Islamic and Indian Medicine

Islamic and Indian medicine originated in distinct cultural traditions but have been in close contact for many centuries. The terms Islamic and Indian as they refer to medicine do not describe static, idealized, or monolithic systems that can be categorized by referring to the medical texts of a distant golden age. Medical practices in Islamic and Indian cultures were, as elsewhere, eclectic and pluralistic, evolving in response to complex influences that varied according to time and place. This essay briefly traces the origins and the major components of the two traditions and compares and contrasts their institutional responses to the challenges of modern times.

Islamic medicine is based largely on the Greek medical knowledge of later antiquity and is more properly called Greco-Islamic or Galenic-Islamic medicine, reflecting the influence of Galen, whose works dominated medical learning in the eastern Hellenic world. At the time of the Muslim conquests of the seventh century A.D., the major centers of Greek medical learning in the eastern Mediterranean were flourishing.

Because of theological constraints, Greek Orthodox scholars were more interested in the Greek sciences, which included medicine and philosophy, than in literature, historiography, and other humanistic subjects. The Muslim conquerors recognized the excellence of Greek learning, and the Umayyid and Abbasid caliphs subsequently sponsored the translation of a large portion of the available scholarly works into Syriac and Arabic (Ullmann 1978).

The Hellenic culture had in large part been developed in the Near East and was an integral part of the Near Eastern culture inherited by the Muslims. The belief that the Greek sciences were transported from the Occident to the Orient, where they were preserved in Arabic translation until their eventual repatriation by the Occident, is mistaken. The infusion of Greek scholarship transformed the Arabic language and Islamic culture and must be viewed as a major historical process in which Islamic civilization energetically built on the existing Near and Middle Eastern cultures.

The major period of translation spanned the years from the ninth to the eleventh century and was a complex process that drew on several routes of cultural transmission. Even before the Muslim conquest, numerous Greek texts had been translated into Syriac, and many of these as well as a few original medical works written in Syriac were in turn translated to Arabic. The transmission of Greek scholarship into Arabic, which became the learned language, accelerated during the Abbasid era when, beginning toward the end of the eighth century, Harun al-Rashid and his successors sponsored centers of translation and learning in Baghdad. Almost all of Galen's lengthy medical texts were translated by the end of the ninth century, and Greek knowledge had also reached the Islamic world through Persian sources. The Achaemenid rulers of western Iran, who valued Greek knowledge, had founded in the third century A.D. a center of learning at Jundishapur where Greek scholars, captured in war, could work. In the fifth and sixth centuries A.D., Nestorian Christian scholars, persecuted in Greek Orthodox Byzantium, found refuge in Jundishapur, then under Sasanid rule. The Sasanid rulers sponsored numerous translations of Greek medical texts into Pahlevi. In the ninth century many of these Pahlevi texts were in turn translated into Arabic. Finally, the major Indian medical works were translated into Arabic or Persian and were accessi ble to Islamic physicians from a relatively early date (Ullmann 1978).

In answer to the often asked question regarding the originality of Islamic medicine, Manfred Ullmann, a specialist in Islamic medicine, has suggested that the question is inapplicable because it is inherently anachronistic. The physicians (hakims) of the Islamic Middle Ages, he observes, were not interested in discovering new knowledge, but rather in developing and commenting on the natural truths learned from the ancients (Ullmann 1978). This view, however, may overstate the case, for within the framework inherited from the Hellenic sciences, the Islamic scholars made numerous discoveries. For example, Alhazen (Ibn al-Haytham), a mathematician who worked in Cairo, used inductive, experimental, and mathematical methods inherited largely from Ptolemaic science to discount Greek and Islamic theories of light and vision and to produce a new, more accurate and intellectually sophisticated theory (Sabra 1972; Omar 1977).

A. I. Sabra (1987) has suggested that scholars study the Islamic sciences as part of Islamic civilization. The question then becomes not whether the Islamic scholars made original discoveries or how the Greek sciences were translated into Arabic and then into Latin, but rather by what process Islamic civilization appropriated, assimilated, and "naturalized" the Greek sciences.

According to the Greco-Islamic medical theories, diseases were caused by imbalances of the four humors of the body: hot, cold, moist, and dry. The matters of the four humors, blood, phlegm, and yellow and black bile, influenced the temperament of individuals. When the balance was upset, the body would become ill. Thus, an excess of blood would produce a sanguine condition, whereas an excess of phlegm would produce a phlegmatic condition, and so forth. The physician's role was to correct the imbalance, perhaps by prescribing foods or medicines with "hot" or "cold" properties or by removing excess blood. This system was essentially secular because it did not ascribe disease causation to supernatural influences. When Greek medical works referred to the Greek gods, Muslim translators simply inserted Allah when appropriate or made the gods historical figures.

Prophetic medicine can be viewed as a "science" that integrated medical knowledge derived from the hadiths, or sayings and traditions of Mohammed and his companions, and local medical customs, magical beliefs, incantations, charms with ideas and con cepts drawn from Greco-Islamic medicine. It was, in other words, an effort to incorporate Greek medical knowledge into an acceptable Islamic framework. The authors of prophetic medicine were generally not practicing physicians but ulama (specialists of Islamic theological and legal sciences), who worked out "religiously correct" compendia of medical lore. In recent years, many prophetic medical works have been printed and can be purchased in bookstores throughout the Islamic world.

Sufis, or mystics, believed that illness should be treated through prayer or other religious observances and not by medical means at all. In addition, many people believed in astrological influences on disease causation. Astrological medicine was widely practiced, and most astrological manuals had sections giving medical advice (Savage-Smith 1988). The obvious contradiction between natural causation, divine causation, and planetary control of events was never entirely resolved. The late Fazlur Rahman, the noted Muslim philosopher and scholar, while dismissing astrology, confronted the dilemma of the orthodox theological insistence on total reliance on God's will and the necessity of seeking secular medical intervention. He concluded that "the Qur'an's position appears to be that God acts through natural causation and human volition to further His purposes" and that whereas many theologians and Sufi leaders clearly advocated resignation to the will of God at all times, most, when sick, sought medical treatment (Rahman 1987). The average person presumably subscribed to a variety of medical beliefs without great concern for the obvious contradictions. In short, in emergencies, all possibilities were to be tried.

It might be said that over time the difference between Greco-Islamic medicine and daily medical practices resembled the difference between the classical Arabic and the spoken language. One was formal and was carefully studied and developed by savants for scholarly discourse. The other was informal, eclectic, and used for everyday needs.

Only a few of the major Greco-Islamic physicians will be mentioned here, in chronological order, to suggest their varied origins and interests. Mesue (Yuhanna ibn-Masawayh), court physician to four Abbasid caliphs during the late eighth and first half of the ninth centuries, was a renowned clinician and teacher who wrote influential texts on nosology and therapeutics. Joannitius (Hunayn ibn-Ishaq al-Ibadi) was a ninth-century physician who studied in Jundishapur, Basra, and Baghdad. He was proficient in Greek,

Syriac, and Arabic, and was renowned for his excellent translations of Greek medical texts, which secured his place in the history of medicine and of Islamic civilization. He also wrote monographs on ophthalmology and other subjects. His contemporary, Ali ibn Sahl Rabban al-Tabari, who worked for most of his life in Rayy, wrote a compendium of medicine based on the works of Hippocrates, Galen, Aristotle, Dioscorides, and other authors, mostly from Syriac translations. Qusta ibn-Luqa al-Balabakki, who died in 912, practiced in Baghdad and, toward the end of his life, in Armenia. He wrote on the relationship between mind and body, in addition to other medical, philosophical, and mathematical treatises. His famous contemporary, Rhazes (Abu Bakr Muhammad ibn Zakariya al-Razi), was born in Rayy and practiced medicine in Baghdad and at various locations in Iran. He was a noted philosopher and alchemist who compiled the famous medical texts entitled Kitab al-Mansuri and Kitab al-Hawi. He is best known for his exceptionally precise (but not original) descriptions of diseases such as smallpox and measles. Haly Abbas (Ali ibn al-Abbas al-Majusi), who died in 994, was a physician at the Buwayhid court. He wrote the famous Kitab al-Malaki, one of the most concise and well-organized expositions of Greco-Islamic medicine. At about the same time, Albucasis practiced in Cordoba and wrote an encyclopedic study that contained an influential section on surgery based on Greek sources and his own findings. Avicenna (Abu-Ali al-Husayn ibn-Sina) was a polymath who during his checkered career practiced medicine at various locations in Iran. Early in the eleventh century he compiled the famous Qanun, a five-volume study dealing with physiology, nosology, etiology, symptomatology and therapy, simple remedies, pathology, and the preparation of compound remedies. This work is a compilation of medical knowledge of the era that was enormously influential in the Islamic world and in the West in Latin translation. He also wrote a book refuting astrology, a "science" held in ill-repute by most of the prominent physicians of the era. Averroes (Ibn Rushd) was twelfth-century Aristotelian philosopher and government official in Cordoba and Marrakesh who wrote a major medical work divided into seven parts dealing with anatomy, dietetics, pathology, nourishment, materia medica, hygiene, and therapeutics. His pupil, Maimonides (Ibn Maymun), was, like Ibn Rushd, born in Cordoba. But he left Spain following Almohad persecution and sought refuge in Cairo, where he became court physician and the official representative of Egypt's large and flourishing Jewish community. Among his medical works is the famous Kitab al-Fusul, which was derived largely from Galen.

Abd al-Latif al-Baghdadi, who died in 1232, was a scientist who demonstrated that simple observation of human anatomy revealed substantial errors in Galen's anatomic descriptions. Also prominent in the thirteenth century was Ibn Nafis, who studied medicine in Damascus and became director of the Mansuri Hospital in Cairo. He wrote al-Mujiz, a widely used commentary on Avicenna's Qanun. In it he stated his famous theory of the pulmonary, or lesser, circulation of the blood, later proved correct. Finally, Ibn Abi Usaybia should be mentioned. An oculist at the Nuri Hospital in Damascus, he later worked at the Mansuri Hospital with Ibn Nafis. He compiled Uyun al-Anba fi Tabaqat al-Atibba, a biography of more than 400 physicians of Greco-Islamic medicine. It remains a major source on the history of Islamic medicine (Ibn Abi Usaybia 1882—4; Brockel-mann 1937-49; Ullmann 1978).

These Greco-Islamic medical scholars were a diverse group, among whom were Muslims, Christians, Jews, and Zoroastrians. Persian Muslims probably outnumbered those of other origins. Although nearly all wrote their major works in Arabic, many also wrote in Syriac or Persian, as well as in Hebrew (written in either Hebraic or Arabic letters) or, later, in Turkish. Regardless of ethnic or cultural origin, all shared and contributed to the Islamic cultural tradition. Most, though by no means all, practiced medicine at some time in their careers. A few were ulama, or lay persons with a special interest in medicine. Women are conspicuously absent from the biobibliographies but are known to have acquired medical expertise and to have practiced medicine in medieval times (Issa 1928; Goitein 1967).

Medical education was far less structured than in modern times. Medical students studied the medical texts independently or sometimes in mosques and madrasas (schools) along with the other sciences. Often an aspiring physician studied with one or more masters and acquired practical experience through an apprenticeship. There was no formal certification system or formal curriculum. Proof of medical expertise depended on the recommendation of a physician's teachers, demonstrated familiarity with the medical texts, as well as a reputation established through practical experience. Only much later did a system of certification come into existence, in which a head doctor (bash hakim), appointed by the ruler, would issue an ijaza (permission or license) to a prospective physician testifying to his competence.

Most of the physicians discussed earlier limited the realm of their activities to the large cities, usually at court or in the homes of the wealthy. Several were directors of major hospitals in Baghdad, Damascus, Cairo, and elsewhere.

Hospitals in Islamic regions were usually funded by waqfs (religious endowments for charitable purposes). The concept of waqf funding of hospices for the sick, which may have been adapted from Byzantine custom, remained standard practice in Islamic regions until the expansion of the modern nation-state. For example, in 1662, in Tunis, the ruler Hamuda al-Muradi established a waqf funded by revenues from designated hotels, shops, public ovens, kilns, water pipes, mills, and baths and from the rent on houses. The funds were for a doctor, nurses, servants, and food for the staff and patients. In addition, the funds were to maintain the building itself, which contained 24 rooms and was intended for the sick and wounded of the army and navy and the poor who had no family to care for them. The charter of this waqf specifically stated that there was to be no distinction among Arabs, Turks, or foreigners. In Tunis and elsewhere, those who could, however, preferred to seek medical care at home from relatives and local practitioners (Gallagher 1983).

In the sixteenth and seventeenth centuries when Muslim rulers became aware of the military and commercial expansion of the European powers, they did not hesitate to recruit European physicians to their courts. Although European physicians of the era could treat most diseases no better than their Muslim counterparts, Muslim rulers, extrapolating from European advances in other fields of science and technology, suspected that the Europeans could (Gallagher 1983). The European physicians had an advantage because, although they still relied on the medical texts of Avicenna, Averroes, and Rhazes, they were more systematically educated than their Muslim counterparts. Often both Muslim and European physicians were retained at Muslim courts and were consulted according to the dictates of the ruler. European physicians at Muslim courts also sometimes served as intermediaries, interpreters, and diplomatic representatives. They were generally well compensated and held in high esteem.

A few prominent Muslim physicians also sought the new European medical knowledge. In the seventeenth century, Ibn Sallum, an important physician at the Ottoman court, relied on the works of the sixteenth- and seventeenth-century Paracelsian scholars, whose theories of chemistry (later proved wrong) had emphatically rejected the ancient Greek medical theories. Ibn Sallum translated several treatises in Paracelsian medicine from Latin to Arabic, modifying them slightly for use in Islamic regions. He is credited with being the first Muslim physician to subscribe to the new European science and was not himself trained in Greco-Islamic medicine (Savage-Smith 1987). In the eighteenth and nineteenth centuries, Muslim physicians from North Africa to Iran occasionally used European source materials to discuss the etiology and treatment of new diseases such as syphilis and cholera. Muslim scholars did not, however, understand or adopt the new experimental methods that underlay the Scientific Revolution.

The transmission of European medical knowledge was accelerated in the early nineteenth century when Muhammad Ali, the modernizing ruler of Egypt, recruited Antoine Clot-Barthelemy to organize his medical services. Clot founded a medical school in Cairo where European medicine alone was taught. European physicians were subsequently called to Istanbul, Tunis, Tehran, and other Muslim captials to organize modern medical schools and health services. By the early twentieth century, Islamic medicine, which bore little resemblance to medical practices of the medieval era, was held in official disrepute and the Greco-Islamic theories themselves had been overturned by the experimental methods and systematic observations of modern Western medicine.

The term Indian medicine usually refers to Hindu or Ayurvedic medicine. It is a medical tradition distinct from either Greek or Islamic medicine. Ayurvedic scholars trace its roots to verses from the ancient Vedic hymns, which contain medical doctrines, mostly of a magicoreligious character, and date from as early as the second millennium B.C. The medical doctrines based on treatment with extracts of plants (vegetable decoctions, oils, and ghees, usually prepared at home) featured in classic Ayurvedic medicine are, however, not found in the Vedic hymns. Perhaps they derived from the herbal medicines of Buddhist monks. The term Ayurveda may have served to legitimize the medical system by associating it with the Vedic religious tradition. The term Veda refers to an abstract idea of knowledge that is found in all branches of Hindu learning. Ayur means prolonging or preserving life or the science of longevity. Ayurveda is, in fact, a code of life. It deals with rebirth, renunciation, salvation, soul, the purpose of life, the maintenance of mental health, and of course the prevention and treatment of diseases.

The most important Ayurvedic medical texts are the samhitas (the four canonical texts of the Hindu scriptures) of the mythical savants Caraka and Susruta. Both are compilations of medical traditions and exist only in incomplete or copied form. Caraka's work was apparently compiled in about the first century A.D. and that of Susruta in the fourth or sixth century. Caraka described more than 200 diseases and 150 pathological conditions. He also mentioned older magical ideas along with the rational humoral approach based on drug therapy and diet. Susruta included a long chapter on surgery, which was apparently widely practiced in antiquity but was nearly unknown in later years.

The ideas of Ayurveda have permeated Hindu cultural ways of dealing with life and death and sickness and health. Whereas Greek medicine has four humors, Ayurvedic medicine has three humors, or dosas, wind, bile, and phlegm, which govern health and regulate bodily functions. These are the three microcosms of the three divine universal forces, wind, sim, and moon. Illness results from an imbalance of the three dosas. Although an essentially rational understanding of disease and treatment underlies Ayurvedic medical doctrine, Brahmin myths, gods, and demons are sometimes cited in the classic texts to explain the origins of diseases and the character of medicine. Epidemic diseases, for example, might be caused by drought, excessive rainfall, calamities sent by the gods in punishment for sins, poisonous miasmas, or the influence of planets. The body is considered to be a manifestation of divine energy and substance, and is a microcosm of the universe. Whereas Islamic medicine acknowledged its Greek and Indian origins, Ayurvedic medicine emerged from the Hindu religious and cultural tradition (Zimmer 1948; Jolly 1951; Basham 1976; Zyzk 1985).

Medical knowledge was generally transmitted from a master practitioner to his pupil. Often, medical knowledge was handed down from father to son for many generations. Medical students also studied at medical establishments attached to large temples or in schools and universities. In the ideal, Ayurvedic physicians (vaidyas or vaids) were to be Brahmin and thoroughly learned in the Sanskrit texts. In practice, they were usually from the top three castes (varna), Brahmin, Kshatriya, and Vaisya, but were sometimes considered to have compromised their status by the nature of their profession. Brahmins, for example, would often not accept food from a vaidya because he had entered the homes of persons of lower caste and had touched excrement and other impure substances (Basham 1976). Most people, however, had no access to the formal or learned Ayurvedic medical tradition and relied on home remedies and consultation with local medical healers. With few exceptions, only the rulers, military leaders, and male members of elite castes had access to Ayurvedic medicine.

Yunani (Ionian or Greek) medicine should also be considered a part of the Indian medical tradition. Yunani medicine was probably introduced into India with the Turco-Afghan conquests of the thirteenth century and the expansion of Persian culture in the fifteenth century. Lahore, Agra, Delhi, and Lucknow became renowned centers of Islamic learning where the classic medical texts were copied, studied, and reformulated, usually in Arabic. From the thirteenth century, Indian physicians attempted to synthesize Islamic and Ayurvedic medicine and there was much borrowing between the two systems (Leslie 1976). Ayurvedic physicians learned to classify and interpret diseases in Yunani terms. They began to diagnose disease by feeling the pulse of the patient, a practice developed in Yunani but not in Ayurvedic medicine. They used mercury, which Muslim physicians had borrowed from Europe, and opium and practiced alchemy, a science not found in Ayurvedic texts. They studied the case histories found in Yunani but not in Ayurvedic texts. In turn, the Yunani physicians (hakims) borrowed extensively from the Ayurvedic pharmacopeia and adopted many Ayurvedic ideas concerning dietary principles. Both systems were widely used in India's Muslim and Hindu communities, and Muslim physicians are known to have practiced Ayurvedic medicine and Hindu physicians to have practiced Yunani medicine.

Ayurvedic medicine reached its highest point of development from the first to the sixth century A.D., considerably earlier than Islamic medicine, which reached its highest point from the ninth to the thirteenth century. Both traditions lent themselves to sophisticated reasoning, earnest speculation, and scholarly curiosity, but also to involuted argumentation, abstract distinctions, and increasingly obscurantist generalizations. In Indian as in Islamic medicine, there was no systematic experimental research. In the sixteenth and seventeenth centuries, Ayurvedic and Yunani physicians were even less exposed than were their counterparts in the Middle East and North Africa to the new ideas of the Scientific Revolution.

The British conquest of India, begun in the mid-eighteenth century, did not immediately disrupt long-standing medical traditions. In 1822 the British colonial authorities established the School of Native Doctors at Calcutta, where students could study both Ayurvedic and Western medicine. The British authorities also sponsored courses for the training of hakims and recruited them for medical relief projects. Within little more than a decade, however, the British government had decided that higher education in India would follow a Western model and the schools and courses in indigenous medicine were abandoned. In 1841 a British medical surgeon in the Bengal medical service found that only four or five Ayurvedic medical practitioners could read the Sanskrit texts (Leslie 1976; Metcalf 1985).

Even after the British suspended patronage of indigenous medical systems, a few princes continued to sponsor Ayurvedic and Yunani colleges. In 1889 the family of Hakim Ajmal Khan, the famous Muslim reformer and physician, established a Yunani school in Ballimaran and later a pharmacy that provided Yunani and Ayurvedic medicines. In 1906 Ajmal Khan established the Tibb (medical) Conference. Its purpose was to reform and develop Yunani medicine and to work with Ayurvedic physicians for their shared interests. In 1907 Ayurvedic practitioners established the All-India Ayurvedic Congress, which remains the leading Ayurvedic professional association. In 1910 Ajmal Khan expanded his earlier organization into the All-India Ayurvedic and Yunani Tibb Conference. The medical associations successfully opposed the Registration Acts that fully certified only allopathic, or Western-trained, British and Indian physicians. They also called for placing the ancient indigenous medical systems on a scientific basis (Metcalf 1985). Indigenous practitioners established links between their medical concepts and those of modern Western medicine in order to sanction them. When British authorities moved the capital to Delhi, Ajmal Khan requested and received land for an indigenous medical college. With funding from princes and merchants, the foundation stone for the Ayurvedic and Yunani Tibb College was laid in 1916 and the college was formally opened in 1921. Despite much ambivalence, both the British viceroy and Mahatma Gandhi gave their support to the college because it was an important symbol of the Indian cultural revival and of Hindu-Muslim cooperation (Metcalf 1986). The Indian National Congress, founded in 1920, called for government sponsorship of Indian medicine. In the 1920s and 1930s vaidyas and hakims who had formed professional associations in rural areas actively campaigned for government recognition.

Well before independence in 1947, more than 60 Ayurvedic and Yunani colleges existed throughout India and there were official Boards of Indian Medicine in Bombay, Madras, and elsewhere. After independence, Ayurvedic and Yunani physicians expected to win equal status with physicians trained in the Western medical schools, but despite strikes and other organized protests they did not do so. In 1956 the government established the Central Institute of Research in Indigenous Systems of Medicine and the Post Graduate Training Centre for Ayurveda in Gujarat State and similar institutions elsewhere. Although the number of Ayurvedic and Yunani colleges and dispensaries has multiplied since independence, government funding has been minimal. Many of the colleges teach anatomy, nosology, and other Western medical subjects in addition to the basic courses in Ayurvedic and Yunani medicine, but the result is popularly regarded as inadequate training in any medical system. Ayurvedic and Yunani practitioners, for example, often prescribe antibiotics and give injections, but without the understanding of the physician educated in Western medicine. According to Paul Brass, a political scientist specializing in modern India, the students in the indigenous medical schools are popularly perceived to have failed in secondary school or to have failed to gain admission to modern medical or professional schools (Brass 1972). For the treatment of serious ailments, Western medicine is preferred by those who can obtain and afford it. Nevertheless, the struggle for "medical equality" continues.

The process of medical professionalization in the Middle East was quite different. In Egypt in the late nineteenth century, medical works by Avicenna and others were published by Cairo's Bulaq Press. This could have been a sign of a revival or of a new institutionalization of Islamic medicine. Thus, Ull-mann (1978) suggests that the manuscripts were published because they were part of a living medical tradition rather than part of medical history. It is probably truer that they were part of Egypt's nationalist revival and were valued primarily as part of its cultural heritage. Egyptian medical students studied exclusively Western medicine at the Qasr al-Ayni medical school or went abroad to study in British or French medical schools. By the post-World War I era, most governments in the Middle East required practicing physicians and pharmacists to be licensed, and medical schools specializing in Western medicine alone had been established in Istanbul, Beirut, Cairo, Tunis, Tehran, and many other major cities. In Iran, for example, the modernizing government of Reza Shah required all physicians and pharmacists to be licensed by the early 1930s. Unlicensed physicians with established practices had to take an examination that, according to Byron Good, an anthropologist specializing in Iran, covered internal medicine, pharmacology, and traditional Galenic-Islamic medicine. The license given to these (mojaz, or permitted) physicians was not equivalent to that given by the accredited Western medical schools but was rather comparable to the médecin toléré license given to indigenous practitioners in French colonies. To pass the exam, the candidates had to study European medical texts in order to familiarize themselves with the new medical theories and practices. This resulted in a modification of existing medical practices, and after the early 1930s all new physicians and pharmacists had to hold licenses from the accredited medical schools (Good 1981).

The unlicensed indigenous practitioners in Egypt, Iran, and elsewhere - health barbers, midwives, bonesetters, herbalists - continued to have clients, of course, because most people did not have access to European medicine, which was expensive and confined to the large cities. But such practitioners did not themselves organize in order to establish medical schools, pharmaceutical companies, or journals specializing in Greco-Islamic medicine.

There are several possible explanations for these very different responses to the new dominance of Western medicine. Ralph Croizier (1968), a specialist in Chinese medical systems, has suggested that Islamic medicine differed from Ayurvedic and Chinese medicine because it did not claim that it contained special knowledge unknown in the West. Indeed, unlike the Hellenic medical theories shared by both Islamic and pre-Renaissance Western medicine, the ideas of Ayurvedic medicine were nearly unknown to Western scholars until the colonial era. The unique origin of Ayurvedic medicine therefore may have distinguished it from Islamic medicine.

Another explanation may be that the Ayurvedic texts were believed to have originated in Hindu holy scripture, whereas the Greco-Islamic medical texts were clearly of non-Islamic, secular origin. Barbara Metcalf, a historian of India and Pakistan, has observed, however, that, in Muslim India, Yunani medicine was considered to be an ancillary dimension of religion and its practitioners were expected to be pious men. Yet, as she cautions, Muslim scholars were aware that Yunani medicine did not contain the truths of the religion as did the Quran and the hadiths, and did not consider it part of the Islamic religious sciences (Metcalf 1982).

In the Middle East, there was no competing medical system associated with a dominant indigenous religion, and Muslim, Christian, and Jewish physicians all studied the Greco-Islamic medical theories. Although Islamic medicine was not an integral part of the Islamic sciences, most people considered it to be compatible with correct Islamic values. Because not only Ayurvedic but also Yunani physicians formed professional associations, it would seem that the "unique origin" and the "religious versus secular or foreign origin" explanations can only partially explain the different responses to modern medicine and to colonial rule. An additional explanation may lie in the fact that the Middle East was closer to the European metropoles than was India, making its exposure to European political and cultural influence more intense. The main support for Ayurvedic and Yunani professional organizations has, in fact, come not from the main cities of India but from the provinces. A further explanation may be found in British colonial administrative policies. The British authorities in India initially attempted to preserve local traditions. They even combined the indigenous and European systems in their new medical schools, where courses were taught in Sanskrit and English.

The process was quite different in the Middle East and North Africa because in the nineteenth century, when the British and French established colonial rule, indigenous ruling elites such as Muhammad Ali of Egypt and his successors had for some time been trying to strengthen their own power by learning the secrets of European power. India's rulers had not had such a long exposure to European science and technology before the onset of colonial rule. Indigenous rulers in India had not, therefore, been able to emulate Muhammad Ali of Egypt or the other modernizing rulers of the Middle East, for they had been relegated to a largely ceremonial and traditional role in the British raj. The sequential establishment of colonial rule may thus have contributed to the difference in medical professionalization. Furthermore, as the nineteenth century progressed, the discovery of quinine, smallpox vaccination, new methods of public health sanitation, anesthesia, antisepsis, and other advances made the prevention and treatment of disease more effective and the modern medical profession in general more confident. The Ayurvedic and Yunani physicians, protected by British colonial policies, managed to upgrade their skills by adopting new methods of medical intervention learned from European medicine and, rather like practitioners of home opathy and chiropractic in the West, were able to obtain a degree of official recognition.

Finally, because the ruling elites of the Middle East and North Africa had opted for European medicine long before the colonial era, indigenous practitioners in these regions, unlike their counterparts in India, had no support from their local (Muslim) rulers and none from their European colonial rulers. Because they had been represented at most by a head doctor appointed by the ruler, they had no organized means of protest. In contrast to the authoritarian, centralized political systems of the Middle East, the constitutional form of government established in India in the twentieth century lent itself to lobbying by special interest groups such as professional associations. The result is a dual system of officially recognized medical education, professional organization, and certification in India and a single system in the Middle East and North Africa. Nevertheless, in all these regions, as in the West, a wide variety of medical practitioners continue to flourish.

Apologists for the Islamic and Indian medical traditions argue that Western medicine cannot treat all diseases. They correctly observe that many diseases have a cultural component that a local healer familiar with the beliefs of the patient might treat more satisfactorily than a counterpart trained in European medicine. It is widely recognized that diseases partly caused by psychological stress can be more effectively treated by healers who understand the religious, cultural, and political beliefs of the patient. Recognizing this and, more important, the unavoidable fact that the majority of the world's population does not have access to modern medicine, the World Health Organization has been attempting to upgrade existing indigenous medical traditions rather than to replace them with modern medicine. In practice this has meant studying local remedies with the techniques of modern science in order to distinguish between effective and harmful practices and to train practitioners to modify these methods in accord with their findings. Success has been very limited, however.

Today, in India, as Charles Leslie, an anthropologist specializing in Indian medicine, has pointed out, one must distinguish between the Ayurvedic medicine of the Sanskrit classic texts; the Yunani medicine of the classic Arabic texts; the syncretic Ayurvedic and Yunani medicine of the traditional culture; contemporary professionalized Ayurvedic and Yunani medicine (both of which have borrowed from modern Western or allopathic medicine); folk medicine; popular culture; homeopathic medicine;

and learned magic-religious medicine (Leslie 1976). Yet all must be considered part of Indian medicine.

Similarly, in the Middle East, one must distinguish between the classical Islamic medical tradition; the everyday practices of the health barbers, herbalists, midwives, bonesetters, and religious healers; and, of course, Western medicine. Throughout the Islamic world, Muslim fundamentalists are especially active in the medical schools. But outside of India and, to a lesser extent, Pakistan, they have given no thought to developing Islamic medicine along Western institutional lines. They argue that medical sciences have no nationality, but that (modern or Western) medicine should be administered according to Islamic law. Thus, charitable clinics attached to fundamentalist mosques dispense Western medicine, and the fundamentalists call merely for the revival of the comprehensive worldview and the humanistic concern that, they contend, characterized the Islamic medical system. They advocate what would in the West be called the holistic approach to patient care, with modern medicine subsidized through the legal Islamic taxes and accessible to all.

Nancy E. Gallagher

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