Aristotle, godfather of evidence-based medicine (cLAST)


(being continued from 9/06/18)

Arabian medicine in the middle ages Following the death of the Muslim prophet Mohammed in June 632 AD, a wave of expansion spread out of the Arabian Desert. In 640 AD, an Arab Muslim army conquered Egypt and by the beginning of the ninth century AD, the Arab/Muslim Empire extended fromAndalusia in Spain to parts of the Far East. In Alexandria and in many parts of the old Greek world, Arab scholars discovered the ideas of Aristotle. Although various schools of philosophy were established in Baghdad, Cordoba, Cairo and Tashkent, Arab scholars considered Aristotle the greatest philosopher of all time. For them, he was the “first teacher”, while their great philosopher “ Al-Faraby” was always called the “second teacher” (Fig. 8). His remaining works were translated from Greek into Arabic and widely read by Arab scholars (de Micheli-Serra, 2002).

Based on the ideas of common sense and logic (the Aristotalian principle), a great cultural wave swept the Arab/Islamic empire. In the field of medicine, physicians were always described as philosophersphysicians and medical knowledge thrived under these circumstances. Many of the physicians in the Arab/Muslim Empire were not Muslims. Ibn Maseweih (Joannes Damascenus, died 875 AD), Yacub ben Ishak el-Kindi (Alkindus, 813-873 AD) and Honein ben Ishak (Joannitius, 809-873 AD) were Christians. Ishak ben Soleiman el-Israili (Isaac Judaeus, 830-932 AD) was an Egyptian Jew. Other famous physicians of the time were Abu Bakr er-Razi (Rhazes, 850-923 AD) who practiced in Rayy and Baghdad, Abul Kasim el-Zahrawi (Abulcassis 912- 1013 AD), who practiced in Cordoba and Al-Hosein Ibn Sina (Avicenna, 980-1037 AD) who practiced in Bukhara (in present day Uzbekistan) and Rayy (near modern Tehran). Similarly, Abd el-Malik Ibn Zohr (Avenzoar, 1113-1162 AD) practiced in Seville, Abul-Welid Ibn Roshd (Averroës, 1126-1198 AD) practiced in Cordoba and Mousa ibn Meimoun (Maimonides, 1135-1204 AD), the famous physician and Jewish philosopher born in Cordoba, practiced and died in Cairo (Lindroth, 1999; Mestiri, 200; Martín-Araguz et al., 2002; Courtemanche, 2002; Tan, 2002; Franzin-Garrec, 2003; Urquhart, 2006; Modanlu, 2008; West, 2008; Aciduman et al., 2009). By the end of the 12th century, history repeated itself and dogma started to prevail again over common sense. The Muslim scholar Al-Ghazali (1058-1111 AD) attacked the great philosopher/physician Averroes (Ibn Roshd) in his book “Incoherence of the philosophers” (Tahafut al-falasifa) to which the latter answered by his book “the incoherence of the incoherence” (Tahafut al-tahafut). Unfortunately, dogma conquered and the books of Averroes were burned in a public square (Fig. 9). Some of his books, however, survived, notably his important treatises on the surviving works of Aristotle which found their way to the Spanish intelligentsia (Kyle and Shampo, 1976; Tamani, 1994; Front, 2001; Belen and Bolay, 2009).

Medicine in Europe during the Renaissance

Meanwhile in Europe, some of this work was preserved and/or translated from Greek or Arabic to Latin by various Christian monks and physicians, most notably St Isidore of Seville (560-636), St Benedict of Nursia (480-547), Cassiodorus (490- 573), Bertharius of Monte Cassino (810-883), Walafrid Strabo of Reichenau (808-849), St Hildegarde (1099-1179) and Marbodus of Angers, Bishop of Rennes (1035-1123) (Iorio and Avagliano, 2002; Rengachary et al., 2009). With time, the Aristotalian principles were reaffirmed and rational medicine stared to be firmly established in the new European medical schools. The most famous of these were the medical school of Salerno (Scuola Medica Salernitana founded in the 9th century), the University of Bologna (founded in 1088), Oxford University (founded c. 1096), the University of Paris (founded c. 1165), Cambridge University (founded in 1209), the University of Montpellier (founded in 1220), the University of Padua (founded in 1222) and the University of Naples (founded in 1224) (Andrioli and Trincia, 2004).

During the Renaissance, more rational work was discovered and described according to the principles of Aristotle and universities started to differentiate into “religious” and “free”. The most notable physicians of the time were Andreas Vesalius (1514-1564) who was born in Brussels and practiced in Bologna, Padua and Basel, Gabrielis Fallopio (1523-1562) who also practiced in Padua, Ambroise Paré of the Hotel Dieu in Paris (1510-1590) considered one of the fathers of modern surgery and Paracelcus who practiced in Basel and later in Vienna (1493-1541) (Romero-y Huesca et al., 2005). Modern western medicine The seventeenth century saw the expansion of modern Western medicine with the discovery of the circulation by William Harvey, the spermatozoa by Anthony van Leeuwenhoek, the capillary circulation by Marcello Malpighi, the ovarian follicles by Regnier de Graaf, the introduction of the obstetric forceps by the Chamberlen family and the obstetric crotchet by Francois Mauriceau. The Royal Society was also founded in 1660 (Dunn, 1999; Kaufman, 2005). During the eighteenth century, more scientific advances were made by Edward Jenner who developed the first ever known vaccine, William Smellie, master of British midwifery, William Hunter, the anatomist and obstetrician, André Levret who introduced a more modern obstetric forceps, Jean Louis Baudelocque the famous gyneaecologist, Bartholomew Mosse founder of the Rotunda Hospital in Dublin and Giovanni Battista Morgagni, father of modern anatomical pathology (Dunn, 1996; Dunn, 2004; Saliou and Girard, 2005). During the nineteenth and twentieth centuries, western medicine was permanently established as the leading school of medicine and other medical schools started to follow suite. Important discoveries were made by Robert Koch (1843-1910), Wilhem Conrad Röntgen (1845-1923), Louis Pasteur (1822- 1895), Aloïs Alzheimer (1864-1915), Claude Bernard (1813-1878), Marie Sklodowska-Curie (1867-1934) and Pierre Curie (1859-1906), Joseph Lister (1827-1912), Alexander Fleming (1881- 1955) and others.

But despite these developments and the great leaps taken by modern medicine, the practice of medicine was frequently tainted by procedures and treatments based on experience rather than evidence. In every specialty, some of these treatments and procedures continued to be practiced on the basis of tradition, despite the lack of scientific evidence.

Evidence-based medicine

In 1972, Professor Archie Leman Cochrane, a Scottish epidemiologist published his book Effectiveness and Efficiency: Random Reflections on Health Services (1972) where he advocated the return to the basic concepts behind evidence-based practice, first formulated by Aristotle (Fig. 10). He criticized the medical profession for much of its practices based on experience rather than evidence and awarded the gynaecologists the wooden spoon. When Cochrane died in 1984, his work was honored by the establishment of the Cochrane Collaboration (Sackett and Rosenberg, 1995; Culp, 2002, Winkelstein, 2009). The explicit methodologies used to determine the “best evidence” were subsequently established by the McMaster University research group (Sackett, 1998). The term “evidence based” was first used in 1990 (Eddy, 1990). The term “evidence-based medicine” first appeared in the medical literature in 1992 (Guyatt et al., 1992). Today, evidence-based medicine has permeated all medical disciplines and the national and international medical bodies have embraced it as the right way of practicing medicine. In many specialties, evidence-based guidelines are continuously being formulated by these bodies and are continuously being updated as new evidence emerges (Sackett, 1998; Sackett et al., 2007). It is therefore only appropriate, at this point in time, to remember that evidence-based medicine is in fact a revival of a concept formulated twenty four centuries ago by the great philosopher Aristotle, father of logic.

end

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Hassan N. SALLAM
Professor in Obstetrics and Gynaecology, University of Alexandria, and Director of the Suzanne Mubarak Regional Center
for Women’s Health and Development, Alexandria, Egypt.

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About sooteris kyritsis

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