonesetters. Various historians have mentioned that the hospital was ‘like a great castle’ with water supply from the Tigris and all appurtenances of Royal Palaces. Medicine remained dominated by the Greek tradition, the first to rid the science from supernatural powers and spirits. Around 450 BC, the Italian-born Greek natural philosopher and physician Alcmaeon began forwarding the new theory that disease was caused by a fundamental imbalance in the body between certain opposed qualities, such as heat and cold (sardi/garmi), or wetness and dryness (tari/khoshki). This theory was picked up and elaborated by Hippocrates (460-377BC) who completely disregarded the presumption of the spiritual causes of disease. He proposed that health resulted from the equal influence of four bodily “humours” that was analogous to the four elements of Greek physics (earth, water, air and fire). Blood, phlegm, and two kinds of bile were associated with four major organs heart, brain, liver and spleen – and with the four seasons and the four ages of man: childhood, youth, maturity and old age. Deviations from perfect balance among the four produced diseases. Therapies consisted of attempt- ing to restrain the overactive humour while encouraging the others.

Five centuries later the great Greek physician, Galen (130-200AD) concluded that blood was manufactured in the liver from material provided by the stomach. He also posited two other systems of essential fluid. One originated in the heart and was carried by the arteries. The other ‘anima’ (soul or the life principle) proceeded from the brain by way of the nerve tracts. Though none are correct nevertheless Galen’s meticulous anatomical studies and logical method provided a point of departure for the development of modern medicine. Once this Greek heritage and knowledge was translated into Arabic it became universal and replaced most of the older traditions and schools. Greek, Persian, Arab and Indian scholars refined the assimilated ideas and by the 12th century slow progress was made toward understanding the organic cause of disease. The brilliant Iranian scientist Raze (845-925 AD) dis- tilled alcohol and clearly distinguished smallpox from measles.

The celebrated Iranian physician and philosopher Abu Ali Sina (Avicenna, 980-1037) wrote 100 books in many subjects including his most famous compendium, Canon of Medicine. His magnum opus is one of the classics of medicine ever written. He extensively studied herbal medicine from China, India and Persia. Avicenna like his predecessor Farabi (another well known Iranian) was an outspoken empiricist and insisted that all theories must be confirmed by experience. He argued against the blind acceptance of any authority and improved distillation techniques. Alchemists tried to convert one substance into another in order to make gold. In the process they uncovered a host of medicinal compounds and improved distillation and sublimation techniques. Another major Greek tradition based on theories of Plato and Euclid on light opened the way to the science of optics. Human eye became the focus of study and major advances were made and eye care was improved. The Jewish Physician Masawayh practicing at Jundaishapur joined the medical school at Baghdad at the invitation of Caliph Harun-ul-Rashid and wrote a detailed book on Ophthalmology. Masawayh family produced three more prominent physicians with the most famous, Yuhanna ibn Masawayh, who wrote prolifically and 42 works are attributed to him. Another great Jewish physician who had served at Jundaishapur was Hunain ibn Ishaq. He translated entire collection of Greek medical works including Galen and Hippocrates. His original contributions included 10 works on ophthalmology. He was appointed the director of the royal library by Caliph al Mutawakkil. Tabbari another major physician migrated from Persia to Baghdad in the first half of the 9th century AD. His major work called ‘Paradise of Wisdom’ contained extensive information from all extant sources including Greek, Syriac, Persian and Indian and contained an extensive treatment of Anatomy.

Like their Greek predecessors the new genre of physicians produced Encyclopedias of medical knowledge based on observation and experience. The main topics included anatomy, classification and causation of disease, symptoms and diagnosis. Urine, sputum, saliva and pulse were observed and used to aid diagnosis. External or visible manifestations of disease and internal symptoms like fever, headache etc were listed and studied. Hygiene was observed dietetics, cosmetics, therapy with drugs and herbs were used to improve the patient’s conditions.

 

ISLAMIC MEDICINE

 

Medicine of the Arab-speaking world (Spain, North Africa, Arabia, Turkey, and Persia, now Iran) from the foundation of Islam in the early 7th century to the beginning of the European Renaissance in the 15th century. Following the end of the Roman Empire in AD 476 Europe was plunged into the Dark Ages, a period of regression and lost knowledge, while medicine flourished in the Middle East. Medical advances were aided by the strong central governments of the Arab empires, the importance placed on helping the sick by Islam, and the preservation in Arabic of medical texts by Galen, Hippocrates, and other classical Greek and Roman theorists, that had either been lost or remained unread in Europe.

 

MEDICAL HERITAGE

 

In 431 the Syrian ecclesiastic Nestorius, Christian patriarch of Constantinople, was deposed for asserting that Mary was only mother to the human nature of Jesus. Expelled from the city, he moved to Persia (modern Iran), taking with him a collection of texts that included the works of Galen and Hippocrates. Nestorius’ followers translated his library into Arabic, giving the Arab- speaking world access to a large fund of classical theory and knowledge. The books were available in Baghdad, capital of the

Muslim Abbasid dynasty, who led the largest and foremost Islamic empire from the 8th to the 13th centuries. Muslim scholars who gathered in Baghdad used the Arabic translations of classical texts as a source of medical knowledge. Universities and libraries were established, with two of the greatest being in Baghdad and the Egyptian city of Cairo. Both contained hundreds of thousands of books.

 

HEALTH SYSTEM

One of the obligatory rules of the Koran, the sacred book of Islam, is that the rich must care for the poor, and the healthy must

look after the sick. This tenet encouraged the wealthy and powerful to provide hospitals and public health systems. Baghdad (now

the capital of Iraq) had its first hospital by 850, and more than 60 had been founded by the 11th century. London, although already

an important trading centre in the same era, did not have a proper hospital until the 11th century. Cities in the Muslim world often

had public baths, sewers, and paved streets. Baghdad had over a thousand public baths, and the Spanish city of Cordoba had

900.

 

MEDICAL PRACTICE

 

Doctors in Islamic hospitals were trained according to the ideas of Hippocrates, including his technique of clinical observation that focused on recording the symptoms and course of an illness. The anatomical works of Galen were also used. From 931 all medical students in Baghdad had to take examinations to qualify to be a doctor, and be licensed before they could work. Patients were kept in separate wards according to their illnesses, and provided with trained nurses and clean water. Patients were often given money after they were discharged to ensure that they could take time off work to recover.

 

MEDICAL AND ANATOMICAL KNOWLEDGE

 

Doctors in the Muslim world mainly followed the ideas of Hippocrates and Galen without question. Their main sources were translations of works taken from Constantinople by Nestorius and his followers in the 5th century, and Greek texts collected for the Abbasid court in Baghdad by Joannitius, Hunayn ibn Ishaq al Ibadi, a Nestorian Christian and Arabic translator who travelled in Greece in the 9th century. The works of the classical theorists were revered as a source of perfect knowledge and instruction, so Galen’s ideas regarding anatomy, including his errors, remained unchallenged as facts for many centuries.

Islamic law forbade dissection, and this prevented doctors from discovering the errors of Galen or making new discoveries. Some surgeons, however, made small advances in anatomical knowledge through applying Hippocrates’ system of clinical observation to their work, while others, such as the 12th-century Spanish Muslim surgeon Avenzoar, also made discoveries through limited postmortem dissections.

As the knowledge of Arab medicine increased, the findings of a few doctors began to challenge the ideas of Hippocrates and Galen. When Avenzoar proved that the skin disease scabies was caused by a parasite, the discovery upset Hippocrates’ theory of humors and Galen’s treatment by opposites. Removing the parasite from the patient did not involve purging, bleeding, or any

of the other traditional treatments associated with the four hum ours. Galen’s belief that blood flowed from one side of the heart to the other through holes in its septum (dividing wall) was overturned by the Syrian physician Ibn an-Nafis, who correctly described pulmonary circulation (the passage of blood from one side of the heart to the other through the lungs) despite the ban on dissection. His work, however, was lost and did not reach Europe until 1924; discovery of the anatomy of the heart and pulmonary circulation was only made in Europe in the 16th century following the work of Andreas Vesalius and Matteo Realdo Colombo.

Despite the beginning of doubts about Galen’s ideas, they remained extremely powerful across the medieval Muslim world. In general, although Islamic medicine kept the ideas of the ancient world alive during this period, it did not develop anatomical knowledge to any greater heights than had been reached in the Roman era.

Another source of medical knowledge in the Arab world came from the trade links established with India and Persia. Trading offered access to other medical traditions as well as new ingredients for medicines.

 

INDIVIDUALS

 

Rhazes, a Persian doctor practicing in Baghdad in the 9th and early 10th centuries, is considered the greatest physician in the Arab world. A follower of the Hippocratic technique of clinical observation, Rhazes recorded the difference between measles and smallpox many centuries before such discoveries were made in Europe. Rhazes’s ideas spread through other doctors who trained in his hospital, and through his many writings, such as al-Hawi/The Comprehensive Book, which were available to medical schol- ars through the great Arab libraries in Baghdad and other cities. The texts were also translated into Latin, and became important sources for European medical students up to the 18th century.

Another important physician was Avicenna (Arabic Ibn Sina), a doctor to the rulers of Baghdad in the early 11th century. He was also regarded as the greatest philosopher in the medieval Muslim world. Avicenna produced a complete system of medicine,

the al-Qanun/Medical Canon, which incorporated the theories of Hippocrates, Aristotle, and Galen, and his own ideas and new observations. His work spread across the Islamic world and reached Europe through trade links and the Crusades. Translation of the Canon by European scholars played a crucial part in Europe’s rediscovery of the ideas of Galen and Hippocrates in the Middle Ages. It remained a standard medical text used in European universities throughout the Renaissance, and was still in use in the early 18th century, seven centuries after publication.

The Spanish Muslim physician and surgeon Abulcasis, working in the 10th and early 11th centuries, wrote an encyclopedia of medical knowledge al-Tasr?f li man ajaz an-il-talif/An aid for the man who can’t read big books (completed about AD 1000) that included instructions on when and how to operate on patients, the first independent book to do so. He encouraged surgeons

to use the Hippocratic technique of clinical observation to decide when it was appropriate to perform surgery. Abulcasis gave instructions for surgery on the bladder and the amputation of limbs. He also gave advice on treating broken or dislocated bones and joints. Abulucasis and other surgeons were hindered by the ban on dissection, but were still able to make progress by recording cases and testing out new techniques on their patients. Once their work was recorded their ideas spread through the great libraries, hospitals, and universities of the Muslim world.

 

IMPACT OF ISLAMIC MEDICINE

 

The importance of Islamic medicine during this period lies in its preservation of the texts of classical scholars, lost to Europe fol- lowing the fall of the Roman Empire, and its creation of new sources of medical knowledge in the books written by doctors such as Avicenna and Rhazes. While Europe underwent a period of regression in many areas during the Dark Ages and early medieval period, the Muslim world continued to grow in power, organization, and knowledge. As contact increased between the Christian and Muslim civilizations, ideas known in the classical worlds of Greek and Rome returned to Europe. Without the preservation of the works of Galen and Hippocrates in the Arab-speaking world, medical knowledge in Europe may have remained in the Dark Ages for much longer. The Muslim world kept the public health practices of the Romans alive, when European public health had ceased to function. It also improved hospital technology and practice at a time when such institutions had almost disappeared across Europe.

1. Nunn JF. Ancient Egyptian medicine. London: British Museum Press, 2000.

 

 

 

A PANORAMA OF ARABIAN MEDICINE

The history of Arabian medicine can be conveniently divided into three phases, characterized briefly as :

1 .Phase I: Greek into Arabic

2. Phase II: Arabic

3. Phase 111: Arabic into Latin

 

Phase I was the period of translation of Greek scientific and philosophical works into Arabic. This started in the eighth century A.D. when Islam covered nearly two thirds of the known world, and contacts with the West were already established through Byzantium, Spain, and Sicily. The Khalifs at Baghdad became aware of what was to be learned from Greek science, and in the reign of al-Ma’mun an institution was founded for this purpose, “The House of Wisdom”. The first translations were made from Syriac, the language of the Nestorian Christian physicians of Jundi-Shapur. These Nestorian Christians were forced to abandon their Byzantine homeland because of controversies over dogma. Originally, the principal seat of Nestorian scholars was the theo- logical school at Edessa (Urfa), which had developed into a Syriac-language center of Greek philosophy; this institute of higher learning eventually was ordered closed by Emperor Zeno (491 A.D.). In the year 489, the Nestorieans had migrated practically in

a body to Persia, where they found refuge and employment under the Sassanid rulers. At the time, Jundi-Shapur, now Shahabad, was the metropolis of Khuzestan Province, in southern Persia, not far from Susa, the ancient capital of the Land of Elam. There, the Sassanids had established an academy and a teaching hospital, one of the oldest (if not actually the oldest) in the world. Among the most distinguished physicians at Jundi-Shapur were the Bukht Yishu’s, a dynasty of doctors whose members were summoned to Baghdad at least from time to time, where they served as the personal physicians to the Abbasid Khalifs. They were active in this capacity for over two hundred years, their motto being “Safer under the khalif’s turban than under the Pope’s cloak”. In the course of time, however, translations came to be made directly from Greek into Arabic. The most famous of all the translators was Hunayn Ibn-Is’haq, a Nestorian Christian who became court physician to the Khalif al-Mutawakkil. He and his team translated a large number of medical works of Hippocrates and Galen, as well as philosophical works by Plato and Aristotle and mathematical works of Euclid and Archimedes. Hospitals and medical schools flourished during that period, first in Baghdad and later in the main provincial cities. One of the greatest was the Mansuri hospital in Cairo, said to have had accommodation for

8000 people. “This hospital was lavishly appointed. Not merely were male and female patients separated, but there were separate wards for different categories such as fevers, ophthalmia, dysentery and surgical cases. Besides a number of surgeons and physicians, some of whom were specialists, there were attendants of both sexes, a large administrative staff, a dispensary, store-rooms, a mosque, a library and facilities for lecturing”. The founders of these hospitals were khalifs and other wealthy men such as Viziers who gave a large sum of money as an endowment; the income from this was then used to pay the staff. Medical service was free. We also hear of doctors making medical rounds in prisons, and of arrangements for a traveling clinic and dispensary to visit the village of lower Iraq. In the medical schools attached to the hospitals, the study of medical theory through the standard texts of Galen and others was combined with clinical instruction. In the curriculum, Greek science and philosophy were also included, and graduates were usually well-versed in more than one field. The history of Arabian medicine abounds in polymaths.

After the first period of translation, when the chief works of Galen and Hippocrates were made available in Arabic, achieved this by combining vast theoretical knowledge with acute clinical observation and a critical sense. Here, it will be possible to mention only few of the most famous, but it is worth noting the fact that for the five centuries from 800 to 1300 A.D. Arabic medical writings have been preserved from the pens of over 70 authors, mostly Muslims but including a few Christians and Jews. .

Ar-Razi, known to the West as Rhazes, was born in 865 at Rayy near Tehran, and died at Baghdad between 923 and 932. He was the first head of the first hospital founded in Baghdad. He was a voluminous writer on all the scientific and philosophical subjects then studied, and over fifty of his works are still extant. One of the best known is a treatise “On Smallpox and Measles”, which has been translated into Latin, Greek, French and English. His greatest work was al-Hawi, “The Continents” or “Comprehensive Book”, which was an encyclopedia of all medical science up to that time, and had to be completed by his disciples after his death. For each disease he gave the views of Greek, Syrian, Indian, Persian and Arabic authors, and then added notes on his clinical observations and expressed a final opinion. Rhazes was a keen observer and a critical thinker. Here is one of his case histories in which he relates his initial confusion, how he arrived at the correct diagnosis, and, retrospectively, some sort of self-criticism.

“Abdalla Ibn Sawada used to suffer from attacks of mixed fever which overtook him sometimes every six days, sometimes like a tertian, quartan or quotidian. They were preceded by a slight rigor, and micturition was very frequent. 1 gave it as my opinion that either these attacks of fever would turn into quartan, or that there was an abscess of the kidney. Only a short while elapsed before the patient passed pus in his urine; I informed him that these feverish attacks would not recur, and so it was. The only thing that prevented me initially from giving it as my definite opinion that the patient was suffering from an abscess of the kidney was that

he had previously suffered from tertian and other types of fevers. Moreover, the patient did not complain to me of heaviness in his loin, and I had neglected to ask him about this. The frequency of micturition should have strengthened my suspicion of a kidney abscess. It is, therefore, our duty to avoid lack of solicitude with the utmost possible care-if Allah will!”.

In addition to his extensive knowledge and vast experience, Rhazes always urged for high ethical standards in the profession. Many of this aphorisms are still relevant: “Doctors are nominally many, virtually few”, “Ignorant doctors are killers”, “Don’t treat with drugs what you can treat with diet, and don’t treat with compound drugs what you can treat with simple ones”, “Those who consult many doctors are likely to fall in the errors of every one of them”.

Although the excellence of Rhazes’ book was widely recognised, some felt that it was too lengthy a work, and about half a century later a Persian physician set out to produce an equally comprehensive but less bulky encyclopedia. The man was al-Majusi, known to the West as Haly Abbas, and the book was “The Complete Art of Medicine” or alternatively “Al-Kunnash al-Malaki”. It

was one of the earliest medical books to be translated into Latin and proved popular, being chiefly referred to as “Liber regius”. Probably the most outstanding writer on medicine in Arabic was Ibn-Sina or Avicenna (d. 1037). Like ar-Razi, he wrote many subjects, and is accounted to have been greater as a philosophthan as a physician. Nevertheless, his vast “Canon of Medicine” is rightly acclaimed as the “culmination and masterpiece of Arabic systematization” (Meyerhof). It was translated into Latin in the

twelfth century, and continued to dominate the teaching of medicine in Europe until the end of the sixteenth century at least. There were sixteen editions of it in the fifteenth century, one being in Hebrew, twenty editions in the sixteenth century, and several more in the seventeenth.

There were also innumerable commentaries on it in Arabic, Latin, Hebrew and the vernaculars. One distinguished commentator on Avicenna was Ibn an-Nafis, who practiced in Cairo and was the first to describe the lesser or pulmonary circulation of the blood. Islamic was not restricted to anyone region of the Islamic empire, but was widely spread wherever Islam was strong. Scholars traveled far afield to have personal contact with the most celebrated teachers. Though Umayyad and Moorish Spain did not recognize the Abbasid Khalif in Baghdad, it remained in cultural contact with the Islamic East. From Spain, it was easy to travel to intellectual centers like Medina, Damascus and Baghdad. Important books found their way to Spain within a few years of their publication in the East, while the scholars and writers of Islamic Spain made notable contributions to Arabic literature and learning. In medicine the most original writer was Abul-Qasim az-Zahrawi (d. after 1009), known in Latin as Abul- casis. His writing on surgery and surgical instruments, many of which he invented and illustrated in his books, is the outstanding Arabic contribution to this aspect of medicine. Several of the philosophers of Spain were also competent physicians. In addition to Ibn-Rushd or Averroes, the greatest commentator on Aristotle, there may be named Ibn-Zuhr or Avensoar of Seville and the Jewish scholar Ibn-Maimon or Mainlonides (d. 1024), who studied in Spain though he eventually became court-physician to Saladin in Egypt. Mention should also be made of Ibn-al-Baytar of Malaga, who was primarily a pharmacologist, but made valuable contributions to botany. In the related fields of alchemy and optics the experiments of Jabir Ibn-Hayyan, of al-Biruni and of Ibn al-Haytham are well known. In his book “The Influence of Islam on Medieval Europe”, W .Montgomery Watt, Professor Emeritus of Arabic at Edinburgh, concludes his survey of Arab achievements in science and philosophy with the following remark, which I quote fully: “When one becomes aware of the full extent of Arab experimenting, Arab thinking and Arab writing, one sees that without the Arabs European science and philosophy would not have been developed when they did. The Arabs were no mere transmitters of Greek thought, but genuine bearers, who kept alive the disciplines they had been taught and extended their range. When about the year 1100, Europeans became seriously interested in the science and philosophy of their Saracen enemies, these disciplines were at their zenith; and the Europeans had to learn all they could from the Arabs before they themselves could make further advances”. It was in the twelfth century that European scholars interested in science and philosophy came to appreciate how much they had to learn from the Arabs, and set about studying Arabic works in these disciplines and translating the chief of them into Latin. The earliest name in this third phase, the phase of Arabic into Latin, is that of Constantine the African, a merchant dealing in drugs and travailing between Tunisia and Southern Italy. On a visit to Salerno, where the oldest school of medicine in Europe was established, he realized how backward the school was, and decided to go and study medicine in the Islamic world. On his return to Europe, where he spent the final part of his life at the Benedictine monastery of Monte Cassino, he translated into Latin the medical works he had studied; among these was the “Liber regius” of al-Majusi. Another great translator was Gerard of Cremona, an Italian who came to Toledo and worked there for many years. To him are ascribed about a hundred translations. A third name is that of Michael Scot, who died in 1236, probably in Scotland. He travelled widely to Toledo, Bologna, Rome, and finally settled at the Sicilian court of Frederick II. This monarch, like his I grandfather Roger II (both of whom have been called “the two baptized sultans of Sicily”), was personally interested in the various branches of Arab science, and it was for him that Michael translated many of the works of Avicenna and Averroes.

Practical experience of Saracen medicine stimulted the Crusaders to establish new hospitals and medical schools in addition to the old ones at Salerno and Montpellier, but these still fell below Arab standards in such matters as having separate wards for infectious diseases, or full-time resident physicians. Another Arab practice-clinical instruction to students in a hospital-was not copied in Europe until about 1550. Rhazes’ “Continens” and Avicenna’s “Canon” remained the standard texts for European medicine through the fifteenth and sixteenth centuries.

 

THE CARDIOLOGY OF ARABIAN MEDICINE

 

Medieval Arabian or Islamic medicine offers a very colorful and varied picture. In addition to tribal traditions of the Arabian peninsula, there were influences from Syria, Mesopotamia, Persia and India. The unparalleled expansion of Islam created within a century an empire that extended from Spain to India. Contact with the West, and especially with Hellenism was inevitable, and eventually led to an active movement of translation, sponsored by the khalifs and wealthy patrons, in which major works of Greek philosophy, science and medicine were translated into Arabic. Of all the Greek doctors, Galen was for the Arabs by far the most significant, and Hippocratic tradition only followed in his shadow. From Galen came the teleological thinking that sought to recognize and explain each organ and each natural process in terms of its purpose, and to Galen can be traced back that rationalism that has left its impress on most Arabic writings. This is not to say that the Arabs were uncritical; there were indeed some cases in which individual doctrines of Galen were questioned, but the general Galenical system was usually accepted as perfect and final. This system was based largely on “The Four Humors Theory”. According to this theory, the body has four cardinal fluids or “humors”: blood, phlegm, chole (yellow bile) and melanchole (black bile). The variant mixtures of these humors in different persons determined their’ ‘temperaments’, their physical and mental qualities and their disposition. The ideal person had the ideally proportioned mixture of the four; a predominance of one produced a person who was sanguine, phlegmatic, choleric, or melancholic. Each of theses temperaments had specific characteristics. Health required f an equilibrium between the four humors (eucrasia) and it was the, physician’s task to restore this equilibrium whenever it was disturbed by disease (dyscrasia). There was even considered to be some son of analogy, and probably interrelation, between the four humors of man (the microcosm) and the four elements of the universe (the macrocosm): fire, water, earth and air, as formulated by Empedocles. In addition to the humors, Galen also believed in what he called the “pneuma”- a material but very subtle component carried by the blood and responsible for guiding many body processes.

This, in brief, is the basic, general doctrine underlying Galen’s physiology. Galen’s anatomy was largely based on the dissection of lower animals, particularly the African monkey, from which he made inferences concerning human anatomy. He described the valves of the heart, and observed the structural differences between veins and arteries. One of his most important demonstrations was that the arteries carry blood, not air, as had been taught for 400 years. Galen did not discover that the blood circulates.o

According to his view, the most important organ in the vascular system was the liver, where blood was formed from the chyle of absorbed food, and where the veins originated. Blood vessels carried the blood out to the periphery of the body where it was transformed into flesh. He accounted for the large amount of blood in the aorta by suggesting a passage from the right to the left ventricle of the heart through minute invisible pores in the septum that separates them. The two ventricles pulsate in unison, but the left one does so more strongly because it contains a greater amount of blood, “animal spirit” and “innate heat”. The right ventricle contains only blood, and only in a small amount. The function of the heart consists in the fact that it is the storehouse and source of the “innate heat” by which life is maintained, but it was not realized that it was a mechanical pump. The movement of the blood and the pneuma in the two vessel systems is unidirectional, centrifugal and tidal.

Such was the theory of the structure and function of the cardiovascular system that dominated medieval Arabian cardiology. To understand it we must free ourselves completely from what is taught today. It was the natural corollary of the teleological rationalism and schematization that characterized the theology and scholasticism of the Middle Ages. However it did not prevent the keen observers of Arabian medicine form recording some of the most interesting clinical reports. Consider for example this case history from Rhazes’ “continens”:

“I was consulted by a man who complained of palpitation of his heart within his chest. When I laid my hand on his left mamma, I felt a pulsation of his aorta so violent as I had never observed before. When he stretched out his left arm to show me his basilic vein, the pulsation of his brachial artery was equally violent, so that it was visible, the flesh being raised and sinking in a regular fluctuation. He informed me that he had been bled from his basilic vein without any useful result. His condition as regards the pulse is the same as in asthmatic patients who have an emphysematous distention of the chest, which is not able to inhale the breath sufficiently”.

This case of Rhazes is quoted very often; Meyerhof believes it was a case of aortic regurgitation; the late Prof. Kamel Hussein considers also the possibility of a traumatic aneurysm or arteriovenous fistula with a water-hammer pulse. Avicenna, the other great name of Arabic medicine, devotes an entire chapter in his encyclopedic “Canon of Medicine” to a description of the pulse and its clinical significance. Rate, rhythm, volume, force, tension -are all dealt with at length, and a wide range of arrhythmia’s

is described in detail, including premature beats, pulsus bigeminus, dicrotism, paroxysmal tachycardia and atrial fibrillation. It is really Interesting how Avicenna could squeeze all this information about the pulse in twenty lines of rhyme in his famous “Poem of Medicine”, in which the entire “Canon of Medicine” was summarized in just over a thousand lines as an aid to his pupils.

It was however, a later Arab physician who made the real breakthrough in the concepts of medieval cardiology. This was Ibn-an- Nafis, who practiced and taught medicine in Damascus and Cairo and died in 1288. Ibn-Al-Nafis wrote several commentaries on Hippocrates, but he is chiefly known for his “ Al-Mujiz”, an epitome of Avicenna’s “Canon” which was widely known as a practical handbook. He also commented on Avicenna in a larger work, and here he mentions how the blood in the right ventricle is refined so that it was prepared and ready to be mixed with the air:

“When the blood has been refined in this ventricle, it must reach the left ventricle where the pneuma (ar-ruh) is formed. But between these two ventricles there is no passage because the substance of the heart is here compact (musmat). In it there is neither a visible passage, as some suppose, nor an invisible passage which would serve to carry the blood through, as Galen thought, because the pores (masamm) of the heart are closely placed here and its substance is firm. Thus this blood, when it has been refined, must certainly reach the lungs by the arterial vein, so that it can spread out in their substance and mix with the air, so that its finest constituents can be clarified, and so that it can then reach the venous artery, and from there the left ventricle”.

In these words Ibn-an-Nafis described for the first time the pulmonary circulation. Several Western historians of medicine believe that he gained his knowledge not on the basis of systematic physiological research but by plain logical deduction derived from knowledge about the impenetrability of the septum. They base their argument on the fact that dissection of human cadavers was forbidden on religious grounds. However, there is ample evidence to suggest that Ibn-an- Nafis did practice dissection secretly. In this respect, it is noteworthy that he was also the first to point out that the nutrition of the heart was derived, not from the blood in its cavities, but through special blood vessels penetrating its muscle wall, i.e. the coronary vessels.

Unfortunately, Ibn-an-Nafis’s discoveries received little attention in the Islamic World. Almost three centuries later, the Spaniard Michael Servetus published his book “Christianismi restitutio” in 1553, in which he gives a presentation of the pulmonary circulation which resembles Ibn-an-Nafis’ so strongly that one can hardly reject a direct influence. Following on Servetus, Giovanni de Valverde and Realdo Colombo, both in the middle of the sixteenth century, described the “ lung circulation similarly, and after another eighty years the Englishman William Harvey succeeded in 1628 in proving that the blood flows in a complete circle. But in his account too, one problem remained unexplained, namely, the transfer of the blood from the arteries into the veins. It was the microscope that first allowed Marcello Malpighi in 1661 to see the capillaries in the lungs and in the bladder of the frog. Only in this way was the last gap closed, so that the circulation of the blood was proved to be uninterrupted.

Considering therapy, this was again dictated by the four humors theory. Since disease was the result of a disturbance of their balance, treatment consisted in an attempt to restore this balance by applying measures and using drugs possessing the opposite effect. Restoration of health could often be achieved simply by a change of life style, or by due observance of the air conditions and the change of the seasons, so that instead of unclear and misty air the patient is advised to breathe clear air that purifies his pneuma. Arab doctors were aware of the double-edged nature of drugs, and always preferred the use of dietetics whenever possible. Drugs were differentiated into simpl

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