THE WONDER OF IT ALL

SWEET THOUGHTS - ON DIABETES MELLITUS

2008-09-16T21:10:00.000-07:00

ON DIABETES MELLITUS

INTRODUCTION

This fascinating illness afflicts over 170 million people, a number that is expected to double by the year 2030. It consumes over 5% of the NHS healthcare budget and its various afflictions lead to a vastly increased use of hospital beds. It affects over 12% of Middle Eastern and Asian peoples and is therefore worthy of our greatest attention.

I have heard it being said that having diabetes is worse than having cancer or HIV, and although this may be said in just pure frustration, there may be an element of truth in that. It is a disease of glucose utilisation, and since all body cells require glucose, all of them are afflicted by it. This contrasts with cancer, usually a disease of a single organ, or HIV, a disease of the CD4 cells of the immune system. Aretaeus, a Cappadocian physician of the second century vividly characterized it as “being a melting-down of the flesh and limbs into urine” and coined the term diabetes, meaning ‘to run through’.

Diabetes occurs when we have a lack of (type 1), or deficient action (type 2) of the hormone insulin, which is involved in many different biochemical processes, including protein synthesis, lipid and carbohydrate metabolism. Some types of diabetes are secondary to increased antagonism of insulin, such as thyrotoxicosis, Cushing’s syndrome and phaeochromocytoma, but most are primary, due to insulin-related problems.

EPIDEMIOLOGY OF DIABETES

One of the saddest things about diabetes is that it is more prevalent in the poor, and affects them in the worst manner with the most complications. A BBC report recently stated:
“Britain's poorest communities are 2.5 times more likely to develop Type 2 diabetes than the general population, research suggests. They are also 3.5 times more likely to develop serious complications of diabetes, including heart disease.”

Overall it is a common disorder, and is increasing in incidence. The table above shows the current prevalence of diabetes in many parts of the world, with over 10% of Hong Kong, Pakistanis and Czechs, and a ridiculously high prevalence among Egyptians and Cubans too. The following table illustrates how things will worsen within the next few decades:

But by far, the highest prevalence of diabetes is in the Pima Indians, native American Indians who live in Arizona and Mexico – with a prevalence of 21%. The study of this population has taught us much about diabetes, most importantly, one of the biggest risk factors for type II diabetes – the sudden shift in diet from traditional agricultural goods towards processed foods. The more Westernised Arizona Pimans are those primarily affected, and the genetically similar Pimas in Mexico have virtually no type 2 diabetes. The rising incidence of diabetes around the world can be attributed to the rise of obesity, and the increasing inactivity (due to the comfortable lives we lead) and reliance on processed foods.

The Arab world is increasingly afflicted by diabetes and its ills, which can be explained by the thrifty genotype hypothesis. As explained by Raz et al (2008):

“This phenomenon of shifting disease patterns, termed epidemiological transition, initially occurred in developed countries and subsequently spread to developing nations. Arthur Koestler coined the term 'Coca- colonization' to describe the impact of the lifestyle of Western societies on developing countries. The devastating results of intrusion by Western society into the lives of traditional living indigenous communities can now be seen across the globe”.

Having introduced syphilis and tuberculosis to the developing word in the 19th century, the West has introduced diabetes everywhere else. Does the answer for modern civilization still lie in the Western civilization, with so much mental and physical illness around? There is so much good in it no doubt, but anyone looking deeply into it, will find that all the basic ideas of any quality in the Western world are embodies, to an even greater extent.

In addition, the great poverty that afflicts some leads to lack of education, and a further misunderstanding and poor treatment of the condition. Because it is a chronic condition, with poverty, appropriate drugs are not bought as they are too expensive, and traditional herbal remedies are used. For instance, in the Gaza Strip, where the annual income (for those lucky enough to work) is just under £350 a year, people are resorting to pomegranate seeds and chamomile for treatment, and the management of the condition is careless, with no monitoring facilities, a crucial aspect of its care. This sad truth illustrates the importance of justice, social equality and even distribution of wealth in medical care, things which can only be found in a fair society governed by wisdom and truth.

There are many famous diabetics out there, what I would like to focus here on some of its more interesting victims, whose stories may teach us something about the condition.

FAMOUS DIABETICS

With regards to aetiology, knowledge that former Egyptian president Jamal Abdel Nasser had diabetes, and possibly slipped into a diabetic coma before he died would help us recall two points – the high prevalence of the disease among Egyptians, and the existence of secondary cause of diabetes; his biographers insist that he had haemochromatosis, although his physician, Alsaway Habib recently published his memoirs and, “He denies that Nasser (1918-1970) had slipped into a diabetic coma before his death. Nor did Nasser suffer from bronzed diabetes as once published in the local press. "Nasser suffered from the ordinary type of adult diabetes," says Dr Habib.”

One of the more recent victims is Halle Berry, the American award winning actress. Her story highlights one of the problems that celebrities can cause to the health awareness of people, and how misinformed they can be.

Halle Berry is a type 1 diabetic – in other words dependent on insulin. She has made many fascinating comments on the condition, like "Diabetes turns out to be a gift. It gave me strength and toughness because I had to face reality, no matter how uncomfortable or painful it was", and interesting stories, like her diagnosis, when she “lay dangerously ill in a diabetic coma for a week before waking to a life that would never be the same again”. As a result of this, she became a spokesperson for Novo Nordisk, the pharmaceutical company specialising in diabetic products.

But it is terrifying when such celebrities make comments on therapeutic aspects of a disease. On 6th of November 2007, the ABC News Channel reported Berry to have said, "I've managed to wean myself off insulin, so now I'd like to put myself in the Type 2 category". As everyone knows, this is nonsense, and what Berry is saying is suicidal. I very much doubt that Berry actually said that, because she remains with us to this day. But what her story highlights is that one should always take celebrities comments on the treatment of disease with a pinch of salt. Symptoms yes, management no. The damage that actors and actresses can cause by making statements such as these in our celebrity culture could be devastating.

Another celebrity whose story I am tempted to discuss here is the Honorary Vice President of ‘Diabetes UK’, the great British oarsman and Olympic champion Sir Steve Redgrave, the only person ever to have won gold medals at five consecutive games. But I have opted to discuss his case in the section on ulcerative colitis, since that is a rarer disease, with fewer famous victims that I can think of.

Talking of Diabetes UK, the creation of this excellent charity society which provides a lot of patient support and guidance as well as funding for scientific research and publications over the disease, was due to the efforts of two great men, both diabetic and both very influential.

The story of Robert Daniel Lawrence, the ENT surgeon is so fascinating that his version is quoted in full in that excellent pharmacology book, ‘Clinical Pharmacology’, by Bennett and Brown (2005). I will do the same:

“Many doctors, after they have developed a disease, take up the speciality in it... But that was not so with me. I was studying for surgery when diabetes took me up. The great book of Joslin said that by starving you might live four years with luck. [He went to Italy and, whilst his health was declining there, he received a letter from a biochemist friend which said] there was something called 'insulin' appearing with a good name in Canada, what about going there and getting it. I said 'No thank you; I've tried too many quackeries for diabetes; I'll wait and see'. Then I got peripheral neuritis ...So when [the friend] cabled me and said, 'I've got insulin — it works — come back quick', I responded, arrived at King's College Hospital,London, and went to the laboratory as soon as it opened ... It was all experimental for [neither of us] knew a thing about it... So we decided to have 20 units a nice round figure. I had a nice breakfast. I had bacon and eggs and toast made on the Bunsen. I hadn't eaten bread for months and months ... by 3 o'clock in the afternoon my urine was quite sugar free. That hadn't happened for many months. So we gave a cheer for Banting and Best.But at 4 pm I had a terrible shaky feeling and a terrible sweat and hunger pain. That was my first experience of hypoglycaemia. We remembered that Banting and Best had described an overdose of insulin in dogs. So I had some sugar and a biscuit and soon got quite well, thank you"

The disease changed Lawrence’s life entirely, and he devoted all his time to research on the condition and the care of its patients. He set up a clinic which quickly became overcrowded, and this is where Herbert George Wells comes in. The great creator of science of fiction was also a diabetic and a patient of Lawrence. The details were summarised by Curnow (2002):

“The number of people with diabetes attending the clinic doubled within four years, conditions were crowded and the equipment was inadequate. The hospital authorities supported Lawrence’s request to make a personal appeal to his more wealthy private patients to fund improvements to the facilities available to outpatients, and possibly build a small unit for in-patients. HG Wells, who had been referred to Lawrence in 1931, was one of the patients Lawrence approached. Wells donated half a crown, saying he was not a wealthy man and believed that the appeal should be of interest to all people with diabetes, and offered to write to The Times to involve a wider audience. The letter to ‘The Select Company of Diabetics – for the Benefit of Their Cult’ was published on 19th April 1933. He ended it saying, "I am a little surprised we have not already formed a Diabetic Association to watch over and extend this most benign branch of medicine to which we owe our lives" (Br J Diabetes Vasc Dis 2002;2:469–72).

In 1934, the ‘Diabetic Association’ was founded, with RD Lawrence as the Chairman and HG Wells the President of the Association, with the nominated Vice Presidents including Professor FG Banting and Dr CH Best and two diabetic well-known novelists, GDH Cole and Hugh Walpole.

I cannot help but digress and talk a little about H G Wells, who was one of the best writers of both fiction and non fiction of the 20th century. There are an abundant number of biographies of the great man, to which I would like to refer the kind reader, for he is a most interesting person.

For the medical man, Wells is interesting for several reasons. Firstly, because of his diabetes, and his massive contribution to the creation of the ‘Diabetic Association’ (now Diabetes UK) together with Lawrence, as explained above. Indeed, the first time it was revealed to me that Wells was diabetic was while reading a very moving letter of his to the great Bertrand Russell, who incorporated it in his ‘Autobiography’, one of the most beautiful books I have ever read. An extract from the letter, written the year before his death in 1946, says a lot about the impact diabetes can have on one’s life:

“I have been ill & I keep ill. I am President of the Diabetic Society and diabetes keeps one in and out, in and out of bed every two hours or so. This exhausts, and this vast return to chaos which is called the peace, the infinite meanness of great masses of my fellow creatures, the wickedness of organised religion give me a longing for a sleep that will have no awakening. There is a long history of heart failure on my paternal side but modern palliatives are very effective holding back that moment of release. Sodium bicarbonate keeps me in a grunting state of protesting endurance. But while I live I have to live and I owe a lot to the decaying civilisation which has anyhow kept alive enough of the spirit of scientific devotion to stimulate my curiosity and make me its debtor.”

Secondly, because of his very interesting ideas regarding future health care. Wells was a great historian, and he illustrated this with his tour-de-force, ‘An Outline of History’, a 1324 page work that was the most popular book sold in America after its publication (after the Bible). Backed with this huge historical expertise, he gave some marvellous visions of how the future may turn out to be, and in one work, ‘An Englishman Looks At The World’, he envisages a system that seems to predate the GMC and NHS by many years:
“In that extravagant world of which I dream, in which people will live in delightful cottages and ground rents will serve instead of rates, and everyone will have a chance of being happy--in that impossible world all doctors will be members of one great organisation for the public health, with all or most of their income guaranteed to them: I doubt if there will be any private doctors at all.

Heaven forbid I should seem to write a word against doctors as they are. Daily I marvel at the wonders the general practitioner achieves, having regard to the difficulties of his position.

But I cannot hide from myself, and I do not intend to hide from anyone else, my firm persuasion that the services the general practitioner is able to render us are not one-tenth so effectual as they might be if, instead of his being a private adventurer, he were a member of a sanely organised public machine. Consider what his training and equipment are, consider the peculiar difficulties of his work, and then consider for a moment what better conditions might be invented, and perhaps you will not think my estimate of one-tenth an excessive understatement in this matter.”

How nice is it to see praise of the general practitioner, at a time when he or she is regarded, somewhat unfairly, as a second class physician!

Moving on from Wells, who has taught us so much, we can move smoothly to another British genius, who shared much with Wells – his creativity and invention, disbelief in God, faith in eugenics (which is almost inextricably intertwined) and last but not least, his diabetes. It’s the great inventor of the telephone, Alexander Graham Bell.

I will not deal here with the full biographical details of this great man, his numerous struggles and tragedies, his many success stories, and his great romanticism and his love and marriage to his deaf student Mabel Hubbard. But I will focus on what I regard as interesting from the medical point of view.

Robert V. Bruce writes in his biography, ‘Bell: Alexander Graham Bell and the Conquest of Solitude’:

“By 1915 Bell himself was in the grip of that incurable and (in pre-insulin days) perilous condition, diabetes. He had occasion for somber thought now in his sessions of nocturnal solitude. He could not have been deaf to the meaning of what was upon him. Diabetes had been the death of his uncle David 14 years before, but Bell's motto was 'keep on fighting'”.

He was later diagnosed with pernicious anaemia, which is a recognized association with diabetes, although not with type 2 diabetes, which is what Bell likely had (no one with type 1 diabetes survives without insulin to the age of 75). And although it is stated in many places that Bell died of pernicious anaemia, including in the Wikipaedia article on him, I feel that is unlikely to be the case. Although it sounds paradoxical, diabetes, particularly when uncared for is a more pernicious than the pernicious disease!

It is clear that Bell’s diabetes was uncared for, for obvious reasons. Firstly, he lived in the pre-insulin age – he was unlucky to have died in the same year Banting and Best discovered insulin, although it would be difficult to foresee if their treatment would have made any difference to him had he survived. For example, he developed neuropathy, as Charlotte Gray discloses in her biography of Bell, ‘Reluctant Genius’ (pages 418-419) – he was able to keep on wiggling “his toes, even though he had lost sensation in them. None of his family realized that the loss of sensation was an indication that he had pernicious anemia". (Although giving a clever possibility, it will never be known which one it is that led to his peripheral neuropathy). Neuropathy happens after years of damage, as we will soon see.

There was an absence of the routine care we now have for diabetes (which has been formulated after many years of intensive research into its most appropriate management). Knowing the above, Bell would have surely benefited from seeing a chiropodist, something all diabetics of today are routinely familiar with. He would have also possibly benefited from a dietitian, but by sounds of things, he would have probably been, as are most diabetics, pretty non-compliant with their recipes. As Bruce illustrates in the aforementioned biography:

“Always a hearty eater, Bell broke loose now and then from the coils of medical caution and, to the distress of his family, defied restrictions on starch and sugar. “Melville," he would say to his grandson as they walked by a redolent bakeshop on Wisconsin Avenue, "would you like some apple pie?" Bell himself would then join in the snack. "Don't you say a word to your grandmother," he would caution the boy. But when he toyed with his dinner, Mabel would notice. "Alec, you stopped in that bakeshop, I know." Ignoring the smoke screen of an exciting story, she would keep after him until he confessed like a small boy caught out. Charles Thompson kept an eye on the state of the refrigerator, but one night Bell made a raid, washed the china, and brushed up every crumb. Called to treat his acute indigestion, the doctor extracted the confession, "To go downstairs at three in the morning, load up on Smithfield ham, cold potatoes, macaroni cheese, and then go right to bed is the most ridiculous thing imaginable, " said the doctor severely; "that meal might have put an end to you, sir" "Well, as it is," said Bell, "the game was worth the candle. It was the best meal I've enjoyed in an age"!”

In knowing that Alexander Graham Bell had type 2 diabetes we will immediately dispel the idea that type 2 diabetes is a twentieth century phenomenon. It is not, although it certainly has increased in prevalence since. Indeed, the two different types of diabetes were distinguished as early as 1875, by Apollinaire Bouchardat in his book on glycosuria (Kiple, 2003).

In addition, the story of his doctor suspecting that “Bell’s diabetes had affected his liver” reveals a very clever insight into diabetes, which has only recently been recognized. Liver disease is now thought to be a not uncommon cause of problems in diabetics. Indeed, it is now felt that NASH, non-alcoholic steatohepatitis, the commonest liver pathology seen in diabetics is now a not uncommon cause of progressive chronic liver injury overall (Evans et al, 2002).

Quite smoothly, history moves us on to discuss one of Bell’s close associates, Thomas Edison, the great American inventor. If Bell invented the telephone, it was Edison who made improved on it greatly and made it the technological masterpiece that it is today. He devised a mouthpiece for it that contained carbon powder, which when compressed, carried more current than when not compressed. As the sound waves compressed and decompressed it, the electric current fluctuated accordingly.

Edison died of complications of diabetes aged 84, namely renal failure. In ‘Edison - Inventing the Century’, Neil Baldwin describes the experience of his physician:

“Dr. Howe had a challenging patient in Thomas Edison - a totally deaf, eighty-four-year-old-man who did not bathe more than once a week, but did not believe in exercise, still (by his own account) "chewed tobacco continuously" and smoked several cigars a fay, and whose only foods were milk and the occasional glass of orange juice... In later years, Edison also suffered from diabetes and Bright's disease”.

Bright’s disease is the old name for renal failure. He died uraemic on October 18th 1931. One can see how Edison would have benefited, like Bell, from attending a dietitian, and having smoking cessation advice. And unlike his Scottish counterpart, he would have been more likely to heed their advice. After all, wasn’t Edison the one who famously said:
“The doctor of the future will give no medicine, but will interest her or his patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease”?

Now let us move on to diabetes itself.

DIABETES – THOUGHTS ON PATHOPHYSIOLOGY

One of the biggest lessons of diabetes, is that it induces a feeling of appreciation of normal metabolism. The primitive human being, by virtue of instinct, knows that through lack of food and water, oxygen and warmth, he will die. We know this death is caused by cardiac arrest, and treating these three, if present, is part of the established cardiac arrest management algorithm (namely hypothermia, hypoxia, hypovolaemia). We always pierce the patient’s finger to check his blood glucose (in any comatose patient, including that due to a cardiac arrest). Both hypoglycaemia and hyperglycaemia are sinister and are treated aggressively, and what is important to realise is that they are both forms of ‘body starvation’ – not just hypoglycaemia. Whereas in hypoglycaemia, the body is starved of fuel, in diabetic hyperglycaemia, the body is starved of glucose utilisation, and in a desperate attempt, tries to consume other fuels, fats and proteins, which is only possible for a short while without severe consequences, which we shall discuss later. What is important to realise too is that hyperglycaemia not only leads to metabolic consequences, but also to hypovolaemia. This is because of the increased urine output and intracellular fluid loss due to osmotic shift. Indeed, in a patient with severe uncontrolled hyperglycaemia, such as diabetic ketoacidosis or HONK (hyperosmolar non-ketotic diabetic coma), it is dehydration that kills them, not the hyperglycaemia per se.

Normal glucose regulation is maintained by several complex mechanisms. After any carbohydrate meal, the pancreas responds by releasing insulin from its beta cells (islets of Langerhans). This serves to stop gluconeogenesis and glycogenolysis, and stimulate glycogen synthesis (stimulating the enzyme glycogen synthase) by the liver (as well as glycerol for triglyceride synthesis), and shifts glucose intracellularly (via GLUT-4 receptors) into skeletal muscles and adipose tissue. Note that the liver does not need insulin to get glucose into its cells. It enters simply via a concentration gradient.

Why should this be the case? Perhaps the body is being economical with its insulin, knowing that the insulin is required for the insulin-induced stimulation of glycogen synthase and triglyceride synthesis. I do not know, but am sure there is a clever reason behind it.

One of the fascinating facts is that the brain, which consumes about 80% of the glucose utilised at rest in the fasting state, it too, like the liver, does not depend on insulin to get to it. The brain has exclusive GLUT-3 receptors. Now, imagine if the brain depended on insulin. This would be a disaster for all type 1 diabetics, who would quickly go into a coma and die once their pancreas is overwhelmed by the disease.

Now we mentioned above a fact that everyone knows – after a high carbohydrate meal, the pancreas releases insulin. What we fail to realise and appreciate is that, these four words – ‘the pancreas releases insulin’ is one of the most majestic events of the cosmos. This is not an exaggeration, as I will explain below. Perhaps because we are see so many diabetic patients in hospital and in general practice that we regard it all as monotonous, and so we do not reflect on or appreciate this majesty. But let me break away and begin reflecting on this process like an intelligent child, and prove my point.
To begin with – the pancreas needs to detect the glucose cells. Harun Yahya summarises this amazing process as follows, “First, the pancreas cells would find and distinguish the sugar molecules from among all the millions of other molecules in your blood. Moreover, they would count the sugar molecules to decide if the number were too high or too low. Amazingly, cells too small for the eye to see, without eyes, hands, or a brain know the correct proportion of sugar molecules in a fluid.” The glucose enters the beta cells by facilitated diffusion through the glucose transporter, GLUT-2. Although the majority of human cells require insulin to shift insulin into them, the pancreas, like the liver, doesn’t. It is a basic rule of the human body that an organ synthesising a chemical or hormone is never itself dependent on it. It is a form of altruism.

Within the beta cells, glucose is metabolised to produce ATP. This ATP closes ATP-dependent potassium channels present in the beta cell membrane, which then depolarises the cell, causing calcium entry, which stimulates exocytosis of insulin. Sulphonylurea drugs, like gliclazide act like ATP here, inhibiting the ATP-dependent potassium channels.

The insulin is synthesised as a large molecule – called pre-proinsulin. The reason for this is that it includes a signal peptide, called C-peptide, which is important for directing its proper folding and movement through the Golgi apparatus where it is synthesised (Kaufmann, p.240). Just before storage this is converted to insulin and C-peptide.

Unfortunately, for reasons of space, we will not be able to talk about many of these magnificent processes which we are passing by here without much reflection. ATP manufature, depolarisation, insulin (protein) synthesis, exocytosis and cleavage. But the details may be found in any decent biochemistry textbook. I preferred Stryer back in the day.

Once insulin is secreted into the bloodstream it exerts its action by binding to receptors primarily in the liver, muscle and adipose tissue; these are tyrosine kinase linked receptors which when bound to insulin result in a conformational change and autophosphorylation, and phosphorylation of IRS (insulin receptor substrate) proteins which activates intracellular signal cascades and enzymes.

The actions of insulin are summarised in the table below:

Following discussion of insulin’s roles, Harun Yahya concluded wondering, “How can it be that cells without a brain, nervous system, eyes or ears can manage to make such a complex calculation and carry out their function perfectly? How can these unconscious cells formed by the coming together of proteins and fat molecules do things too complicated for humans to achieve? What is the source of this remarkable awareness demonstrated by these unconscious molecules? Surely all of these delicate operations taking place in our bodies show us the existence and power of God Who rules over the universe and all living things.” I wish I were the first to say that!

So insulin’s main role is in glucose homeostasis, and indeed, it is the only hormone in the human body that lowers blood glucose, whereas several other hormones can raise it. Why is this the case? As one researcher postulates, “Our body has no back-up system if insulin stops working. Why would that be, do you think? Does it not strike you as odd that in the fabulous system that is our body there is no back-up system for insulin, when our body tends to have all kinds of fall-back plans if something should fail? Perhaps it is worth looking at the question through the eyes of primitive humankind. Not having lived at that time I can't be certain, but I would imagine that there would have been times of limited food, and being able to increase blood sugar levels would have been critically important in order to fuel the body when there was very little or no food being consumed. Just like many other animals, in the spring and summer when fruit, plants and grains were available, it was advantageous to have insulin store some fat to aid chances of survival through the lean winter months. Fruit would be dried, and other foods fermented, but especially in the colder climates, people would rely on wild animals or fish for most of their food in the winter. Meat and fat do not induce a big insulin response. So, perhaps in the body's wisdom, it did not think it needed more than one method to lower blood sugar, as high carbohydrate (plant food) diets simply did not happen day in day out all year round except possibly in tropical climates.”

So what happens if there is not enough insulin? Quite simply, there is unopposed action of glucagon and other anti-insulin hormones (catecholamines, cortisol), and the following results:

DIABETES AETIOLOGY & PATHOGENESIS

But how is diabetes caused? The general consensus is that type 1 is an autoimmune condition triggered by environmental and genetic factors.

The autoimmune aspect is postulated because three reasons:

The association of type 1 diabetes with other autoimmune diseases such as vitiligo, pernicious anaemia, Grave’s disease, and Addison’s disease.
The presence of T-cell infiltrates within the islets of type 1 diabetics
Detection of antibodies to islet cell antibodies (ICA) and glutamic acid decarboxylase (GAD) in their serum.

Autoimmune diseases are a minefield, and we will discuss them in more detail in the immunology section, but just to overview, they chiefly result from what is known as loss of tolerance. The normal human body has mechanisms that ensure B-cells are unresponsive to self-components, and that T-cells are not mobilized by self-peptides expressed on the MHC of healthy cells. This tolerance may be central, achieved by clonal inactivation or deletion of autoreactive T-cells in the thymus and B-cells in the bone marrow, as well as peripheral.

Autoimmune diseases, although dreadful, highlight to the majority of mankind the presence of these mechanisms. Were they not present, would we have appreciated ‘tolerance’ and its very clever mechanisms? The answer is probably not. This is another argument for intelligent design – a normal human body cannot exist without a perfect immune system, which recognizes itself and only attacks others. Even with a normal heart, lung, joints, GI tract etc; if the immune system does not institute tolerance, disaster will follow, as all type 1 diabetics, and patients of other autoimmune disease know. Other examples of autoimmune disease are tabled below.

The autoimmune event may be triggered or propagated by environmental factors. This is suggested by epidemiological studies, which show that clinical onset of type 1 diabetes peaks in the spring and autumn months, coinciding with higher incidence of viral infections at these times.

Genetic factors are suggested by studies on its prevalence in twins – 50% in monozygotic twins, and 6% in dizygotic twins, and an increased risk of 6% of developing type 1 DM in first-degree relatives of patients with it. It is interesting to note that people at such increased risk may be monitored in the future by measuring the aforementioned ICA antibodies, which precede development of hyperglycaemia by many months, possibly years.

An interesting observation is that the body has a huge reserve of islet cells, and that hyperglycaemia only develops once 75% of beta cells are lost. Such is the kindness of the Creator. He has given us more than we need.

As for type 2 diabetes, there is no autoimmune component, but genetic, environmental and possibly also fetomaternal factors are important. Let us reflect on these aspects for a minute.

Genetic factors are suggested by a higher concordance in monozygotic than dizygotic twins, as for type 1 diabetes, and also a higher prevalence in certain full-blooded populations compared to mixed races (e.g. Naurans in the South Pacific). Indeed, certain genetic defects have been illustrated in some cases (MODY – maturity onset diabetes of the young). These are listed in the tables below, with a table of the classification of MODY disorders. It is important to have an intact enzymatic pathway for insulin action and beta cell function. In addition, there are a number of ‘insulinopathies’, very rare genetic conditions inherited also in an AD fashion where abnormal insulin is secreted. The amino acid changes are so subtle, yet end in disaster, highlighting the magnificent accuracy of the human body in the majority of us with normal insulin. Had we not known about these insulinopathies, would we have appreciated this aspect, one wonders? Very unlikely, and the synthesis of insulin would have been taken for granted.

GENE
% OF MODY
CASES
CLASSIFICATION
Glucokinase
20
MODY 2 – mild; complications are rare
HNF-1a
60
MODY 3 – diagnosed later (around 35 years of age)
HNF-4a
1
MODY 1
HNF-1b
1
MODY 5
IPF-1
1
MODY 4
Unknown
15
MODY X
SUR1
<1
Hyperinsulinism in infancy and beta cell failure in childhood

The main risk factor for type 2 diabetes is obesity, with the accumulation of visceral abdominal fat rather than subcutaneous fat being deleterious. About 80% of type 2 diabetics are obese. Fat is a highly active tissue, and not as inert as people think. It produces a variety of hormones and chemicals which modulate insulin action, including TNF-alpha. Why should the distribution of the fat be of any significance? The mechanism is still unclear.

Now we shall discuss obesity and its complications in due course, but it is worthwhile mentioning the verse, “Eat and drink but not to excess” (7:32). Umar, the second Caliph, is reported to have said: “Avoid getting a pot-belly, for it spoils the body, causes diseases, and makes doing the prayer tiring. And avoid all excess, for God hates a learned man who is fat.” Ali ibn al-Husayn ibn al-Wafid said. ‘God put all medicine into half of one verse [of the Qur’an] when He said: Eat and drink but not to excess.’ The Prophet (PBUH) also drew attention to obesity and over-eating. For example, as recorded by Al-Haythami, on seeing a fat man, he said: “If you did not have a paunch, it would be better for you”. He also is reported to have said, “Overeating does not go with good health”.

It is also felt that physical inactivity is a risk factor for type 2 DM independent of weight gain. Exercise possibly reduces the risk but increasing whole body insulin sensitivity. Hence, there is great wisdom in the Islamic advice regarding physical activity.

CONSEQUENCES OF DIABETES

KNIVES

· Kidneys - leading eventually to diabetic nephropathy and chronic renal failure
· Neuromuscular – causing peripheral neuropathy, autonomic neuropathy, mononeuritis, radiculopathy, and amyotrophy
· Infective – increased risk of urinary tract infections, skin and soft tissue infections, tuberculosis and moniliasis
· Vascular – affecting both large vessels (leading to ischaemic heart disease and peripheral vascular disease) and small vessels (microangiopathy producing renal failure, gangrene of skin and feet, with wedge-shaped infarcts.
· Eyes – an increased risk of cataracts, retinopathy, glaucoma, blurred vision, and retinal detachment.
· Skin – particularly affecting the feet (deformities, ulcers and gangrene, necrobiosis lipoidica, granuloma annulare, cellulitis, acanthosis nigricans)

Almost all organs and body processes are afflicted by diabetes. The main chronic ones are summarized by KNIVES. However, it is important to realize that diabetes affects virtually all body organs in one way or another, to the extent that I have heard consultants advise their students that, if asked about the causes of any illness (or risk factors) then saying diabetes and drugs is likely to be a successful choice! The reason for this is simple – all organs need metabolism to survive, and glucose is its chief currency. If glucose cannot be utilized, metabolism will eventually fail in one way or another. In addition, if it accumulates it can cause microvascular and macrovascular damage. The former is how the eyes and kidneys are damaged, and the latter is how the nerves and arteries are damaged.

How does this occur? Several mechanisms have been suggested. The most established one is that of nonenzymatic glycosylation of proteins in capillary basement membranes and other tissues, leading to damage through loss of function, turning on and off of signal pathways within cells, or alteration in gene expression. Very cleverly, this observation is used in the assessment of long term control of diabetic patients. One of the proteins which is glycated is haemoglobin. Because red blood cells survive in the blood for 90-120 days, the HbA1c provides a means to assess glycaemic control over this period. I have seen many patients who, in order to please their doctor, decide to optimize their glucose control in the days immediate to their next appointment with him, failing to realize that by HbA1C, we have the truest reflection of their control over the past three months. BMs can be easily manipulated, through an excess intake of medication, but glycated haemoglobins are not. The following table illustrates the average BMs of patients with relation to their glycated haemoglobin:

HbA1c(%)
Avg. Blood Sugar
(mmol/L)
(mg/dL)
4
3.3
60
5
5.0
90
6
6.7
135
7
8.3
170
8
10.0
205
9
11.7
240
10
13.3
275
11
15.0
310
12
16.7
345
13
18.3
380
14
20.0
415

Note therefore, that in patients with a shortened RBC lifespan, such as those with haemolytic anaemia or sickle cell disease, there is no point using HbA1C. In these patients, fructosamine is used; this is formed when the carbonyl group of glucose reacts with an amino group of a protein. This is usually albumin, and because the half life of albumin is about 3 weeks, fructosamine assays are only true measures of diabetic control for that time. Unfortunately, patients with thalassemia have an increased affinity to glucose anyway, as well as patients with uraemia – this may lead to falsely high HbA1C, and this possibility should be raised in such cases.

The other mechanism by which microvascular damage is caused is by hyperglycaemia increasing the activity of the enzyme aldose reductase, which converts glucose to sorbitol. This causes damage by the mechanisms outlined below, and indeed one of the exciting developments in the management of diabetic complications is the manufacture of specific aldose reductase inhibitors, which have been successful in many animal trials, but owing to their high toxicity profile, remain far from human application.

Macrovascular complications are due to atherosclerosis, which we explain in the section on ischaemic heart disease. One of the interesting suspected reasons for increased atherosclerosis in type 2 diabetics is hyperinsulinaemia; this occurs due to increased insulin resistance. This explains why drugs that increase peripheral insulin sensitivity such as biguanides (e.g. metformin) are preferred to insulin secretagogues such as the sulphonylureas.

A reflection point here is that, if hyperinsulinaemia were to cause disease, it is an absolute prerequisite that a system to counteract it, namely the hyperglycaemic hormones – glucagon, adrenaline and cortisol – should be present at the same time to ensure survival. This is another pointer in the direction of intelligent design.

KIDNEYS

Significant renal disease occurs in 40% of type 1 diabetics and 20% of type 2 diabetics. The reason for the higher incidence in type ones may be the earlier onset of the disease in their case.

So why is the kidney affected by diabetes? Partly, it is because of the fact that the kidney is an extremely vascular organ, and a huge proportion of the body’s cardiac output is delivered to it.

It is interesting to note that there appears to be a genetic link in diabetic nephropathy; a history of nephropathy in other members of the family with diabetes greatly increases the risk of nephropathy. Studies have shown the possibility of problems with the ACE gene; there may be increased secretion of ACE, leading to increased microvascular damage. This may explain why ACE-inhibitors are of prognostic value in diabetic patients, and, as put by the OHCM, every type II diabetic should be on one. There is another reason how ACE-I may help, which we shall explain later.

The kidneys of diabetics show an increase in the mesangial matrix, increased width of the glomerular basement membrane and arteriosclerosis of the afferent and efferent arterioles. The kidneys become malnourished and disfigured, so to speak, with what are called ‘Kimmelsteil-Wilson’ nodules, characteristic of diabetic nephropathy. This leads to an increase in transglomerular pressure, and eventually to a decrease on capillary filtering area. The GFR declines. The increased transglomerular pressure is followed by loss of the negative charge on the basement membrane and thus reduced repulsion between it and the polyanionic albumin molecule. This leads to microlalbuminuria initially, then macroalbuminuria when the pore size enlarges. Later on, the tubules start to fail to reabsorb filtered protein.

Microalbuminuria is the first manifestation of diabetic nephropathy. This can be assessed by timed urine collections (20-200 micrograms/minute, or 30-300 mg/day). To make life easier, and rather than get a patient to give a 24-hour sample, the urinary albumin:creatinine ratio in a random sample of urine can be used. An ACR of >2.5 defines microalbuminuria. Later on, grams of albumin may be lost in a day, at which point the patient may have what is called the nephrotic syndrome, defined as proteinuria of >3.5 g/day, hypoalbuminaemia and oedema.

Now, let us for a few moments discuss this concept of nephrotic syndrome, which has previously puzzled me. Why is this disease, defined by a clinical finding (oedema) and two biochemical tests (proteinuria and hypoalbuminaemia) discussed in textbooks as if it were a separate disease entity? Are they not all part of the same thing – in other words, isn’t proteinuria obviously going to cause hypoalbuminaemia and oedema? Why do we call it a syndrome?

The usefulness of the concept of the nephrotic syndrome is that, once its triad occurs, the patient is at a highly increased risk of hyperlipidaemia, infection, thromboembolism and iatrogenic acute renal failure (due to the diuretics used for the oedema), and the patient must be put on appropriate anticoagulants, antibiotics, and statins. The diagnosis simply guides more cautious treatment of the patient, and not new pathology. That is why some believe that syndromes should not be in the ICD, the list of human diseases as published by the World Health Organisation (WHO), because they are not diseases, but the disease and its sequelae.

NEUROPATHY

This is the most common chronic complication of diabetes. The pathogenesis of these neuropathies is mainly microvascular, although lack of neurotrophic factor support (important in maintenance of normal neural function) and laminin expression (involved in neurite extension and normal function) are also likely to be important. There are many different forms which it can take, summarized as follows:

There is a lot to learn from neuropathy, in particular the importance of pain. Anyone who denies the existence of God based on the fact that pain exists should attend a diabetic clinic, and observe the feet of a patient with poorly controlled diabetes. The most distal parts of the longest nerves are the first things to be affected, with feet first then hands. Perhaps it is because the longest nerves are the ones that need the most support. There is loss of pain sensation firstly, then numbness and tingling, and eventually unrecognized trauma, severe pain, ulcers and neuropathic joints. The ulcers may become infected, leading to osteomyelitis and possible amputation.

Here we have a clear illustration of the importance of pain. As one philosopher put it, “Despite its unpleasantness, pain is an important part of the existence of humans and other animals; in fact, it is vital to survival. Pain encourages an organism to disengage from the noxious stimulus associated with the pain. Preliminary pain can serve to indicate that an injury is imminent, such as the ache from a soon-to-be-broken bone. Pain may also promote the healing process, since most organisms will protect an injured region in order to avoid further pain. People born with congenital insensitivity to pain usually have short life spans, and suffer numerous ailments such as broken bones, bed sores, and chronic infection.” To argue that the presence of pain is inconsistent with the presence of a merciful deity is invalid. Pain is – if anything – a pointer towards the contrary.

Virtually any nerve can be affected by diabetes. The brain is affected chiefly through the increased risk of stroke, which is actually a macrovascular, not a microvascular complication.

The cranial nerves are also affected. Most commonly, the third, fourth and sixth cranial nerves are affected, causing diplopia. Why these nerves are most affected is unclear.

The autonomic nervous system has its origins in the brainstem. Neuropathy may manifest itself in cardiac arrhythmias, postural hypotension, vomiting (gastroparesis), diarrhoea, urinary retention (neuropathic bladder) and impotence.

INFECTION

The risk of infection is increased in diabetes because of impaired leukocyte, particularly neutrophil, function. Urinary tract and skin infections (e.g. cellulitis, boils, abscesses), as well as candida and tuberculosis, are increased. The destructive effects of the infection in diabetics are multiplied, because the infection leads to activation of the fight-and-flight (sympathetic) response, in an attempt to counteract the insult. This results in release of the hyperglycaemic hormones, cortisol and adrenaline, which further worsen the hyperglycaemia, and may lead to such severe consequences as DKA. Knowledge of this can only lead to gratefulness about the perfect metabolic state of the immune system in the 97% of human beings, who are not diabetic.

EYES

Several aspects of the eye are affected by diabetes. This includes the nervous control (discussed above due to neuropathy), the lens (cataracts), aqueous humour (glaucoma) and retina.

The mechanism for diabetic retinopathy is analogous to that of nephropathy. In both cases, there is thickening of the basement membrane as an early pathological feature. There is loss of vascular tone regulation (similar to that which occurs in the afferent and efferent renal arterioles), which is partly due to loss of pericytes (contractile cells which control vessel caliber and flow). There is loss of endothelial cells like in the kidneys. The capillaries become more fragile and leaky, and the first sign usually seen with an opthalmoscope is microaneurysm formation, which are blind outpouchings of the capillaries which appear as red dots. These aneurysms, like any aneurysm, can bleed, and these are the ‘blots’, and once they become more frequent and more severe, cotton-wool spots form. These are not areas of infarction as is commonly believed, but elevations of the nerve fibre layer due to intracellular accumulation of axoplasmic material at the areas of microvascular infarction. Whereas in the kidneys there is mainly leakage of albumin and other protein, in the eyes there is leakage of both protein and lipid, and these form hard exudates. All these changes form the non-proliferative phase.

Once the above becomes excessive, the preproliferative phase occurs. This is characterized by multiple haemorrhages in all four quadrants, five or more cotton wool spots, venous dilatation and beading, and intraretinal microvascular abnormalities (IRMAs) – abnormally branched vessels in the retina, representing attempts to revascularise the ischaemic retina.

Contrary to intuition, when one would expect ischaemia to mean reduction and loss of activity, the ischaemic areas of the retina actually secrete several growth factors, especially VEGF. This is the body’s attempt to compensate, and if they were normal vessels, then all would be well. However, these vessels are both histologically and anatomically defective. They are very fragile, and bleed easily, and grow forward towards the vitreous fluid and can overlie the optic disc. These are the most dangerous ones. Their bleeding can lead to vitreous haemorrhage and retinal detachment. Growth of new vessels can also occur over the iris, leading to ‘rubeosis iridis’. Obstruction of the drainage angle by new vessels may then cause a painful secondary glaucoma. All these things constitute proliferative retinopathy. Maculopathy occurs if any of the above takes place around the macula site. The following table summarises the pathophysiology of diabetic retinopathy.

SKIN

The skin is affected in diabetes through multiple mechanisms. In fact, one can use the surgical sieve to organize skin disease in diabetes.

Vascular disease can lead to arterial ulcers. Infections lead to cellulitis, boils, abscesses, candidiasis, and tinea (dermatophyte infections). Trauma, due to neuropathy, can also lead to ulcers and all sorts of skin damage. Autoimmune conditions such as vitiligo are associated with type 1 diabetes. The condition necrobiosis lipoidica diabeticorum is felt by some to be a metabolic condition, where there is hyaline degeneration of collagen (necrobiosis) surrounded by fibrosis. Lysyl oxidase levels have been found in some diabetic persons to be elevated and are responsible for increased collagen cross-linking. Increased collagen cross-linking could explain basement membrane thickening in this condition. (Why it occurs only in the legs is an interesting question).

Iatrogenic skin conditions in diabetes include lipoatrophy and lipohypertrophy. Neoplastic conditions (although not malignant) include Dupytren’s contracture and acanthosis nigricans, a hyperpigmented velvety outgrowth of the epidermis, usually in the flexural areas of the axilla, groin and neck. It also occurs in several malignancies. It is most likely caused by factors that stimulate keratinocyte, melanocyte and dermal fibroblast proliferation. The factor is probably insulin or an insulinlike growth factor. In malignant AN, the stimulating factor is believed to be a substance secreted either by the tumor or in response to the tumor.

OTHER ORGANS

The liver and most other organs are affected by diabetes. LFTs can be deranged.

HISTORY

Patient presents with symptoms of fatigue, thirst, polyuria, weight loss or weight gain, features of complications, or are completely asymptomatic and detected on assessment for other illnesses. The patient may present for the first time with diabetic ketoacidosis, i.e., smelling of ketones, hyperventilating, dehydrated, and even drowsy, confused, or comatose

PMH

Other HLA-DR3 associated disorders; rare causes of DM – chronic pancreatitis, cystic fibrosis, Cushing’s syndrome, acromegaly, phaechromocytoma, pregnancy, MJ THREADS.

DH

Steroids
Thiazides
Beta-blockers

FH/SH

Smoking
Determine if patient drives or not in ADL (need to notify DVLA if private vehicle license, and is banned permanently if HGV)
Alcohol (needs to stop)
May be a strong FH of DM

ROS

As appropriate; all systems are affected by DM.

PHYSICAL EXAMINATION

GENERAL

Unwell, obese or wasted patient – check BMI in all endocrine patients
Raised BP very common
Urine output increased
Other vital signs variable
JACCOL may or may not be relevant, e.g. jaundice in fatty liver, anaemia in pernicious disease. May be dehydrated

CVS

Blood pressure must be measured sitting & standing (to detect any postural drop)
Peripheral pulses may be absent
Signs of ischaemic heart disease or PVD

RS

Apart from the increased risk of tuberculosis, no marked consequences here

ABDOMEN

Hepatomegaly possible
Ensure urine is dipsticked, looking for PBL KNG

NEUROLOGICAL

Diabetic neuropathy may be somatic (including polyneuropathy which may be symmetrical, sensory and distal or asymmetrical motor and proximal); to remember which is which – remember pROximal is motOR (includes amyotrophy), therefore distal is sensory
Cranial nerves commonly affected include optic nerve, oculomotor and abducens nerves.
Examine eyes fully, including the red reflex (cataracts), acuity, colour vision, and fundoscopy.

Fundoscopy may reveal any of the four grades of diabetic retinopathy; spots (cotton wool spots which are ischaemic nerve fibres), dots (microaneurysms) and blots (haemorrhages due to rupture of microaneurysms)

1) Background à dots and blots and hard exudates
2) Preproliferative à add soft exudates
3) Proliferative à add new vessels
4) Maculopathy à if visual acuity is down and no cataract
- Hypertensive changes commonly co-exist; also note that venous dilatation is the earliest change, including central vein occlusion

Other commonly affected nerves include the femoral and sciatic nerves. Lateral polpliteal nerve palsy and carpal tunnel syndrome also may occur.

SKIN

The dermatological complications of diabetes are:

CENTURY

· Cellulitis / Candidiasis
· Eruptive xanthomas
· Necrobiosis lipoidica (the most specific; occur on shins mainlyl yellow plaques with red edges & may ulcerate)
· Tense bullae over lower legs
· Ulcers (neuropathic, arteriopathic)
· Rubeosis (chronic flushed appearance of face caused by decreased vascular tone and pooling of blood)
· Yellow skin (increased beta carotene levels)

INVESTIGATIONS

DIAGNOSTIC

Random blood glucose > 11 in a symptomatic patient (only one value needed); in asymptomatic patient blood glucose > 11 on two separate occasions

Fasting glucose > 7.0 (at least 8 hour fast) is diagnostic; if borderline .i.e. 6-7.0 then do an OGTT (75 g glucose, a lucozade bottle); if it shows 7.8-11.0 then it is diagnostic of impaired glucose tolerance; 20-50% of people with impaired glucose tolerance will progress to type 2 diabetes within 10 years of diagnosis. In addition, people with impaired glucose tolerance are known to be at significantly increased risk of cardiovascular disease, which may present before the onset of diabetes. Rates of cardiovascular risk factors are intermediate between those with normal glucose tolerance and those with diabetes. Impaired fasting glycaemia has not been shown to be a risk factor for cardiovascular disease. Baseline plasma glucose is the most consistent predictor of progression to diabetes. Impaired glucose tolerance has not been clearly associated with microvascular complications, e.g. nephropathy, retinopathy or neuropathy

CAUSE

BMI (obesity)
TFTs (thyroid disease so commonly associated)
US or CT (pancreatic disease)
Iron & TIBC (haemochromatosis)

CONSEQUENCES

HbA1C or fructosamine (long-term diabetic control)
U&Es & creatinine & urinalysis (kidneys)
ECG (IHD)
ABPI (PVD)
Blood cultures (infections)
Retinal photography (retinopathy)
LFTs (fatty liver, GGT)
Lipids
Ketones, blood glucose, ABG – diabetic ketoacidosis

DIABETIC KETOACIDOSIS

Its clinical features are DKA:

· Dehydrated / Drowsiness that can lead to coma
· Ketoacidosis/Kussmauls breathing / K+ imbalance
· Acidosis / Acetone breath / Abdominal pain

The treatment involves the following ABC, MOVE & FUCKING:

Fluids (crystalloids) (1 L over first 30 minutes, then over 1 hour, then 2 hours, then 4, then 6 – use normal saline, switching over to dextrose when glucose < 11 mmol)
Urea & Creatinine (check it)
CXR / Cultures (blood, urine) / Clexane
K+ (potassium)
Insulin sliding scale
Nasogastic tube (if patient comatose)
Glucose (once serum levels < 12)

*Soluble insulin mixed with normal saline should be given intravenously by syringe pump. The rate is usually 4-12 units per hour according to the blood glucose level. When the blood glucose level has normalized and the patient is rehydrated and eating, the patient may be returned to subcutaneous insulin.

*Under MOVE, monitor all vital signs, including GCS and urine output (often neglected)

*Example of sliding scale is as follows:

- The aim is to maintain the blood glucose between 4.0 and 7.0mmol/l.- Prescribe 50U soluble insulin (e.g. actrapid) in 50mls N Saline to run IV according to sliding scale below (a stat dose of insulin is not necessary).- Measure glucose hourly for the first 4 hours, then 2-4 hourly thereafter, and alter insulin infusion accordingly.
Capillary glucose (mmol/l)
Soluble insulin (units/hour) e.g. actrapid
0 - 4.0
If appropriate treat for hypoglycaemia
4.1 – 7.0
1
7.1 - 11.0
2
11.1 – 14.0
3
14.1 – 17.0
4
17.1 – 20.0
5
>20
6
This is one of the most common and important emergencies. Although it is commonly believed that it only occurs in type one diabetics, this is not true. Any patient with severe starvation of any sort can becoming ketotic, and severe type 2 diabetes (usually they would be on insulin too) can be regarded as a form of starvation – body cells are starved of glucose, so to speak, which they cannot use. They resort to ketones instead. Indeed, ketoacidosis is less common in type 2 diabetics, because they have some insulin which suppresses ketogenesis by the liver.

One of the clever aspects of starvation physiology is that the brain, normally glucose-exclusive in its fuel usage, can then switch over to ketone use. The ketones are acids, which lead to the acidosis.

The most important aspect of DKA is fluid replacement. Patients die first of hypovolaemia, not hyperglycaemia. Fluid losses of over 5 litres are not uncommon; this is a huge proportion of the cardiac output, with severe possible complications (see below). The fluid replacement not only rehydrates the dry patient but also lowers serum glucose levels even without the insulin, which we shall come to next. This is does by increasing urine flow (and hence glycosuria) and by decreasing the levels of catecholamines and cortisol, which were increased by the stimulus of hypovolaemia.

It is always said that fluids should be replaced in a specific order (see figure below). Why should fluids be replaced in that way? Well, it is important to realize that no randomized trials of fluid replacement have been conducted, and over the years, a variety of regimens have been proposed. This is simply the most common one used in England, and it appears pretty safe.

The next question is – should all DKA patients have a central line put in to monitor their fluid balance? This is a difficult question to answer. CVP lines are not without complications, and two of them in particular – infection and thrombosis – may even worsen the scenario.

Because insulin is important in shifting potassium into the intracellular compartment, DKA patients often have hyperkalaemia initially, which increases their cardiovascular morbidity. The insulin that is administered to control the hyperglycaemia will treat this, and infact may lower potassium to hypokalaemia levels, at which point replacement may be necessary.

The insulin is the second most important aspect of the treatment, and must be administered intravenously. This is because volume depletion and vascular collapse impair the absorption of IM or SC insulin.

Now, the logical explanation to a severe hyperglycaemia, as occurs in DKA, is to lower it as much as possible as quickly as possible. However, this should never be done. This is because of the risk of cerebral oedema. Brain cells take longer than other cells to adjust, and if plasma glucose is reduced too fast, water enters the brain cells by osmosis. The aim therefore is to reduce glucose by 3 mmol/litre/hour. Indeed, cerebral oedema is the main cause of death in children with DKA.

It is important to realize another point with regards to the sliding scale. It should not be stopped even if the BMs of the patient have normalized. This is because patients may still be acidotic and need insulin to metabolize their ketones.

Because of the severe hypovolaemia, the patient’s urea, electrolytes and creatinine are vastly deranged. Sodium may be high (due to dehydration) or low (pseudohyponatraemia or vomiting). The patient is an increased risk of DVT due to haemoconcentration of the clotting factors and the ‘stickiness’ if you like of the blood – it is hyperviscous. It is important to monitor U&Es regularly (initially two hourly) and put the patient on clexane.

Finally it is important to look for and treat the cause of DKA. This is frequently forgotten but crucial. Perhaps it is because the majority of cases have unknown triggers. The table below illustrates this. Causes can be recalled thus:

8 I

Initial presentation
Infection (UTI, pneumonia)
Insulin reduction or omission
Injury
Intercurrent illness (e.g. MI)
Ignorance (poor control)
Intoxication (alcohol)
Idiopathic

HONK is very similar in management; it occurs in type 2 diabetics. The onset of this is gradual over days. The patient is often elderly and may not be a known diabetic. Polyuria leads to dehydration. The blood glucose is very high and plasma osmolality is increased – this is calculated follows:

- Plasma osmolality = 2 (Na+K) + urea + glucose; normal = 285 – 295 mOsm/L

There is no acidosis or ketonuria as there is no change to ketone metabolism. Patients require small doses of intravenous insulin and hypotonic saline, although long-term insulin may not be required. Central venous pressure monitoring may be required. Patients are at a high risk of DVT and are given prophylactic subcutaneous heparin. The mortality rate is up to 50%.

What about hyperosmolar non-ketotic coma (HONK)? This is treated in the same way as DKA, with more aggressive attention to the fluid balance and osmolality; whereas in DKA the main aim is to reduce plasma glucose by 3 mmol/l/hr but in HONK plasma osmolality is the more important guide; aim to reduce plasma osmolality by 3 mOsmol/l/hr.

TREATMENT OF CHRONIC DIABETES

The management of diabetes is multidisciplinary and involves attention to SAFE WEIGHT & INFORM:

Salt reduced/Smoking stop
Alcohol stop
Fats reduce
Exercise increase
Weight loss
Information – diabetic nurses, leaflets, websites, exaplining DM, control, complications, consequences of disease & implications on life, pregnancy, breast feeding. Need to inform DVLA unless controlled by diet alone
Nutrition – optimising meal plan, diet comprising complex carbohydrates, SAFE WEIGHT, dietitian referral
Foot care – regular inspection and chiropody inpit
Organisations – local and national support groups, e.g. diabetes UK
Recognition of hypoglycaemia
Monitoring of glycaemic control

The oral types of drugs used in type II diabetes include SMART:

Sulphonylureas
Metformin
Acarbose
Repaglinide
Thiazolidinediones (e.g. rosiglitazone, proglitazone)

Very interestingly, intensive BP control is believed to be at least as important as intensive treatment of glucose levels in reduction of complications in diabetic patients.
REVIEW ASSESSMENT

All patients with type 2 diabetes should have glycaemic control reviewed at 2-6 monthly intervals. Other aspects of diabetes should be reviewed every 6-12 months and should include:

Glycaemic control and any perceived problems
Reinforce need for lifestyle measures
BMI
HbA1c (check every 2-6 months, aim for level of 6.5%-7.5%)
Full lipid profile
Level of urinary albumin/protein
+/- U+Es
BP measurement (Maintain below 130/80)
Examination of eyes for signs of retinopathy and cataracts
Examination of feet for ulceration /sensation/peripheral pulses
Examination of injection sites if appropriate
If male, ask about impotence

SPECIAL CIRCUMSTANCES

Surgery - diabetic patients should be first on the operating list, and fasted on the morning of surgery. Oral agents should be stopped 24 hours before surgery, and restarted postoperatively unless the patient is ill or the blood glucose is very high, necessitating a period on insulin.

For patients already on insulin, the usual insulin should be given the night before the operation. An intravenous infusion of 500 mL of 5% glucose with 10 mmol KCl should be started early on the day of the operation and run at a constant rate to the patient's fluid requirements. A 1 unit/mL solution of soluble insulin in 0.9% saline should also be infused intravenously using a syringe pump. The rate varies according to the patient's blood glucose concentration, which should be measured every 2 hours until stable and every 6 hours thereafter. When the patient starts to eat and drink, he or she may be restarted on the normal insulin regimen.

NOTES ON MEDICATION

Metformin is the first line oral antihyperglycaemic. This is because the vast majority of type 2 diabetics are obese, and metformin is an appetite suppressant. How it does this is by unclear; perhaps it is because it is derived from a bitter herb – Galega Officinalis, or French lilac. It is biguanide; and this name helps us remember ‘bi’ (two) actions of the drug – suppressing gluconeogenesis and increasing peripheral metabolism of glucose. Because it does not act on insulin, it cannot cause hypoglycaemia. Its most interesting side effect is lactic acidosis – caused by reducing pyruvate dehydrogenase activity and mitochondrial transport of reducing agents, thus enhancing anaerobic metabolism. Because of this risk, it is contraindicated in those with creatinine of >150 (where the excretion of lactate would be reduced), and other conditions where lactic acidosis is a risk, such as sepsis, severe heart failure, liver disease or any potentially nephrotoxic procedure.

The thiazolidinediones are a product of genetic studies. One of the current pocketbooks popular among medical students, Baby Kumar, describes them as follows: “Glitazones e.g. rosiglitazone bind to and activate a transcription factor called nuclear peroxisome proliferators-activated receptor gamma (PPAR-gamma), which is a nuclear receptor expressed predominantly in adipose tissue.” As you can see, this is a very poor and confused explanation, and should be revised. What the authors should have done is reverse the order – the glitazones bind to and activate PPAR-gamma, which is an intracellular receptor (as it says on the tin), which in turn shifts into the nucleus, acts as a transcription factor, and stimulates the transcription and synthesis of lipoprotein lipase, fatty acid transporter protein, insulin-sensitive glucose transporter (GLUT-4) and other proteins. In addition, they are believed to reduce the production of TNF-alpha, which is implicated in the pathogenesis of type 2 diabetes.

These two types are antihyperglycaemic, and need insulin to act, unlike the sulphonylureas, whose mechanism of action was explained earlier.

Many type 2 diabetic patients will eventually require insulin, and all type 1 diabetics need it. There are many peripheral issues which we can discuss with regards to this amazing hormone.

Its remarkable history is outlined in the endocrine drugs section in the Cannon. The genius of Banting, McLeod and Best (then a medical student), and the grace of God, is the reason why so many diabetics survive their difficult illness. It is truly fascinating that the patent for this life saving medication was sold for just one dollar.

Insulin was originally extracted from dogs, then cows and oxen, and eventually pigs and finally, we have the human version.

There are two questions that are raised here. Are Muslims allowed to use porcine insulin?

Unfortunately, there is a huge misunderstanding with regards to this issue. The Muslim position is believed by some to go along the following lines, "Muslims are strictly forbidden to drink alcohol. Eating pork is totally prohibited, so porcine insulin is unacceptable to Muslims" (Gwen Hall, 2007). Other authoritative textbook states, “Animal-derived insulins are unacceptable to devout followers of Islam and Judaism and to strict vegans” (Krentz & Bailey, 2005).

The truth of the matter is that – porcine insulin is not forbidden in Islam, and in essence, the refusal of Muslims to use it, is due to psychological, rather than religious issues. This is because the Islamic stance over pig products is clear. The verses are:

"Forbidden to you for (food) are: dead meat, blood and the flesh of the swine and that which hath been invoked the name other than Allah." (5:4)

"Allah has forbidden you only what dies of itself and blood and the flesh of swine and that over which any other name than that of Allah has been invoked; but whoever is driven to (it), not desiring nor exceeding the limit, then surely Allah is Forgiving, Merciful." (16:115).

So it is the ‘flesh’ of swine, not its products that are forbidden. Insulin is not flesh – it is a hormone. Even if it were flesh, the Qur’an does not forbid it if it were a medical necessity, as the second verse concludes.

This brings us to the broad topic of the use of ‘prohibited substances’ in the case of illness. The Islamic stance is discussed very comprehensively by Yusuf Al-Qaradawi, as follows:

“In case of a necessity a different rule applies, as was discussed earlier. Allah Ta'ala says: ...He has explained to you what He has made haram for you, except that to which you are compelled... (6:119)

And after mentioning the prohibitions concerning the flesh of dead animals, blood, and so, He says: ...but if one is compelled by necessity, neither craving (it) nor transgressing, there is no sin on him; indeed, Allah is Forgiving, Merciful. (2:172-173)

The consensus of the jurists is that necessity in this case signifies the need for food to alleviate hunger when no food other than the prohibited food is available, some jurists holding the opinion that at least one day and one night should pass without food. In such a situation a person may eat as much will satisfy his hunger and thus save himself from death. Said Imam Malik, "The amount of it is what will alleviate his hunger, and he should not eat more than what will keep him alive." This, perhaps, is the meaning of Allah's words, "neither craving (it) nor transgressing,"—that is, neither desiring it nor eating more than necessary. That hunger can be a compelling need is expressly mentioned in the Qur'anic ayah: ...but if one is compelled by hunger, without any inclination to sin, then indeed Allah is Forgiving, Merciful. (5:4 (3))

Concerning the question of whether some of the prohibited food substances can be used as medicine, there is a difference of opinion among jurists. Some do not consider medicine to belong in the category of a compelling necessity like food, and in support of their position they cite the hadith: "Assuredly Allah did not provide a cure for you in what He has prohibited to you." (Reported by al-Bukhari on the authority of Ibn Mas'ood.)

Others consider the need for medicine equal to that of food, as both are necessary for preserving life. In support of their position that prohibited food substances may be used as medicine, they argue that the Prophet (peace be on him) allowed 'Abd al-Rahman bin 'Awf and al-Zubair bin al-'Awwam to wear silk because they were suffering from scabies. (The text of this hadith is quoted in the subsection of this book entitled "Clothing and Ornaments.")

Perhaps this latter view is closer to the spirit of Islam which, in all its legislations and teachings, is concerned with the preservation of human life. However, taking medicine containing some of the haram substances is permissible only under the following conditions:

The patient's life is endangered if he does not take this medicine.
No alternative or substitute medication made from entirely halal sources is available.
The medication is prescribed by a Muslim physician who is knowledgeable as well as God-fearing.

We may, however, add that on the basis of our own observations and the opinions of expert physicians, we have arrived at the conclusion that there hardly exists any medical necessity which requires ingesting what is haram, as for example, taking medicine. Nevertheless, we have stated this principle in case a Muslim happens to be in a place where he cannot find medications other than those which contain haram substances.”

To this I may add that God created the entirety of the universe for the service of man. This is clear from the following verse, "Do you not see that Allah made available for you all what is in the skies and what is in the earth, flooded you with many blessings known and unknown." (31:20).

Now, the other interesting issue that arises with insulin is the topic of genetic engineering. The vast majority of insulin these days is genetically engineered, which is regarded by some as ‘playing God’ or changing the creation.

There is no changing the creation here – all that is done is an organism is modified to serve a function that it does not normally have, and since the entire universe was made for the service of humans, there can be no real objection to the use of the products of genetic engineering. Once again, it is valuable to quote Qaradawi on this issue, in an article published on his IslamOnline website:

“One of the blessings of Islam is that it never abstracts scientific programs or narrows the scope of the mind in the field of science and technology. Unlike other religions, there is no conflict between science and religion in Islam. Christian clergy opposed scientists, thinkers and pioneers of technology that we take for granted today. Many were punished, tortured and sentenced to death.

The Qur’an shows that Allah, Almighty, bestows many gifts on mankind enabling them to discover the mysterious nature around them and to recognize the laws that control the universe. Allah Almighty also submits the whole universe with its heavens, earth, sun and moon to mankind.

Allah Almighty says: (See ye not how Allah hath made serviceable unto you whatsoever is in the skies and whatsoever is in the earth and hath loaded you with His favors both without and within? Yet of mankind is he who disputeth concerning Allah, without knowledge or guidance or a Scripture giving light.) (Luqman 31: 20)

He Almighty also says, (And in the earth are portents for those whose faith is sure. And (also) in yourselves. Can ye then not see??w (Adh-dhariat 51: 20-21)

When man’s knowledge advances, it becomes compulsory for him to deepen his faith and moral virtues. One must not go alone, doing whatever one wants, ignoring religious morals or the welfare of people in general. The problem in Western civilization is that science is separated from religion and in some cases it fights religion. Allah Almighty says, (And when he turneth away (from thee) his effort in the land is to make mischief therein and to destroy the crops and the cattle; and Allah loveth not mischief.) (Al-Baqarah 2: 205)

We welcome the idea of genetic engineering. It is one of the greatest discoveries of our time and is shared by many countries. Whether it is considered more important than the discovery of penicillin or man landing on the moon, we hope it is used for the benefit of humanity and that its guidelines will be according to the views of qualified jurists.

There are many benefits we can derive from this, say, for instance, in treating genetic diseases by using the effective genes to prevent harm or disease. This is something commendable in Islam according to the legal rule "Prevention is better than cure"; the rule is taken from the hadith; “There should be neither harm nor reciprocating injury.” By this, through the assistance of such a scientific device, man will be able to prevent many diseases.”

The ultimate dream of the diabetic is to retrieve normal pancreatic function and/or peripheral sensitivity to insulin. They would like to stop taking these tablets, stop injecting themselves, and retrieve a normal metabolism. That is a gift many of us do not appreciate. By reflecting on their adversity, we must learn to be appreciative of normal glucose metabolism and the gift of not being a diabetic.

REFLECTIONS ON STROKES

2008-09-16T21:08:00.000-07:00

ON STROKES

This disease is a serial killer, being the third commonest cause of death and the biggest cause of serious physical disability in the Western world. It is any focal CNS disturbance due to a vascular cause where the deficit persists.

The first question that can be raised regarded something so deadly, is why it carries such a gentle name, can mean ‘an inspired or effective idea or act’ or even to caress. The etymology of the term was explained by Dirckx (1986) as follows, “According to the Oxford English Dictionary, a sudden, inexplicable cerebrovascular accident was first likened to a "stroke of God's hand" in 1599. The relationship of a cerebral infarction to an act of God exists in other cultures as well: the Greek verb plesso means to "stroke, hit, or beat," and the derivative plegia gives us our term hemiplegia.”

The epidemiology of stroke, although certainly a subject of great importance has not really been studied in the depth it deserves. What is established however is that although from 1950 to 1980 the incidence of stroke was on the fall, an effect attributed to increasing awareness, detection and treatment of hypertension, the biggest risk factor for stroke other than ageing, there has been a gradual increase since 1980 (Robinson, 2007), attributed to “the adoption of less healthy lifestyles” (Davidsons, 2005). However, because of improving management of the condition, perhaps most importantly due to the development of the concept of the stroke unit, morbidity and mortality from the condition is falling.

Cerebrovascular accident is a sudden onset of a focal neurological deficit lasting >24 h= stroke; <24 h = TIA. It is the 3rd most common cause of death, and the biggest cause of serious physical disability. It costs the NHS £2.3 billion a year (2 x CAD). The epidemiology is:

Incidence is 2/1000/yr
Occurred in 8/1000 population
> 50 years mainly
Preceded by TIA in 15% pts
> 50% are physically dependent on others 6 mths after

The International Stroke Trial “highlighted that the UK centres had the poorest survival from stroke in the world” (Newson & Patel, 2002)

A HISTORY OF STROKE

There are great difficulties in understanding the history of stroke. This is because it is difficult to really ascertain whether many of the descriptions given are truly those of stroke, or other conditions causing focal neurological deficits like epilepsy. Apoplexy, the old term for stroke simply means ‘struck down with violence,’ and the word stroke was used as a synonym for apoplectic seizure as early as 1599. Nevertheless, we can probably share the view expressed by Thompson in his Willis Lectures in 1999, where he said that, “With the advent of Hippocrates (460 to 370 BC), ancient descriptive neurology was born. It was known that paralysis and convulsions followed injuries to the brain, with paralysis on the opposite side to the wound. Hippocrates described paralysis of the right arm with loss of speech in what is probably the first written description of aphasia. In one of his aphorisms Hippocrates stated, "Unaccustomed attacks of numbness and anesthesia are signs of impending apoplexy," a description of a TIA”.

Without a CT-scan, we would really be unable to identify if what historians regard as stroke is truly stroke or not. But if we are to go by tradition, which classifies stroke as a clinical diagnosis, then all acute neurological presentations of history, pre-CT must be regarded as stroke.

With regards to the famous victims of stroke, being such a common condition, it has claimed victims in every province of human enterprise. No one is spared – young or old, male or female, of all colours and races. But we shall focus on a few interesting cases which teach us something about this fascinating condition.
In an imaginary political graveyard, where the world leaders of the 20th century are laid to ‘rest’, would very interestingly, have a great proportion of victims of stroke. There are no formal reports or papers on the association of stroke and politics, but it would make for interesting reading.

POLITICIANS

RUSSIA

We have already looked at the fates of three of Russia’s former leaders in our reflections on hypertension, namely Lenin, Trotsky and Stalin. We only briefly mentioned Lenin there, stating that his hypertension diagnosis is rather uncertain. But we he certainly had, based on a detailed autopsy report, is a stroke, due to “haemorrhage over the corpora quadrigemina area of the brain, and it was stressed that most of the very severe brain damage must have been present for some time before death” (Leavesly, 1998).

Lenin’s case is interesting for three reasons. Firstly, the manner of his death. As everyone now knows, he was a very evil man, who is responsible for the deaths of nearly 4 million people, according to the ‘Black Book of Communism’, all in the name of communism. He was a faithless man, who believed that “the end justifies the means”, that “there are no morals in politics; there is only expedience. A scoundrel may be of use to us just because he is a scoundrel”, that, “We need the real, nation-wide terror which reinvigorates the country and through which the Great French Revolution achieved glory” and that the communist “program necessarily includes the propaganda of atheism”, and felt that “liberty is precious - so precious that it must be rationed”. Is it surprising that a man of such evil dies should die the humiliating death he did? Perhaps the best description anyone has made of him is Bertrand Russell, who met him personally in 1920, and described the encounter in his ‘Autobiography’ as follows:

“Lenin, with whom I had an hour’s conversation, rather disappointed me. I do not think that I should have guessed him to be a great man, but in the course of our conversation I was chiefly conscious of his intellectual limitations, and his rather narrow Marxian orthodoxy, as well as a distinct vein of impish cruelty”

Under the heading, ‘Lenin’s End is a Lesson for All’ in his book, ‘Communism in Ambush’, Harun Yahya put the above picture and the following caption, which says more than a thousand words, “Before he died, Lenin became mad. This photograph, taken shortly before his death, teaches an example of the torment God sends in this world upon leaders of irreligion. This end is announced in Verse 30:10 of the Qur'an: "Then the final fate of those who did evil will be the Worst because they denied God's Signs and mocked at them."…he suffered his first stroke in May 1922. On December 16, 1922, he suffered another major attack. Half paralyzed, he was confined to bed. In March of 1923, his illness worsened significantly and he lost the ability to speak. Afflicted by terrible headaches, he spent most of 1923 in a wheelchair. In the final months of his life, those who saw him were horrified at the frightful, half-mad expression on his face. He died of a brain hemorrhage on January 21, 1924.”

The second interesting lesson that Lenin’s stroke teaches us is that it highlights the difficulties inherent in the diagnosis of stroke in pre-CT days. Apparently, only eight out of the 27 physicians looking after Lenin believed that he died of a stroke. But the post-mortem is pretty conclusive. Our suggestion in the hypertension chapter that Lenin had a hypertension-induced stroke is based purely on epidemiological suspicions. However, it is possible that he had another cause – namely syphilis. Learning about Lenin’s case teaches us about this often forgotten cause of stroke, which is generally not mentioned in most medical books, but is always cited in the biggest books. We read in Adams and Victor’s ‘Principles of Neurology’ that, “Whereas in the past strokes accounted for only 10 percent of neurosyphilitic syndromes, their frequency is now estimated to be 35 percent. The most common time of occurrence of meningovascular syphilis is 6 to 7 years after the original infection, but it may be as early as 9 months or as late as 10 to 12 years”. The following table from Harrison’s also lists it among the causes of ischaemic stroke.
The possibility that Lenin had neurosyphillis was raised and extensively discussed in an article, ‘The Enigma of Lenin's Malady’ (Eur J Neurol. 2004 Jun;11(6):371-6) by Lerner, Finkelstein and Witztum. We will discuss this at greater length in our discussion of syphilis in our infectious diseases section. But it is a very interesting possibility.

Another interesting informative Russian stroke case is that of the wife of the last leader of the USSR, Mikhail Gorbachev, Mrs. Raisa Gorbachev. She suffered from leukaemia, but died following a stroke in 1999. Knowing this will help recall leukaemia, and indeed chemotherapy, as a risk factor for stroke; both lead to a hypercoagulable state which like we saw in the DVT section, leads to vascular thrombosis.

USA

As opposed to Russian leaders, who hide much of their health data, the American leaders are a lot more open, and conform much more to the contemporary requirement for accountability. Hence we have a lot more data regarding their illnesses.

Many American presidents sustained strokes – including John Adams, John Tyler, Woodrow Wilson, Eisenhower, Richard Nixon and Gerald Ford. We will only focus on what I feel are the more interesting cases here.

Woodrow Wilson was the man who led the USA during the First World War, and who is famous for setting up the ‘League of Nations’, the immediate precursor of the United Nations, and was awarded the Nobel Peace Prize in 1919 “in recognition of his Fourteen Points peace program and his work in achieving inclusion of the Covenant of the League of Nations in the 1919 Treaty of Versailles”. His fascinating medical history is recounted extensively by Edwin Weinstein in ‘Woodrow Wilson: A Medical and Psychological Biography’. John Sotos, a cardiologist and America's leading Presidential health historian and an expert in unusual signs of disease summarised many of the points made by Weinstein in his Doctorzebra website:

“Wilson's first stroke was in May 1896. It caused marked weakness of the right upper limb plus sensory disturbances in the fingers. The finger problems were mis-diagnosed as neuritis. Wilson was unable to write normally for almost a year afterwards.

In June 1904 Wilson developed weakness in the right upper limb that lasted for several months. On May 28, 1906, Wilson suddenly lost vision in his left eye. This persisted. Weakness of the right upper limb was present. In November 1907 he developed weakness and numbness of fingers or right upper limb that lasted several months; in July 1908 he had two attacks of "neuritis" affecting the right upper limb; in December 1910 he had transitory weakness of the right hand. Wilson's problems with blood circulation in his brain and eyes continued after he became President: April 1913 - Attack of "neuritis" involving right upper limb; May 1914 - Abnormal retinal arteries observed; May-Sept. 1915 - Episodes of transient weakness in his right hand. From 1915 to 1919 Wilson had episodic severe headaches, lasting for days. It is possible these were due to [uncontrolled] hypertension. In September 1919 Wilson was having severe headaches, double vision, and signs of a weakened heart. On Sept. 25 he developed a transitory weakness on the left side of his body. Wilson suffered a catastrophic, disabling stroke while President (Oct. 3, 1919), as recounted in multiple sources, including an entire book on the subject. (Any biography covering Wilson's presidential years should devote extensive coverage to this event.) This was the most serious illness suffered by any sitting President. Wilson had bad headaches before becoming president, but presidential physician Cary Grayson ascribed the stroke to a thrombosis, stating it was not hemorrhagic”.

Aside from his multiple strokes, I will take this occasion to go through one of Woodrow Wilson’s little known political contributions - The King-Crane Commission’s report. This is how Ron David, the Jewish author of ‘Arabs and Israel For Beginners’ summarised it in that absolutely splendid book:

“When WW-I ended, no one could reconcile the claims of Arabs, Zionists, British & French so, in 1919, Woodrow Wilson and his democracy-mad Americans "dispatched the King-Crane Commission to the former Arab provinces of the Ottoman Empire to ascertain the wishes of their inhabitants regarding the postwar settlement of their territories." [Britannica]
The King-Crane report stated:

90% of Palestine's inhabitants were non Jewish & did NOT want a Jewish state in Palestine;

If they are given Palestine, "Zionists looked forward to a practically complete dispossession of the present non-Jewish inhabitants."

The King-Crane Commission said that a Jewish state in Palestine would violate the Palestinian Arabs' right to self-determination. They recommended that Zionists respect the wishes of Palestine's inhabitants & find another place to plant the Jewish state.

The Zionists were furious! They didn’t want democracy; they didn’t give a damn about “the will of the people.” The Zionists wanted Palestine, no matter what they had to do to get it. So they simply “rewrote” the history of the conflict.

The usual versions of Israel's history either don't mention The King-Crane Commission Report or they minimize its importance. In my opinion, any lover of democracy must consider the King-Crane Commission’s report a major event. Anyone who believes in Democracy must consider the King-Crane Commission's official report—which even now can be documented by any interested partyment agency—irrefutable proof that:

In 1919, even after 30 years of iintensive Jewish emigration into Palestine (inspired by Theodore Herzl’s The Jewish State, published in 1898), 90% of Palestine’s inhabitants were non-Jewish and did not want a Jewish state in Palestine. The will of the people was clear

The Zionists knew they were acting against the will of the people.

The Zionists knowingly subverted Democracy.

The Government of the United States confirmed the legitimacy of the claim that Palestinians make today

Some Quotes from the Commission's Report

"a national home for the Jewish people is not equivalent to making Palestine into a Jewish State."

"nor can the erection of such a Jewish State be accomplished without the gravest trespass upon the civil and religious rights of existing non-Jewish communities in Palestine."

"In his address of July 4, 11918, President Wilson laid down the following principle as one of the four great 'ends for which the associated peoples of the world were fighting': 'The settlement of every question, whether of territory or of political relationship upon the basis of the free acceptance of that settlement by the people immediately concerned, and not upon the basis of the material interest or advantage of any other nation or people which may desire a different settlement for their own exterior influence or mastery."

"If that principle is to rule, and so the wishes of Palestine's population are to be decisive as to what is to be done to Palestine, then it is to be remembered that the non-Jewish population of Palestine—nearly nine-tenths of the whole—are emphatically against the entire Zionist program. To subject a people so minded to unlimited Jewish immigration, and to steady financial and social pressure to surrender the land, would be a gross violation of the principles just quoted, and of the peoples' rights, though it kept within the forms of the law."

"No British officer, consulted by the Commissioners, believed that the Zionist program could be carried out except by force of arms."

"That of itself is evidence of a strong sense of injustice of the Zionist program.”

"The fact came out repeatedly in the Commission's conference with Jewish representatives that the Zionists looked forward to a practically complete dispossession of the present non-Jewish inhabitants of Palestine.''

“The initial claim, often submitted by Zionist representatives, that they have a 'right' to Palestine, based on an occupation of two thousand years ago, can hardly be seriously considered."

The full report can be found on the internet, and makes for even more fascinating reading. I cannot agree more with Ron David, that the report is a major event that should be more widely known.

The other interesting case of stroke among the American presidents is that of Gerald Ford. His story reveals an interesting cause of stroke, a tongue abscess. This is how Tasos summarises things,

“During the 2000 Republican National Convention in Philadelphia, Ford appeared "sluggish and sick" on television during a tribute to him. A few hours later, shortly after midnight on Wednesday, August 2, Ford presented to the emergency room at Hahnemann University Hospital, complaining of facial pain. The physician diagnosis was "a sinus attack." Ford stayed only a half-hour, and declined the recommendation to have a CT scan. Upon awakening on Wednesday morning, Ford had new symptoms and returned to the hospital. He apparently had left arm weakness, balance difficulties, and slurred speech. A stroke was diagnosed and he was treated with "blood thinners". The slurred speech, however, was ascribed to a swollen, painful tongue, which proved to be abscessed with actinomycosis. (This is an exceedingly rare cause of a tongue abscess.) The abscess was drained under general anesthesia. (It is not clear when the anticoagulants were started, in relation to the abscess drainage.) Later, a Ford spokesman declared that Ford had developed tongue pain while in Colorado, before Ford departing for the convention. By August 5 Ford was "completely recovered from the stroke" (there were also questions about a possible other strokes). He left the hospital on August 9, still taking antibiotics and blood thinners. The Hahnemann University Hospital was obviously embarassed by missing the diagnosis on the first night, but refused to admit anything. A hospital spokesman said "We do not believe there was any misdiagnosis there." He then shamelessly shifted the blame to the patient, saying "The activities that evening were totally controlled by the President". The question is: how could the abscess have been missed on physical examination the first night, especially when Ford had noted tongue pain days earlier? How did the physician(s) arrive at the mistaken diagnosis of a sinus problem? A CT scan is usually not required to discover a tongue abscess. It is possible that missing the tongue abscess the first night played a role in causing the stroke, as there is a tight relationship between inflammation and acute vascular events. In simple terms, inflammation (the classic response to an infection) makes the blood more likely to clot (the actual event triggering a stroke). Older physicians, for example, will recall the classic association between pneumonia and acute myocardial infarction. In Ford's case, the missed diagnosis allowed the infection, hence the inflammation, to progress for the extra few hours leading to the stroke.” In any case, Ford was to die of stroke many years later, in 2006, at the age of 93, completely unrelated to his first far more interesting one.

ENGLAND

Although many British leaders suffered strokes, including most recently Princess Margaret, who died of a massive stroke on the 9th of February 2002, and Baroness Margaret Thatcher, which has affected the Iron Lady tremendously; apparently she has no short term memory now.

But of far more interest and importance are the strokes of Sir Winston Churchill. In an article entitled ‘Was Winston Churchill Fit to Rule?’, George Biro argues that Churchill failed miserably with regard to his duties as a prime minister by hiding away the fact that he had several major strokes while leading the nation. He argued that, “Should not have Moran (Churchill’s personal doctor) have balanced the duty to his patient against the interests of the country? Could he have induced Churchill to step down earlier? Could anyone else have done so? If we make pilots and bus drivers pass medical examinations, why don’t we do the same for politicians?” We all know, as doctors, confidentiality is important, is part of the basic right to autonomy. But if maintaining confidentiality will impinge on the health and safety of others, the principle can be broken.

Churchill was certainly not a sane man. He was renowned for his bouts of severe depression, his ‘black dog’, and many people have labelled him a cyclothyme. In ‘Encounters with Winston Churchill’, W Russell Brain, the great neurologist of the 20th century said, “I should think that from what Moran told me that Churchill is a cyclothyme. Apparently he was subject to depression in his earlier days. He has the drive and vitality and youthfulness of a cyclothyme.” (Medical History, 2000, 44: 3-20). A man no less than the great psychiatrist Anthony Storr devoted a whole book to the issue, entitled, ‘Churchill’s Black Dog’. He argued that, "Had he been a stable and equable man, he could never have inspired the nation. In 1940, when all the odds were against Britain, a leader of sober judgment might well have concluded that we were finished." He also said, "The kind of inspiration with which Churchill sustained the nation is not based on judgment, but on an irrational conviction independent of factual reality. Only a man convinced that he had a heroic mission, who believed that, in spite of all evidence to the contrary, he could yet triumph, and who could identify himself with a nation's destiny could have conveyed his inspiration to others." We will leave the discussion of whether people with chronic psychiatric illness should be allowed to lead nations to our psychiatry section.

But as for those with acute confusional states, the answer must be a definite no, until he or she recovers fully from it. In 1944, following several attacks of pneumonia, Allanbrooke, Chief of the Imperial General Staff stated, “He seems quite incapable of concentrating for a few minutes on end, and keeps wandering continuously”. In 1952, “Churchill had a more serious stroke affecting his speech. By now he insisted on even the most complex issues being condensed into one paragraph before he would consider them. Moreover, the Prime Minister often could not even follow a discussion. Moran wrote, “He was not doing his work. He did not want to be bothered by anything; he was living in the past””.

But rather than advise Churchill to resign, Moran did the opposite. He said, “Winston once asked me whether he ought to have retired earlier. I was, I think, alone in urging him to hang on, though I knew that he was hardly up to his job for at least a year before he resigned office. His family and friends pressed him to retire; they feared that he might do something which would injure his reputation. I held that this was none of my business. I knew that he would feel that life was over when he resigned. It was my job as his doctor to postpone that day as long as I could”.

Biro continues, “But somehow, the wilful, wily old man defied such opinions, and carried on the pretence: instead of dealing with matters of state, Churchill read novels and played cards…In 1954, he had to apologise after misleading the Commons (and jeopardising the government’s foreign policy) about a telegram he claimed to have sent to Field-Marshal Montgomery during the war. There was no such telegram; by now even the Conservatives had had enough. But it was April 1955 before the Prime Minister finally stepped down. By then, he was spending most of his days in bed.” Reflecting on this, I feel Russell Brain is deeply mistaken in his reflections on Churchill, that between in 1949 and 1964, Churchill was “fit enough to go to the House of Commons”. However, his description of his stroke has not been bettered:

“I found that Churchill had had a stroke. He had been feeling very tired lately on account of the Coronation and of having to do the work of the Foreign Secretary as well as his own on account of Eden's illness. The previous morning Moran had been to see him to pay a routine visit and thought his speech was somewhat slurred. In the evening, he had presided over a dinner for the Italian Premier, at the end of which he had made a speech, and again his speech was somewhat slurred, and he became unsteady on his legs, and had to be assisted out of the room. He had a good night and on the morning of June 24th, Moran saw him again, and found his speech still slurred. He presided over a Cabinet Meeting, however, which lasted two hours. He felt very tired, and his slurring speech was noticed by his colleagues. He slept in the afternoon and his secretary mentioned that she thought there was some drooping of the left side of his face. This was apparent when he spoke and also when he smiled, and his speech was at first somewhat slurred, but there was at no time any evidence of aphasia. There was slight weakness of the left lower face on voluntary and emotional movement, and his tongue deviated slightly to the left. There was no weakness of the limbs, and no change in sensation, but the left plantar reflex was extensor while the right was flexor. He walked about the room with only a slight trace of unsteadiness. He said he had no headache but felt as though there was something in his head. He was put on a dose of trinitrin night and morning.”

Winston Churchill illustrates several risk factors for stroke – he was overweight, probably obese, a heavy drinker ("Alcohol has been a very good friend to me…I like to take a fair proportion of my calories in the alcohol"), and famously a chain smoker. He smoked about ten cigars a day. One of his interesting stories regarding these two things was told in his memoirs, regarding a meeting he had in February 1945 in honour of King Ibn Sa'ud of Saudi Arabia, "A number of social problems arose. I had been told that neither smoking nor alcoholic beverages were allowed in the Royal Presence. As I was the host at the luncheon I raised the matter at once, and said to the interpreter that if it was the religion of His Majesty to deprive himself of smoking and alcohol I must point out that my rule of life prescribed as an absolutely sacred rite smoking cigars and also the drinking of alcohol before, after and if need be during all meals and in the intervals between them. The King graciously accepted the position." (One is immediately reminded here of the famous hadith, reported on the Prophet (PBUH), "Whoever believes in Allah and the Last Day must not sit at table at which khamr is consumed.") Surprisingly, Churchill, according to the website of his name, had “a normal blood pressure for his age”.

ISRAEL

Moving on swiftly from ‘The Last Romantic Zionist Gentile’, as Yoav Tenembaum described Churchill (he is clearly unaware of Churchill’s Jewish ancestry and his Jewish mother, Jenny Jacobson), let us look at some interesting cases from Israel.

We have already discussed the case of Ariel Sharon in our reflections on congenital heart disease. His is actually a fascinating one, because it illustrates a very rare risk factor for stroke – paradoxical embolism.

The case of David Ben-Gurion, the first Prime Minister of Israel, is a lot less interesting, but he endured the same fate. This is how his biographer Bar Zohar somewhat dramatically depicted it,

“In 1973 Ben-Gurion suffered a massive stroke. I hurried to the hospital where he was lying and was let into a quiet, white room. Ben-Gurion was lying quietly in his bed. He couldn't speak, he just looked at me with his deep, wise eyes. He communicated with me by tightening his grip on my hand. I was looking at the quiet, calm face of the father of my nation, the man who made me and so many homeless Jews a people again; and I thought of his moral testament to all of us. "The existence of Israel," he told me over and over again, "depends on her force - and on her righteousness. We must be a light into the nations." I had never met another statesman or political leader for whom moral values were so important, who believed that his nation will have the right to exist only if it sticks to those moral percepts, given to us all, Jews and Christians and Muslims, in the Bible. I don't know if we have succeeded to accomplish this moral commandment of Israel's Old Man. But I see it as a call to my generation and those who will come after me - to try to build a country worthy of the teachings of Israel's ancient prophets.”

The sheer deception and hypocrisy of this statement, highlights a high degree of confusion in Ben-Gurion’s mind, as it contradicts a lot of what he said and believed. But then again, Ben Gurion is a politician, and there are hardly any politicians out who have clarity and consistency of thought. Politicians are not mathematicians or scientists. They are not concerned with truth, but power and control, no matter by what means these are achieved. The classic recent example is that of the crimes of George W. Bush and Tony Blair in Iraq. Bertrand Russell brilliantly summed it all up, “I am persuaded that there is absolutely no limit in the absurdities that can, by government action, come to be generally believed. Give me an adequate army, with power to provide it with more pay and better food than falls to the lot of the average man, and I will undertake, within thirty years, to make the majority of the population believe that two and two are three, that water freezes when it gets hot and boils when it gets cold, or any other nonsense that might seem to serve the interest of the State…Politics is largely governed by sententious platitudes which are devoid of truth.”

Ben-Gurion was not the romantic that Bar-Zohar is trying to depict. He is not “part Washington, part Moses”, as Amos Oz was foolishly telling us in his article on Ben-Gurion in ‘Time Magazine's’ ‘100 Most Important People of the Century’. For one, both Moses and Washington believed in God, and Ben-Gurion, a Russian in origin, was an atheist, like so many other Zionist leaders, including the founding father of Zionism, Theodor Hertzl. As stated by Alfred Mendes, “The State of Israel was … set up in 1948 by the Zionists, under the leadership of the Russian-born David Ben-Gurion (another atheist) who had emigrated to Palestine in 1906. The very term ‘atheist’ means disbelief in any ‘God’ and/or ‘religion’. Hence, an atheist cannot consider him/herself a Jew in the strictly religious sense of the term. To quote Rabbi E. Weissfish: “The Zionist ideology has no connection whatsoever with Judaism, on the contrary Judaism is totally opposed to Zionism”. It is thus incontrovertible that the two terms ‘Judaism’ and ‘Atheism’ are antonymous, a fact that Ben Gurion would certainly have been aware of - but here we have Ben Gurion himself, in his address to a special session of the Knesset in 1971, saying “An Arab can be Muslim or Christian. A Jew, however, cannot be a member of another faith and still be a Jew. A Jew can be an atheist, but if he adopts the Christian or Muslim faith - he is no longer a Jew”. This was clearly a duplicitous statement on his part, and, as such, therefore designed to confuse and divert attention from some hidden agenda”.

Moses and Washington were not racists, while Ben Gurion was. He “never believed in the possibility of coexistence with the Arabs. The fewer Arabs there were within the borders of the future state of Israel, the better it would be. He did not say so explicitly, but the overall impression one gets from his speeches and his comments is clear: a major offensive against the Arabs would not only defeat their attacks but would also reduce as far as possible the percentage of the Arab population within the State. "He can be accused of racism, but then one will have to put on trial the entire Zionist movement, which is founded on the principle of a purely Jewish entity in Palestine."” He also, according to his official biographer Shabtai Tebeth, “advocated exclusively Jewish labor (Avodah Ivrit) in Jewish businesses. He explained why a Jewish laborer should earn a higher salary because "[he was] more intelligent and diligent" than the Arab.” His racism extended, of course to destruction of all Arabs, both within Palestine and outside.

Within Palestine, Israeli historian Simha Flapan exposed him, saying, “That Ben-Gurion’s ultimate aim was to evacuate as much of the Arab population as possible from the Jewish state can hardly be doubted, if only from the variety of means he employed to achieve his purpose...most decisively, the destruction of whole villages and the eviction of their inhabitants...even [if] they had not participated in the war and had stayed in Israel hoping to live in peace and equality, as promised in the Declaration of Independence.”

Outside of it, two examples suffice to expose Ben-Gurion, one from Egypt, the other from Lebanon. He was exposed in Egypt after the famous Lavon affair. Ron David summarised this beautifully, exposing him fully, “Around the time that Gamal Abdul Nasser became Egypt’s leader, David Ben Gurion had decided (partly out of spite) to step down as Prime Minister of Israel and let Moshe Sharett see if he could do a better job. Sharett was less of a ‘Hawk’ than Ben Gurion and, by 1954, had reached the point where he was on the verge of signing a peace treaty with Nasser of Egypt. Nasser is usually depicted as one of the bad guys. Recently declassified State Department documents indicate the exact opposite. Documentary evidence [1948-54] shows Nasser expressing tolerance and respect for Israel to CIA officials, members of British Parliament, and two American Ambassadors. In October 1954 Nasser became one of the only heads of state to refuse military aid from the U.S. He preferred economic aid. Then, in 1954, Israeli terrorists attacked American installations in Egypt! Then the Israelis rigged it so the attacks would be blamed on Egyptians! Then the Israelis got caught and put in Egyptian prisons....all of which convinced Egypt’s Nasser that the Israelis couldn’t be trusted, so he broke off the peace talks and took weapons from whomever offered them—including the Soviets. Ben Gurion blamed the blundering terrorists on his Defense Minister, Pinchas Lavon—but several years later, Lavon found documents that proved Ben Gurion was behind it! Ben Gurion’s motive was simple: he and Moshe Dayan wanted a war with Egypt and Sharett’s peace talks might deprive them of it. In June 1955, Moshe Sharett [in his Diaries] wrote: ‘Dayan said, “above all, let us hope for a new war with the Arab countries, so that we may finally get rid of our troubles and acquire space.”’ Another of Sharett’s Diary entries for June 1955: ‘Ben Gurion himself said it would be worthwhile to pay an Arab a million pounds to start a war. What a slip of the tongue!’”

His crimes in Lebanon are also summarised by Ron David in his aforementioned book, “In 1954, former Prime Minister Ben Gurion mentioned to Prime Minister Moshe Sharett that it would be in Israel's interest to provoke a Civil War in Lebanon between Christians and Muslims. On May 16, 1955, Ben Gurion got more specific: he said that Israel should provoke Lebanon's Muslims to attack Lebanon's Christians in the hope of igniting a Civil War in Lebanon. Prime Minister Sharett (whose published Diary details this) was shocked.”

Most fundamentally (apart from the obvious difference of theological beliefs), Moses (PBUH) was the saviour of the people of the People of Israel, the man who gave them a moral and religious foundation, while Ben-Gurion lacked morals, and at times was the anti-Saviour of the Jewish people. His only obsession was the creation of the state of Israel, at all costs, even if it meant the destruction of world Jewry. Did he not say, "The Zionist's task is not to save the "rest" of Israel which finds itself in Europe, but to save the land of Israel for the Jewish people"? Was he not involved, in the murder of many Jews throughout his life. To quote his official biographers yet again, “In 1940, to arouse indignation against the English, who had decided to save the Jews threatened by Hitler by taking them to Mauritius, the Zionist leaders of the "Hagannah" (led by Ben Gurion) did not hesitate to blow up the ship when it called at Haifa on December 25th 1940, causing the death of 252 Jews and English crew-members.” (Dr. Herzl Rosenblum, director of "Yediot Aahronot", revelation made in 1958 and justified in "Jewish Newsletter", N.Y.,November 1958). Did he not famously say, "If I knew it was possible to save all the children in Germany by taking them to England, and only half of the children by taking them to Eretz Israel, I would choose the second solution. For we must take into account not only the lives of these children but also the history of the people of Israel"? How could a man of any morals praise the actions of Adolf Hitler - "Jewish suffering is also a political factor, and whoever says that Hitler diminished our strength, is not telling the truth." In one of history's crueller ironies, those words proved prophetic. Millions of Jews did not storm the beaches of Palestine, for they could not rise from the ashes of the death camps. But the Holocaust--they zenith of Jewish agony-- became the same "political force" of which Ben-Gurion spoke before he even imagined the systematic destruction of European Jewry. After the war, the Holocaust was a powerfully influential factor in turning world public in Zionism's favor, and was the decisive factor in defeating the policy of the British 1939 White Paper (which called for a united bi-national Palestinian state no later than 1949 and the cessation of Jewish immigration). Guilt, sorrow, and remorse---what might be called the collective conscience of humanity--led many nations (referring to 1947 UN proposed partition plan) finally to grant survivors, that which might have saved the many victims: a "Jewish state."” (Shabtai Teveth, p. 196).

The Israeli historian, Tom Segev, in his book ‘The Seventh Million’ exposed Ben-Gurion too, saying that, “In the wake of the Kristallnacht pogroms, Ben-Gurion commented that ‘the human conscience’ might bring various countries to open their doors to Jewish refugees from Germany. He saw this as a threat and warned: ‘Zionism is in danger.’”. How could anyone regard this evil man as a Prophet, the highest accolade that can be bestowed on a man?

What puzzles me about Ben-Gurion is that, as evil as he is; he did say many truthful things throughout his political career. Perhaps it is one of the characteristics of the hypocritical mind that it often exposes itself under close scrutiny, where the power to withhold the truth is overwhelmed by the power of truth itself. It is one of the ironies of history that one could easily quote the creator of Israel to support the Palestinian cause, and oppose the falsities of other Zionist politicians!

For example, in response to Golda Meir’s famous statement, “It was not as though there was a Palestinian people in Palestine considering itself as a Palestinian people and we came and threw them out and took their country away from them. They did not exist”, Ben-Gurion defends us saying, “Palestine is not an empty country” and "The Arab community in Palestine is an organic, inseparable part of the landscape. It is embedded in the country.” In response to the eternal question – who is the true criminal, Ben Gurion has the true answer, "When we say that the Arabs are the aggressors and we defend ourselves - that is only half the truth. As regards our security and life we defend ourselves. . . . But the fighting is only one aspect of the conflict, which is in its essence a political one. And politically we are the aggressors and they defend themselves." He even went so far as to say, “Why should the Arabs make peace? If I was an Arab leader, I would never make terms with Israel. That is natural: we have taken their country. Sure, God promised it to us, but what does that matter to them? Our God is not theirs, We come from Israel, it’s true, but two thousand years ago, and what is that to them? There has been anti-Semitism, the Nazis, Hitler, Auschwitz, but was that their fault? They only see one thing: we came here and stole their country. Why should they accept that?”

Even Ben-Gurion’s exposures of his fellow colleagues are very telling. Take for instance what he says about Menachem Begin, the Prime Minister who signed the first Camp David accords with Anwar El-Sadat in 1979, "Begin undeniably belongs to the Hitlerian type. He is a racist, ready to destroy all the Arabs in his dream of unification of Israel, prepared to resort to any means to realize this sacred goal”.

It is probably time to move on to other figures whose strokes are of interest for medical history, apart from politicians.
NOVELISTS

Two of the most famous people to have died of stroke are among the greatest of English authors: Samuel Johnson, the most quoted English writer after Shakespeare, and author of ‘A Dictionary of the English Language’, the father of all dictionaries, and Charles Dickens, arguably the greatest English novelist. Their strokes are of interest as they teach us a few things.

Although he is often referred to as Dr. Johnson, Samuel Johnson was not a physician. He was a great friend of physicians, and was very interested in all matters medical, as is highlighted in his biographies (see for example, the article by T Jock Murray, ‘Samuel Johnson: his ills, his pills and his physician’ in ‘Clinical Medicine’ (Vol 3 No 4 July/August 2003)). He even gave medical advice to people on a regular basis – perhaps therein lies the confusion.

In any case, Samuel Johnson suffered a stroke in 1783, which he described in the following words, “Another time ... another place...[I] waked and sat up ... when I felt a confusion and indistinctness in my head ....I was alarmed and prayed God, that however he might afflict my body he would spare my understanding ... Soon after I perceived that
I had suffered a paralytick stroke and that my Speech was taken from me”. Johnson had many risk factors for stroke; he was obese (and therefore likely to be hyperlipidaemic in the pre-cholesterol age), had “suffered from oedematous legs, shortness of breath, a smothering sensation when lying down, and attacks of dyspnoea that awoke him from sleep – all signs of right heart failure” (Murray, 2003) (heart failure is a major cause of stroke), and most likely had the most important risk factor for stroke other than age, hypertension. Henry Rolleston argued that his right heart failure and other illnesses of late life were due to hypertension, a condition unknown in his time (Rolleston, 1929). Hypertension may have indirectly led to his right heart failure via causing ischaemic heart disease – he very likely suffered this, according to Murray (2003), “At age 71 he was having chest discomfort, ‘convulsions in my breast which had distressed me for more than 20 years’”. But only pulmonary, as opposed to systemic hypertension, can cause right heart failure directly. This is the stronger possibility, which is also suggested by his autopsy results which showed pulmonary fibrosis and cardiac failure (ibid). It is possible that he had polycythaemia too – this may be related to his chronic lung disease (which was incorrectly attributed to asthma – highlighting difficulties in diagnosis in pre-CXR and CT days). This polycythemia, an independent risk factor for stroke as we outline below is suggested by his frequent phlebotomies - he “even cut his own vein to do his own phlebotomy, bleeding so much that the stream of blood had to be stopped with the help of Robert Levet and Johnson’s black servant Francis Barber” (ibid). Johnson was also a heavy drinker, who “admitted that at times he drank a lot, and at other times abstained – it was moderation he found difficult. Although he mostly abstained, he lamented, ‘There is no doubt that not to drink wine is a great deduction from life’.” Excess alcohol is risk factor for stroke.

As for Charles Dickens, he too “had signs of heart disease, perhaps precipitated by renal disease, for several years, and in 1866 he was prescribed iron, quinine, and digitalis. Watson also noted signs of cardiac enlargement” (McManus, 2001). His stroke has even been localised – without an autopsy or CT-scan, highlighting some of the unique aspects to neurological diagnosis. As explained by McManus, “For the last 5 years of his life, Charles Dickens had a range of symptoms, mostly affecting his left side, including hemispatial neglect for words, paroxysmal pains, hyperpathia or allodynia and hypoalgesia in the left foot, and a feeling of the world falling to the left. He also seemed to be unaware of the seriousness of his symptoms, which suggests some form of anosognosia. Dickens was known to have had a definite attack of right-sided cerebral insufficiency, and he died of apoplexy affecting the right side of the brain. Dickens' left-sided symptoms thus could suggest damage to the right temporoparietal area.”

There is much of interest in Dickens’ life, but if I were to look at him from my two most personal perspectives, I find him most amusing.

As a doctor, Dickens views on the medical profession are peculiar and reveal to us a lot about how the medical profession was viewed in early Victorian times. He portrayed many doctors in his novels, 27 according to Dana (1898), and “out of these twenty-seven medical men, not one is characterized especially as having ability, as being a person of good sound sense having ability, as being a person of good sound sense; not one would seem to indicate by anything he is allowed to say in the pages in which he lives, that he is a man of brains, with the possible exception of Dr. Manette in the " Tale of Two Cities," and Joe Specks in the ' Uncommercial Traveller." Alfred Heathfield, Alexander Manette, Joe Specks and Allan Woodcourt are men whom one might be willing to associate with freely, though even they rather savor of the cheap comic paper. The remaining twenty-three are, as the notes indicate, either silly, idiotic, pretentious, weak, or are simply caricatures of men. As I went on with my examination I was at first inclined to draw some rather broad conclusions from this table. It seemed to indicate that in Dickens' time, say forty years ago, the medical profession in England received very little consideration at the hands of people of thought. The doctors generally, were looked upon as weak and r.,ther silly; and the lower middle class, even, considered them as little more than necessary evils or subjects for jokes.”

As a Palestinian, I find his views on the Jews very interesting. Even this great novelist was not spared the accusation of anti-Semitism by his Jewish readers. Why can’t Jews accept criticism? Why are they so pathetic? Why do we need to distort history so that we please them? Why can’t they accept that they committed the many crimes that they have committed throughout their history? Why do they want everyone to think that they are the angels of Earth, perfect, innocent, who have never done any evil, the ones who are hated ‘because they are so good’, because we are jealous of them? The Jews’ portrayal of themselves in current media as the most perfect of people is nonsense, pure fiction. The Jews are like every other people – there is both good and evil in them, although history, and the word of God, tells us that there is probably more evil in them than good.

The Quran indicates to us that there are good Jews, saying, “Not all of them are alike: of the People of the book are a portion that stand (for the right); they rehearse the signs of Allah all night long and then prostrate themselves in adoration. They believe in Allah and the Last Day; they enjoin what is right and forbid what is wrong; and they (hasten in emulation) in (all) good works; they are in the ranks of the righteous. Of the good that they do nothing will be rejected of them; for Allah knoweth well those that do right” (3:113-115). It even promises Paradise to some of them, “Verily! Those who believe and those who are Jews and Christians, and Sabians, whoever believes in Allah and the Last Day and do righteous good deeds shall have their reward with their Lord, on them shall be no fear, nor shall they grieve”.( 2:62). But in the main, it is critical of their actions; entire books have been dedicated to this topic, which I will not recount here.

God cannot be accused of the anti-Semitism that so many fair and just thinkers have been accused of because they spoke the truth about the Jews. Everyone knows that Shakespeare has been accused of anti-Semitism following his depiction of the character Shylock in the Merchant of Venice, the famous miserly money lending Jew. So was Dickens, following his depiction of the character Fagin, in his novel Oliver Twist, the Jewish leader of “a group of children, the Artful Dodger among them, whom he teaches to make their livings by pickpocketing and other criminal activities in exchange for a roof over their heads.” The great man was criticised by readers everywhere, and responded, "I know of no reason the Jews can have for regarding me as inimical to them...on the contrary, I believe I do my part toward the assertion of their civil and religious liberty, and in my Child's History of England, I have expressed a strong abhorrence of their persecution in old time"

To a criticism published in the Jewish Chronicle, Dickens wrote the following response:

"If there can be any general feeling on the part of the intelligent Jewish people that I have done them what you describe as a 'great wrong', they are a far less sensible, and far less just, and a far less good-tempered people than I have always supposed them to be be. Fagin, in Oliver Twist, is a Jew, because it unfortunately was true of the time to which that story refers, that that class of criminal almost invariably was a Jew. But surely no sensible man or woman of your persuasion can fail to observe...that all the rest of the wicked dramatis personae are Christians"

Dickens was being fair, and a true observer of history. We shall not feign history to portray the Jews as they wish were, rather than what they actually were. One can give statement by virtually all great non-Jewish thinkers of all ages to show what a terrible people they generally were. I find it an extremely useful exercise to list some of these statements.

1. François Marie Arouet Voltaire, the 18th century French philosopher and novelist:

“Why are the Jews hated? It is the inevitable result of their laws; they either have to conquer everybody or be hated by the whole human race. The Jewish nation dares to display an irreconcilable hatred toward all nations, and revolts against all masters; always superstitious, always greedy for the well-being enjoyed by others, always barbarous--cringing in misfortune and insolent in prosperity”. (Essai sur les moeurs)

“You seem to me to be the maddest of the lot. The Kaffirs, the Hottentots, and the Negroes of Guinea are much more reasonable and more honest people than your ancestors, the Jews. You have surpassed all nations in impertinent fables, in bad conduct and in barbarism. You deserve to be punished, for this is your destiny. (From a letter to a Jew who had written to him, complaining of his 'anti-Semitism.' Examen des quelques objections. . . dans l'Essai sur les moeurs.) You will only find in the Jews an ignorant and barbarous people, who for a long time have joined the most sordid avarice to the most detestabJe superstition and to the most invincible hatred of all peoples which tolerate and enrich them. ("Juif," Dictionnaire Philosophique)”

“I know that there are some Jews in the English colonies. These marranos go wherever there is money to be made But whether these circumcised who sell old clothes claim that they are of the tribe of Naphtali or Issachar is not of the slightest importance. They are, simply, the biggest scoundrels who have ever dirtied the face of the earth. (Letter to Jean-Baptiste Nicolas de Lisle de Sales, December 15, 1773. Correspondance. 86:166)”

“They are, all of them, born with raging fanaticism in their hearts, just as the Bretons and the Germans are born with blond hair. I would not be in the least bit surprised if these people would not some day become deadly to the human race. (Lettres de Memmjus a Ciceron, 1771)”

2. Benjamin Franklin – the great American thinker:

“I fully agree with General Washington, that we must protect this young nation from an insidious influence and impenetration. That menace, gentlemen, is the Jews. In whatever country Jews have settled in any great number, they have lowered its moral tone; depreciated its commercial integrity; have segregated themselves and have not been assimilated; have sneered at and tried to undermine the Christian religion upon which that nation is founded, by objecting to its restrictions; have built up a state within the state; and when opposed have tried to strangle that country to death financially, as in the case of Spain and Portugal. For over 1,700 years, the Jews have been bewailing their sad fate in that they have been exiled from their homeland, as they call Palestine. But, gentlemen, did the world give it to them in fee simple, they would at once find some reason for not returning. Why? Because they are vampires, and vampires do not live on vampires. They cannot live only among themselves. They must subsist on Christians and other peoples not of their race. If you do not exclude them from these United States, in this Constitution, in less than 200 years they will have swarmed here in such great numbers that they will dominate and devour the land and change our form of government, for which we Americans have shed our blood, given our lives, our substance and jeopardized our liberty. If you do not exclude them, in less than 200 years our descendants will be working in the fields to furnish them substance, while they will be in the counting houses rubbing their hands. I warn you, gentlemen, if you do not exclude Jews for all time, your children will curse you in your graves. Jews, gentlemen, are Asiatics, let them be born where they will or how many generations they are away from Asia, they will never be otherwise. Their ideas do not conform to an American's, and will not even though they live among us ten generations. A leopard cannot change its spots. Jews are Asiatics, are a menace to this country if permitted entrance, and should be excluded by this Constitutional Convention.”

3. Mark Twain – the great American writer:

“I feel convinced that the Crucifixion has not much to do with the world's attitude toward the Jew; that the reasons for it are much older than that event...I am convinced that the persecution of the Jew is not in any large degree due to religious prejudice. No, the Jew is a money-getter. He made it the end and aim of his life. He was at it in Rome. He has been at it ever since. His success has made the whole human race his enemy. You will say that the Jew is everywhere numerically feeble. When I read in the Cyclopedia Britannica that the Jewish population in the United States was 250,000 I wrote the editor and explained to him that I was personally acquainted with more Jews than that, and that his figures were without doubt a misprint for 25,000,000. People told me that they had reasons to suspect that for business reasons, many Jews did not report themselves as Jews. It looks plausible. I am strongly of the opinion that we have an immense Jewish population in America. I am assured by men competent to speak that the Jews are exceedingly active in politics... ("Concerning the Jews," Harper's Monthly Magazine, September 1899)”

4. George Bernard Shaw, the 20th century Irish dramatist:

“This is the real enemy, the invader from the East, the Druze, the riffian, the oriental parasite; in a word the Jew”. (London Morning Post, December 3, 1925)

“This craving for bouquets by Jews is a symptom of racial degeneration. The Jews are worse than my own people. Those Jews who still want to be the chosen race (chosen by the late Lord Balfour) can go to Palestine and stew in their own juice. The rest had better stop being Jews and start being human beings”. (Literary Digest, October 12, 1932)

5. H G Wells, English novelist and historian:

“Zionism is an expression of Jewish refusal to assimilate. If the Jews have suffered, it is because they have regarded themselves as a chosen people”. (The Anatomy of Frustration)

“A careful study of anti-Semitic prejudice and accusations might be of great value to many Jews, who do not adequately realize the irritations they inflict”. (Letter of November 11, 1933)

Can all these people be wrong, and the Jews right? I think not. I hasten to add however, that I am not against Judaism, but only against Zionist Jews, and believe historical accounts given by people whose judgement and veracity I cannot question.

MUSICIANS

There is much interest these days on the effect of music therapy on strokes, and the effect of strokes on the minds of musicians. As for famous musicians who endured them, the two most interesting cases are those of Johann Sebastian Bach, widely regarded as the third greatest composer of history, after Beethoven and Mozart, and Georg Handel, another great German composer.

As for Bach, his “cerebrovascular risk profile included age, obesity, possible hypertension and diabetes that led to his fatal stroke in 1750" (Breitenfeld et al, 2006). The stroke was complicated by pneumonia, presumably, as it usually is in those cases, due to aspiration.

Bach, as we say is thought to be the third of the greatest composers of history, though he preceded and influenced all of them. His ‘Mass In B Minor’ is widely regarded as only second to Beethoven’s ninth symphony as the greatest classical piece ever. His legacy was clear to all, non-musicians and musicians. For example, George Bernard Shaw remarked that, “Bach belongs not to the past, but to the future - perhaps the near future.”
Douglas Adams, author of the ‘Hitchhiker’s Guide To The Galaxy’ wrote, “I don't think a greater genius has walked the earth. Of the 3 great composers Mozart tells us what it's like to be human. Beethoven tells us what it's like to be Beethoven and Bach tells us what it's like to be the universe.” The great German poet Goethe suggested that listening to Bach was “as though eternal harmony were conversing with itself, as it may have happened in God's bosom shortly before He created the world.” The famous American physician and author, Lewis Thomas remarked somewhere about how he reckons the people of Earth should communicate with extraterrestrials, "I would vote for Bach, all of Bach, streamed out into space, over and over again. We would be bragging of course, but it is surely excusable to put the best possible face on at the beginning of such an acquaintance. We can tell the harder truths later." He was a true genius.

As for musicians, the contemporary American composer Michael Torke made the fantastic remark, “Why waste money on psychotherapy when you can listen to the B Minor Mass?” As for the more famous ones, their praise is even greater. Beethoven played a pun on Bach’s name in German, “Not brook but sea should be his name” (“nicht Bach, sondern Meer”). On a visit to Thomasschule, Mozart heard a performance of one of Bach’s pieces and exclaimed, "Now, here is something one can learn from!"; on being given the motets' parts, "Mozart sat down, the parts all around him, held in both hands, on his knees, on the nearest chairs. Forgetting everything else, he did not stand up again until he had looked through all the music of Sebastian Bach". The great French pianist Chopin described Bach as “like an astronomer who, with the help of ciphers, finds the most wonderful stars...Beethoven embraced the universe with the power of his spirit...I do not climb so high. A long time ago I decided that my universe will be the soul and heart of man.” Schumann stated that “music owes as much to Bach as religion to its founder”. Wagner made the greatest claim, that Bach is “the most stupendous miracle in all music”.

Bach was a remarkably religious man, who felt that “music's only purpose should be for the glory of God and the recreation of the human spirit." His music is to this day, heard in Churches all over the world. His religiosity is deeply expressed in his work, as the Wikipedia article on him explains:

“Bach's apparently devout, personal relationship with the Christian God in the Lutheran tradition and the high demand for religious music of his times inevitably placed sacred music at the centre of his repertory; more specifically, the Lutheran chorale hymn tune, the principal musical aspect of the Lutheran service, was the basis of much of his output. He invested the chorale prelude, already a standard set of Lutheran forms, with a more cogent, tightly integrated architecture, in which the intervallic patterns and melodic contours of the tune were typically treated in a dense, contrapuntal lattice against relatively slow-moving, overarching statements of the tune. Bach's theology also informed his compositional structures: Sei Gegrüsset is perhaps the finest example where there is a theme with 11 variations (making 12 movements) that, while still one work, becomes two sets of six—to match Lutheran preaching principles of repetition. At the same time the theological interpretation of 'master' and 11 disciples would not be lost on his contemporary audience. Further, the practical relationship of each variation to the next (in preparing registration and the expected textural changes) seems to show an incredible capacity to preach through the music using the musical forms available at the time.”

As for Handel, he too is regarded as one the top ten composers of all time, being ranked ninth in a recent poll, although the ‘Hallelujah Chorus’ of his masterpiece, ‘The Messiah’, is regarded as the most popular of all classical compositions (whether it is truly the most popular or simply the most well known or imposed (being always played in every Christmas) is a matter of debate. His legacy is celebrated in many places, such as this interesting piece that compares him with Bach:

“Throughout his life Handel avoided the rigorous contrapuntal techniques of his compatriot and exact contemporary Johann Sebastian Bach and achieved his effects through the simplest of means, trusting always his own innate musicianship. The music of both composers, however, sums up the age in which they lived. After them, opera took a different path; the favorite baroque genres of chamber and orchestral music, trio sonata and concerto grosso, were largely abandoned; and the development of the symphony orchestra and the pianoforte led into realms uncharted by the baroque masters. Thus, their influence cannot be found in specific examples. Rather, Handel's legacy lies in the dramatic power and lyrical beauty inherent in all his music. His operas move from the rigid use of conventional schemes toward a more flexible and dramatic treatment of recitative, arioso, aria, and chorus. His ability to build large scenes around a single character was further extended in the dramatic scenas of composers such as Wolfgang Amadeus Mozart and the Italian Gioacchino Rossini. Handel's greatest gift to posterity was undoubtedly the creation of the dramatic oratorio genre, partly out of existing operatic traditions and partly by force of his own musical imagination; without question, the oratorios of both the Austrian composer Joseph Haydn and the German composer Felix Mendelssohn owe a large debt to those of Handel”

In an article, ‘Georg Friedrich Händel’s Strokes’ by Bazner and Hennerici (2005), it was concluded, “that Händel, a man with a probable wide profile of risk factors including systemic hypertension, smoking and most probably hyperlipidemia, had recurrent palsies of his right side (following the available sources involving uniformly his upper extremity), partly with simultaneous speech impairment, either dysarthia as a component of the dysarthria-clumsy-hand-syndrome or dysphasia as a result of embolic middle cerebral artery stroke, which may have been interpreted as confusion. He may well have had a severe stenosis of his left carotid artery with recurrent embolism to the left hemisphere. Since for a certain period of time only his left eye was affected by visual loss, the suspected left carotid artery stenosis may also have been the source for embolic events within the left retina.”

OTHER ARTISTS

In addition to musicians and novelists, the impact of strokes on the creative output of artists is demonstrated in many other types of artist. For example, it was only “when a stroke rendered painting impossible” that the great Italian painter of the Mona Lisa, Leonardo da Vinci stopped and focused on his other artistic passion of designing, until his death on May 2, 1519. Strokes robbed the Arab world of some of its biggest comedian actors, stripping it of a great element of laughter – actors like George Sidhom, Sayyid Zayyan and Younis Shalabi.

SCIENTISTS

I cannot recall reading about any great scientist’s stroke as vividly as I recall that of Louis Pasteur, the great Frenchman, whose life teaches us so much wisdom, and indeed teaches us some interesting aspects about stroke.

Pasteur is arguably the only scientist in history to find his way into every single home in the Western world, into every Western refrigerator – with his invention of the procedure of Pasteurisation – a procedure that must have saved millions of lives. It is this, plus many dozens of other contributions that led David Wood to justifiably state that, “If one were to choose among the greatest benefactors of humanity, Louis Pasteur would certainly rank at the top. He solved the mysteries of rabies, anthrax, chicken cholera, and silkworm diseases, and contributed to the development of the first vaccines. He debunked the widely accepted myth of spontaneous generation... He described the scientific basis for fermentation, wine-making, and the brewing of beer. Pasteur's work gave birth to many branches of science, and he was singlehandedly responsible for some of the most important theoretical concepts and practical applications of modern science...All of these achievements point to singular brilliance and perseverance in Pasteur's nature. His work served as the springboard for branches of science and medicine such as stereochemistry, microbiology, bacteriology, virology, immunology, and molecular biology.”

Pasteur was immortalised in the Oscar winning movie ‘The Story of Louis Pasteur’, and was regarded by Michael Hart as the eleventh most influential person in history. He was a remarkable genius, and there are many excellent biographies describing this genius. What I would like to pay attention to here is two aspects of his life which are highly educational from the perspective of this book.

The first aspect is his great religious zeal, and his great faith in God. Pasteur famously remarked that, "A bit of science distances one from God, but much science nears one to Him; the more I study nature, the more I stand amazed at the work of the Creator." His grandson and first biographer, Vallery-Radot commented that, “Absolute faith in God and in Eternity, and a conviction that the power for good given to us in this world will be continued beyond it, were feelings which pervaded his whole life; the virtues of the gospel had ever been present to him. Full of respect for the form of religion which had been that of his forefathers, he came simply to it and naturally for spiritual help in these last weeks of his life”. To see such a great scientist believe in God, and showing great gratitude to Him, is a sign that He is the truth.

Louis Pasteur suffered his first stroke on October the 19th 1868, at the age of forty-five. He described it saying, “There is a time in every man's life when he looks to his God, when he looks at his life, when he wonders how he will be remembered. It can happen with age or with tragedy or closeness of death. I am lying here at age 45, not able to feel my left side. Not knowing if this stroke that has befallen me will end my life before the mysteries that I have unlocked can be resolved”. His suffering teaches us two main things about stroke. Firstly, that it can happen to every one of all ages – stroke is not just a disease of the elderly, although it is true that age is its biggest risk factor.

Secondly, it teaches us that stroke need not be the end of the contributions of a human being. Some of his greatest work was produced after his stroke, with his election to the Academy of Medicine in 1873, publishing his studies on beer in 1876, and his studies on anthrax in 1877. In 1879, during his studies on chicken cholera, Pasteur discovered how to immunize against disease using weakened bacteria, and in 1880 he began his legendary studies of rabies. In 1885, Joseph Meister, bitten by a rabid dog, was brought to Pasteur who decided to vaccinate him, the first person ever to be vaccinated. After his survival, patients flocked from all over the world to see Pasteur. In 1894, The Pasteur Institute succeeded in producing a vaccine for diphtheria. All this life-saving work was done after Pasteur’s stroke. It all shows that stroke does not necessarily mean the end, and rehabilitation from stroke should always be hoped for and considered.

TYPES OF STROKE

Strokes are divided into two main types – ischaemic and haemorrhagic. There is a division of strokes into TIAs and completed strokes, the difference being duration; TIA – as it says on the tin – are transient attacks, lasting less than 24 hours. The importance of their diagnosis is that by detecting them and treating them, you can avoid their escalation into completed strokes; about 15% of patients who have had a TIA develop a completed stroke at a later stage.

Strokes develop when the blood supply to the part of the brain involved in the stroke is reduced to levels at which the neurons do not meet their minimum blood supply. As usual, the human body has been endowed with protective mechanisms that help in these circumstances, one physiological – the CNS ischaemic response, and one anatomical - the Circle of Willis.

The CNS ischaemic response is explained clearly here by Guyton:

“Most nervous control of blood pressure is achieved by reflexes that originate in the baroreceptors, the chemoreceptors, and the low-pressure receptors, all of which are located in the peripheral circulation outside the brain. However, when blood flow to the vasomotor center in the lower brain stem becomes decreased severely enough to cause nutritional deficiency—that is, to cause cerebral ischemia—the vasoconstrictor and cardioaccelerator neurons in the vasomotor center respond directly to the ischemia and become strongly excited. When this occurs, the systemic arterial pressure often rises to a level as high as the heart can possibly pump. This effect is believed to be caused by failure ofthe slowly flowing blood to carry carbon dioxide away from the brain stem vasomotor center: at low levels of blood flow to the vasomotor center, the local concentration of carbon dioxide increases greatly and has an extremely potent effect in stimulating the sympathetic vasomotor nervous control areas in the brain’s medulla.

It is possible that other factors, such as build up of lactic acid and other acidic substances in the vasomotor center, also contribute to the marked stimulation and elevation in arterial pressure. This arterial pressure elevation in response to cerebral ischemia is known as the central nervous system ischemic response, or simply CNS ischemic response.

The magnitude of the ischemic effect on vasomotor activity is tremendous: it can elevate the mean arterial pressure for as long as 10 minutes sometimes to as high as 250 mm Hg. The degree of sympathetic vasoconstriction caused by intense cerebral ischemia is often so great that some of the peripheral vessels become totally or almost totally occluded. The kidneys, for instance, often entirely cease their production of urine because of renal arteriolar constriction in response to the sympathetic discharge. Therefore, the CNS ischemic response is one of the most powerful of all the activators of the sympathetic vasoconstrictor system.”

This explains why it is advised not to treat hypertension in the case of an ischaemic stroke. It is actually a protective response in the acute scenario.

Without the amazing spider-like structure called the Circle of Willis, the like of which is not present in any other part of the human body, the incidence of strokes will be multiplied manifold. Somehow, the human body knew that neurons are very fragile structures, and they need a persistent blood supply. So it devised this incredible system, which unfortunately been a cause of headache in the vast majority of medical students who are always asked to recall its many branches during their exams! It is a great example of Divine Providence.

So how do strokes occur? The risk factors for stroke are the same as those of ischaemic heart disease (SHIFTMAID) in the case of ischaemic strokes, which account for the majority:

§ Smoking
§ Hypertension / Heart disease (esp. heart failure & atrial fibrillation)/ Hypercoagulability (including polycythemia)/ Hypocoagulability conditions
§ IDDM/NIDDM
§ Family history
§ Triglycerides (cholesterol)
§ Male
§ Age
§ Inactivity
§ Drinking (alcohol)

In addition, heart disease itself, prothrombotic (including polycythaemia) conditions, and a previous CVA predispose to them. In addition, haemorrhagic stroke is predisposed to by any bleeding diathesis (including iatrogenic due to warfarin) and weakening of the blood vessels by the SHIFTMAID. The rupture may be caused by sudden rise in blood pressure. These risk factors take time to cause disease, and hence stroke is usually a disease of the elderly (generally over 50s).

However, if confronted with a young patient with stroke, one must think of the 7Cs, which are:

Cocaine
Cytological (mitochondrial diseases - MELAS)
Consanguinity [familial such as neurofibromatosis and von Hippel-Lindau]
Cardiogenic emboli (e.g. infective endocarditis)
Coagulopathy (e.g. ALASCA, antiphospholipid syndrome, contraceptive)
Congenital heart disease
Cerebral vasculitis (e.g. Moya Moya, carotid/vertebral dissection, vasculitis)

So what does knowledge of SHIFTMAID and stroke teach us? Well, it teaches us that there are multiple factors in the prevention of stroke. You need normal vasculature, blood and blood supply.

The supply of blood is provided by the heart – and hence a normal heart is a prerequisite to the prevention of strokes. If the heart is not working properly, it would naturally fail to pump arterial blood up to the brain. In addition, a failing pump leads to blood stasis in the chambers of the heart, leading to emboli, which can be pumped eventually into the brain, blocking off the arterial supply. This is the same way through which atrial fibrillation can lead to strokes, and why anticoagulation is such an important aspect of its management.

Normal blood is the other precondition to the prevention of stroke. As we all know, blood contains red blood cells, white blood cells, and platelets, clotting factors, other blood proteins and plasma. Defects in any of these will lead to stroke. Defects can be divided into excess, deficiency and function defects.

Excessive red blood cells – namely polycythaemia can cause stroke. This is because of hyperviscosity of blood. This reduces its flow rate, and predisposes to clot formation.
Low levels of red blood cells – namely anaemia can also lead to stroke. This is a logical, although not a commonly mentioned textbook cause of stroke – a typical list goes along the following lines:

If there is not enough blood, highlighted by a low haemoglobin, then clearly the brain is not going to receive the oxygen it needs to function, and therefore it will infarct. A very interesting recent study by Maguire et al (2008) showed that, “More than half of the stroke cases among children without underlying medical illness consisted of children with IDA, suggesting that IDA is a significant risk factor for stroke in otherwise healthy children.” (Association between iron-deficiency anemia and stroke in young children. Maguire J, deVeber G, Parkin PC. Pediatrics 120(5): 1053-7. )

However, one type of anaemia is nearly always mentioned as a cause – namely sickle cell anaemia. The mechanism is due to occlusion of brain vasculature by long-jams of sickled red cells.

A chronic severe excess of leukocytes can lead to stroke by the same hyperviscosity mechanism as polycythemia. (Inoue, 2006). Leukopenia does not lead to stroke.

An excess of platelets (thrombocytosis) can lead to strokes by predisposing to emboli formation. It is important to realise too that any infarction or bleed can cause secondary thrombocytosis. So if you find a high platelet count in a patient who has had a stroke – it may be a cause or consequence. A low level of platelets can lead to all sorts of bleeds, haemorrhagic brain strokes included. This is the same mechanism by which low clotting factors can lead to stroke. The most common reason for this is warfarin use, but other reasons are failure to synthesise clotting factors (e.g. cirrhosis) or to keep them in the circulation (nephrotic syndrome).

An excess of clotting factors (thombophilia) or deficiency of endogenous anticoagulants can lead to stroke by increasing the risk of emboli formation. The prothrombotic conditions are ALASCA:

· Acquired (e.g. smoking, surgery, HRT, OCP, dehydration, malignancy, cancer chemotherapy)
· Leyden (factor V Leyden)
· Antithrombin-III deficiency
· S- and C- protein deficiency
· Antiphospholipid syndrome

The final risk factor for stroke is abnormal vasculature. This is how the majority of strokes occur. The main disease affecting the vessels is atherosclerosis, whose main risk factors are SHIFTMAID. In addition we have the vasculitides, which include Moya Moya disease and carotid arterial dissection.

Knowledge of the above highlights the importance of the normality of the above in most human beings, who are spared the torment of strokes. To that we should be grateful.

Now that we have discussed the causes of stroke, we can discuss its presentation.

THE PRESENTATION OF STROKES

Strokes can present in virtually any mixture of neurological symptoms – weakness, altered sensation, tremor, convulsions, headache, visual, auditory, and speech problems.

To reflect on the presentation of strokes is to reflect on the magnificence of the normal brain. Indeed, our knowledge of the normal brain is based mostly on knowledge of the aftermath of strokes and traumatic head injury, being the most common neurological presentations, if I may call head injury a neurological, rather than surgical condition. Correlating autopsy and more recently, MRI findings to presentations of patients during their life, we have learnt much about the role of different areas of the brain. What such studies have revealed is the specific role of each part of the brain. Although, macroscopically at least, brain tissue appears pretty much homogenous, there are huge differences between different parts. The functions of the different lobes are as follows:

Frontal - associated with reasoning, planning, parts of speech, movement, emotions, and problem solving
Parietal - associated with movement, orientation, recognition, perception of stimuli
Occipital - associated with visual processing
Temporal - associated with perception and recognition of auditory stimuli, memory, and speech

When one reflects on the symptoms that patients present with in stroke, it is hard to not think of the brain as yet another example of intelligent design and part of an outstanding irreducibly complex system.

Stroke is the most common neurological emergency, and, because effective treatment is available that must be started within minutes, most acute neurological presentations should be assumed to be a stroke until proven otherwise by history, exam, or radiographic testing. The diagnosis is often clear from the history and examination, but the following pathologies can also produce a clinical picture that is identical to stroke and should be considered in atypical presentations – namely MICES:

Multiple sclerosis / Migraine (hemiplegic) (typical features of migraine also present, resolving within 24 hours).
Intracranial mass e.g. tumour (history of cancer) or abscess (consider if patient has bronchiectasis or murmur (infective endocarditis)).
Chronic subdural haematoma – consider in elderly and alcoholics
Encephalitis / Epilepsy - Todd's paralysis following a Jacksonian seizure.
Sugar – hypoglycemia mainly

Any patient with a suspected stroke should be assessed with ABCDEFG and MOVE first as large strokes and reduced GCS, or with strokes affecting the tongue and pharynx, can lead to severe airway problems. If hypertensive, do not treat HT (Cushing’s reflex); take a full history, enquiring carefully into all neurological symptoms, and PMH of CV illness. This should be enough to differentiate CVA from other focal lesions (e.g. migraine, fits, and tumour). Consider an urgent CT if suspect intracranial bleeding (headache, on warfarin, history of trauma or falls). Otherwise get CT within 24 hrs.

A basic understanding of brain vascular anatomy is important to understand strokes, as follows:

CLASSIFICATION OF STROKE

Oxfordshire Stroke Subtype Classification uses clinical history and physical exam findings to classify stroke patients into 5 subtypes
675 cases of first-ever stroke encountered over 5 years
Interobserver reliability for classification employing the Oxfordshire system is good
Subtypes are associated with different incidences of medical complications and dependency at discharge:

1. Primary intracerebral hemorrhage (PICH)
2. Total anterior circulation infarct (TACI): 17%, high mortality and poor chance of good functional outcome
3. Partial anterior circulation infarct (PACI): 24%, more likely to have an early recurrent stroke
4. Lacunar infarct (LACI: )25%.
5. Posterior circulation infarct (POCI): 24%, more likely to have a late recurrent stroke but an overall good functional outcome

TACI FEATURES - 3H

· Hemiplegia (contralateral to lesion)
· Homonymous hemianopia
· Higher cortical dysfunction (e.g. dysphasia, dyspraxia, neglect)

- PACI is 2/3 of the above
- LACI is a pure hemimotor or hemisensory loss.

With posterior circulation strokes the main features are of homonymous hemianopia, with macular sparing and brainstem disturbance - 4D:

· Dizziness
· Diplopia
· Dysarthria
· Dysphagia

The presence of dysphasia or Gerstmann’s syndrome suggests dominant parietal lobe involvement

SITES & MANIFESTATIONS OF STROKE

1.Cerebral hemisphere infarcts may be classified by vascular territory:

Anterior cerebral artery infarcts: proximal to the medial striate branch, they cause contralateral hemiplegia; distal to the medial striate branch, they cause contralateral paralysis with sparing of the arm and face.
Middle cerebral artery infarcts: causes contralateral hemiplegia, often sparing the leg, and hemianopia. Aphasia is present if the dominant hemisphere is affected.
Posterior cerebral artery infarcts: causes contralateral hemianopia.
Motor signs are upper motor neuron.

2. Lacunar strokes

Lacunar strokes are due to small areas of infarction usually occurring around the basal ganglia, thalamus, and pons.
Clinical features include pure motor or sensory signs, a mixed motor and sensory picture, ataxia, and dysarthria.
They may also be asymptomatic and found at post-mortem examination.

3. Brainstem infarcts

Clinical features include hemi- or quadriplegia, sensory loss, diplopia, facial weakness and numbness, nystagmus, dysphasia, and coma due to damage to the reticular formation.
The locked-in syndrome results from upper brain-stem infarction. The patient is conscious but unable to respond.
The most common brainstem vascular syndrome is lateral medullary syndrome (Wallenberg's syndrome), which is due to thromboembolism of the posterior inferior cerebellar artery. The patient presents with sudden vertigo and vomiting. Ipsilateral signs include 9th and 10th nerve lesions, Horner's syndrome, spinothalamic sensory loss in the face, diplopia, and cerebellar signs in the limbs. Contralateral signs include spinothalamic sensory loss in the body.

HISTORY

HPC

Either sudden onset or a step-wise progression of symptoms and signs over hours (or even days) is typical. TIA <> 24 hours. The features depend on the vascular territory involved (as above). Note risk factors for stroke. The neurological symptoms that stroke victims may present with include:

1. Weakness

· Determine if in lower face, arms and legs.
· Pure weakness à internal capsule
· A leg weakness à anterior cerebral
· A face, leg AND arm weak à middle cerebral
· Both legs weak à vertobrobasilar (but hemiparesis more common) (Posterior cerebral vasculopathy not associated with weakness)

2. Walking (gait) abnormalities

Patient primarily complain of this because of weakness, but it may also be due to basal ganglia disease, or multi lacunar infarcts (marche a petits pas)

Hemiplegic gait shows the pyramidal pattern of weakness.
Ataxic gait may occur in VB CVA

3. Altered sensation:

Middle cerebral artery supplies the somatosensory cortex; therefore sensory loss occurs only in MCA disease
If pure sensory loss however with no other features, internal capsule (medial lemniscus) infarct likely.
Thalamic infarcts cause hemisensory deficit (PCA supply), but so rare & associated excruciating pain is almost pathognomonic

4. Tremor and involuntary movements

Suggest basal ganglia stroke (i.e. lacunar infarct)

5. Confusion & convulsions

Patient is confused and disorientated in most cases
Rare in ischaemic stroke; more common is haemorrhagic stroke

6. Headache

Common; but if of severe intensity then suggests a haemorrhagic stroke

7. Eye & Ear problems

Visual problems are common, and can only truly be distinguished by physical examination
Amaurosis fugax points to carotid disease
‘like a curtain descending over my field of view’ (OHCM, p.350)
Deafness and/or tinnitus occur in vertebrobasilar strokes (OHCM, p.350).

8. Other

Dysphagia
Incontinence in anterior cerebral occlusion
Consciousness; coma does not occur in early stroke unless severe haemorrhagic; need to differentiate ‘locked-in-syndrome’ (‘pseudocoma’). Reticular strokes do not occur!
Speech (especially articulation and language production) - any dysphasia may occur

PMH

· Previous CVA, IHD or MI
· RF
· DM
· HT
· Congenital heart disease
· Arrhythmias
· Hyperlipidaemia
· Vasculitis
· Connective tissue disease
· Coagulopathies & other blood disease
· Virchow’s triad applies here as it does for DVT (so OCP equally as important)

DH

· Warfarin suggests haemorrhagic stroke
· Cocaine abuse in young patients
· OCP

FH/SH

· Note any FH of stroke or risk factors for stroke
· Smoking
· Alcohol
· Determine occupation and if patient drives; a one month ban applies if normal driver, if HGV and persistent deficit then banned for good.

ROS

· Note particularly the presence of any cardiorespiratory or arteriopathy symptoms

PHYSICAL EXAMINATION

GENERAL

· Acutely unwell patient
· GCS (falls if extensive hemispheric involvement due to cerebral oedema or severe bleed)
· BP may be high as a cause or consequence; a low BP may occur in haemorrhagic stroke
· Tachycardia (stress response, AF)
· Tachypnea (stress, anxiety, aspiration pneumonia, PE)
· Saturations (ensure saturations are above 95% [Witham 2005])
· Pyrexia (if aspiration pneumonia or UTI - common)
· Urine output (catheterise)

OTHER

· Neuro à full higher function, CN, sensory and motor testing
· CVS à JVP raised, xanthelasma, arcus, murmurs, carotids, peripheral pulses, check for DVT (may be difficult). (Fundoscopy done)
· RS à pneumonia
· Abdo à urinary retention

NEUROLOGICAL EXAMINATION IN STROKE

Posture is flexed upper limbs and extended lower limbs (pyramidal weakness); may have clear involuntary movements in lacunar infarcts.

CRANIAL NERVES

I à rarely involved
II à contralateral homonymous hemianopia in anterior circulation; with macular sparing in posterior circulation . Fundoscopy.
III, IV, VI à diplopia, ipsilateral Horner’s in lateral medullary syndrome. Nystagmus.
V à facial sensory loss; brisk jaw jerk in pseudobulbar palsy
VII à facial weakness (differentiate from Bell’s palsy)
VIII à rarely useful
IX & X à lateral medullary infarcts; PBP
XI à not useful
XII à PBP – this is bilateral IX, X, XII lesions

MOTOR

Wasting is not a feature of UMN lesions
Involuntary movements may be seen in basal ganglia infarcts
Initially flaccid hemiplegia; within days becomes spastic
Spastic weakness of pyramidal distribution (weakness greater in extensors than flexors in UL, and vice versa) – reason unclear; myometry has cast doubt on this pattern (Ginsberg, 1999), but remains clinically useful
Incoordination and other cerebellar signs common in posterior circulation CVAs
Reflexes decreased initially, then exaggerated.
Clonus present (>4 beats)
Check pts gait

SENSORY IMPAIRMENT

More for proprioception and light touch, than for pain and temperature
Loss of two-point discrimination
Astereognosis
Extinction

INVESTIGATIONS

4Ps

Plasma – FBC, U&E, ESR, glucose, lipids
Pump – i.e. heart (ECG, echocardiogram)
Pipes – carotid Doppler US
Picture of brain – CT or MRI

DIAGNOSTIC

Stroke is a clinical diagnosis
CT scan done urgently or within 24 hrs to establish mechanism

CAUSE

FBC (e.g. polycythemia. Raised WCC. If HB low and African, consider SCD)
ESR (e.g. IE, vasculitis)
Glucose
Lipids
Blood film in Afrocarribean of unknown sickle status
Blood cultures
Cholesterol
Glucose
VDRL
Coagulation screen
ECG
CXR
Echocardiography (to detect cardiac abnormalities and lung tumours)
Doppler carotids
MRA – this delineates extracranial arterial disease (internal carotid artery dissection must be considered in young patients) and proximal intracranial arteries, and detects thrombosis of major cerebral veins, venous sinuses and aneurysms

CONSEQUENCES

FBC, CXR (pneumonia), blood cultures (e.g. pneumonia, UTI)
Doppler US (legs – for DVT)

Note that large strokes, especially bleeds, can cause ST elevation on ECG and result in a rise in cardiac enzymes. This is often secondary to sympathetic activation, not necessarily to a primary myocardial event.

TREATMENT OF STROKE

Acutely, once ABCDEF & MOVE, and keep patient NBM if swallowing impaired until assessed by speech therapist.
Patients should be admitted to hospital (ideally a stroke unit for initial care and treatment, unless the diagnosis will make no difference to management, e.g. where optimal management is palliative care).
Aspirin (300 mg) should be given as soon as possible after the onset of stroke symptoms once a diagnosis of primary haemorrhage has been excluded. Antiplatelet therapy should then be continued indefinitely. Aspirin should be delayed for 24 hours following thrombolysis.
Anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke.
Unless there are contraindications, thrombolytic treatment appears to be effective in improving prognosis after an acute stroke. Treatment with alteplase should only be given provided that it is administered within three hours of onset of stroke symptoms (unless as part of a clinical trial) and haemorrhage has been definitively excluded.
Bleeds require an urgent neurosurgical opinion
Drugs depressing the function of the central nervous system (e.g. anxiolytics and tranquillisers) and new prescriptions for sedatives should be avoided.
Patients with TIA, or patients with a stroke who have made a good recovery when seen, should be assessed and investigated in a specialist service (e.g. neurovascular clinic) as soon as possible within seven days of the incident.
Conservative and supportive management is the mainstay of treatment subssequently
Treat underlying cause and RF, e.g. AF, hyperlipidaemia, HT, DM, smoking
All blood pressure medications should be held in order to ensure proper brain perfusion. Increases in the ICP sometimes force the systemic blood pressure higher than normal. In the presence of an acute bleed, the ICP should be measured. For ischemic stroke, blood pressure should not be treated unless it is severe (>220 systolic or >120 diastolic). This is often true for up to 2 weeks following acute presentation as well.
If there is a severe internal carotid artery stenosis (of more than 70%) and the patient has had TIAs within the past 6 months, endarterectomy should be considered.
Medical therapy includes aspirin 75 mg od for life. Clopidogrel or dypiridamole if intolerant.
Surgical options are carotid endarterctomy and STA-MCA anastamoses
Multidisciplinary care
Recovery and rehabilitation require an integrated approach between physicians (neurologists or geriatricians), nurses, dieticians (nasogastric feeding in 24-48 hours if bulbar function compromised), physiotherapists, OTs, and social workers
Stroke units improve outcome relative to general ward

PSYCHOLOGICAL ISSUES IN STROKE

Reaction to illness (depression in >30%)
Financial status and occupation assessment
Disability insurance (pt may be worried about how family will cope financially)
Emotional lability explanation to family so that they do not feel responsible for pts reactions

SPEECH THERAPIST ROLE

Need to distinguish from depression
Facial muscle exercises
Communication, repetition, patience and positive reinforcement
Communication board if Broca’s aphasia
Speech pathologist may be involved if very severe (?)

OCCUPATIONAL THERAPY ROLE

Assesses requirement for and arranging provision of various aids and modifications in the home
Done before discharge from hospital
Stair rails, hoists, wheelchairs, antiskid patches in bathtub
Free home of scatter rugs or other obstacles in walking pathways

PHYSIOTHERAPIST ROLE

Especially useful in first few months
Reduce spasticity
Relieve contractures
Walking aids

STROKE UNIT NURSE

Ties everything together
Intermittent catheterisation
Bladder training program – patient offered urinal, or put on commode every 2 hrs
Bowel training program
Encourage dietary fibre and fluid intake of >2L/day to avoid constipation
Apple or prune juice may help

DISCHARGE PLAN

To home, rehabilitation centre, long-term care facility (e.g. nursing home)
Ensure OT recommendations in place and pt understands them
Educate patient about drugs and schedule
Ensure pt confident in safely climbing stairs, transfer from chair to bed, etc
Family education
Provide information leaflets and details of support groups (e.g. NSF)

Ø Adaptive devices in place & understood
Ø Bowel and Bladder control
Ø Communication possible
Ø Dietary advice
Ø Eats without choking or aspiration
Ø Family support

PROGNOSIS IN STROKE

10% dead in 1 month
50 % survivors disabled
10 % recurrence in 1 yr

MEDICINE AND THE PHILOSOPHERS

2008-09-16T21:06:00.000-07:00

PHILOSOPHY AND MEDICINE

I mentioned in the introduction that one of my aims is to attempt to exhibit medicine as ‘an integral part of scientific, philosophical, social and political life’, and to highlight the ‘philosophical’ aspects of various diseases.

It is very fortunate that there are philosophy books like the fantastic one by Bertrand Russell, ‘History of Western Philosophy’, whose full title (which is rarely put on new editions) is ‘A History of Western Philosophy and Its Connection with Political and Social Circumstances from the Earliest Times to the Present Day’, where he very successfully shows philosophy as “an integral part of social and political life: not as the isolated speculations of remarkable individuals, but as both an effect and a cause of the character of the various communities in which different systems flourished”. He also states in the first few lines of his introduction:

“The conceptions of life and the world which we call "philosophical" are a product of two factors: one, inherited religious and ethical conceptions; the other, the sort of investigation which may be called "scientific," using this word in its broadest sense”.

In the presence of his book, my aim will be a lot easier to achieve. Russell has done all the hard work; all that I can do is quote and slightly expand on what he says!

In any case, Russell’s works are what introduced me to this wonderful world of philosophy. As I learn more and more about it, the more I realize how ignorant we are of many of the deeper questions of life, and how rarely, in the hustle and bustle of everyday life, we think about them. Philosophy does not give answers; it is merely about those questions, as I explained above.

There are many definitions of philosophy; to say it is ‘the love of wisdom’ is not a definition but a translation. In addition, defining it like so ignores a very important aspect to it - that it is an active pursuit, rather than a passive sentiment. It is an intense training on how to think clearly, reason and put together sound arguments, and indeed, some philosophers have described themselves as, “specialists in thinking and thoughts”. Thinking and thoughts about everything in life, especially those that deal with “with ultimate reality, or with the most general causes or principles of things and ideas and human perception and knowledge of them, physical phenomena (natural philosophy) and ethics (moral philosophy)”.

Needless to say therefore, medical professionals, who deal with matters of life and death everyday of their careers, would benefit from learning what the great philosophers have to say about these matters. And it is indeed excellent news, for those who wish for the survival of philosophy in our rather unreflective age, that medical professionals are obliged, in most countries (including England) to learn a bit about the ideas of some philosophers. They learn about the moral philosophers, such as Immanuel Kant, Jeremy Bentham and John Stuart Mill in the course of medical ethics lectures. All medical students know, or should know, Kant who came up with the ‘deontological ethics’ sometimes named after him (‘Kantian ethics’) ((duty-based ethics, based on an inherent sense of right and wrong)), whose ideas were extended by Tom L. Beauchamp and James F. Childress, two American philosophers, who consequently laid down several fundamental duties, based primarily on the ideas of Kant, which include fidelity, reparation, gratitude, justice, beneficience, self-improvement, non-maleficence, autonomy and veracity, which are the basis for much that the medical professional stands for. They also ought to be familiar with Jeremy Bentham and John Stuart Mill, who came up with the teleological (consequence based) ethics (where right actions are determined by the results produced without regard to the nature of the action), the most important of which is ‘utilitarianism’ (greatest happiness for the greatest number.

NHS directors, and those interested in such things ought to be familiar with the ideas of political philosophers, such as John Rawls, about whom a recent article was published in a major psychiatry journal, with the following abstract:

“Scarcity of resources compared with need results in resource-allocation decisions that will have a beneficent effect on some clinical populations and will be detrimental to others. Political philosophy, through theories of social justice, aims to establish generally applicable principles to guide such decision-making. We introduce here the work of the foremost liberal political philosopher of the second half of the 20th century, John Rawls. As well as having implications for resource allocation, John Rawls’s work is of relevance to law and ethics in clinical practice, especially for psychiatrists, who often work with vulnerable, disadvantaged and stigmatised people”

Anyone sitting the ‘MRCPsych’ (the membership exam for the Royal College of Psychiatrists) is obliged to have a solid background in philosophy, a welcome move instigated by K.W.M, Fulford and G. Adshead over 14 years ago, in a wonderful little paper, ‘The attitudes of psychiatrists to philosophy,’ published in ‘Psychiatric Bulletin’ ((1994), 18, 343-345).

It is a really big shame that most medical professionals, except those involved in psychiatry, do not pay much attention to philosophical questions, except in times of crisis, when confronted with a difficult ethical clinical dilemma for instance. This is because I feel medicine is one of the few fields that can benefit from, and be of benefit to philosophy, and medical professionals and philosophers can greatly benefit from one another.

The most important contribution medicine can make to philosophy is to ground it in deep everyday questions of life, the questions that intrigued the great philosophers of the past. For me, philosophy began with the Ancient Greeks and has been in a long coma since the beginning of the existentialist movement. It will never die, so long as thinking human beings exist[1]. But if it remains in its current state of ‘disciplinary narcissism’, as Peter Suber put it, in its obsession with questions far removed from everyday life, in the almost sterile discussions which pervade it (which are too dry and technical for any ones liking, converting philosophy, which was always meant to be for everyone, into a discipline for few ivory tower intellectuals), it will also remain in its coma, and the fears of Julie Von Camp, another American philosopher, would be realized:

“My worst fear is that philosophy will go the way of classics, Latin, and Greek... The responsibility for avoiding the fate of classics lies with those of us in philosophy. We must ensure that the rest of the academy understands the importance of what we do as much as we do”.

Medicine, being the most down to earth specialty, and probably the oldest specialty known to man (as the great William Osler put it, “The desire to take medicine is perhaps the greatest feature which distinguishes man from animals”) can provide philosophy with a great deal of solid substance, probably only second to quantum physics and cosmology. It is for this reason that Patrick Bracken (a psychiatrist and professor of philosophy) and Philip Thomas (a psychiatrist) highlighted the usefulness of philosophy to the physician in an editorial in the BMJ a few years ago, and concluded that “medicine should have a deeper relation with philosophy”[2]. In addition, philosophy can provide something of great importance to medicine, which was highlighted brilliantly by the great Canadian physician and medical thinker Earle P. Scarlett many years ago:

“In these days, we should be proclaiming the fact that uniformity and dull conformity are a crime against the intelligence and are indeed the sad abortion of creation. At a time when science both inside medicine and without is increasingly concerning itself with practical affairs and is ceasing to be related in any way to the fundamental problems of the meaning and purpose of life, it is imperative that a place be found for philosophy and its business of inquiring into the meaning of things”.

Von Camp was not mistaken when she said that those who wish for ‘proper’ philosophy to survive can do so by highlighting that, “Philosophy can enrich all the disciplines at the university”.

And the relationship is reciprocal. Through learning philosophy, the medical professional becomes a better thinker, since philosophy “teaches how to analyse alternatives, and how to speak and think clearly”.

He or she would also become a more fulfilled professional. No one put it better than the great Bertrand Russell:

“It is not to be supposed that young men and women who are busy acquiring valuable specialized knowledge can spare a great deal of time for the study of philosophy, but even in the time that can easily be spared without injury to the learning of technical skills, philosophy can give certain things that will greatly increase the student's value as a human being and as a citizen. It can give a habit of exact and careful thought, not only in mathematics and science, but in questions of large practical import. It can give an impersonal breadth and scope to the conception of the ends of life. It can give to the individual a just measure of himself in relation to society, of man in the present to man in the past and in the future, and of the whole history of man in relation to the astronomical cosmos. By enlarging the objects of his thoughts it supplies an antidote to the anxieties and anguish of the present, and makes possible the nearest approach to serenity that is available to a sensitive mind in our tortured and uncertain world”

The point about ‘exact and careful thought’ that Russell makes is extremely important, particularly for the Muslim physician, who in developing this habit, would see the great inconsistencies, weaknesses, and contradictions of most of our ‘Islamic heritage’. It is only through an honest analysis and critique of our thought, stripped of any emotional attachment and preconceptions that we will progress. As Russell put it in the chapter, ‘The Philosophy of Logical Analysis’ in his ‘History of Western Philosophy’:

“Morally, a philosopher who uses his professional competence for anything except a disinterested search for truth is guilty of a kind of treachery, and when he assumes, in advance of inquiry, that certain beliefs, whether true or false, are such as to promote good behaviour, he is so limiting the scope of philosophical speculation as to make philosophy trivial; the true philosopher is prepared to examine all preconceptions. When any limits are placed, consciously or unconsciously, upon the pursuit of truth, philosophy becomes paralysed by fear, and the ground is prepared for a government censorship punishing those who utter "dangerous thoughts"- in fact, the philosopher has already placed such a censorship over his own investigations”.

I could not have put it better. The almost religious reverence that Muslims have for those who wrote their works more than a thousand years ago is one of the most abhorrent features of our culture. There is a fear of thought, a fear of criticism of their ideas, that will lead us to nowhere but our current state of intellectual, moral, spiritual and scientific stagnation. As Taha Jibir Al-Alwani, a contemporary Islamic thinker said:

“There is general agreement that the Ummah is passing through an extremely difficult stage, one of disintegration and schism, loss of identity, failure of institutions, and inability to extract itself from its present state of bewilderment…After pondering the matter at length, looking at it from different perspectives, and considering objectively the attempts of the Ummah in the past to extract itself, we are convinced that the process of change must begin in the thought of the Ummah. This is because thought naturally precedes deeds, whether they prove to be correct or faulty. Only sound thinking will result in sound reconstruction, and only sound thinking will deliver the Ummah from the crisis which threatens to strangle the life from it.”

Another thinker put it thus:

“The Muslim mind, therefore, has remained a prisoner of those concepts and basic approaches that doom it to remain bound by past mistakes and digressions and bereft of the ability to penetrate, distinguish, and amend its own course, or to plumb the depths of the issues confronting it. Thus it is unable to boldly chart a course for the future, for it sits bound and blindfolded in a dusty corner of the distant past.

If the methodology of thought does not undergo change, and if its approaches are not rectified, the Muslim mind will remain unable to take a critical or penetrating look at anything. Instead, it will continue to gravitate from one failed solution to the next. There can be little doubt that continuing along this path can only lead to further disintegration and collapse.

To add to the burdens of the wretched Muslim mind, the Ummah's intellectual and political leaders, whether by design or otherwise, despaired of ever having a complete monopoly on leadership. What each group sought, then, was to force its own kind of terrorism on the Ummah. Regardless of what its Intentions might have been, the political leadership practiced a sort of material terrorism, whereas the intellectual leadership perpetrated a sort of psychological terrorism. These two groups engaged in this type of activity in order to ensure the continued pacification, weakness, and subjugation of the Muslims vis-à-vis the leadership in their private and public lives. What is so laughably regrettable, however, Is that this terrorism reached a point where even the intellectual and political leadership themselves were negatively affected. The final result was that the infirmity of the Ummah caused the collapse of the leadership's power base and left it unable to defend itself in the face of the onslaught of foreign colonial powers.

Owing to the fogginess of the Muslim vision and the way that it has been hampered, we find that Muslims either accept their past with all its deviations and peculiarities of thought, society, and organization, or they reject it, along with all its inherent values, entirely. Over the centuries, this vision has grown increasingly weaker as the Ummah's personality has been beset by a series of devastating illnesses that have left it unable to distinguish between truth and dogma, ends and means, religion and folklore, values and commonplace events, and concepts and imitation.

In essence, the Muslim mind was divided between groups that called upon it either to reject or to accept everything, without differentiating between historical fact and fiction or distinguishing between the means and the end. Some groups within the Ummah even claimed that peoples and societies whose material resources have suffered are actually the victims of Immaterial or abstract crises.

In order to progress, we must understand that many past mistakes were made with the best of intentions. It therefore behooves us to study the past in order to extract from it only that which is positive and beneficial.”

In learning about Aristotle and other epistemologists, the medical professional will understand how much he or she is indebted to those great philosophers who devised what is knows as the ‘classificatory approach’ to knowledge. Edward de Bono, one of the few great thinkers of our times says (who is also a qualified physician) explains:

“The benefits of medicine as a practical art have depended almost entirely on the classificatory approach. The scientific basis of medicine has been very slow to catch up with the operative needs of medicine because the human body is so very complex a system. Meanwhile, patients cannot wait. They are treated on the classification basis. Diseases are recognized and labeled on the basis of a sort of classification of manifestations. Experience and observation attached to one classification is fed back as treatment. Now and then further understanding breaks down and resorts the classifications”

In learning philosophy, the medical professional involved in psychiatry can help ‘elevate the threshold’ for the likelihood of mental illness. This is done by teaching new coping strategies and ways of dealing with life, based on the thought and experience of some of the greatest minds to embrace the Western world.

As one professor of psychology remarks:

“Without it (philosophy), human beings are at risk of psychological damage. A psychologically damaged human being unquestionably requires medical treatment that focuses on the illness. This is why many health insurance policies cover psychological services. Philosophy, on the other hand, is a condition that makes psychological health possible, but it is not itself a kind of medical or psychological treatment”

The same writer makes the following analogy:

“Philosophy is analogous to proper shelter and clothing… Proper shelter and clothing is essential to sound physical health. If someone is left exposed, in shorts and a t-shirt, in the snow, it will be extremely difficult to maintain physical health. Exposure to cold puts a human being at risk of hypothermia, infection, and pneumonia. Illness is not guaranteed; natural physical strength, prior exposure to microorganisms, poor diet, lack of exercise, etc, vary from person to person. But exposure to cold makes illness more likely. Once a person has developed illnesses as a result of improper shelter and clothing, it isn't enough to simply supply sweaters and an insulated building. Medical treatment will be required. But treatment alone is not enough, either: even if antibiotics and fluids are provided, clothing and shelter must also be supplied, and the person will be in danger of ill-health returning if clothing and shelter are not constantly available in the future. Thus, it's obvious that clothing and shelter are required for good health, but neither the clothing industry nor the building industry are medical professions, and medical insurance has never covered sweaters and cold-weather insulation. Clothing and medicine are entirely separate specialties”

The renowned American psychologist, Dr. Abraham Maslow, even remarked that, “the great case of much psychological illness is the fear of oneself – of one’s emotions, impulses, memories, capacities, and potentialities”. And what was the first instruction in philosophy? ‘Know thyself!’ (This command was even engraved at the entrance to the Temple of Apollo at Delphi).

It is for this reason that many great physicians and philosophers recommended philosophy, because they realized its therapeutic value. Plato remarked somewhere that, “The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated”. Tertullian, a prolific early Christian writer stated, “Medicine is the sister of philosophy”. Cicero, the greatest of the Roman philosophers famously told his students:

“There is, I assure you, a medical art for the soul. It is philosophy, whose aid need not be sought, as in bodily diseases, from outside our selves. We must endeavor with all our resources and all our strength to become capable of doctoring ourselves”

The renowned Roman physician Galen even wrote a short book he entitled ‘The Best Doctor Is Also a Philosopher’. This book had a tremendous influence on many physicians, especially those of the Islamic civilization. In his book, ‘Physical and Psychological Health in Islam’, Professor Muhammad Abu Radieh of the University of Kuwait argued that, “All Muslim physicians - owing to the historical location of Muslim civilisation - are philosophers in both the Greek and Islamic senses”. In particular, Galen’s famous work had a deep impact on the medical approach and practice of Abu Bakr Al-Razi, the most famous of all the Muslim physicians (“the father of paediatrics, the author of the first medical book printed in Europe, and the world's greatest physician in the middle ages”).
And indeed, there is a current discipline called philosophical counseling, which aims to use philosophy as guidance in order to ameliorate everyday life situations. When Gerd Achenbach opened up the first practice in Cologne in Germany, it was the first clear sign that philosophy may be able to lessen the burden on psychiatrists. Dr. Schlomit Schuster summed up the essence of the approach of the philosophical counselor as follows:

“This new approach to so-called psychological problems (consists) of various forms of open-ended dialogue and reflection on life, (and) may prevent or resolve many of the "illnesses" for which people would seek psychiatric or psychological treatment. If successful, philosophical counseling would mark not only a radical shift in the direction of psychological care, but a radical return to the original, practical purposes of philosophy”.

A knowledge of the works of the great Austrian philosophers of the 20th century, Ludwig Wittgenstein and Karl Popper will help immensely in psychiatric medical work, for they provided some of the most powerful arguments against Freud’s psychodynamic psychotherapy, which dominated the psychiatry scene for many years, and remains with us to this day, despite the fact that it is expensive, lengthy, demanding, unscientific, and most of all, rather ineffective. This is something we will turn to in more detail in the introduction to psychiatry chapter. But in short, it is Popper’s principle of falsification which provided some of the biggest blows to Freud’s ideas.

Furthermore Popper was one of the fathers of ‘evidence-based medicine’, which can legitimately be claimed to be the greatest reason for some of the successes of modern medicine. As Gareth Owen, a London-based doctor said in a not unrecent BMJ publication, “Evidence-based medicine is a philosophical movement par excellence. Would it have been possible without dozens of ponderous doctors reading the works of Karl Popper?” His influence of ‘philosophical surgeons’, like Michael Baum, Emeritus Professor of Surgery at the University College Hospital in London (who recently presented the ‘Karl Popper Memorial Lecture’ in Popper’s last base, the London School of Economics, in November 2007, entitled ‘The Philosophical Surgeon: in Defence of Evidence-Based Medicine’) has been immense, as evidence by the conclusion of that lecture:

“Karl Popper inspired me, taught me to think critically and changed my life from that of a technocrat to that of a scientist. Science fed my curiosity and my original observations provided an open ticket to travel the world. I shall therefore leave the last word to him; “It is not truisms that science unveils. Rather, it is part of the greatness and the beauty of science that we can learn, through our own critical investigations, that the world is utterly different from what we ever imagined”

Karl Popper also spent a lot of his time in debunking all sorts of philosophical authorities and ideas, and in trying to spread a scientific, rational frame of thought. He famously attacked Plato, Hegel and Marx in his work, ‘The Open Society and Its Enemies’, whose ideas, he thought, provided great fuel to some of the most dictatorial movements of our time. This is relevant to clinical practice, as an epidemiology journal put it a year after his death:

“Karl Raimund Popper, who died on September 17, 1994 at age 92, was not an epidemiologist,but he solved the most basic problem in epidemiology: how to anchor our conclusions to our data using rigorous logic. In so doing he has contributed immeasurably to the public health by equipping us with a formidable weapon against the scourge of authoritarianism, which in this century, has been one of the main causes of death and suffering.

Widely accepted by practising scientists as the foremost contemporary philosopher of science, Popper's approach to his work was much like that of the epidemiologists I admire : slow, with painstaking logic, in pursuit of the public good, with deference to evidence and skepticism of popular opinions. In my view, the 'chronic disease' he studies and attempted to cure is authoritarianism, a contributing cause of which is dogmatism.

A recent manifestation of dogmatism is the infectious and pathogenic idea that science is the New Authority. In his youth, Popper saw Marxists and Freudians attract large following by pronouncing themselves scientific authorities. He was disturbed by how flexible were their theories, adaptable even to contradictory evidence. This diffuseness was in stark contrast to Einstein's General Theory of Relativity, with its precise and boldly deviant prediction that light would bend in a gravitational field. The distinction between pseudoscience and science, he discovered, lies in the testability (which for him meant falsifiability or refutability) of their statements. Hypothetical statements are more testable if they are more precise, more universal and more deviant from expectations derived from alternative theories. Authoritarians prefer less precise, less generalised and less deviant statements, because they do not like their authority to be challenged"

In this, Popper the philosopher helps everyone – in debunking the myths of alternative medicine, which have cost nations much in terms of money and health of their people, something which I will turn to in the next chapter.

Knowledge of what great philosophers like Plato, Rene Descartes and Bertrand Russell said about the value of medicine can serves as a great antidote to all those uncertainties that many of us working in the medical profession have, after having a bad day at work, whether triggered by inappropriately demanding patients or staff.

While we are taught that it was Hippocrates who first appealed to reason, rather than supernatural forces, as the cause of illness, it was Plato who first popularized this notion, in his ‘Timaeus’. As the late Roy Porter said in his classic text on the history of medicine, ‘The Greatest Benefit To Mankind’

“Thanks to Plato, Western thinking could consider medicine as having its share in understanding human nature. He emphasized the common ground between what would later become the separate disciplines of philosophy, medicine and ethics”.

In his ‘Discourse on Method’, Rene Descartes, the eminent French philosopher stated his belief that medicine is the most important tool for improving the intelligence of mankind:

“The mind so strongly depends on temperament and the disposition of bodily organs, that if it is possible to find some means which will make men generally more wise and more clever than they have been till now, I believe that it is in medicine one should seek it.”

This praise of the practice of medicine by the eminent thinker and founder of the modern scientific movement must have surely increased its respectability among the intellectual elite.

Another great French philosopher who highlighted the greatness of the medical profession was Voltaire, who remarked:

"Men who are occupied in the restoration of health to other men, by the joint exertion of skill and humanity, are above all the great of the earth. They even partake of divinity, since to preserve and renew is almost as noble as to create"

Voltaire’s insights however go beyond this. This is the same man who famously said, “The art of medicine consists in amusing the patient while nature cures the disease”. As I have mentioned before in the course of this book, medical men do not cure. They simply palliate or attempt to control the features of the disease. Diseases like diabetes, heart failure, rheumatoid arthritis – virtually every single medical disorder we know is irreversible and incurable.

He also was one of the first to highlight the importance of trying to know the social and psychological aspects of patients’ lives in helping them; he remarked:

“Doctors are men who pour drugs of which they know little, to cure diseases of which they know less, into human beings of whom they know nothing”

He made that remark in the eighteenth century, and thus helped begin a proper scientific understanding of medicine, which only really a century later. By making this remark however, he was trying to teach doctors not to be over keen on prescribing drugs, and to try to get them to focus on understanding the human being in a holistic fashion. His remarks were paraphrased by the great William Osler two centuries later, who said in his ‘Aphorisms’, “One of the first duties of the physician is to educate the masses not to take medicine”, and, “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has”. We will come back to Voltaire in a minute.

Such praise and speculation continues to this day; Sir Bertrand Russell (1872-1970), arguably the last of the great philosophers, argued the case for medicine in an essay written in 1932, entitled, ‘Why Are We Discontented?’ In it Russell stated his belief that the state of modern day anguish and despondency is more related to physiological causes than it is to “decay of faith and difficulty of finding some continuous purpose in life”:

“I believe the lack of zest and of fruitful purpose itself has physiological causes. A man in a really good physical condition finds something to believe in, whereas a man whose digestion or glands are out of order is prey to all the gloomy forms of doubt and despair”

And he concluded:

“If I am right, the cure for modern despair is a matter for the physician, not for the philosopher”

He had argued a belief in the superiority of physicians in his famous essay, ‘What I Believe’, published in 1925:

“An able physician is more useful to a patient than the most devoted friend, and progress in medical knowledge does more for the health of the community than ill-informed philanthropy”.

And so did the philosopher Alfred North Whitehead praise medicine and doctors a few years after Russell published his thoughts; in 1941 he, the man who collaborated with him in many of his projects, most famously ‘Principia Mathematica’, stated:

“One of the most advanced types of human being on earth today is the good American doctor…He is skeptical toward the data of his own profession, welcomes discoveries which upset his previous hypothesis, and is still animated by humane sympathy and understanding”.

Thus, those great philosophers must be given a lot of credit by medical professionals for the very survival of medicine as a scientific discipline, and for its permanent role as a valuable contributor to the understanding of human life. Their words give us hope.

In learning about the works of the man, who in my view, is the most powerful of all philosophers, David Hume, the medical professional would develop a skeptical tendency which would be extremely invaluable in facing the false pretences of patients, pharmaceutical company representatives and others who wish to abuse the medical profession. Reading Hume sharpens one’s thinking more than reading any other philosopher, and that can only be of benefit to the one person who matters most to the practicing medical professional – the patient. Hume would make any consultant shake certain about his diagnosis and his or her clinical acumen, shake and shudder, and the necessity of making every statement made about a diagnosis, a mere probability. This he did by putting to doubt the very validity of inductive reasoning, the basis of all scientific (and therefore medical) thought:

“Hume concludes that no event in the world can be shown to be necessarily connected to any other event – a conclusion quite the opposite of our assumptions about daily experience, and one with implications for everything from research on the causes of cancer to the equations of physics to religious doctrines”

In a way, we ought to be thankful that oncologists and other physicians have not paid attention to Hume, for to this day philosophers have found his arguments irrefutable. As Russell says in his discussion of this great philosopher in his classic ‘History of Western Philosophy’, “I cannot but hope that something less sceptical than Hume’s system may be discoverable”. But to those who have encountered his genius, uncertainty is a very certain matter.

I have already mentioned the contributions of philosophers to the ethical theories which are used in clinical practice. It is very interesting to know that some of the fundamental posits of medical practice, such as informed consent were originated by philosophers, like Moses Maimonides. In the Ancient Egyptian, Greek and Roman civilizations, there was no such thing as informed consent; and this opinion generally continued until the Nuremberg Code was established in 1947. However, hundreds of years before, this is what Maimonides wrote:

“Medicine recommends what is beneficial and warns against what is harmful, and does not compel this . . . but leaves the matter to the sick in the form of consultation; it is they who have the choice”

Furthermore, Maimonides is believed to have been one of the first to advise the holistic approach to medicine, and was identified by George Engels as his biggest influence when he constructed his now well-established biopsychosocial model of illness. His ‘Regimen Sanitatis’, published in 1200 (750 years before Engels), embodies the essence of that model.

Finally, medical professionals can learn a lot from the ‘laughing philosophers’. Many now realize that laughter is indeed a great medicine, and indeed this is stated by some very recent medical research. For instance, Michael Miller, a director of the Center for Preventive Cardiology at the University of Maryland Medical Center and associate professor of medicine at the University Of Maryland School Of Medicine remarked in a recent article:

"The old saying that 'laughter is the best medicine,' definitely appears to be true when it comes to protecting your heart...We don't know yet why laughing protects the heart, but we know that mental stress is associated with impairment of the endothelium, the protective barrier lining our blood vessels. This can cause a series of inflammatory reactions that lead to fat and cholesterol build-up in the coronary arteries and ultimately to a heart attack."

Two philosophers have been given that title. Democritus was “known in antiquity as the ‘laughing philosopher’ because of his emphasis on the value of ‘cheerfulness,’”. Voltaire, the man in whose hands, Anatole France said, “the pen runs and laughs” is more entitled to the title however. As James Sebastian put it:

“Probably no other man in history understood better “the health restoring role of laughter in our lives.... it has been suggested that his laughter might be after all his greatest contribution to his and every age”.

So much for the philosophers’ contributions to medicine; but what of the possible medical professionals’ contributions to philosophy? Do they exist?

Indeed they do, and some of the best philosophers were originally trained partly or completely in medicine, and this provided them with a very fertile ground for their philosophical ideas.

Many believe that the idea of Aristotle (arguably the most famous of all philosophers), about the ‘unity of being’ was brought about mainly by his study of medicine:

“The fields of biology and medicine left such an indelible mark on Aristotle’s thought that he borrowed from the field of medicine the analogy needed to show how, despite the multiplicity of irreducible genera, there is a sort of unity of being”

John Locke is regarded by some as “the most worthy and undistinguished of the indisputably great philosophers. His influence has been enormous”. He was also a renowned physician, who trained in Oxford, and his medical skill and knowledge was acknowledged by Lord Shaftesbury, who appointed him as his physician from 1667 until his death in 1683.

The basic tenets of John Locke’s thought can be summarized in three words - opposition to authority. Locke always encouraged the use of reason to find the truth rather than simply accept the opinion of others or be subject to superstition. In medicine, Locke denounced the scholasticism and overt respect for past medical traditions. He and his friend Thomas Sydenham (1624-1689) (famed for the eponym ‘Sydenhams’ Chorea’) were the earliest physicians to advocate the experimental method in medicine, and collaborated in writing an influential treatise on infectious diseases, ‘Observationes Medicae’, published in 1676.

It is now clear to many scholars that a lot of John Locke’s thought was coloured by his medical outlook, to a much greater extent than has been suspected previously. In his short book, ‘John Locke and Medicine’, the late Patrick Romanell stated that, “Locke's medical thought and his background as a physician that provided the paradigm for his famed "historical, plain method" of inquiry that he applied to his philosophical analysis of human understanding.”

In his classic work, ‘An Essay Concerning Human Understanding’, Locke argued influentially that all human knowledge originates in ‘sense impressions’. He stated that direct experience is a much more reliable source of knowledge than logic and reason. This is in contrast to Descartes, who thought the exact opposite – that reason is the most important source of knowledge for man. In an article on the epistemology of John Locke, Dr. David Kerns argued that their perspectives are a logical consequence of their daily life professions – Descartes the mathematician, Locke the physician:

“Locke is, after all, a physician. Physicians rely on evidence they get from their patients, they form hypotheses as to what might be the underlying problem with their patient, and they attempt treatments. If the treatments don't work they form another hypothesis and attempt another treatment, and so on. Absolute certitude may be something mathematicians can hope for, but the physician must rely on experience and testing. Locke believes that is also how we derive our knowledge about the world”

Thus, in the life of John Locke we have a fine example of the philosopher-physician, who was perfectly at home in both fields.

In the 18th century, the age of Enlightenment, Paris became the centre of the medical revolution and a distinctive type of medicine developed, “characterized by scientific observation, and raised on pathological anatomy, the paradigm of the lesion, quantification and not least, sublime faith in its own superiority”. The finest physician in Paris for the greater part of the Enlightenment was the philosopher-physician Pierre Cabanis, who believed morality and ethics is not simply a matter of education, but that it might be affected by deficits in the nervous system. Cabanis was a very staunch materialist, and this and his study of medicine provided him with the central pillar of his thought, that the “physical determines the moral”. He believed that “medical knowledge regarding the functioning of the human body is indispensable for the understanding of the formation of ideas”.

The 19th century saw the birth of one of the greatest thinkers of American civilisation, William James (1842-1910). He is generally considered to be not only the most influential of all American philosophers, but also one of the greatest thinkers of all time. Some have regarded him as “the very representation of American thought”. The Indian scholar TK Mahadevan even remarked, “American civilisation is what it is because of William James.”

In any case this great philosopher was also a physician, having received his MD from Harvard University in 1869. The main impetuses for his study of medicine were his chronic psychosomatic complaints. To quote one of his biographers:

“James shared fully his family’s neurasthenia. He was plagued with chronic backache (he dubbed it ‘this dorsal insanity’), and suffered from digestive disorders, depressions, and acute attacks of diffuse anxiety. His eye trouble was his only truly somatic complaint”

At the same time, his medical problems are believed to have given James a “personal intimacy and intensity to the deepest problems that philosophy and religion can present to a man’s understanding”. In the life of William James we have a fine example of how medicine can help the philosopher, and how philosophy can aid the medical professional.

James was one of the cofounders of the pragmatic school of thought. The central pillar of pragmatism is that philosophy should be put to work solving the more pressing human problems instead of preoccupying itself in metaphysical speculations, as many prominent figures in philosophy had done. This, is a direct offshoot of his medical studies, there can be no doubt about it. I cannot agree more with Russell who said, “There were two sides to William James's philosophical interests, one scientific, the other religious. On the scientific side, the study of medicine had given his thoughts a tendency towards materialism, which, however, was held in check by his religious emotions”. William James is also considered as the father of modern psychology, and that too, “He was led (to) by the study of medicine”. The connections between philosophy, psychology and all medical fields (and not just psychiatry) are clear for all.

The 20th century saw the rise of many outstanding thinkers, but very few have reached the fame, wealth and fortune of Edward De Bono, the Maltese physician and philosopher (1933- ). De Bono was a genius, who entered medical school at the age of 15, and graduated as a high-flying doctor at the age of 20. He worked in several hospitals in England and elsewhere throughout his career, and eventually was given the chair of Professor of Investigative Medicine at Cambridge University.

This remarkable man attributes to his study of medicine much of his later work on philosophy and thought, which has earned him his many fortunes. It is probably no surprise that when he was asked in a BBC survey who he thought were the greatest thinkers of the last 1000 years, he put William James as his number one choice.

In an interview published in ‘the Independent’, De Bono admitted that his medical background inspired and enabled him to teach and design his now world famous thinking methods:

“Three things came together to kick off my work in the area of thinking: in medicine I was dealing with self-organizing systems such as the glands, kidneys, respiration, and circulation, and I started to ask myself what would happen if the same principles were applied to the brain. From psychology came an interest in thinking, and from computers an interest in the types of perceptual and creative thinking that computers couldn't do. The fusion of these elements led to my key book 'The Mechanism of Mind' in 1969”.

In another interview, De Bono specifically pointed out that the study of neurology as the key influence on his future work on thinking:

“My background is in medicine and in medicine I had to develop concepts of self-organising systems and by examining the behaviours of such systems as applied to neural networks designed some of the methods for thinking.”

Raymond Tallis is the latest in this long line of philosophers trained as physicians, but what is different about him is that, in contrast to Locke and De Bono, who are much more ‘thinkers’ rather than physicians, and James who never practiced what he qualified with, Raymond Tallis was equally adept, devoting equal amounts of time to both until his retirement in 2006, when he was Emeritus Professor of Geriatric Medicine at the University of Manchester. By that time, he showed he was equally adept at writing or editting books like ‘Advanced Geriatric Medicine’, ‘Brocklehurst's Textbook of Geriatrics and Gerontology’ and ‘The clinical neurology of old age’ as he was at writing books on Freud (‘Burying Freud’), existentialism (‘A conversation with Martin Heidegger’), and postmodernism, of which he is a foremost contemporary critic, highlighted in his works, ‘Not Saussure’ and ‘Theorrhoea and After’. Since his retirement he has been dedicated mostly to his philosophical pursuits, particularly in developing a solid philosophical basis for the medical profession, as outlined in his wonderful book (which I have quoted extensively before, ‘Hippocratic Oaths’) and attack on the assumptions of much artificial intelligence research (in his book, ‘Why the Mind is Not a Computer: A Pocket Dictionary on Neuromythology’). As explained by one encyclopedia article on him:

“The focus of his philosophical writings has been an attempt to supply an anthropology that acknowledges what is distinctive - and remarkable - about human beings. To this end his most recent work has been a trilogy of books entitled ‘The Hand; I Am: A Philosophical Inquiry into First-Person Being’; and ‘The Knowing Animal”.

Another example of a contemporary philosophical-physician is the aforementioned Michael Baum, who remarked:

“In defence of the thinking surgeon, I wish to propose that a modern surgeon practicing evidence-based, humane and ethical medicine must have a sound grounding in some of the fundamental principles of philosophy. I shall illustrate these principles, drawing on 40 years experience as a surgeon within the NHS and in particular my specialist practice in the diagnosis and management of breast cancer.”

Thus, I conclude, the relationship between philosophy and medicine is great, and professionals in both fields can benefit immensely from one another. To those like Dr. Philip A Sugarman, medical director at St Andrew's Hospital in Northampton who believe that ““Philosophy can be detrimental to doctors” (and contends that “human physical and social biology are far more relevant areas of study for doctors than philosophy”), I leave them with three inspiring messages.

The first is from Karl Popper, who upon being asked why he decided to refer one of his best friends to Michael Baum for breast surgery, said:

“If I wanted a surgeon to cut me open my first wish would be that he was a master of his craft, the fact that he might have an interest in philosophy would be well down on the list of personal traits I would be looking for.”

The second is from another surgeon, the contemporary Swiss paediatric surgeon Andreas M Worel, writing in the BMJ a few years ago:

“Philosophy, as the art of questioning and source of scientific evolution as well as of individual ethical responsibility, and doing the good, are both essential in medicine: science and the art of healing are the two sides of the coin. Conclusion: Banning Philosophy will result not only detrimental for doctors, but far more for patients. Philosophy, Art and individual ethical responsibility are the best active immunization against inhuman medicine.”

The final one is from an article published 42 years ago in ‘Time’, ‘What (If Anything) to Expect from Today's Philosophers’:

“There is an old saying that philosophy bakes no bread. It is perhaps equally true that no bread would ever have been baked without philosophy. For the act of baking implies a decision on the philosophical issue of whether life is worthwhile at all. Bakers may not have often asked themselves the question in so many words. But philosophy traditionally has been nothing less than the attempt to ask and answer, in a formal and disciplined way, the great questions of life that ordinary men might put to themselves in reflective moments.”

Similarly, the act of healing, of giving medicine, of surgically operating, would never have been done were it not for philosophy, for the act of ‘physik’ implies “a decision on the philosophical issue of whether life is worthwhile at all”. There can be no more fundamental question to ask in medicine. There is no doubt about that.
[1] Or as put by Peter Suber, an American philosopher, “For philosophy to leave its questions unaddressed would be a tragic abandonment of reflection and meaning. Yet it is precisely the inescapability of philosophical questions, the fact that they are not merely academic, but arise in life, which makes me doubt that we will ever suffer such a loss. A wave of barbarism and a spate of bad philosophy, yes; but never the utter end of philosophy until human beings have lost their ingenuity, curiosity, troubles, contradictions, and hopes”.
[2] Bracken & Thomas, ‘Time to move beyond the mind-body split’, (BMJ 2002;325:1433-1434)

AN INTRODUCTION TO WONDER

2008-09-16T21:04:00.000-07:00

INTRODUCTION

“Medicine, then is more than a profession.
Medicine is a worthy calling, a true avocation.
Medicine is a most magnificent obsession.
Medicine requires all the abilities in one's possession
Its influence on life and death's progression
Makes medicine more than a profession”

- Billy F. Andrews

“Medicine has been called both a master and a mistress - a master when it is allowed to possess, oppress, and enslave; a mistress when it preserves the passion by remaining engrossing, intriguing and exhilarating. It is as a mistress that medicine will delight and fulfill the physician”

- Phil R Manning & L. De Bakey

YOU ARE NOT ALONE

“Je le pansai, et Dieu le guarist” (I treat the wounds, but God heals them)

- Ambroise Pare, 16th century French surgeon

It has been nearly five centuries since Ambroise Pare, the great French military surgeon made his most famous remark. Since then, mankind has gone through a series of trials and tribulations, and its most prominent and intelligent figures went from a fervent spirituality and religiosity, best exemplified perhaps by the great Sir Isaac Newton[1] to the criticism of religion but the defence of the idea of God, perhaps best exemplified by Voltaire and several other children of the Enlightenment, to the militant attack on religion and the idea of God, led primarily by three Germans – Ludwig Feuerbach, Karl Marx and Friedrich Nietzsche, to the establishment of the spread of atheism and its corollary, secularism[2] among the intelligent men and women of today, a move triggered, to a great extent, by the ideas of a certain Charles Darwin, without whom it would be impossible to be “an intellectually fulfilled atheist”. Atheism and the neglect of God is the current status quo, and, regrettably, looks set to remain so in the face of so much irrationality and incoherence in the minds of those who believe in God.

Almost all the most popular and intelligent writers of the twentieth century and our time, were, or are, atheist or agnostic. This gives people who believe in God the impression that they may be mistaken in their beliefs, or are upholding an unintelligent, primitive idea, which is never easy for one who does not want to be troubled by the gnawing attacks of the intellect that seeks nothing but the objective truth.

Take for instance Bertrand Russell, a man who, along the course of a very long career, took every opportunity to criticize religion and God, expressing a belief that, “there is no reason to believe any of the dogmas of traditional theology and, further, that there is no reason to wish that they were true”, that, “Religion is something left over from the infancy of our intelligence, it will fade away as we adopt reason and science as our guidelines”, that “it as a disease born of fear and as a source of untold misery to the human race”.

Or the more contemporary Gore Vidal, who regards himself as a “born-again atheist”, who believes that “monotheism as the greatest disaster ever to befall the human race. I see no good in Judaism, Christianity, or Islam, good people, yes, but any religion based on a single, well, frenzied and virulent god, is not as useful to the human race as, say, Confucianism, which is not a religion but an ethical and educational system”.

And most recently, people the likes of Noam Chomsky, who regards the idea of God as “unimportant”, Christopher Hitchens, who recently published the best selling book, ‘God is Not Great’, and the ever-militant Richard Dawkins[3], who does not spare a page in any of his works without an attack on religion or God, most recently his best seller, ‘The God Delusion’.

Along the way we have people the likes of Karl Popper, Richard Feynmann, Linus Pauling, Francis Crick, George Gamow, Steven Weinberg, Isaac Asimov, Carl Sagan, Roger Penrose, Stephen Hawking, John Gribbin, Gore Vidal, Edward Said, Noam Chomsky, and many others whose ideas are less clear, although my impression is that they too were atheist – men the likes of Albert Einstein, Paul Dirac and Erwin Schrodinger.

Can the idea of God be therefore upheld, in the face of this devastating onslaught by those icons of the age? An age when, as with previous times, the innocent idea of God is used and abused by men of all doctrines and creeds – from the totalitarian oppression of the Saudi ‘Islamic’ regime, and the Taliban, who were responsible for the tragic events of the 11th of September 2001. To the blood thirsty, born again-Christian evangelists Neo-Conservatives presiding America, who have killed thousands more, extending the crimes of the Church in previous times to our own century, to the Zionists who make a mockery out of Palestinian blood, in the name of a tribal God and His ‘Chosen people’.

The answer is yes. There can be no poll on justice and truth. The fact that so many intelligent men and women do not believe in God is not evidence that He does not exist. The Qu’ran tells us, “And though thou try much, most men will not believe” (12:103). Similarly, the fact that so many God-professing bigots have abused the idea is not evidence that it is incorrect. God, as the Qur’an quite simply and repetitively tells us, enjoins what is good, and forbids what is bad. There is not a single current political party out there that is not using this most noble of ideas to have entertained the human mind since its inception, to achieve its end target of power and control. All are guilty of treason and abuse of this most beautiful idea, from which sprung all the good that humanity stands for.

The fact of the matter is that there will always be great men and women who believe in God at every time. The important thing for these people is to remember that they are not alone, that their belief in God is not primitive, but has equally been upheld by great men and women who too were aware of atheism (atheism is an extremely ancient idea – upheld by pre-Socratic philosophers like Protagoras and Democritus). Rene Descartes, Isaac Newton and James Clerk Maxwell continuously sung the praises of God, and they were the two most intelligent men of the 17th, 18th and 19th centuries respectively. Even today, mathematicians, who deal with the most complex ideas known to man, and are arguably the most intelligent of all professionals, are the most fervent believers in God our of all professionals, as illustrated by a ‘Nature’ article published a few years ago. Listen to the greatest of them all, the man called ‘Analysis Reincarnate’ by Eric Temple Bell, the incredible Swiss mathematician of the 19th century, Leonard Euler who sang the praises of God throughout his long productive life, saying:

“Every creative act involves a new innocence of perception liberated from the cataract of accepted belief. For since the fabric of the universe is most perfect and the work of a most wise Creator, nothing at all takes place in the universe in which some rule of maximum or minimum does not appear”.

"Though we are very far short of a perfect knowledge of the subject, the little we do know of it is more than sufficient to convince us of the power and wisdom of the Creator. … We discover in the structure of the eye perfections which the most exalted genius could never have imagined....The eye alone being a masterpiece that far transcends the human understanding, what an exalted idea must we form of Him who has bestowed this wonderful gift, and that in the highest perfection, not on man only, but on the brute creation, nay, on the vilest of insects!

"The works of the Creator infinitely surpass the productions of human skill”
If you believe in God – you are not alone. Your belief was, and is still shared by men and women who are of equal, if not greater intelligence than of the atheists and agnostics of our time. In our time, I can think of only a few – Miguel de Unamuno, Martin Gardner, Paul Davies, John Eccles, John Polkingthorne, Mustafa Mahmood, Muhammad Al-Ghazzali, men who went through phases of skepticism, but ended with a faith that, like Pare above, sought, the signs of God everywhere, and sang His praises continuously, not unlike the manner of the believers who God described in the following verses:

“Surely in the creation of the heavens and the earth, and the alternation of night and day, are signs for people of understanding— those who remember God while standing, sitting, and on their sides, contemplating the creation of the heavens and the earth: “Our Lord! You did not create this in vain! Glory to You! Keep us, then, from the torment of the fire! “Our Lord, whomever You cause to enter the fire You have disgraced; and there are no saviors for the unjust. “Our Lord, we have indeed heard someone calling, inviting us to faith— ‘Believe in your Lord’—and we believed. So forgive us our sins, our Lord, and efface our evils; and take our souls with the just. “And grant us what You promised us, our Lord, according to Your messengers; and do not disgrace us on the day of resurrection. For You surely do not break a promise.” And their Lord answered them, “I am never unmindful of the work of a worker among you, male or female. You are from each other. So for those who emigrated or were driven from their homes or suffered harm for My sake, or fought or were killed, I will efface their evils and admit them to gardens below which rivers flow, as a reward from the presence of God. And the finest reward is in the presence of God.” (2:190-200)

When it comes to medicine, my own specialty, it is extremely unlikely to find anything like the above statement by Ambroise Pare, in present day medical journals or textbooks, or uttered by currently practicing physicians or surgeons. The idea of God and religion has become a joking matter, and the majority of people of our time take religion in vain – and none more so than the secularists, who dare not remember God in their daily living, but only if they feel the need to. Atheists, like Dawkins and Hitchens continuously mock, ridicule and insult religion and God, a practice akin to that of many of our ancestors described in the Quran:

“If thou dost question them, they declare (with emphasis): "We were only talking idly and in play." Say: "Was it at Allah, and His Signs, and His Messenger, that ye were mocking?" (9:65)

“And never came there unto them a messenger but they did mock him (15:11)

“And never came there unto them a messenger but they did mock him (40:83)

I cannot help but agree with those people that the majority of religious men and women of our times are the laughing stock of mankind. They have a reverence for tradition, as if it were divine writ. A desire for power and control that the old medicine man wished for, and a general abhorrence for intelligence and reason, and a love of the exterior over the essence of religion. Watching a religious programme on television these days is like watching a comedy of errors, foolishness and unreason, and is often an insult to the intelligence. “Is it halal (religiously permitted) to enter the toilet with my right foot”, “can I call my son ‘Abdi’”, “can I eat with my left hand”. The questions that engage the religious mind these days (and I confine myself to the ‘Islamic world’ here) are so bizarre, that I cannot be sympathize with the atheists general negative conception of religion, which is not helped by the crimes of the followers of the Taliban and other religious parties.

Nevertheless, I believe that those men are intelligent enough to realize that it is not God who is to blame for those excesses of mankind. I believe that one who listens to his or her heart and mind will eventually come to the natural, instinctive conclusion that God is.

Which brings me to the first reason for writing this book, and that is, to bring back God back to his rightful place in the medical world, the way people like Pare would have Him.
Over the last century, medicine, particularly in the Western world, has been taught and practiced without any regard to God, or any sense of the divine. God has been displaced, and His glorious name seems to be confined, if that, to ethical discussions and ‘moral’ affairs. God, to who belongs the dominion of the Heavens and the Earth, to whom we are indebted for everything, is discarded, ridiculed, insulted and forgotten, and the consequences of that are only too painful for me to remind the kind reader thereof, but I will attempt to do so. The question of God is, contrary to what Chomsky would have us believe, is not a frivolous question. It is of ultimate importance, for the world without God, a world that neglects Him is bound for failure, as the next section shows.

THE CONSEQUENCES OF THE NEGLECT OF GOD

THE WORLD NEGLECTS GOD

The most prominent characteristic of this time is that, as the historian Martin Gilbert put it, it is an extension of the century of war. There is no peace in this world. This is natural, when the ‘Peace’[4] is going to be neglected. As a result, it is an absolute mess. It is a state of chaos, of lack of security, which can only be redeemed by the remembrance of God, and not a tablet of diazepam or citalopram. As He informs us, “Those who believe, and whose hearts find satisfaction in the remembrance of God: for without doubt only in the remembrance of God do hearts find satisfaction” (13:28). Nearly 150 years on from the day when Charles Dickens wrote the famous introductory lines of his great novel, ‘A Tale of Two Cities’ , the words are more applicable then ever before:

“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way--in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only.”

It is the best of times in terms of technological and scientific advance, but the worst of times in terms of the degeneration of modern man and all his moral and artistic pursuits.

Albert Einstein put it very well:

“By painful experience we have learnt that rational thinking does not suffice to solve the problems of our social life. Penetrating research and keen scientific work have often had tragic implications for mankind, producing, on the one hand, inventions which liberated man from exhausting physical labor, making his life easier and richer; but on the other hand, introducing a grave restlessness into his life, making him a slave to his technological environment, and—most catastrophic of all—creating the means for his own mass destruction. This, indeed, is a tragedy of overwhelming poignancy”.

The Egyptian Islamic thinker Sayyid Qutb summarized our current state very well too in the introduction to his book, ‘Milestones’. He said:

“Mankind today is on the brink of a precipice, not because of the danger of complete annihilation which is hanging over its head-this being just a symptom and not the real disease -but because humanity is devoid of those vital values which are necessary not only for its healthy development but also for its real progress. Even the Western world realises that Western civilization is unable to present any healthy values for the guidance of mankind. It knows that it does not possess anything which will satisfy its own conscience and justify its existence.

Democracy in the West has become infertile to such an extent that it is borrowing from the systems of the Eastern bloc, especially in the economic system, under the name of socialism. It is the same with the Eastern bloc. Its social theories, foremost among which is Marxism, in the beginning attracted not only a large number of people from the East but also from the West, as it was a way of life based on a creed. But now Marxism is defeated on the plane of thought, and if it is stated that not a single nation in the world is truly Marxist, it will not be an exaggeration. On the whole this theory conflicts with man's nature and its needs. This ideology prospers only in a degenerate society or in a society which has become cowed as a result of some form of prolonged dictatorship. But now, even under these circumstances, its materialistic economic system is failing, although this was the only foundation on which its structure was based. Russia, which is the leader of the communist countries, is itself suffering from shortages of food. Although during the times of the Tsars Russia used to produce surplus food, it now has to import food from abroad and has to sell its reserves of gold for this purpose. The main reason for this is the failure of the system of collective farming, or, one can say, the failure of a system which is against human nature… The leadership of mankind by Western world is now on the decline, not because Western culture has become poor materially or because its economic and military power has become weak. The period of the Western system has come to an end primarily because it is deprived of those life-giving values which enabled it to be the leader of mankind.”

As a result of this neglect of God, we live in the worst of times. This is precisely the Qur’anic viewpoint. God says, “Do not be like those who forgot God so He made them forget themselves. Such people are the deviators” (59: 19). It is natural law that God has declared – those who forget Him, will never remember anything of any benefit to themselves or humanity. They will become followers of desire. God talks about this repetitively:

“Now there hath succeeded them a later generation whom have ruined worship and have followed lusts. But they will meet deception. Save him who shall repent and believe and do right. Such will enter the Garden, and they will not be wronged in aught (19:59)

And Allah would turn to you in mercy; but those who follow vain desires would have you go tremendously astray (4:27)

Restrain yourself patiently with those who call on their Lord morning and evening, desiring His face. Do not turn your eyes from them, desiring the attractions of this world. And do not obey someone whose heart We have made neglectful of Our remembrance and who follows his own whims and desires and whose life has transgressed all bounds. (18:28)

Do not let those who have no faith in it and follow their whims and desires debar you from it or you will be destroyed. (20:16)

Have you seen him who has taken his whims and desires to be his god? Will you then be his guardian? (25:43)

If they do not respond to you then know that they are merely following their whims and desires. And who could be further astray than someone who follows his whims and desires without any guidance from Allah? Allah does not guide the people of the wrongdoers. (28:50)

However, those who do wrong pursue their whims and desires without any knowledge. Who can guide those whom Allah has led astray? They will have no helpers. (30:29)

Have you seen him who takes his whims and desires to be his god–whom Allah has misguided knowingly, sealing up his hearing and his heart and placing a blindfold over his eyes? Who then will guide him after Allah? So will you not pay heed? (45:23)”

The Quranic law is – forget God, you will forget yourself, and you will end up following your desires. It’s a simple law. Without God, life becomes an undisciplined affair.

The majority of human beings do not carry the correct idea of God. Statistics may tell us that the majority of human beings believe in a god, but the truth of the matter is that they have a distorted view of Him (e.g. the ethnocentric God of Judaism, the trinity of St. Paul’s Christianity, and the absurd concept of God ‘The Father’, and the polytheism of Hinduism, not to say the polytheism of the former two) or a distorted view of His teachings (manifest most evidently by traditional Islam as it is taught in this day and age by the various religious institutions in Saudi Arabia and Egypt, the two nations with the most prominent Islamic institutions). Once again, the words of God rule supreme, “And though thou try much, most men will not believe” (12:103).

It is only by a return to God that the mess that is this world will be tidied up, and therefore the medical world. As Harun Yahya concludes one of his works, “All the problems of the world today can end provided that the values of the Quran and the Sunnah, in their original form purified from all bigotry and innovation are introduced to mankind”. Note the purification clauses – it is herein that the Muslims, the carriers of God’s blessed message, have failed. They have contaminated interpretations of both with many corrupt ideas. Only by their eradication will we have success.

Let us look at some of the details of the consequences of the neglect of God in various areas of human life.

MEDICINE

Since this book is primarily aimed at medical professionals, who are affected to a great extent by the neglect of God, perhaps more than any other professionals, I start with a discussion relating to medicine.

Probably the main frustrations of medical professionals these days stem mostly from the increasing politicization of the profession, and also, due to the daily encounter of lifestyle related problems.

Medicine has become so intertwined with political motives and party agendas. In the United Kingdom hardly a day passes by without a statement of sorts being made by some politician regarding the NHS. This has been on an exponential rise over the past year (2008), while England celebrates the 60th anniversary of its declining health care system.

As for ‘the daily encounter of lifestyle related problems’, I can say from personal experience that a great deal of frustration hits the doctor when he or she is dealing with the smoker who does not stop smoking, despite advice, and comes to hospital with his umpteenth exacerbation of COPD in two years.

Or the alcoholic who comes to hospital withdrawing, or following a head injury, or following an acute attack of pancreatitis, or hepatitis.

Or the heroin addict coming for an injection of the analogous morphine while acting out that he is in tremendous abdominal pain, or the more honest DVT or leg cellulitis.

What about all those who are not prepared to face their ‘sadness’, those who are prepared to commit suicide because ‘they had an argument with their boyfriend (or girlfriend)’.[5] What about the 16 year old girl, who is coming with an ectopic pregnancy, predisposed to by her smoking and previous STD. I can go on and on. This is the bread and butter of the daily practice of every single medical professional. Because of these lifestyle diseases, patients present to medical professionals, and he or she is expected to take the burden and ‘look after’ these patients (sometimes at the expense of patients who are ill due to diseases that they have not brought upon themselves), until they have been safely discharged, and until they return yet again with the same presentation a few weeks or months later.

I may be accused in saying this of being judgmental. That is a fair criticism, but I ask, how could one not be judgmental in the face of all this. Medical professionals are human beings, not robots, and it is the nature of human beings to judge a certain situation to be bad or good. Provided the treatment you offer does not differ between patient and patient, then every medical professional has that basic natural human right to express a like or dislike towards certain habits. The best medical professional (and human being) is one who can completely dissociate his or her judgments about a certain belief or habit from the human being carrying that belief or habit. This I don’t find very difficult, because I have never had any personal relationships with any of my patients.

Needless to say, it is the job of the medical professional to help those patients acutely. But his or her role does not just stop there. He or she ought to try to prevent future problems from occurring; this is simply because, our elders said, prevention is better than cure. Not that cure is available for all problems; infact we are yet to devise a cure for anything in medicine, except perhaps some infectious diseases.

Alas, prevention advice is rarely successful. Smoking remains widespread, despite all attempts at reducing the incidence of this horrible habit. Only the diagnosis of a terminal or serious illness, like cancer or a heart attack, forces the patient to believe that smoking kills, and to stop smoking afterward. Alcohol abuse and sexually transmitted diseases are on the rise, the latter reaching epidemic proportions, and leading the BBC not unrecently to state that, “There is widespread concern throughout the medical profession that increasing levels of promiscuity coupled with failure to take precautions is leading to an explosion in the numbers of STIs in the UK”.

In addition, there are some disorders for which there is no ‘prevention’ advice. These include depression, anxiety, and a whole host of other psychiatric problems, as well as suicide. These extremely important disorders have become a huge burden. A recent ‘Guardian’ article announced two years ago:

“Depression, anxiety and other forms of mental illness have taken over from unemployment as the greatest social problem in the UK, a health economist warns today…. Around 15% of the population suffers from depression or anxiety, says Lord Layard, emeritus professor at the Centre for Economic Performance of the London School of Economics. The economic cost in terms of lost productivity is huge - around £17bn, or 1.5% of UK gross domestic product. "There are now more than 1 million mentally ill people receiving incapacity benefits - more than the total number of unemployed people receiving unemployment benefits," he writes in the British Medical Journal.”

The connection between the neglect of God and those problems is there for all who attempt to understand why these problems occur. Why do people smoke, why do they drink excessively, why do they act promiscuously and become slaves to their sexual passions as soon as they have been introduced to the subject of sex? Why do they get so depressed, and are prepared to commit suicide, and forsake their entire lives for a relationship difficulty, or other ‘petty’ matter? Why is it that humanity has come to act so mindlessly, with the doctor eventually carrying most of its burden? Why is it that minds and hearts cannot rest, with a great number of people on anxiolytic medication, and sadness so prevalent, with so many on antidepressants?

Sigmund Freud tried to explain all the actions of humanity as being due to the conflict of psychological impulses and sexual desires. Karl Marx tried to reduce them to the struggle of dialectical materialism, saying in the preface of one of his books, “It is not the consciousness of men that determines their existence, but their social existence that determines their consciousness”, that the prime triggers for human behaviour are the struggle for wealth and economic power. Bertrand Russell tried to reduce all of human behaviour as the struggle for power of all types.

None of these, I feel, explains human behaviour in our contemporary world well. When a girl is taking a paracetamol overdose, is she thinking of ‘power’, of ‘money’, of ‘sex’? Of course not. Her behaviour cannot be explained in those terms. And neither can the young chap who is taking a heroine overdose, or getting drunk[6], or smoking away despite his asthma, all different forms of suicide. Albert Camus was not that wrong when he stated “there is but one truly serious philosophical problem and that is suicide”. In many ways, we can rephrase that and say, “there is but one truly medical problem, and that is suicide”. But that would be a great exaggeration, not without an element of truth however.

Their behaviour can only be explained in three words – loss, forgetfulness and neglect. They are at loss regarding their purpose in life – no one with a sense of purpose in life will consider suicide. They are forgetful of their duties to others. They are neglectful of logic, reason and common sense, and when man turns away from those, his only refuge is his animal instincts and desires. There is no third route.

In their neglect, and in becoming the slaves of their passions, the everyday man and woman living here in England (and I am sure it is not very different in other nations) has become no different to the beasts.[7] He or she works, eats, drinks, copulates, defaecates, sleeps but rarely thinks. Bertrand Russell put it brilliantly, saying, “Most people would rather die than think; in fact, they do so”.

But why are people lost, forgetful and neglectful? Why is rational thinking so uncommon? Why has it become an almost cumbersome activity for some? What is it that makes a person like Bertrand Russell state, “It has been said that man is a rational animal. All my life I have been searching for evidence which could support this”?

It is all due to the neglect of God, or a pathetic idea of Him. A society devoted to Him, to His remembrance, and the realization of His wishes, will never fail or stutter. A society that realizes that the purpose of life (which, all three Abrahamic religions teach) is the worship of God[8] will never fall prey to its passions.[9]

Of course, there are many who are fulfilled by medicine – the joy they derive from seeing the recovery of the health of others is the greatest source of happiness of their lives. Such an attitude was epitomized, in our time by the late Michael De Bakey, a man whose story we recount in a later section. The sight of the grateful patient, whose doctor is the lucky recipient of a material gift, or a grateful smile, is one of the most beautiful things any one can encounter.

Such joy is probably experienced to the greatest extent and most frequently by the surgeon, who, using the minimum of tools (they are arguably the most clinical of doctors – we are yet to devise an instrument that can adequately describe a lump or any other mass for that matter) [though by no means always] proceed to heal the surgical defect, with a much quicker recovery rate than most other specialists. Compare this to the physicians, the medical consultants, whose daily practice seems to be confined to the encounter, on their ‘post-take’ ward rounds, of acute exacerbations of ‘chronic diseases’ (such as myocardial infarction (or acute coronary syndrome - an acute exacerbation of a chronic inflammatory (atherosclerotic) process), the acute exacerbation of COPD or asthma, of Crohn’s disease or ulcerative colitis, diabetic ketoacidosis or HONK), and in their clinics with the chronic picture of these diseases. There is no healing here – just control, sometimes coming at the price of iatrogenic damage. And the control often comes after months and months of experimentation, trial and error. Compare this to the immediacy with which good surgeons achieve their desired outcomes (of course, the story is very different with the technically-incompetent surgeon, but those are mostly filtered out by the extremely efficient and progressive surgical tutoring systems in place throughout the world).

But the vast majority of us are not surgeons, and therefore will not be able to achieve that great joy and fulfillment that men like De Bakey experience on a daily basis. And if things continue as they are, the unhappy, joyless doctor will remain the norm, the one who would nod in agreement with anything that Arthur Schopenhauer, the philosopher of pessimism has to say, or even the more balanced Bertrand Russell, who despite his occasional optimism, was led to say, “The secret of happiness is to face the fact that the world is horrible, horrible, horrible....” This tide of unhappiness is beginning to engulf the medical professional, as a BMJ article a few years ago showed:

“Doctors are unhappy. They are not all unhappy all the time, but when doctors gather, their conversation turns to misery and talk of early retirement. The unhappiness has been illustrated in a plethora of surveys and manifests itself in talk of a mass resignation by general practitioners from the NHS. The British government is rattled by the unhappiness of doctors, recognising that a health service staffed by demoralised doctors cannot flourish. It has responded by trying to hand more control of the service to frontline staff.”

A point reiterated by Raymond Tallis:

“There is mounting evidence that doctors are increasingly unhappy with their professional life. The rising levels of job dissatisfaction are striking. Of doctors graduating in 1974, the majority were reasonably content with their lot, though the prospect of the early retirement many were planning may have had something to do with this. In contrast, 25 per cent of the 1995 cohort had only a lukewarm desire to continure in medicine, and only 13 per cent still had a strong desire to be doctors. These alarming figures may be due to the greater expectation of happiness, and specifically of job satisfaction, of the more recent generation; but they will also be due to alterations in the working life.

In the USA, where morale among doctors is also low, the most important factor is loss of professional independence. What made medicine a profession in the modern sense of the term, in the authonomy they enjoyed in their everyday work, meant that they were not organisation men. Ronald Dworkin observes, “They did not have to be backslappers or joke-tellers or handshakers; they did not have to get along with their boss or be shrewdly political…they answered to no one but their patients”. Now, “they must please some faceless bureaucrat without a medical education before ordering a test”. They are forced to become organisation men; and “since they get little more out of their work than a paycheck, the money is much more important to them, and they try increasingly to make more of it”. This is what happens “when the medical profession is shorn of its transcendent qualities – its mistique, its notion of duty, its code of honour – and made into a rational economic enterprise”.”

POLITICS

Politically, we are not only threatened by religious fundamentalism and terrorism done under the name of religion (and I put American foreign policy, which is based on the ideas of Christian Evangelism under this category), but also by irreligion. Hasn’t the Chinese government, since 1949 been “officially atheist, which viewed religion as emblematic of feudalism and foreign colonialism.” If atheism was a blessing, then how why do we have what Jampal Chosang, the head of the Tibetan coalition stated recently, that, “China had introduced "a new form of apartheid" in Tibet because "Tibetan culture, religion, and national identity are considered a threat" to China”. Hasn’t Russia endorsed no official religion (in communist times, it was atheism), and then turned to attach the Chechnyans, in not one, but two wars since the demolition of the USSR. The impact of politics on medicine I have discussed elsewhere.

ECONOMICS

Economically, the following story says it all. Only a few days ago, on the 19th of July 2008, I came across an article in ‘USA Now’ by the economist Thomas Haffner, entitled, ‘A Defeated and Conquered Nation’, which he introduced saying, “Americans have been defeated in an economic war with consequences as meaningful and damaging as if having lost a military war”. A day later, in the British broadsheet paper, the ‘Independent’ we were informed by journalist Margareta Pagano, under the heading, ‘Recession next year: forecaster says things can only get worse’, that, “The UK economy is heading for recession next year and unemployment could top two million by 2010”. A day later, Ambrose Evans-Pritchard tells us in another British broadsheet, ‘The Daily Telegraph’, that, “The global economy is at the point of maximum danger”.

POVERTY, WATER AND FOOD CRISIS

As a result of political greed and economic collapse, poverty and famine is rife, due to our lack of wisdom and foresight, and other factors, such as natural disasters and disease. They have led to the current ‘Water Crisis’, through which it is estimated that, “Not only are there 1.1 billion without adequate drinking water, but the United Nations acknowledges 2.6 billion people are without adequate water for sanitation (e.g. wastewater disposal)”, with its great impact on human welfare, particularly human health. It is felt by experts that:

“Waterborne diseases and the absence of sanitary domestic water are one of the leading causes of death worldwide. For children under age five, waterborne diseases are the leading cause of death. At any given time, half of the world's hospital beds are occupied by patients suffering from waterborne diseases.[6] According to the World Bank, 88 percent of all diseases are caused by unsafe drinking water, inadequate sanitation and poor hygiene.”

They have also led to the current food crisis; the year 2008 has been labeled by economists as ‘The Year of Global Food Crisis’. Kate Smith and Rob Edwards, writing in a recent issue of the ‘Sunday Herald’, a Scottish broadsheet, report:

“It is the new face of hunger. A perfect storm of food scarcity, global warming, rocketing oil prices and the world population explosion is plunging humanity into the biggest crisis of the 21st century by pushing up food prices and spreading hunger and poverty from rural areas into cities. Millions more of the world's most vulnerable people are facing starvation as food shortages loom and crop prices spiral ever upwards. And for the first time in history, say experts, the impact is spreading from the developing to the developed world.”

The economic crisis has led to escalating health care costs – with many people unable to pay for their medication, thus instigating a vicious circle of poverty – as illustrated in the last issue of the Global Competitiveness Report, a yearly report published by the World Economic Forum, “poor access to affordable health care makes individuals less resilient to economic hardship and more vulnerable to poverty.” The following picture is worth a thousand words; it is taken from the ‘Statistics’ section of the WHO website:

The economic crisis will also have negative effects on crime rates; hardly a month passes by these days in England without hearing about two or three victims, usually in their teens, of ‘knife crime’ – so far in 2008 there have been 22 victims, the youngest aged 14, and the oldest aged 42. Writing under the headline, ‘Crime rates expected to soar as economic difficulties deepen, fall in car theft and robberies could be short-lived, officials warn’, Alan Travis, home affairs editor of ‘The Guardian’ said (on Friday July 18th 2008), “The credit crunch threatens to bring to an end the longest recorded period of falling crime in living memory in England and Wales, Home Office criminologists said yesterday…government officials predicted the economic slowdown would lead to "upward pressure" on levels of property crime, such as burglary and car break-ins.” The American economist Steven D. Levitt described living in the United States in the early 1990s, saying:

“Anyone living in the United States in the early 1990s and paying even a whisper of attention to the nightly news or a daily paper could be forgiven for having been scared out of his skin. The culprit was crime. It had been rising relentlessly—a graph plotting the crime rate in any American city over recent decades looked like a ski slope in profile—and it seemed now to herald the end of the world as we knew it. Death by gunfire, intentional and otherwise, had become commonplace. So too had carjacking and crack dealing, robbery and rape. Violent crime was a gruesome, constant companion. And things were about to get even worse. Much worse.”

Crime rates are increasing everywhere, and security is a very difficult to attain these days, or it comes at a very huge price. And insurance companies, as many of my friends will tell you, come to do their job very slowly, very reluctantly and often at very high prices.

The following picture (courtesy of the CIA World Factbook) is worth another thousand words; it shows the percentage of populations who are living below their nations’ poverty line, and is truly shocking:

As explained by Randy Charles Epping, a financial advisor based in Zurich in his book, ‘A Beginner’s Guide to the World Economy’:

“Economic and political misjudgment can be blamed for much of the Third World's poverty, but an important factor has also been the population explosion. Many developing countries have seen their populations double in as little as twenty years. This growth was due mainly to lack of birth control and declining mortality rates, resulting from improved medical care.

Extreme poverty in the Third World has forced many parents to create ever larger families, hoping that their children can work and increase family income. But the economic opportunities are often not available, and unemployed children and their parents end up moving into already overcrowded cities, in a fruitless search for work.Many underdeveloped nations have found themselves in a vicious circle of poverty and overpopulation, with no hope in sight. The flood of poor families into major cities puts enormous strain on the economic infrastructure. Shantytowns in such cities as Bombay, Sio Paulo, and Shanghai have become glaring reminders that the world economy has left behind many of the world's poor.

Saddled with enormous debt payments, hyperinflation, surging populations, and mounting unemployment, many Third World countries struggle just to keep their economies afloat. Sometimes, with no money available for investment, even the infrastructure, such as roads and water systems, literally falls apart.

The solution for many overburdened governments is to simply increase debt in order to keep the money flowing. However, this often results in rampant inflation, which ends up eroding most of these efforts, and creates an ever-widening gap between the Third World's poorest and richest economies.”

MEDIA CORRUPTION

I love the way Epping refers to the crimes of our many politicians as ‘misjudgments’! This brings me nicely to another aspect of our ugly world that fills me with pessimism – the corruption of the media. This is something that has been spoken and written about extensively of late, especially by the great Noam Chomsky. I find the following explanation of Chomsky’s ideas on the Wikipaedia online encyclopedia extremely helpful and do not hesitate to quote it in full:

“Another focus of Chomsky's political work has been an analysis of mainstream mass media (especially in the United States), which he accuses of maintaining constraints on dialogue so as to promote the interests of corporations and the government.

Edward S. Herman and Chomsky's book ‘Manufacturing Consent: The Political Economy of the Mass Media’ explores this topic in depth, presenting their "propaganda model" of the news media with several detailed case studies in support of it. According to this propaganda model, more democratic societies like the U.S. use subtle, non-violent means of control, unlike totalitarian systems, where physical force can readily be used to coerce the general population. In an often-quoted remark, Chomsky states that "propaganda is to a democracy what the bludgeon is to a totalitarian state" (Media Control).

The model attempts to explain such a systemic bias in terms of structural economic causes rather than a conspiracy of people. It argues the bias derives from five "filters" that all published news must pass through which combine to systematically distort news coverage.

The first filter, ownership, notes that most major media outlets are owned by large corporations.

The second, funding, notes that the outlets derive the majority of their funding from advertising, not readers. Thus, since they are profit-oriented businesses selling a product — readers and audiences — to other businesses (advertisers), the model would expect them to publish news which would reflect the desires and values of those businesses.

In addition, the news media are dependent on government institutions and major businesses with strong biases as sources (the third filter) for much of their information.

Flak, the fourth filter, refers to the various pressure groups which go after the media for supposed bias and so on when they go out of line.

Norms, the fifth filter, refer to the common conceptions shared by those in the profession of journalism.

The model therefore attempts to describe how the media form a decentralized and non-conspiratorial but nonetheless very powerful propaganda system that is able to mobilize an "élite" consensus, frame public debate within "élite" perspectives and at the same time give the appearance of democratic consent.”

The corruption of the media has not just affected our journalism. Leaving the Western media world aside, I don’t know when the last time I watched a decent Arabic movie was. Are not the songs of today a far cry from the enchantments of Farid and Fairuz, Om Kalthoom, Abdel Halim, Abdel Wahab and others? Even the serials – they have lost their innocence and simplicity; compared to previous times, when serials, the comedies and soap operas used to host at most twenty actors, now they have become an example of extravagance and excess – the costs of some reaching millions of dollars, with the wages of some Arab actors and actresses reaching millions. Of course, this corruption, and treatment of everything as an industry, which has taken the joy out of everything in life, has affected all that media covers, from football to horse racing. I recall reading an interview with Zionist media mogul Rupert Murdoch, who owns ‘Sky’ and other major media, published in ‘The Guardian’ a year ago, entitled, ‘Murdoch: How I changed football’. He indeed has, and has made it ugly. Is it just, or humane that footballers (and these men are not prophets or people who render any great service to humanity) get paid so much, for the very noble and civilized act of kicking a ball around. ‘The Encylopedia of British Football’ reveals to us that, in September 1893, Derby County made the controversial move of proposing “that the Football League should impose a maximum wage of £4 a week. At the time, most players were only part-time professionals and still had other jobs. These players did not receive as much as £4 a week and therefore the matter did not greatly concern them. However, a minority of players, were so good they were able to obtain as much as £10 a week.” Goodness knows what those first footballers would think if they were brought back from the dead a hundred years later, to find out what their colleagues are earning nowadays, or cast an eye on the list of the highest earning footballers in the world today (note that the earnings are annual and without considering the footballers’ commercial interests, advertising involvement etc); we are told that Ricardo Kaka of AC Milan earns about 9,000,000 € a year, his compatriot Ronaldinho over 8,520,000 € and Frank Lampard of Chelsea FC 8,160,000 €.

BUT THERE IS HOPE, I HOPE

Nevertheless, I live in hope that all of these things will change. I recently completed a book on the Palestinian problem, one of the most difficult problems of our time, which many have come to regard as insoluble. I introduced it with a message of optimism, stating that truth and justice is a promise from God, and that moroseness and pessimism have no place in Quranic moral values.

As much as circumstances could lead me to believe, I cannot think that my life and practice so far is futile. Perhaps I have become attached to it, by virtue of having studied it for six long years in medical school, and having practiced and earned my living from it over the past three years. But I don’t think that entirely explains why I have a great hope in medicine, and a deep attachment to it. It remains, regardless of what I have mentioned above, a quite beautiful world.

GOD AND THE BEAUTIFUL WORLD OF MEDICINE

As everyone who knows me knows, I never wished to be part of this world in my youth, and always wished I would enter university and study the more intellectual fields of philosophy or physics and philosophy. Having entered it, owing to parental persuasion, I tried to philosophize it, and this is what has kept me going to this day. Despite its current ugliness, most of which I had not known about until I started working and beyond, I now know that medicine, stripped of its political and economic cloak is, as I say, a beautiful world, worthy of all our attentions, and that its study, besides being of immense human and societal benefit, could be of great comfort to one who believes in God, for His majesty shines everywhere within it.

Soon after he discovered his One Lord, the great prophet Ibrahim described God as ‘the Healer’, in Arabic, ‘Al-Shafi’, saying to his people, “Do you see these idols that you worship. You and your ancestors. I am against them, for I am devoted only to the Lord of the universe. The One who created me, and guided me. The One who feeds me and waters me. And when I get sick, He heals me” (26:76-82). God is inextricably connected with the healing process, something Ibrahim, in his great insight (PBUH) realized at a very early stage. It is this same quality that was described by Pare thousands of years later in his aforementioned statement, “Je le pansai, et Dieu le guarist (I treat the wounds, but God heals them)”.

But anyone with the idea of God as the most perfect of all beings will realize that there is much else that medicine can teach besides that of the idea of God as the Healer. As Pare and other religious explorers of the human body realized, the study of the human body and its diseases can reveal to us much about the ingenuity of God’s design. To quote one of Islam’s finest scholars of the past, Abu Hamid Al-Ghazzali, who wrote in his ‘Alchemy of Happiness’:
“An important part of our knowledge of God arises from the study and contemplation of our own bodies, which reveal to us the power, wisdom, and love of the Creator. His power, in that from a mere drop He has built up the wonderful frame of man; His wisdom is revealed in its intricacies and the mutual adaptability of its parts; and His love is shown by His not only supplying such organs as are absolutely necessary for existence, as the liver, the heart, and the brain, but those which are not absolutely necessary, as the hand, the foot, the tongue, and the eye. To these He has added, as ornaments, the blackness of the hair, the redness of lips, and the curve of the eyebrows.
Man has been truly termed a "microcosm," or little world in himself, and the structure of his body should be studied not only by those who wish to become doctors, but by those who wish to attain to a more intimate knowledge of God, just as close study of the niceties and shades of language in a great poem reveals to us more and more of the genius of its author”.
He is the Creator, the great Designer, and Great Architect of the Human Body. He is the Master, the most Beautiful, whose grandeur and artistry is immanent in all of His Creation, and very vividly in the human body, in health and disease. For without disease, would we have known health? Without the human capacity to suffer illness, would humans have entertained the idea of the study of the human body, at least as seriously as we do now? I think not, for human beings are driven chiefly by necessity. The study of disease provides a great opportunity to learn about normal human anatomy and physiology, and the great genius that is present in every single such aspect. This was highlighted by the great Charles Horace Mayo, founder of the Mayo Clinic, in a statement he made to the American College of Surgeons at the turn of the century, saying, “Disease at times creates experiments that physiology completely fails to duplicate, and the wise physiologist can obtain clues to the resolution of many problems by studying the sick” and the greatest medical writer of our time, Arthur Clifton Guyton, in the introduction to one of his fine physiology books, saying:

“A small but important part of this text presents not only knowledge that has come from basic experiments in animals, but also knowledge that has come from human experiments, especially unplanned experiments caused by disease. Literally thousands of human experiments proceed each day in the fields of high blood pressure, congestive heart failure, gastrointestinal disturbances, respiratory disease, and so forth. The physiology of these abnormalities is discussed briefly, partly because study of the diseases themselves can be enlightening, but even more because they give important insights into basic physiological concepts”.

With the intoxication of the love of God, akin to that of the great mystics of the past, there would be no need to get drunk, and thus we are spared the thousands of admissions that we see every day with alcohol related problems. Ignoring the very wise injunction in the Quran about the prohibition of alcohol consumption given in the verse, “Oh You who believe! Wine and gambling, stone altars and divining arrows are filth from the handiwork of Satan. Avoid them completely so that hopefully you will be successful. Satan wants to stir up enmity and hatred between you by means of wine and gambling, and to debar you from remembrance of Allah and from prayer. Will you not then give them up?” (5:90-91), I am sure that neither Jesus nor Moses (PBUT), nor the great Rabbis and teachers of Judaism and Christianity would not endorse the attitude many people have towards drinking. Even if such religions allowed for excessive drinking, it would never occur to the mind of a strong believer in them, since there is no reason to drink excessively, an attitude usually triggered by a misunderstanding of life events and the purpose of life, and again, the neglect of God.

With a firm belief in God, we would be spared of much mental illness. In this Godless world, it is the firm conviction of many prominent thinkers and physicians that much of the misery and melancholy of modern man is caused by an incorrect or inappropriate conception of the meaning of life and the lack of a grand worldview. Professor Alexis Carrel, for example (the famous French vascular surgeon and Nobel Prize winner wrote many books on the spiritual crisis of modern man, where he blamed capitalism and consumerism for the present suffering of mankind (he was also a great critic of communism for that matter). In his ‘Reflections on Life’, Carrel said:

“Modern society has been preoccupied with material values. It has neglected fundamental human problems, which are both material and spiritual. Not only has it not brought us happiness but it has shown itself incapable of preventing our deterioration. The conquest of health is not enough. We must also bring about in every individual the finest development of his hereditary power and of his personality, for the quality of life is more important than life itself”

A contemporary psychiatrist, Dr. Victor Frankl also made the following testimony about his practice, “More and more of our patients are crowding out our clinics and consulting rooms complaining of an inner emptiness, a sense of total and ultimate meaninglessness of their lives.” This is increasingly due to a lack of reflection on the deeper questions of life, brought on by the exhilarating pace of our materialistic, consumerist culture. Here the words of Socrates are most apt, “The unexamined life is not worth living”. Life without deep examination of the questions that matter is utterly unworthy, because it causes too much distress and pain. Not reflecting on God would lead to a huge vacuum in one’s life. As Blaise Pascal put it, “There is a God shaped vacuum in the heart of every man which cannot be filled by any created thing, but only by God, the Creator”. A contemporary professor of philosophy, William Lane Craig put it well too, “Modern man thought that when he had gotten rid of God, he had freed himself from all that repressed and stifled him. Instead, he discovered that in killing God, he had also killed himself”.

In the past history of the West (and to this day in many other parts of the world), religious faith provided man with the grand worldview, and there is evidence that that is the reason why psychiatric disorders are a lot less common, or are far less symptomatic in religious people (18-21). The great Swiss psychiatrist Carl Gustav Jung (1875-1961) was even led by this evidence to write, “Religions are systems of healing for psychic illness”

And let’s not mention sparing the world the burden of sexually-transmitted diseases, alcohol and drug-related problems, and other diseases of excess, which as I mention above, have inflicted even doctors and those aspiring to be doctors. With the idea of God fixed firmly in one’s mind, can we imagine those problems? I certainly can’t. Can one imagine in a God-conscious society, children deposit their parents in nursing and residential care homes, and not ask about them except until the time of inheritance comes, a not too infrequent occurrence in this day and age in the United Kingdom, or a residential care home nurse force a 90 year old man, who she does not wish to look after for a night, to go to hospital, who she cunningly ‘diagnosed’ with ‘worsening confusion’ when the poor man has remained in a chronic confusional state (we call it dementia) for years? I think not. Respect for one’s parents is an axiom of all religions – it is part of the Ten Commandements, and the Quran repetitively tells us:

“We have instructed man to be good to his parents. His mother bore him with difficulty and with difficulty gave birth to him; and his bearing and weaning take thirty months. Then when he achieves his full strength and reaches forty, he says, ‘My Lord, keep me thankful for the blessing You bestowed on me and on my parents, and keep me acting rightly, pleasing You. And makemy descendants righteous. I have repented to You and I am truly one of the Muslims’” (46:15)

“Remember when We made a covenant with the tribe of Israel: ‘Worship none but Allah and be good to your parents and to relatives and orphans and the very poor. And speak good words to people. And perform prayer and give the alms.’ But then you turned away–except a few of you–you turned aside” (2:83)

“Worship Allah and do not associate anything with Him. Be good to your parents and relatives and to orphans and the very poor, and to neighbours who are related to you and neighbours who are not related to you, and to companions and travellers and your slaves. Allah does not love anyone vain or boastful” (4:36).

It is my hope, and indeed my main aim in this book, to show that God is alive and apparent in everything in medicine. I hope to use medicine as a medium, so to speak, of my deepest and most strongly felt belief – that God is, and very much so. In His reverence and praise, we have the kind of religious activity that Carrel describes in the following words:

“Religious activity assumes various aspects, as does moral activity. In its more elementary state it consists of a vague aspiration toward a power transcending the material and mental forms of our world, a kind of unformulated prayer, a quest for more absolute beauty than that of art or science. It is akin to esthetic activity. The love of beauty leads to mysticism. In addition, religious rites are associated with various forms of art. Song easily becomes transformed into prayer. The beauty pursued by the mystic is still richer and more indefinable than the ideal of the artist. It has no form. It cannot be expressed in any language. It hides within the things of the visible world. It manifests itself rarely. It requires an elevation of the mind toward a being who is the source of all things, toward a power, a center of forces, whom the mystic calls God. At each period of history in each nation there have been individuals possessing to a high degree this particular sense. Christian mysticism constitutes the highest form of religious activity. It is more integrated with the other activities of consciousness than are Hindu and Tibetan mysticisms. Over Asiatic religions it has the advantage of having received, in its very infancy, the lessons of Greece and of Rome. Greece gave it intelligence, and Rome, order and measure.

Mysticism, in its highest state, comprises a very elaborate technique, a strict discipline. First, the practice of asceticism. It is as impossible to enter the realm of mysticity without ascetic preparation as to become an athlete without submitting to physical training. Initiation to asceticism is hard. Therefore, very few men have the courage to venture upon the mystic way. He who wants to undertake this rough and difficult journey must renounce all the things of this world and, finally, himself. Then he may have to dwell for a long time in the shadows of spiritual night. While asking for the grace of God and deploring his degradation and undeservedness, he undergoes the purification of his senses. It is the first and dark stage of mystic life. He progressively weans himself from himself. His prayer becomes contemplation. He enters into illuminative life. He is not capable of describing his experiences. When he attempts to express what he feels, he sometimes borrows, as did St. John of the Cross, the language of carnal love. His mind escapes from space and time. He apprehends an ineffable being. He reaches the stage of unitive life. He is in God and acts with Him.

The life of all great mystics consists of the same steps. We must accept their experiences as described by them. Only those who themselves have led the life of prayer are capable of understanding its peculiarities. The search for God is, indeed, an entirely personal undertaking. By the exercise of the normal activities of his consciousness, man may endeavor to reach an invisible reality both immanent in and transcending the material world. Thus, he throws himself into the most audacious adventure that one can dare. He may be looked upon as a hero, or a lunatic. But nobody should ask whether mystical experience is true or false, whether it is autosuggestion, hallucination, or a journey of the soul beyond the dimensions of our world and its union with a higher reality. One must be content with having an operational concept of such an experience. Mysticism is splendidly generous. It brings to man the fulfillment of his highest desires. Inner strength, spiritual light, divine love, ineffable peace. Religious intuition is as real as esthetic inspiration. Through the contemplation of superhuman beauty, mystics and poets may reach the ultimate truth.”

I do not agree with Carrel regarding his bias towards ‘Christian mysticism’, but agree with the main thrust of his argument otherwise. I would much rather he said, ‘ deep reflection about God’ rather then ‘mysticism’, a word that has come to have several negative connotations of irrational behaviour and thoughts of late, such as whirling Dervishes and talking with spirits. I wish mysticism was looked upon like Bertrand Russell over 50 years ago, when he said, “The mystic emotion, if it is freed from unwarranted beliefs, and not so overwhelming as to remove a man wholly from the ordinary business of life, may give something of very great value - the same kind of thing, though in a heightened form, that is given by contemplation. Breadth and calm and profundity may all have their source in this emotion, in which, for the moment, all self-centred desire is dead, and the mind becomes a mirror for the vastness of the universe”, but the world, at large, has become too irrational to take such reasonable men seriously.

One of my main aims through this work is to show that medicine can be a great path to God, as a mystical activity so to speak (in the sense of Russell and Mustafa Mahmood), in a similar sense that Paul Davies, one of the most popular scientific writers of our time, believes that science provides a truer path to God than religion. I do not agree with this entirely of course, but can see exactly why he, coming from a Christian background, with its rather unbelievable depictions of God, would say something like that. As far as I am concerned, only two religions provide a truthful picture of God – deism and Islam, the latter being the only uncompromising monotheistic ancient religion. Islam, correctly portrayed, is the most powerful stimulus to medical enterprise. The fact that ‘Islamic countries’ have such poor medical facilities is not evidence that Islam is fruitless, but rather evidence that what they preach and practice are very different, that true ‘submission to God’ is yet to take place in the hearts of their people.

AIMS OF THIS BOOK

Thus the aims of this book are five. Firstly, it is an attempt to bring back God into the world of medicine, to write a medical textbook where His Glory and intelligent design is highlighted, and His Praises are sung for the first time in the English language, and with that, the greatest delight to the monotheistic soul. It aims to show that we can learn so much about Him from its study, in the spirit of the following reported Hadith Qudsi, “"God says, ‘I was a hidden treasure, and I wished to be known, so I created the creation, through it I will be known”. In the first chapter of this work, I aim to show the flaws of the current approaches to this fascinating subject, and how it ought to be approached most appropriately.

Secondly, it is an attempt at demonstrating that there is a lot more to medicine than the dull, exploitative world that I have described here and elsewhere. Besides being philosophically and theistically intriguing, I propose to show that medicine can be aggrandised as Alexis Carrel, the great French surgeon proposed nearly a century ago, into a true multidisciplinary field, involving all professions and all of knowledge. As he states in his wonderful ‘Man the Unknown’:

“Medicine is the most comprehensive of all the sciences concerning man, from anatomy to political economy. However, it is far from apprehending its object in its full extent. Physicians have contented themselves with studying the structure and the activities of the individual in health and in disease, and attempting to cure the sick. Their effort has met, as we know, with modest success. Their influence on modern society has been sometimes beneficial, sometimes harmful, always secondary…Medicine has been paralyzed by the narrowness of its doctrines. But it could easily escape from its prison and help us in a more effective manner. Nearly three hundred years ago a philosopher, who dreamed of consecrating his life to the service of man, clearly conceived the high functions of which medicine is capable. "The mind," wrote Descartes in his ‘Discourse on Method’, "so strongly depends on temperament and the disposition of bodily organs, that if it is possible to find some means which will make men generally more wise and more clever than they have been till now, I believe that it is in medicine one should seek it. It is true that the medicine now practiced contains few things having so remarkable a usefulness. But, without having any intention of scorning it, I am confident that there is no one, even among those whose profession it is, who does not admit that everything already known about it is almost nothing in comparison with what remains to be learned, and that people could be spared an infinity of diseases, both bodily and mental, and perhaps even the weakening of old age, if the causes of those troubles and all the remedies with which nature has provided us were sufficiently well known." Medicine has received from anatomy, physiology, psychology, and pathology the more essential elements of the knowledge of ourselves. It could easily enlarge its field, embrace, in addition to body and consciousness, their relations with the material and mental world, take in sociology and economics, and become the very science of the human being. Its aim, then, would be not only to cure or prevent diseases, but also to guide the development of all our organic, mental, and sociological activities. It would become capable of building the individual according to natural laws. And of inspiring those who will have the task of leading humanity to a true civilization. At the present time, education, hygiene, religion, town planning, and social and economic organizations are entrusted to individuals who know but a single aspect of the human being. No one would ever dream of substituting politicians, well-meaning women, lawyers, literary men, or philosophers for the engineers of the steel-works or of the chemical factories. However, such people are given the incomparably heavier responsibility of the physiological, mental, and sociological guidance of civilized men, and even of the government of great nations. Medicine aggrandized according to the conception of Descartes, and extended in such a manner as to embrace the other sciences of man, could supply modern society with engineers understanding the mechanisms of the body and the soul of the individual, and of his relations with the cosmic and social world…Men grow when inspired by a high purpose, when contemplating vast horizons. The sacrifice of oneself is not very difficult for one burning with the passion for a great adventure. And there is no more beautiful and dangerous adventure than the renovation of modern man.”

This same belief has been expressed by many other physicians and surgeons throughout the ages, although sadly it is not as commonly expressed in this day and age, thanks to the decline in our reflective faculties. The great Irish surgeon, Abraham Colles, whose name is immortalised in the all too common Colles fracture, remarked in his ‘Treatise of Surgical Anatomy’, “Be assured, that no man can know his own profession perfectly, who knows nothing else; and that he who aspires to eminence in any particular science must first acquire the habit of philosophising on matters of science in general.” The famous (and brilliantly named) neurologist Sir Russell Brain described the world of medicine in the following words in an article published in the ‘Lancet’ in 1953:

“Medicine alone takes as its province the whole man…It is concerned with…man in all the complexity of his body and mind from his conception to his last breath; and its concerns extend increasingly beyond his sicknesses, to the conditions which make it possible for him to lead a healthy and a happy life”.

William Osler, the great Canadian physician put it like this in an essay ‘Chauvinism in Medicine’, in his ‘Aequanimitas’, “In no profession does culture count for so much as in medicine, and no man needs it more than the general practitioner.”

Although my aims are a far cry from the megalomaniac dreams of Carrel, I do indeed aim to show that medicine is wider than commonly thought. I hope to use medicine as a carrier, if you like, of other interesting fields of knowledge, to entertain the reader, and place medicine within the wider scheme of things. I wish to exhibit medicine as an integral part of scientific, philosophical, social and political life, not as the isolated speculations and practices of random physicians. I will attempt to connect the various medical problems that I discuss with aspects of everyday life, to show that medicine is connected with some of our deepest notions about life. In this way, medicine would be regarded as something that transcends traditional boundaries and an intellectual, as well as practical, exercise and art. I hasten to add that this is not a foreign idea, and that I think that it is this magnificent fusion of medicine, art and science that is the secret for the great success of the ‘Oxford Handbook of Clinical Medicine’, the world’s best selling pocket medical handbook – a book that, in its latest (7th) edition together with the medical knowledge of our time, begins its figures not with a picture of an ECG or chest X-ray, but with a picture of the constellation of Orion as its first figure, saying:

“Like the stars, ideals are hard to reach, but they serve for navigation during the night…We choose Orion as our emblem for this navigation as he had miraculous sight (a gift from his immortal lover, Eos, to help him in his task of hunting down all dangerous things) – and as his constellation is visible in the Northern and the Southern hemispheres (being at the celestial equator), he links our readers everywhere”.

And moves on to discussion of historical medical figures like James Paget (“who would regularly see more than 60 patients a day”) and Sir Dominic Corrigan (“who was so busy 160 years ago that he had to have a secret door made in his consulting room so that he could escape from the ever-growing queue of eager patients”), and concludes it with a quote from Shakespeare’s ‘Macbeth’:

“However busy the ‘on take’, your period of duty will end. For you, as for Macbeth:

Come what come may,
Time and the hour runs through the roughest day”

It even has an entire page devoted to ‘Medicine, Art and the Humanities’, discussing the likes of Arthur Connan Doyle, William Carlos Williams, Somerset Maugham and Anton Chekhov, George Bernard Shaw and Sigmund Frued, as well as fictional characters like Dr. Watson and Dr. Faustus. It moves on in the next few sections to quote the likes of Václav Havel, the Czech writer and dramatist, and the last President of Czechoslovakia and the first President of the Czech Republic, Marcel Proust, the great French novelist, “that life long all knowing patient”, even Enid Blyton – author of the ‘Famous Five’. And from then on, the names of Thomas Hobbes, Wilfred Owen, Sylvia Plath, Charles Darwin, Alexander Pope, William Wordsworth, Albert Camus, Carl Friedrich Gauss, and many others are scattered throughout its pages. The point of all this is just what I have said – that there is more to medicine than meets the eye.

Another of its aims is to reinforce the fun factor in medicine. By viewing medicine within the wider context, looking at its impact on history, famous figures, and vice versa, we learn much that is fascinating. Teaching with the 'fascinating case' has a long tradition in medical education and has a popularity that extends beyond medical audiences. At their best, such stories serve more than a didactic purpose - they provide a glimpse of the diversity of human experience and the moral and social dimensions of illness.

In particular, I have tried to incorporate as many artists’ depictions of disease as I possibly could, in the firm belief that, being naturally endowed with a greater power of description than most other people, their views of disease are those that would be most vividly recalled by the reader. Take for instance Anton Chekhov’s (also a medical man) description of his bouts of haemoptysis due to the tuberculosis that eventually killed him. Fyodor Dostoyevsky’s struggles with epilepsy, Benjamin Franklin’s gouty agonies, Jane Austen’s descriptions of her presumed Addisonian crises, and Ludwig von Beethoven’s tears of anguish over his deafness. Nothing that I have read in the medical textbooks available at present compares to the power of the images by which those greats portrayed their illness. This work is full of extracts from their works or statements, in the hope that they will have a similar impact on the reader.

In addition, realising that some figures, typically associated with certain symptoms, had, or possibly had (after all, there is much conjecture in all of history, let alone medical biography) certain disorders, may reinforce the rarer aspects of some diseases. For example, much is written at present of the possibility of Beethoven (a figure immortalised to the layman by his majestic music and deafness, and from the medical perspective with his ascites and multiple paracenteses) suffering from sarcoidosis. On knowing this, one immediately learns three things about sarcoidosis – that it is a multisystemic disorder, that it can affect the liver (though it is certain the alcohol did the greater part of the damage), and also hearing – more specifically the vestibulocochlear nerve. Knowing that his autopsy showed renal calculi will also help recall sarcoidosis as an important cause of hypercalcaemia.

Awareness of how celebrities have endured certain diseases can help in several other ways. The following extract, from Bower and Waxman’s ‘Lecture Notes On Oncology’, summarises these well; although it relates mainly to oncology, it can certainly be applied to other fields too:

“Celebrities influence public perceptions and behaviour inordinately, and this is true in oncology as elsewhere. Celebrities with cancer have contributed in three main ways; personal accounts bring patients’ experiences into the limelight, reports of celebrity patients increase public awareness and may encourage health-seeking behaviour such as stopping smoking, and celebrity patients may support cancer charities and encourage donations. Prominent examples of patient’s perspectives include John Diamond’s account in 'C: because cowards get cancer, too' and Ruth Picardie’s 'Before I say goodbye', both moving accounts by accomplished journalists. Celebrity patients can influence the treatment choices that the public make. Following Nancy Reagan’s mastectomy for localized breast cancer in 1987, there was a 25% fall in American women choosing breast-conserving surgery over mastectomy. Her husband’s successful surgery for Dukes’ B colon cancer while president in 1984 increased awareness and propelled the warning signs of colon cancer into the media. Successful cancer treatment is often most widely publicized, and no article describing Lance Armstrong’s cycling victories seems complete without a mention of his treatment for metastatic non-seminomatous germ cell tumour, or of his two children conceived with stored sperm banked prior to chemotherapy. Other celebrity patients have used their wealth and fame to establish and support charitable projects to support cancer research and treatment, including Bob Champion, the steeple-chase jockey treated for testicular cancer in the 1970s, and Roy Castle, a lifelong non-smoker who was diagnosed with lung cancer in 1992. Of course, no one is immune to cancer, even rock stars whose deaths are traditionally associated with suicide and substance abuse”.

The fourth aim of this work is to oppose the current trend of increasing ‘scientification’ and complexity of medicine and the basic medical sciences. I have been to many medical lectures, where the speaker spends an hour or so dealing with the scientific minutiae of diseases. I always found nearly all of these lectures extremely dull. But this is not a criticism of the speakers; it is a natural consequence of the increasing ‘specialisation’ of medicine. Unless complicated scientific ideas are grounded in philosophical concepts or aspects of everyday life, I find them a lot less exciting or indeed memorable. By relating them to the questions of life that matter most to us, many of which are essentially the substance of philosophy, they will inevitably be a lot more memorable, and much more stimulating. I aim to analyse, as well as synthesise medicine, as I have studied it, into a coherent whole. I cannot help but quote the great (though at times controversial) Alexis Carrel again on this issue:

“Still more harm is caused by the extreme specialization of the physicians. Medicine has separated the sick human being into small fragments and each fragment has its specialist. When a specialist, from the beginning of his career, confines himself to a minute part of the body, his knowledge of the rest is so rudimentary that he is incapable of thoroughly understanding even that part in which he specializes. A similar thing happens to educators, clergymen, economists, and sociologists who, before limiting themselves entirely to their particular domain, have not taken the trouble to acquire a general knowledge of man. The more eminent the specialist, the more dangerous he is. Scientists who have strikingly distinguished themselves by great discoveries or useful inventions often come to believe that their knowledge of one subject extends to all others. Edison, for example, did not hesitate to impart to the public his views on philosophy and religion. And the public listened to his words with respect, imagining them to carry as much weight on these new subjects as on the former ones. Thus, great men, in speaking about things they do not thoroughly understand, hinder human progress in one of its fields, while having contributed to its advancement in another. The daily press often gives us the dubious benefit of the sociological, economic, and scientific opinions of manufacturers, bankers, lawyers, professors, physicians, whose highly specialized minds are incapable of apprehending in their breadth the momentous problems of our time. However, modern civilization absolutely needs specialists. Without them, science could not progress. But, before the result of their researches is applied to man, the scattered data of their analyses must be integrated in an intelligible synthesis.

Such a synthesis cannot be obtained by a simple roundtable conference of the specialists. It requires the efforts of one man, not merely those of a group. A work of art has never been produced by a committee of artists, nor a great discovery made by a committee of scholars. The syntheses needed for the progress of our knowledge of man should be elaborated in a single brain. It is impossible to make use of the mass of information accumulated by the specialists. For no one has undertaken to coordinate the data already obtained, and to consider the human being in his entirety. Today there are many scientific workers, but very few real scientists. This peculiar situation is not due to lack of individuals capable of high intellectual achievements. Indeed, syntheses, as well as discoveries, demand exceptional mental power and physiological endurance. Broad and strong minds are rarer than precise and narrow ones. It is easy to become a good chemist, a good physicist, a good physiologist, a good psychologist, or a good sociologist. On the contrary, very few individuals are capable of acquiring and using knowledge of several different sciences. However, such men do exist. Some of those whom our scientific institutions and universities have forced to specialize narrowly could apprehend a complex subject both in its entirety and in its parts. So far, scientific workers devoting themselves, within a minute field, to prolonged study of a generally insignificant detail, have always been the most favored. An original piece of work, without any real importance, is considered of greater value than a thorough knowledge of an entire science. Presidents of universities and their advisers do not realize that synthetic minds are as indispensable as analytic ones. If the superiority of this kind of intellect were recognized, and its development encouraged, specialists would cease to be dangerous. For the significance of the parts in the organization of the whole could then be correctly estimated.”

The final aim of this work is to show that, just like the world needs submission to God (Islam), the medical world needs Him. In a truly Islamic world, governed by the principles of truth and justice, the patients would be better, the doctors would be better, and overall, we will all lead happier lives.

In short, this book is a set of intellectual, scientific, philosophical and religious ruminations over medical topics, and is full of attempts at finding out ‘why’ things are as they are. It will aim to remain true to the strictest philosophical traditions of the past, where philosophy was defined not as an ivory-tower field, isolated from reality, but, as defined by some, as “the study of humans and the world by thinking and asking questions. It is not part of science, because it is not an observation of things in the real world to find out how they work. Philosophy tries to answer important questions by coming up with answers about real things and asking "why?”. Philosophy encourages people to ask the reason behind everything. It is the speculation bit; when believed firmly without wavering and no scientific evidence, it is labeled faith. If strong scientific evidence abounds, it becomes science. In that sense, no one defined philosophy better than Sir Bertrand Russell, when he said in the introduction to his magnificent monument, and arguably the best introductory philosophy book, ‘The History of Western Philosophy’:

“Philosophy, as I shall understand the word, is something intermediate between theology and science. Like theology, it consists of speculations on matters as to which definite knowledge has, so far, been unascertainable; but like science, it appeals to human reason rather than to authority, whether that of tradition or that of revelation. All definite knowledge -- so I should contend -- belongs to science; all dogma as to what surpasses definite knowledge belongs to theology. But between theology and science there is a No Man's Land, exposed to attack from both sides; this No Man's Land is philosophy. Almost all the questions of most interest to speculative minds are such as science cannot answer, and the confident answers of theologians no longer seem so convincing as they did in former centuries...The studying of these questions, if not the answering of them, is the business of philosophy”.

The medical professional is in an extremely privileged position, in that he or she is engaged in some of the deepest philosophical questions that trouble mankind, sometimes much more directly than the philosopher himself. For who is it who diagnoses the beginning of life, and has the first encounter with death. Who is it who oversees the birth of a child, and his or her growth and development? Who is it who sees man at his frailest, and bears witness to God’s statement, “Man was created weak” (3:28)[10]

However, if I were to mention my biggest hope from this work, it is to reawaken this beautiful thing called the sense of wonder, which is numbed so often by being adults who have seen things so regularly without contemplation over them, is the chief aim of this work. If one were to retain the sense of childlike wonder over medicine, and common disorders, I am sure medicine will advance at a far more staggering rate than it is, and certainly imparting that sense of wonder to its students would only excite them and motivate them to practice it with true passion. Too often students and practising health professional treat medicine as ‘just another job’, forgetting its noble ideas and all that it stood for since its conception, probably with the birth of man. They forget that there is more to medicine than utility and paying the bills. The great French mathematician Henri Poicare once remarked regarding the work of the scientist:

“The scientist does not study nature because it is useful; he studies it because he delights in it, and he delights in it because it is beautiful. If nature were not beautiful, it would not be worth knowing, and if nature were not worth knowing, life would not be worth living”.

In like fashion, the medical professional, especially the doctor, ought not to study medicine, or keep abreast of its progress simply because it is useful, but because it is a great source of delight, because it is it beautiful. And to paraphrase Poincare, if the human body was not beautiful, it would not be worth knowing, and if the human body was not worth knowing, life would not be worth living. Man was created to know, and worship via that ability to know. Hence the very first word in the Holy Quran was, “Read” (96:1). Know. Acquire knowledge.

There have been many descriptions of the ideal doctor, and I will not bore the kind reader with them, many of which are attributes of angels, not of human beings. But to me, the ideal doctor is quite simply, one who combines knowledge and wisdom with humanity. He displays what Phil R Manning described, “An inquiring, analytical mind; an unquenchable thirst for new knowledge; and a heartfelt compassion for the ailing – these are prominent traits among the committed clinicians who have preserved the passion for medicine”. Barton Childs described this physician quite brilliantly saying, “The best of all worlds is attained in the doctor who cleaves to the Oslerian ideal in practice and the Garrodian in thinking” – William Osler was the founder of bedside medicine as we know it now, and Archibald Garrod was a most brilliant clinician and scientist, and the man who succeeded Osler as Regius Professor of Medicine at Oxford. He or she does not aim to pass exams with the aim of entering the field to fulfil a desire for status, power or money. Indeed, this is one of the sad features of modern medical student thinking, as Neville Woolf, Vice-Dean and Faculty Tutor at the University College Medical School and professor of histopathology put it:

“It is a fact, albeit a regrettable one, that many students, perhaps the majority, are obsessively concerned with passing examinations, which become for them the raison-d’etre rather than a by-product of medical education. Even at this pragmatic level, it should be understood that the process of learning transcends the acquisition, partial retention and more or less accurate reproduction of a large body of factual knowledge. Real learning should be based on understanding and the ability to use knowledge in disparate contexts; it is one of the few of life’s pleasures which does not lose its savour with passing time, provided only that we do not lose our sense of wonder as the mysteries of nature are made clear, however slow and tantalisingly incomplete this process seems”.

Instead, they enter its world in order to fulfil the higher purposes of medicine - “to prevent disease, to relieve suffering and to heal the sick” (as the great Canadian William Osler put it, the ideal physician in my humble opinion), regardless of any consequences on power or money. He or she does not learn medicine without books (for that would be, as Osler, put it, like one who “sails an uncharted sea”). But he or she knows that “while books are good enough in their own way, they are a mighty bloodless substitute for life”, as Robert Louis Stevenson brilliantly put it, and using them alone, without seeing patients, is like one who “does not go to sea at all”[11]. He or she is dedicated to their message of advocating health and eliminating disease or its consequences.

I have just touched upon the sense of wonder, and I think it is vital to the progress of medicine and to the happiness of the practising medical professional and thus his or her patients. There is a notorious lack of wonder among members of the profession, perhaps because of external pressures, the way medicine has become much more mechanical, with an emphasis on protocols and guidelines, leading to its current state of mundane monotony. This feeling can only be eradicated with development of a refined sense of wonder. To paraphrase the great British geneticist John Durdon Haldane, the modern medical world I fear, “shall perish not perish for lack of wonders, but for lack of wonder”.

Everything in life is a wonder; nature is full of wonder. Not least medicine; it deals with one of the greatest works of God, the human body, and its diseases. Wonder is the default state in medicine, not the exception. I am not talking here about the wonders that seem to provoke media hype – the 62 year old Californian lady who recently “gave birth to her 12th child”, or the stroke patient who was given no chance of recovery, put on palliative care, yet recovered fully within a few weeks, or the young man whose story is recounted by James Barron in ‘The New York Times’ a few months ago:

“Alcides Moreno plunged 47 stories that morning last month, clinging to his 3-foot-wide window washer’s platform as it shot down the dark glass face of an Upper East Side apartment building. His brother Edgar, who had been working with him on the platform, was killed.

Somehow, Alcides Moreno survived

If you are a believer in miracles, this would be one,” said Dr. Philip S. Barie, the chief of the division of critical care at New York-Presbyterian Hospital/Weill Cornell Medical Center in Manhattan, where Mr. Moreno, 37, is being treated.”

I myself have seen many instances of similar ‘miraculous’ patient recoveries in my few years of practice, cases that struck the minds of even the most sceptical of my consultants, and it really is a stunning thing.

But it really shouldn’t, or at least it shouldn’t shake ones soul more than the observation of the more ordinary patients and their recovery. For wonder is everywhere, and as Francis Bacon put it, “God never wrought miracles to convince atheism, because his ordinary works convince it”. The miracle is the rule, not the exception. It is this sense of wonder, the sense of everything being a miracle that can seriously fill the medical professional, as it does the scientist, with the deepest awe. It’s a feeling that was so beautifully expressed by Albert Einstein, as follows:

“The most beautiful and most profound experience is the sensation of the mystical. It is the sower of all true science. He to whom this emotion is a stranger, who can no longer wonder and stand rapt in awe, is as good as dead. To know that what is impenetrable to us really exists, manifesting itself as the highest wisdom and the most radiant beauty which our dull faculties can comprehend only in their primitive forms - this knowledge, this feeling is at the center of true religiousness”.

All the great scientists were of the wondering type. They never lost their childlike naïveté over the mysteries of nature, and through this faculty of not taking familiar things for granted, succeeded in causing the progress of science. Isaac Newton, the greatest scientist of all time put it this way:

“I do not know what I may appear to the world; but to myself I seem to have been only like a boy playing on the seashore, and diverting myself in now and then finding a smoother pebble or a prettier shell than ordinary, whilst the great ocean of truth lay all undiscovered before me”

The great Albert Einstein (regarded by some as second to Newton) wrote in a letter to a friend towards the end of his life, “We never cease to stand like curious children before the great mystery into which we were born”.

Simone Weil described science saying, “The true definition of science is this: the study of the beauty of the world”, and insisted, “A science which does not bring us nearer to God is worthless.” In a similar vein, I belief that one of the best definitions of medicine would be “the study of the beauty of the human body in health and disease, and the application of that knowledge to the sick”, and that if it were not to bring us nearer to God, the source of all beauty and wonder, it would be worthless.

In the medical world, unfortunately, we lack this sense of wonder, and why, compared with the natural sciences, particularly physics, medicine is still in its infancy. This is probably a harsh criticism of doctors, who are often engrossed in the practical care of patients, allowing little time to pause and reflect upon their practice. This contrasts with most physicists, who are daily engrossed with ‘understanding’ rather than practical problems. But there are practical physicists, involved in electrical and mechanical engineering aspects. Why can there not be a bunch of reflective physicians, who can spread the wonder of medicine around, while the more practical ones are occupied with their work? I feel it is necessary; only that will strip medicine from its current state of relative inexcitement, and strip us of our current overall state of arrogance and bewilderment, in a time when we think science, technology and power is everything, when the educated have lost the simplicity of belief in the One, the Master of All, and resorted to belief in complicated, dubious concepts such as evolution and quantum fluctuation. It will reconnect us with the attitude of our elders, who saw His hand in everything, leaving them stunned and humbled by the beauty of it all, they who knew that there is a greater power than us around, capable of achieving things we cannot achieve, and sang:

“I walk in beauty
Beauty is before me,
Beauty is above me,
Beauty is below me,
Beauty is around me,
I walk in beauty”

A physicist, Paul Heckert described his job as follows:

“Physicists are the perpetual three year olds of science. They always ask: Why? Physics is about observing nature, from elementary particles to the entire universe, and wondering why and how it works. While enjoying the beauty of natural phenomena such as rainbows or dark star filled skies, physicists continue trying to understand how they work. Achieving this understanding enhances nature's beauty. The best physicists keep their childlike wonder while unraveling nature's mysteries. As Whitman's Learned Astronomer, they show "the charts and the diagrams, to add, divide and measure them" while continuing to wander off "in the mystical moist night-air, and from time to time [look] up in perfect silence at the stars"”.

Since reading that I have wondered, how wonderful would it be if we had a bunch of three year olds of medicine!?

And the sense of wonder of physicists has, over the past hundred years, been connected with a sense of higher cosmic purpose. Virtually all the great physicists have been involved, in one way or another, with questions that would have been regarded before as a matter of metaphysics. This has especially been the case in post-Victorian times; prior to that physicists lived in ‘metaphysical security’, and didn’t deal with the deep questions of life the way the 20th and 21st century physicist does. With the sense of loss that has pervaded humanity over the past century, physicists have been trying to find solutions and answers from their studies.

The sense of cosmic purpose that many physicists have been advocating over the past 100 years should, I feel, be analogously utilised by medical professionals. As I have just illustrated, the medical world is an absolute mess at the moment. It is my firm belief that the idea of God and divine involvement within it can impart to it a great deal of order, and with that a great delight to the medical professional and his or her patients. This is what Jacob Needleman, a professor of philosophy at San Francisco State University says on the issue:

“The fate of medicine in the contemporary era is testimony to the teaching contained in the symbol of the caduceus. The meaning of the art of medicine, like the very meaning of being alive, cannot be found through one force alone. When the contemporary physician complains that the meaning of his craft is being taken away from him – by such mundane influences as government intervention, legal restrictions, hospital data banks, and insurance companies – we need to hear this complaint in a special way, because it is the same for all of us. More and more, we are all becoming aware that our lives are being lived for us by influences that, however numerous they appear, are in fact only so many reflections of one kind of movement in the life of man, a movement toward externals, toward needs and gratifications that, however justified in their own right, become destructive when they pretend to represent the whole meaning of human life….The meaning of being a physician can only be recovered through a rediscovery of the question of the meaning of human life itself, the meaning of being alive.”

Only by knowing our purpose in life, that we were created to worship and glorify God, will medicine find its meaning, and the medical professional will find his lost soul. The atheist or agnostic has no higher purpose in life – for he or she do not believe anything exists outside that perceived by our five senses. This point can only be realised by incorporating the idea of God with discussions of medical problems.

And linking this sense of higher purpose with the sense of wonder, one reviewer reviewing Needleman’s fantastic book, ‘The Way of the Physician’, writes:

“The physician has become the dispirited pawn of a "medical arms race" in which financial considerations are taking precedence over the welfare of patients. Cut off from great ideas and awakening experiences, doctors are either complacent or riddled with tension. Addressing them directly, the author mourns: "You are dying in your tracks, and you know it." Medicine for the practitioner and the patient alike, this book says that we need to train doctors to be wise healers working on the heart, not mechanics who fix bodies. Carrying resonances of Robert M. Persig's ground-breaking Zen and the Art of Motorcycle Maintenance, it points to the physician's quest, now, as our own: to rediscover the moral wonder that will enable us "to do the right thing and do it well".

The best physician is one who addresses the body and mind of all his or her patients, and addresses the ideas that impact those two things within his community. He need not do this with drugs; in fact, he should go to drugs only as a last resort for illness of all types, physical and psychological. He knows that, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (the WHO definition, “a definition which was ratified during the first World Health Assembly, and has not been modified since 1948”), and that this will not be achieved in the presence of so many astonishingly bad philosophies and ideas. Thus, in this work I may go off on a tangent here and there, discussing a philosophy or ideology which is connected directly or indirectly, in a very subtle or blatant fashion, so as to help achieve this purpose. (The same case applies of course for the female physician)

With that in mind, let us begin our journey into the medical world, and explore it by way of wonder. There is no more powerful tool for the recall of knowledge than associating it with an element of wonder and the happiness that comes with it. A recently published medical textbook states that, “Facts are most efficiently memorized as visual images, chunks, acronyms, rhymes, webs etc, and as we update our knowledge, we must first recall our pre-existing schema of the topic, and then peg the new data onto this internal structure” (Bentley, 2007). How about if this internal structure was that of happiness and wonder? Socrates remarked that “wisdom begins in wonder”. It is not a surprise that the Arabic words for wise man and physician are the same, (‘hakeem’), both of which also overlap with the word ‘Failasuf’ (philosopher) – from the Greek for ‘the love of wisdom’.

The methodology is this - I begin most discussions of diseases with a brief look at how they have impacted humanity, mainly by glances at their impact on history or historical figures and how the latter particularly coped with their illness. There is much to learn from the historical outlook, and it would enrich the present day medical student in more than one way. Most importantly, it makes the learning of medicine much more pleasurable and enthralling, and less dry than commonly seen in present day textbooks (is it just me or did the medical writers of the past really write more joyfully than their present counterparts?!). I then proceed with discussion of the various presentations of illness, highlighting the features I have discussed in the aforementioned section.

As is natural for a book like this, many of my personal opinions are expressed, and personal heroes have crept in and extensively quoted. I hope the reader will find no offence in this. Finally, if this book were to instill in the kind reader that sensational moment of wonder and delight, the beautiful perception of the mystical, as Albert Einstein would have put it, its aims would have been achieved. I hope that God will accept this work as an act of gratefulness to Him, the source of all beauty and wonder.

Dr. Fahed Al-Daour
2nd of September 2008

[1] Newton, and this may come as a surprise to most readers, spent a far greater proportion of his 85 years in the study of religion and the Bible than on his scientific theories.

[2] For without the idea of God enshrined in one’s daily thoughts, as it is in atheism, putting it on the shelves, as secularists do, to be consulted only when one feels he or she wants to, would be the easiest thing.
[3] I cannot help but quote how the late Martin Seymour-Smith described Dawkins’ writing style in his brilliant ‘The 100 Most Influential Books of All Time’, “He gained a facility for a style of writing which like that of the tabloid press, conceals its confusions beneath a mask of almost bewildering facility. “The argument of this book is that we, and all other animals, are machines created by our genes. Like successful Chicago gangsters, our genes have survived, in some cases for millions of years, in a highly competitive world. This entitles us to expect certain qualities in our genes. I shall argue that a predominant quality to be expected in a successful gene is ruthless selfishness... This gene selfishness will usually give rise to selfishness in individual behavior. However, as we shall see, there are special circumstances in which a gene can achieve its own selfish goals best by fostering a limited form of altruism at the level of individual animals. 'Special' and 'limited' are important words in the last sentence. Much as we might wish to believe otherwise, universal love and the welfare of the species as a whole are concepts that simply do not make evolutionary sense. This brings me to the first point I want to make about what this book is not. I am not advocating a morality based on evolution. I am saying how things have evolved. I am not saying how we humans morally ought to behave. I stress this, because I know I am in danger of being misunderstood by those people, all toll numerous, who cannot distinguish a statement of belief in what is the case from an advocacy of what ought to be the case. My own feeling is that a human society based simply on the gene's law of universal ruthless selfishness would be a very nasty society in which to live. But unfortunately, however much we may deplore something, it does not stop it being true. This book is mainly intended to be interesting, but if you would extract a moral from it, read it as a warning. Be warned that if you wish, as I do, to build a society in which individuals cooperate generously and unselfishly towards a common good, you can expect little help from biological nature. Let us try to teach generosity and altruism, because we are born selfish”. This astonishingly confused rubbish, in which the complex and essentially interactive gene is individualized, simplified, and personalized and then taken quite illogically to resemble a whole human being, had and still has some popularity among certain sorts of reader. ..there is certainly no room here for the archdunce Dawkins”. Seymour was a professor of English Literature, and, as the poet and critic Robert Nye put it, was "one of the finest British poets after 1945”. So he knows what he is talking about. And he was an atheist, so his attack on Dawkins cannot be attributed to a difference of opinion with regards to the idea of God.
[4] ‘Peace’ (Al-Salam) is one of the names of God, as is apparent from the following verse, “He is Allah–there is no god but Him. He is the King, the Most Pure, the Perfect Peace, the Trustworthy, the Safeguarder, the Almighty, the Compeller, the Supremely Great. Glory be to Allah above all they associate with him”(59:23). In addition, “In Arabic, Islām derives from the three-letter root س-ل-م, which means "to be in peaceful submission; to surrender; to obey; peace". Islām is a verbal abstract to this root, and literally means "submission/obedience," referring to submission to Allah”. Islam is about being at peace with oneself, and with others, through a continuous awareness of God.
[5] I am yet to see a suicide attempt that was triggered by something more serious than that.
[6] Bertrand Russell put it best, “Drunkenness is temporary suicide: the happiness that it brings is merely negative, a momentary cessation of unhappiness”.

[7] The Quran put it beautifully, “Already have We urged unto hell many of the jinn and humankind, having hearts wherewith they understand not, and having eyes wherewith they see not, and having ears wherewith they hear not. These are as the cattle - nay, but they are worse! These are the neglectful” (7:179).

[8] We read the following verses of the Bible – Colossians (1:16) which says, "All things were created by him and for him." and Isaiah (43:21), “The people which I formed for Myself, that they might tell of My praise”. In the Quran, two similar verses embody that belief, “I have created not the jinn and men except that they should worship Me” (51:56-58) and, “So glorify the praises of your Lord and be of those who prostrate themselves (to Him). And worship your Lord until there comes unto you the Hour that is certain (i.e. death)” (15:98-99)).

[9] The same idea, of our purpose in life being to glorify God is expressed in the wonderful deistic traditions of the American Fathers and French Enlightenment, whose chief American exponent, the great Thomas Paine, writing in his classic ‘The Age of Reason’ (1794), said, “The true Deist has but one Deity, and his religion consists in contemplating the power, wisdom, and benignity of the Deity in his works, and in endeavoring to imitate him in everything moral, scientific, and mechanical…(his religion) honors reason as the choicest gift of God to man, and the faculty by which he is enabled to contemplate the power, wisdom and goodness of the Creator displayed in the creation; and reposing itself on His protection, both here and hereafter …While man keeps to the belief of one God, his reason unites with his creed. He is not shocked with contradictions and horrid stories. His bible is the heavens and the earth. He beholds his Creator in all His works, and everything he beholds inspires him with reverence and gratitude. From the goodness of God to all, he learns his duty to his fellow-man, and stands self-reproved when he transgresses it. Such a man is no persecutor”.
[10] Indeed, Harun Yahya wrote an article on the issue, ‘The Weaknesses of Man’, which reads like a medical description of the human body. Highly recommended reading (see appendix).
[11] It is the genius of Osler that he does not say ‘the sea’ here; for both the unqualified ‘sea’ is heard the same as see, and the meaning is equally powerful.

THE SUPERIORITY OF SUBMISSION TO GOD

2008-09-16T21:03:00.001-07:00

THE SUPERIORITY OF SUBMISSION TO GOD

One of my main axioms in this book is the superiority of ‘submission to God’, of Islam, over all other beliefs. But the kind reader may oppose my thesis by looking at how primitive current ‘Islamic’ societies are. He or she may ask, if Islam is the religion of around 1.8 billion people around the world, is the world in such a dire state. Surely if Islam were so great, we would not have the chaos we are living in.

My response to this is that ‘Islam’ has come to mean, to the vast majority of people, including most Muslims, as simply a meaningless name. What it actually stands for is simple and not difficult to deduce – its in its very name for goodness sake; it simply means ‘submission to God’. The Islam we have practiced nowadays is merely a name – devoid in the majority of cases from any submission to God. It is more a submission to tradition, to what ‘the scholars of old said’, to what the Prophet Muhammad (PBUH) is reported to have said, than what he actually said, to what is ‘thought to be Islam’ than to God Himself.

The so called Islamic world today lives in a deep myth and illusion that they have referred to as Islam. The vast majority of Muslims hold very strange beliefs, which I do not wish to delve into in this introduction. These beliefs have led to some extraordinary practices that have led to the nightmare we currently live in – most importantly, the relegation of reason and rational thought, as if submission to God means we have to abandon reason. In the Islamic world, Bertrand Russell’s fantastic statement, “Most people would rather die than think: many do” is most descriptive and truthful.

It is as if God, to paraphrase the great Italian scientist Galileo, “who has endowed us with sense, reason, and intellect has intended us to forego their use”. It is as if He never mentioned the words ‘think’, ‘reflect’, ‘ponder’ in the Quran, words used many hundreds of times, as evidenced by the following verses:

“Do you not see that Allah has subjected to you everything in the heavens and earth and has showered His blessings upon you, both outwardly and inwardly? Yet there are people who argue about Allah without knowledge or guidance or any illuminating Book. (31:20)

Do you not see that Allah propels the clouds then makes them coalesce then heaps them up, and then you see the rain come pouring out of the middle of them? Do they not see how We drive water to barren land and bring forth crops by it which their livestock and they themselves both eat? So will they not see? (32:27)

Do you not see that Allah sends down water from the sky and threads it through the earth to emerge as springs and then by it brings forth crops of varying colours, which then wither and you see them turning yellow and then He makes them into broken stubble? There is a reminder in that

And do not follow (blindly) any information of which you have no (direct) knowledge. (Using your faculties of perception and conception, you must verify it for yourself. (In the Court of your Lord,) you will be held accountable for your hearing, sight, and the faculty of reasoning."[17:36]
They will ask you about alcoholic drinks and gambling. Say, ‘There is great wrong in both of them and also certain benefits for mankind. But the wrong in them is greater than the benefit.’ They will ask you what they should give away. Say, ‘Whatever is surplus to your needs.’ In this way Allah makes the Signs clear to you, so that hopefully you will reflect. (2:219)

Would any of you like to have a garden of dates and grapes, with rivers flowing underneath and containing all kinds of fruits, then to be stricken with old age and have children who are weak, and then for a fierce whirlwind containing fire to come and strike it so that it goes up in flames? In this way Allah makes His Signs clear to you, so that hopefully you will reflect. (2:266)

(People with intelligence are) those who remember Allah, standing, sitting and lying on their sides, and reflect on the creation of the heavens and the earth: ‘Our Lord, You have not created this for nothing. Glory be to You! So safeguard us from the punishment of the Fire.’ (3:191)

Say: ‘I do not say to you that I possess the treasuries of Allah, nor do I know the Unseen, nor do I say to you that I am an angel. I only follow what has been revealed to me.’ Say: ‘Are the blind the same as those who can see? So will you not reflect?’ (6:50)

If We had wanted to, We would have raised him up by them. But he gravitated towards the earth and pursued his whims and base desires. His metaphor is that of a dog: if you chase it away, it lolls out its tongue and pants, and if you leave it alone, it lolls out its tongue and pants. That is the metaphor of those who deny Our Signs. So tell the story so that hopefully they will reflect (7:176)

Have they not reflected? Their companion is not mad. He is only a clear warner. (7:184)

The metaphor of the life of this world is that of water which We send down from the sky, and which then mingles with the plants of the earth to provide food for both people and animals. Then, when the earth is at its loveliest and takes on its fairest guise and its people think they have it under their control, Our command comes upon others back for a specified term. There are certainly Signs in that for people who reflect. (39:42)

And He has made everything in the heavens and everything on the earth subservient to you. It is all from Him. There are certainly Signs in that for people who reflect. (45:13)

If We Had sent down this Qur’an onto a mountain, you would have seen it humbled, crushed to pieces out of fear of Allah. We make such examples for people so that hopefully they will reflect (59:21)”

Where is the submission to God in the presence of these verses? Why is it that:

“The Muslim world lags far behind in scientific achievement and research; Muslim countries contribute less than 2 percent of the world's scientific literature. Spain alone produces almost as many scientific papers. In countries with substantial Muslim populations, the average number of scientists, engineers and technicians per 1,000 people is 8.5. The world average is 40. Muslim countries get so few patents that they don't even register on a bar graph comparison with other countries. Of the more than 3-million foreign inventions patented in the United States between 1977 and 2004, only 1,500 were developed in Muslim nations. In a survey by the Times of London, just two Muslim universities -- both in cosmopolitan Malaysia -- ranked among the top 200 universities worldwide… No major invention or discovery has emerged from the Muslim world for well over seven centuries now.”

It is simplistic to say, as Pervez Amirali Hoodbhoy, a Pakistani Muslim physicist does, that, “only when reason bowed to faith, science in the Islamic world essentially collapsed”. Or as one NASA researcher recently put it, "Science has now been replaced by religious thinking…Logic unfortunately is a smaller and smaller part of society." Faith and scientific thought are complementary, and one cannot replace the other. It is only in the complete submission to God that such a harmony is achieved.
The problem lies, therefore in blind adherence to this thing called ‘Islam’, rather than submission to God, which is what it stands for. We have become a people of clichés and labels, rather than people of the essence and what our religion actually stands for. We have become more interested in the scarf and the beard, rather than beauty, justice and rational thought. And, what is even worse, is that those who stand for these things are regarded as ‘deviators’, as ‘corruptors of the religion’. It is the sad state of the world. Those who encourage this view, and advocate the spread of scientific thought and reason, are either rejected, or their life is made difficult, so they leave the ‘Islamic world’ and practice their mental faculties abroad, as one journalist explains, “Today, many of the brightest scientific minds leave their countries to study in Western universities like Virginia Tech and the Massachusetts Institute of Technology, both of which have sizeable Muslim student associations. By some estimates, more than half of the science students from Arab countries never return home to work.”

Among those Islamic thinkers who had to leave the Islamic world because they simply encouraged ‘submission to God’ (as opposed to other authorities), is Muhammad Asad. His story is extremely fascinating, and well worth knowing. One of his biographies reveals this gulf between him and the ‘Muslim world’:

“Unlike so many other Western converts to Islam, Asad chose also to live in Muslim societies, and worked to give Islam direction. But by advocating this reform, Asad remained a foreign body in contemporary Islam, a transplant rejected time and again by his hosts. Saudi Arabia declined to keep him as a journalist; Pakistan, which he served as an official and diplomat, also broke with him; and the self-appointed guardians of Muslim orthodoxy shunned him as a Qur'an translator and commentator. Paradoxically, Asad won genuine acclaim in the West. There he found minds open to his ideas, and opportunities to publish and lecture. And there he ultimately found refuge from the late twentieth-century reality of Islam.”

It is a very sad state of affairs. Personally, I feel like in a manner analogous to Martin Gardner[1], the American mathematician and philosopher that one can drop out of ‘traditional Islam’, the Islam of the beard and the jilbab, and the abandonment of submission to God, and the superiority of the Prophet Muhammad (PBUH) over all men. I also believe that “such a faith, unburdened by strange dogmas”, is truer to the heart of what the Prophet Muhammad (PBUH) and all the great prophets taught, than what the traditional books and most of the current ‘scholars of Islam’ state. Like Gardner believes that “if Jesus were to return to earth today he would not call himself a Christian”, I believe that if the Prophet Muhammad (PBUH) were to return to earth today he would dissociate himself from much that is regarded as ‘Islamic’ today. I would like to regard myself as a follower of the quintessence of Islam, with the aim of becoming a quintessential Muslim, with the utmost respect for reason and science, and the utmost freedom from myth, blind indoctrination and superstition; one who is happy to acquire knowledge and wisdom from everywhere and anywhere, in accordance with the prophetic statement, "Wisdom is like a precious commodity that is lost. A believer must always be in search of it. Wherever he finds it, he must act upon what it dictates"; one who has nothing to fear from any truth, science or wisdom, because all such things emanate from His Beautiful Names in all their glory[2].

Until ‘submission to God’ and His honest and truthful worship are instigated, ‘Islam’ will remain merely be a label, a vacuous concept not worthy of our attentions. It is my firm belief that the Taliban, which stands for everything that ‘traditional Islam’ teaches (those who believe otherwise are mistaken), are but a natural outcome of its blind philosophy. Until we submit ourselves to God, we will remain the defeated, humiliated, irrational, and blind people we are now. Muslims have abandoned God – both the seemingly ‘religious ones’ and the non-religious ones.

The religious ones, as I say, have forgotten the essence of true religion, of submission to God. For them what matters are the rituals and ‘religious laws’, what is permitted and what is forbidden. The principles that the Quran came to advocate are not interesting to them. Even when science is encouraged, it is only encouraged if put under the guise of ‘Islamic science’. One journalist notes, “Muslim scientists who do work in their native countries often find themselves embracing -- publicly at least -- so-called "Islamic science." Popularized in the '80s as an alternative to Western science and its perceived lack of moral values, the Islamic version tries to mesh religion and science with curious results. "Some scholars calculated the temperature of Hell, others the chemical composition of heavenly djinnis spirits," Hoodbhoy writes. "None produced a new machine or instrument, conducted an experiment or even formulated a single testable hypothesis." Instead, fundamentalists typically view science only of value in giving more proof of God or showing the truth of the Koran. One oft-visited Internet site reveals this "astounding scientific fact" -- the Koran anticipated black holes and genes.”

Foremost among these men is Zaghlool Al-Najjar, a wonderful man, I think, who would spend his time better if he were to use his world wide expertise on geology, on glorifying God, and singing His praises through what He has revealed to him of knowledge in the earth, its mountains, its seas, rivers and other aspects of its architecture, rather than trying to correlate all that he has learnt with the ‘Quran’ and ‘Sunnah’, as if God or God’s religion is confined to those two things. I find it immensely contradictory to say that, "The Islamic nation is currently living in a state of backwardness because Muslim intellectuals and figures have been abandoned and their services are being disregarded”, when he is equally as guilt of this backwardness with his advocacy of some rather silly beliefs, some of which I will cast an eye upon in another chapter.

In short, submission to God is not to blame for the demise of the Islamic world and its moral and intellectual decay. Rather, paradoxically, it is the lack of ‘Islam’ or ‘submission to God’. Contrary to common opinion, this demise began not long after the death of the Prophet Muhammad (PBUH); I believe it began soon after the death of the second leader of the Muslims after him, Omar Ibn Al-Khattab. With his death, the Islamic world lost a most powerful and charismatic leader, possibly the greatest political leader of all time.

His successor, our beloved Othman was a great leader too, but, as explained by his biographer, Mohammad Alias Aadil:

“Unlike his predecessor, Umar, who maintained discipline with a stern hand, Uthman was less rigorous upon his people; he focused more on economic prosperity. Under Uthman, the people became economically more prosperous and on the political plane they came to enjoy a larger degree of freedom. No institutions were devised to channel political activity, and, in the absence of such institutions, the pre-Islamic tribal jealousies and rivalries, which had been suppressed under earlier caliphs, erupted once again. In view of the democratic and liberal policies adopted by Uthman, the people took advantage of the liberties allowed them, and as such became a headache for the State, which culminated in the assassination of Uthman.”

Othman was the first Muslim leader to be killed by a Muslim (Omar was assassinated by a Persian non-Muslim), and with his death began a series of political and social disasters that have continued to this day. The golden age of Islam was very brief; what is currently regarded as the golden age of Islam is actually the golden age of pseudo-Islam, contaminated by political feuds, persecutions and submission to authority rather than God; the Islam that came to free man from the chains of human authority and slavery to other men, was no more. Islam was to be turned into a political tool that can be used to exploit others. And what better way to exploit a people than by stripping them off their minds, of their ability to think independently, and force them to follow ‘religious authority’, disguised under the name of ‘hadith’ or ‘the works of the scholars’.

In a review of Sayyid Qutb’s book, ‘Milestones’, David Zeidan remarked that:

“Qutb's view of Islamic history is that of a short golden age under the Prophet and the Rashidun Caliphs. Islam then decayed as it got buried under the rubbish of man-made traditions, interpretations, and superstitions. No true Islamic society has existed for the last several centuries…All accretions must be discarded, and Muslims must return to the model of the first Muslim generation as the paradigm for today's revival…Islam must be incarnated in a dynamic political society, totally obedient to God's sovereignty as expressed in shari`a. Any society or government that does not fully implement shari`a as the sole source of its legislation is jahili. Jahiliyya is not a pre-Islamic historical era of paganism - it is an ever present condition of denying God's rule, usurping His authority, and living by man-made laws that enslave men to their rulers and engender oppression and tyranny”.

This I believe is absolutely spot on; it is only when Muslims started submitting themselves to other authorities that they started to degenerate. The view that the Golden Age of Islam, which was “inaugurated by the middle of the 8th century by the ascension of the Abbasid Caliphate and the transfer of the capital from Damascus to the Persian city of Baghdad”, and which stretched from “the 8th century to the 13th century, though some have extended it to the 15th or 16th centuries”, a period during which “engineers, scholars and traders in the Islamic world contributed to the arts, agriculture, economics, industry, law, literature, navigation, philosophy, sciences, and technology, both by preserving and building upon earlier traditions and by adding inventions and innovations of their own. Howard R. Turner writes: "Muslim artists and scientists, princes and labourers together created a unique culture that has directly and indirectly influenced societies on every continent”” is completely fallacious. There has not really been an Islamic state after the Prophet (PBUH) and the rightly guided caliphs. I am pleased to say that this is not a solitary opinion; many years after deducing this, I found that it was the same opinion given by many of our prominent thinkers, such as Muhammad Asad, who stated the following in the preface to his book, ‘The Principles of State and Government in Islam’:

“For, let us be clear in our minds on one point at least: there has never existed a truly Islamic state after the time of the Prophet and of the Medina Caliphate headed by the Prophet's immediate successors, the four Right-Guided Caliphs, Abu Bakr, 'Umar, 'Uthman and 'Ali. That Medina Caliphate was truly Islamic in the sense that it fully reflected the pristine teachings of both the Quran and the Prophet's Sunnah, and was as yet unburdened by later-day theological accretions and speculations. Whatever forms of state and government came into being in Muslim countries after that first, earliest period were vitiated, in a lesser or higher degree, by ideological deviations from the erstwhile simplicity and clarity of Islamic Law, or even by outright, deliberate attempts on the part of the rulers concerned to deform and obscure that Law in their own interest”.

The reasons for the great praise that has been heaped onto the Islamic civilizations of these times can be deduced from the above quote – it is based on the entirely material aspect of the civilization. It was a civilization akin to modern Western civilization – great in terms of material progress, science and technology, but a lack of or even absence of the human being in it. The leaders of those Islamic civilizations were extravagant, and far more interested in power and wealth than in the welfare of humanity, which is what Islam stood for in the times of the Prophet and the first ‘rightly guided Caliphs’. As put eloquently by the great H G Wells in his ‘Outline of History’, “The splendid opening of the story of Islam collapses suddenly into this squalid dispute and bickering of heirs and widows…For a moment we stand amazed at the greatness of the Abbasid dominion; then suddenly we realize that it is but as a fair husk enclosing the dust and ashes of dead civilizations”
██ Expansion under the Prophet Mohammad, 612-632
██ Expansion during the Rightly Guided Caliphate, 635-661
██ Expansion during the Umayyad Caliphate, 661-750

A brief glance at the above map, looking at the extent of Islamisation of the world during the times of the prophet (PBUH), the rightly guided caliphs, and the Umayyad era, will show that, the no further Islamisation took place afterward – it is as if the universal message of Islam, of submission to God came to a complete stand still. With their demise, as Wells says, “The first tremendous impulse of Islam was now spent. There was no further expansion and a manifest decline in religious zeal”. This is not because Islam’s message, the very simple, down-to-earth monotheism and idea of life being about ‘worship’ of God (and we are not talking here about ritualistic worship, but the dedication of one’s entire life to God) suddenly became inapplicable to the times, but rather because of something else. H G Wells put it well:

“And if the reader entertains any delusions about a fine civilization, either Persian, Roman, Hellenic, or Egyptian, being submerged by this flood, the sooner he dismisses such ideas the better. Islam prevailed because it was the best social and political order the times could offer. It prevailed because everywhere it found politically apathetic peoples, robbed, oppressed, bullied, uneducated, and unorganized, and it found selfish and unsound governments out of touch with any people at all. It was the broadest, freshest, and cleanest political idea that had yet come into actual activity in the world, and it offered better terms than any other to the mass of mankind. The capitalistic and slave holding system of the Roman Empire and the literature and culture and social tradition of Europe had altogether decayed and broken down before Islam arose, it was only when man kind lost faith in the sincerity of its -representatives that Islam, too, began to decay.”

It is because the Abbasid leaders were corrupt, and were not interested in spreading the message – they were more interested in plundering more wealth and property. H G Wells explains this very well and thoroughly in his ‘Outline of History’, in a passage I quote here in full:

“Abul Abbas was the first of the Abbasid Caliphs, and he began his reign by collecting into one prison every living male of the Omayyad line upon whom he could lay hands and causing them all to be massacred. Their bodies, it is said, were heaped together, a leathern carpet was spread over them, and, on this gruesome table Abul Abbas and his councilors feasted. Moreover, the tombs of the Omayyad Caliphs were rifled, and their bones burnt and scattered to the four winds of heaven. So the grievances of Ali were avenged at last, and the Omayyad line passed out of history.

The Abassids were adventurers and rulers of an older school than Islam. Now that the tradition of Ali had served its purpose, the next proceeding of the new Caliph was to hunt down and slaughter the surviving members of his, family, the descendants of Ali and Fatima…. Mansur, the successor of Abul Abbas, built himself a new capital at Bagdad near the ruins of Ctesiphon, the former Sassanid capital. Turks and Persians as well as Arabs became Emirs, and the army was reorganized upon Sassanid lines. Medina and Mecca were now only of importance as pilgrimage centres, to which the faithful turned to pray. But because it was a fine language, and because it was the language of the Koran, Arabic continued to spread until presently it had replaced Greek and become the language of educated men throughout the whole Moslem world.

Of the Abbasid monarchs after Abul Abbas we need tell little here. A bickering war went on year by year in Asia Minor in which neither Byzantium nor Bagdad made any permanent gains, though once or twice the Moslems raided as far as the Bosphorus. A false prophet Mokanna, who said he was God, had a brief but troublesome career. There were plots, there were insurrections; they lie flat and colourless now in the histories like dead flowers in an old book. One other Abbasid Caliph only need be named, and that quite as much for his legendary as for his real importance, Haroun-al-Raschid (786-809). He was not only the Caliph of an outwardly prosperous empire in the world of reality, but he was also the Caliph of an undying empire in the deathless world of fiction, he was the Haroun-al-Raschid of the Arabian Nights.

Sir Mark Sykes gives an account of the reality of his empire from which we will quote certain passages. He says, “The Imperial Court was polished, luxurious, and unlimitedly wealthy; the capital, Bagdad, a gigantic mercantile city surrounding a huge administrative fortress, wherein every department of state had a, properly regulated and well-ordered public office; where schools and colleges abounded; whither philosophers, students, doctors, poets, and theologians flocked from all parts of the civilized globe . . . The provincial capitals were embellished with vast public buildings, and linked together by an effective and rapid service of posts and caravans; the frontiers were secure and well garrisoned, the army loyal, efficient, and brave; the governors and ministers honest and forbearing. The empire stretched with equal strength and unimpaired control from the Cilician Gates to Aden, and -from Egypt to Central Asia. Christians, Pagans, Jews, as well as Moslems, were employed in the government service. Usurpers, rebellious generals, and false prophets seemed to have vanished from the Moslem dominions. Traffic and wealth had taken the place of revolution and famine . . . Pestilence and disease were met by Imperial hospitals and government physicians . . . In government business the rough-and-ready methods of Arabian administration had given place to a complicated system of Divans, initiated partly from the Roman, but chiefly taken from the Persian system of government. Posts, Finance, Privy Seal, Crown Lands, Justice, and Military affairs were each administered by separate bureaux in the hands of ministers and officials; an army of clerks, scribes, writers, and accountants swarmed into these, offices and gradually swept the whole power of the government into their own hands by separating the Commander of the Faithful from any direct intercourse with his subjects. The Imperial Palace and the entourage were equally based on Roman and Persian precedents. Eunuchs, closely veiled 'harems' of women, guards, spies, go betweens, jesters, poets, and dwarfs clustered around the person of the Commander of the Faithful, each, in his degree, endeavoring to gain the royal favour and indirectly distracting the royal mind from affairs of business and state.

Meanwhile the mercantile trade of the East poured gold into Bagdad, and supplemented the other enormous stream of money derived from the contributions of plunder and loot dispatched to the capital by the commanders of the victorious raiding forces which harried Asia Minor, India, and Turkestan. The seemingly unending supply of Turkish slaves and Byzantine spice added to the richness of the revenues of Irak, and, combined with the vast commercial traffic of which Bagdad was the centre, produced a large and powerful moneyed class, composed of the sons of generals, officials, landed proprietors, royal favorites, merchants, and the like, who encouraged the arts, literature, philosophy, and poetry as the mood took them, building palaces for themselves, vying with each other in the luxury of their entertainments, suborning poets to sound their praises, dabbling in philosophy, supporting various schools of thought, endowing charities, and, in fact, behaving as the wealthy have always behaved in all ages.”

I have said that the Abbasid Empire in the days of Haroun-al-Raschid was weak and feeble to a degree, and perhaps the reader will consider this a foolish proposition when he takes into consideration that I have described the Empire as orderly, the administration definite and settled, the army efficient, and wealth abundant. The reason I make the suggestion is that the Abbasid Empire had lost touch with everything original and vital in Islam, and was constructed entirely by the reunion of the fragments of the empires Islam had destroyed. There was nothing in the empire which appealed to the higher instincts of the leaders of the people; the holy war had degenerated into a systematic acquisition of plunder. The Caliph had become a luxurious Emperor or King of Kings; the administration had changed from a patriarchal system to a bureaucracy. The wealthier classes were rapidly losing all faith in the religion of the state; speculative philosophy and high living were taking the place of Koranic orthodoxy and Arabian simplicity. The solitary bond which could have held the empire together, the sternness and plainness of the Moslem faith, was completely neglected by both the Caliph and his advisers . . . Haroun-al-Raschid himself was a winebibber, and his palace was decorated with graven images of birds and beasts and men . . .

Haroun-al-Raschid died in 809. At his death his great empire fell immediately into civil war and confusion, and the next great event of unusual importance in this region of the world comes two hundred years later when the Turks, under the chiefs of the great family of the Seljuks, poured southward out of Turkestan, and not only conquered the empire of Bagdad, but Asia Minor also. Coming from the northeast as they did, they were able to outflank the great barrier of the Taurus Mountains, which had hitherto held back the Moslems. They were still much the same people as those of whom Yuan Chwang gave us a glimpse four hundred years earlier, but now they were Moslems, and Moslems of the primitive type, men whom Abu Bekr would have welcomed to Islam. They caused a great revival of vigour in Islam, and they turned the minds of the Moslem world once more in the direction of a religious war against Christendom. For there had been a sort of truce between these two great religions after the cessation of the Moslem advance and the decline of the Omayyads. Such warfare as had gone on between Christianity and Islam had been rather border - bickering than sustained war. It became only a bitter fanatical struggle again in the eleventh century.”

Compare this excessiveness and spend thriftiness (which of course, we nowadays see on a regular basis in the Gulf Arabs who come to London and Las Vegas to spend their petrodollars, or who have three or four palaces each, if not more) with the simplicity of the great Prophet, who history books tell us, “He was the greatest charitable man. He did not pass a single night hoarding any dirham or dinar. Whenever any excess money came to him and if he did not then get anyone to accept it as charity, he did not return home till he gave it to the poor and the needy. He did not store up for more than a year the provision of his family members which Allah was pleased to give him. He used to take one fifth of what easily came to him out of dates and wheat. What remained in excess, he used to give in charity. He used to give away in charity to one who begged anything of him, even out of his stored up provision”.

Or the great caliph Abu Bakr, who, “When he became a Muslim he had an amount of 40,000 dirhams. The entire amount was spent by him in the cause of Islam. He paid for the liberation of slaves. He financed the journey of the Holy Prophet from Makkah to Madina on the occasion of emigration. He paid for the land acquired for the construction of the Prophet's mosque at Madina. When the Holy Prophet invited contributions for financing the Tabuk expedition, Abu Bakr contributed all his assets for the purpose, and when the Holy Prophet inquired as to what he had kept for himself and his dependents he said that for himself and his dependents he had left Allah and His Prophet. He was an embodiment of selflessness. When he became the Caliph he was paid a meager allowance from the treasury. On his deathbed he sold a plot of his land and repaid the entire amount to the treasury. He lived a simple unostentatious life. One of his wives once expressed the wish to have a sweet dish. Abu Bakr deposited the amount in the public treasury and had his allowance reduced to the extent of the saving made by his wife, on the ground that such amount was surplus to his genuine needs”.

Or the great Omar, whose “abstinence and humility… were not inferior to the virtues of Abu Bakr: his food consisted of barley bread or dates; his drink was water; he preached in a gown that was torn or tattered in twelve places; and a Persian satrap, who paid his homage as to the conqueror, found him asleep among the beggars on the steps of the mosque of Muslims. Economy is the source of liberality, and the increases of the revenue enabled Umar to establish a just and perpetual reward for the past and present services of the faithful.” Or Othman or Ali, both of whom were known for their generosity and humanity.

I don’t agree with the famous Belgian historian George Sarton, when he writes in, ‘The Incubation of Western Culture in the Middle East':

“The decadence of Islam and of Arabic is almost as puzzling in its speed and completeness as their phenomenal rise. Scholars will forever try to explain it as they try to explain the decadence and fall of Rome. Such questions are exceedingly complex and it is impossible to answer them in a simple way."

The reason for the decadence of Islam is actually quite simple. There is one difference between the Muslims during the era of the Prophet and the Rightly Guided Caliphs, and those coming afterward. Muslims neglected God and His word. Sayyid Qutb brilliantly explained this in the introduction to his aforementioned work:

“The callers to Islam in every country and in every period should give thought to one particular aspect of the history of Islam, and they should ponder over it deeply. This is related to the method of inviting people to Islam and its ways of training.

At one time this Message created a generation - the generation of the Companions of the Prophet, may God be pleased with them - without comparison in the history of Islam, even in the entire history of man. After this, no other generation of this caliber was ever again to be found. It is true that we do find some individuals of this caliber here and there in history, but never again did a great number of such people exist in one region as was the case during the first period of Islam.

This is an obvious and open truth of history, and we ought to ponder over it deeply so that we may reach its secrets.

The Qur'an of this Message is still in our hands…The only difference is the person of the Messenger of God - peace be on him; but is this the secret?

Had the person of the Prophet - peace be on him - been absolutely essential for the establishment and fruition of this message, God would not have made Islam a universal message, ordained it as the religion for the whole of mankind, given it the status of the last Divine Message for humanity, and made it to be a guide for all the inhabitants of this planet in all their affairs until the end of time.

God has taken the responsibility for preserving the Holy Qur'an on Himself because He knows that Islam can be established and can benefit mankind even after the time of the Prophet - peace be on him. Hence He called His Prophet - peace be on him - back to His mercy after twenty three years of messengership and declared this religion to be valid until the end of time. Therefore the absence of the Messenger of God - peace be on him - is not the real cause for, nor does it explain, this phenomenon.

We look, therefore, for some other reasons, and for this purpose we look at that clear spring from which the first generation of Muslims quenched their thirst. Perhaps something has been mixed with that clear spring. We should look at the manner in which they received their training. Perhaps some changes have found their way into it.

The spring from which the Companions of the Prophet - peace be on him-drank was the Qur'an; only the Qur'an as the Hadith of the Prophet and his teachings were offspring of this fountainhead. When someone asked the Mother of the Faithful, Aisha-may God be please- with her,-about the character of the Prophet-peace be on him,-she answered, "His character was the Qur'an".

The Holy Qur'an was the only source from which they quenched their thirst, and this was the only mold in which they formed their lives. This was the only guidance for them, not because there was no civilization or culture or science or books or schools. Indeed, there was Roman culture, its civilization, its books and its laws, which even today are considered to be the foundation of European culture. There was the heritage of Greek culture- its logic, its philosophy and its arts, which are still a source of inspiration for Western thought. There was the Persian civilization, its art, its poetry and its legends, and its religion and system of government. There were many other civilizations, near or far, such as the Indian and Chinese cultures, and so on. The Roman and Persian cultures were established to the north and to the south of the Arabian peninsula, while the Jews and Christians were settled in the heart of Arabia. Thus we believe that this generation did not place sole reliance on the Book of God for the understanding of their religion because of any ignorance of civilization and culture, but it was all according to a well thought out plan and method. An example of this purpose is found in the displeasure expressed by the Messenger of God - peace be on him -when 'Umar-may God be pleased with him-brought some pages from the Torah. The Messenger of God-peace be on him-said, "By God, if even Moses had been alive among you today, he would have no recourse except to follow me" [Reported by al-Hafidh Abu Yala from Himad, from al-Shubi, from Jabir.]

It is clear from this incident that the Messenger of God - peace be on him - deliberately limited the first generation of Muslims, which was undergoing the initial stages of training, to only one source of guidance, and that was the Book of God. His intention was that this group should dedicate itself purely to the Book of God and arrange its lives solely according to its teachings. That is why the Messenger of God -peace be on him-was displeased when 'Umar-may God be pleased with him-turned to a source different from the Qur'an

In fact, the Messenger of God-peace be on him-intended to prepare a generation pure in heart, pure in mind, pure in understanding. Their training was to be based on the method prescribed by God Who gave the Qur'an, purified from the influence of all other sources.

This generation, then, drank solely from this spring and thus attained a unique distinction in history. In later times it happened that other sources mingled with it. Other sources used by later generations included Greek philosophy and logic, ancient Persian legends and their ideas, Jewish scriptures and traditions, Christian theology, and, in addition to these, fragments of other religions and civilizations. These mingled with the commentaries on the Qur'an and with scholastic theology, as they were mingled with jurisprudence and its principles. Later generations after this generation obtained their training from this mixed source, and hence the like of this generation never arose again.

Thus we can say without any reservations that the main reason for the difference between the first unique and distinguished group of Muslims and later Muslims is that the purity of the first source of Islamic guidance was mixed with various other sources, as we have indicated.”

Once again, Qutb is speaking the truth. It is only when we developed an adherence to the irrational and sometimes downright bizarre teachings of the ‘hadith’, and ‘words of scholars’ that we collapsed. It is my personal belief that blind adherence to ‘hadith’, and the belief that what certain people wrote hundred of years after the prophet Muhammad (PBUH) lived or is said to have said it can be the foundation of a nation, is one of the most corrupt influences on modern Islam, or submission to God.

The criticism of ‘hadith’ is invaluable – this is because, Islam, as we have it now, is based, to a great deal on it. That is a fact we cannot deny. It has, in many cases (for instance, in the case of apostasy, in the case of punishment of the adulterer, and other things) come to have greater importance than the Qur’an itself. And Islam as we have it now, and I have already made clear, is not submission to God. Muslim nations are the nations of darkness, of foolishness, of utter absurdity. Spirituality is ridiculed, and humanity abhorred. By criticising it, and picking out what is good from it, using the six golden principles originated by Omar Ibn Al-Khattab (RAA), we will benefit a great deal from it:

“Umar was alive to the danger that whatever was ascribed to the Holy Prophet, right or wrong would obtain currency and venerable acceptance. Umar evolved principles on the basis of which the traditions were to be accepted. The basic principles were:

§ The report should be literally faithful;
§ Every Hadith narrated should carry with it the name of the narrator and the chain of narrators;
§ The narrators must be men of proven faith and integrity;
§ In judging the veracity of a report the occasion and circumstances involved should be taken into consideration;
§ The report should not be repugnant to the Holy Quran;
§ The report should be rational.”

This is the opinion of some of our greatest current thinkers, and it is only aiming for the progress of mankind. For instance, this is how Abdul Hamid Abu Sulayman put it:

“It is imperative that the texts of the authentic Sunnah be collected, classified, and placed within easy reach of scholars, researchers, and specialists in all fields of knowledge. These texts must be indexed, ordered by subject content, and purged of all accretions. Such a classification of the Sunnah may be completed in the following manner:

§ Those hadiths which, owing to the authenticity of their narration (sanad) and the soundness of their meaning, may be accepted as authoritative evidence.
§ Those hadiths which, owing to the soundness of their meaning, may be accepted as evidence, even if their narration is open to debate.
§ Those hadiths which, regardless of what may be said about the authenticity or otherwise of their narration, are questionable in terms of meaning (i.e., their meanings seem to be in some way contradictory to the principles or purposes of the Shari'ah).
§ Those hadiths which, owing to the dubious authenticity of their narration and the contradictory nature of their meaning, may not be considered acceptable as evidence.

The importance of this methodological issue is not limited to the mishandling of the Sunnah, for in many cases the Muslim mind is overawed by what is clearly unsound, with the result that when it accepts something unsound as sound, it loses its ability to discriminate and perceive things as they truly are. Finally, the Muslim mind, thought, and methodology lose all value and utility when they become accustomed to accepting principles other than the divinely revealed principles and approaches contained in the Qur'an and the Sunnah”.

All that I find inhumane and abhorrent about Islam as currently practised, can be found in the thousands of ‘ahadith’ that the great Prophet (PBUH) is reported to have said, which I am pretty sure he didn’t, for most of them do not fulfil the above six criteria. We will see evidence of this in the next chapter. I will bring this discussion to a close by drawing the reader’s attention to some interesting historical facts:

“Out of the entire collection of Hadith running into thousands of items, only 142 items are attributed to the authority of Abu Bakr. Of all the companions of the Holy Prophet, Abu Bakr was the closest to him, and one would expect Abu Bakr to be a repository of a larger number of traditions. The comparatively smaller number of traditions owing their authority to the reporting of Abu Bakr is attributed to the extraordinary care and caution exercised by Abu Bakr in sifting the tradition.

According to Ayesha, Abu Bakr had originally a collection of over five hundred traditions, and he deposited the compilation with her for custody. Ayesha relates that one night she noticed that Abu Bakr felt very restless. He tossed about in the bed, and could not sleep. Ayesha got worried whether he was suffering or was worried. He made no reply, but remained restless throughout the night. The following morning he asked Ayesha to bring him the collections that he had deposited with her. She brought the compilation and he set fire to it. On the enquiry of Ayesha, Abu Bakr explained his conduct thus: "The collection contained many traditions that I had heard from other people. I thought that if I died and left behind traditions accepted by me as authentic, but really not so, then I would have to answer for that."

Another fascinating fact, “Lest the people should make mistakes in reporting Hadith direct from the Holy Prophet, Umar forbade the Companions to report direct from the Holy Prophet. Umar also enjoined that Hadith should not be mixed with the Quran. Lest there might be mistake in reporting. Umar enjoined, "Report sparingly from the Holy Prophet". When Umar was asked to quote traditions he would usually say "Had I not feared that I might make a mistake in reporting Hadith I would have quoted one." Umar emphasized that extra care should be taken to ensure that there was no mistake in reporting. The checks and restraints imposed by Umar on the reporting of traditions and the high standard of accuracy required by him paid dividends and all the traditions that were accepted and publicized were free from flaw.” Compare this with the way ‘Islamic scholars’ these days say on an hourly basis, “The prophet said” and “The prophet did”, without any mention of the ‘sanad’, as if they were there to witness the event.

Finally, “Omar Ibn Al-Khattab, the second guided Khalifa threatened Abu Hurayra to send him to exile if he does not stop telling hadiths about Muhammed, he did stop until Omar's assassination then started again. He kept telling hadiths to please the Khalifa of the Muslims then, all the time, including the time he lived in the royal palace of Muawaya in Syria. Abu Hurayra told his audience that he is telling them hadiths that if he ever mentioned when Omar was alive, he would be given several lashes”. Abu Huraya is the most frequent man to give ahadith about the prophet (PBUH), even though he spent only three years with the prophet. The message is clear.

I conclude this section with a quote from a wonderful book I recently picked up, ‘Crisis in the Muslim Mind’ by Abdul Hamid A. Abu Sulayman which I think is essential reading for all who care about our fate:

“The methodology of Islam in its earliest ages was a natural and automatic sort of methodology that relied on the wisdom of revelation and the soundness of human reason and ijtihad that sprang from the untainted human fitrah. Thus the prophetic and the caliphal ages were the best examples of the human spirit for all the generations that followed.”

[1] Martin Gardner stated in the final chapter of his brilliant, ‘The Whys of a Philosophical Scriviner’ (p.347), “I also believe…that one can drop out of a traditional religion such as Christianity without at the same time abandoning faith in a personal God or in life after death. Indeed, I believe that such a faith, unburdened by strange dogmas, is truer to the heart of what Jesus probably taught than the New Testament records indicate. Many of the doctrines of Paul would have astonished Jesus, just as Paul would have been amazed by some myths that became part of the gospels. And Jesus and Paul alike would surely have been bewildered – in my opinion, shocked – by most of the doctrines fabricated later by the Holy Roman Church” .

[2] As He (SWT) describes Himself, “Allah! There is no deity save Him, the Alive, the Eternal. Neither slumber nor sleep overtaketh Him. Unto Him belongeth whatsoever is in the heavens and whatsoever is in the earth. Who is he that intercedeth with Him save by His leave? He knoweth that which is in front of them and that which is behind them, while they encompass nothing of His knowledge save what He will. His throne includeth the heavens and the earth, and He is never weary of preserving them. He is the Sublime, the Tremendous (2:255)” and “He is Allah, than Whom there is no other Allah, the Knower of the Invisible and the Visible. He is the Beneficent, Merciful. He is Allah, than Whom there is no other Allah, the Sovereign Lord, the Holy One, Peace, the Keeper of Faith, the Guardian, the Majestic, the Compeller, the Superb. Glorified be Allah from all that they ascribe as partner (unto Him).He is Allah, the Creator, the Shaper out of naught, the Fashioner. His are the most beautiful names. All that is in the heavens and the earth glorifieth Him, and He is the Mighty, the Wise” (59:22-24).

GOD, TRADITIONAL ISLAM AND MEDICINE

2008-09-16T21:01:00.000-07:00

GOD, TRADITIONAL ISLAM AND MEDICINE

THE MAJESTY OF GOD AS REVEALED IN MEDICINE

If one were to do an internet search, via any search engine, and type the words – ‘God’ and ‘medicine’, one will encounter, almost fully, websites on mythology, chiefly on the ‘Greek God of Medicine’, Asclepios, and other rather uninteresting websites (several on a a group I had never heard of before, called ‘The Mission’ who released an album called ‘God’s Own Medicine’ in the 1980s).

This is rather unfortunate, for God in all His glory is not a myth. He is a living reality in the just and truthful practice of medicine, who we ought to discover, praise and be thankful to in every single moment that we practice seeing patients and studying about disease and its cure, be it medical or surgical. Alas, although one would expect Muslim or deistic doctors and writers to explore this aspect in more depth, this has not, as far as I can see, been the case. There is a virtually complete silence over the topic among deists, while Muslims appear to be more interested in the ethical and psychosocial considerations of medicine, and what their religion says about topics like euthanasia, abortion, and genetic engineering, and the very peculiar fields of ‘Islamic medicine’ (as if medicine has a religion) and ‘Prophetic Medicine’. I hope in the course of this work to start a way of looking at medicine and its associated sciences, in a different fashion, highlighting the glory and the wonder of it all, which stems from He who has the Eternal Glory, Majesty and Beauty. Many of His Glorious Attributes are highlighted in Medicine.

His generosity is highlighted in giving is not one, but two of many organs – the eyes, the ears, the lungs, the kidneys, and others. Even those organs that we have only singularly, like the liver, a quite substantial degree of damage is needed before problems arise. With the heart, the great kindness of God is evident in the fact that disease of the coronary arteries often needs to be quite severe before symptoms occur. This, it goes without saying poses a problem for cardiologists. Nicholas Boon, writing in ‘Davidson’s Principles and Practice of Medicine’, believes:

“Prompt recognition of the development of heart disease is limited by two key factors. Firstly, it is very commonly latent. For example, disease of the coronary arteries can proceed to an advanced stage before the patient notices any symptoms. Secondly, the diversity of symptoms attributable to heart disease is limited and it is common for many different pathologies to present through a common symptomatic pathway”

His architecture and artistry is evident in everything in it. The study of anatomy and dissection was pursued by Leonardo da Vinci and other great sculptors and artists in all times and places – they aspired to emulate the beauty of the human body.

His kindness in giving us medicine, and the intellect and knowledge to search for it and find it – although at times I think it is simply divine providence that has led us to these discoveries; wasn’t penicillin, the father of all antibiotics discovered by accident, when Alexander Fleming, “Quite by accident… found (a) substance in 1928. This substance was produced by a mold that had somehow landed on one of his cultures of staphylococcus. It was evident in a ring of dead bacteria around each speck of mold”. Saeed Hawa, writing in his book, ‘Allah’, describes this thus:

“In the story of the discovery and existence of penicillin, there is another example of this point. Just as man enjoys his food, clothing and beautiful landscapes, he also enjoys knowledge. It will be sufficient if some of Allah’s creatures show His wisdom, mercy and care towards His creatures”.

Even vaccination was a process based originally not on the triumph of human logic taken to its natural conclusion, but by an accident. As explained by Bryan Bunch and Alexander Hellemans in their celebrated ‘History of Science and Technology’, “Louis Pasteur discover(ed) by accident that weakened chicken cholera bacteria fail to cause disease in chickens and that chickens previously infected with the weakened bacteria are immune to the normal form of the bacteria, thus paving the way for the development of vaccines against many diseases”. In such ‘productive accidents’ (which we will talk about in greater detail in a later section) we see the truth of the Quranic statement, “He has taught man what he did not know” (96:5). And so many other things which I will endeavor to talk about in these pages.

And it is not just such external ‘medicines’ that I am talking about; any physician will tell us that the immune system that we have, to protect against, and fight illness, is the most powerful disease combating force there is. Richard C Cabot, an American physician based in Massachusetts General Hospital put it this way, "Every educated physician knows that most diseases are not appreciably helped by medicine." In like fashion, Albert Schweitzer, the great German physician and philosopher said, “It's supposed to be a secret, but I'll tell you anyway. We doctors do nothing. We only help and encourage the doctor within." Voltaire said it another way, “The art of medicine consists in amusing the patient while nature cures the disease”. Before them, the Swiss physician Paracelsus said it, "It is from nature that the disease arises and from nature comes the cure, not from the physician." And before them, Hippocrates, the father of medicine after whom the famous oath is names expressed it thus, "The natural force within each of us is that greatest healer of all." It is this force that the great prophet Abraham noted before them all, saying, “And if I am sick, it is He who heals me”.

In the existence of death, suffering and disease, we see His power and dominion over His Creation. Paul McHugh put it well, "The medical report is an account of nature's power over human life through infections, neoplasms, genes and the like”. Indeed, it is in the deeper daily contact with and reflection over these things, that the physician derives his greatest exclusivity. Or should do, for in most cases, death triggers very few or even no higher thoughts, in the majority of doctors living in our materialistic society today. Benedict Spinoza’s words, "A free man thinks of nothing less than of death; and his wisdom is a meditation not of death, but of life," are very apt in describing the attitude of many doctors to death these days, a generally mechanical, duty based one (diagnosing the patient dead, filling out the death certificate, a cremation form etc) devoid of the use of the higher faculties.

His forgiveness in knowing that, in His great mercy, in all hardship and suffering, there is forgivenss of sins. Does He not say, “Verily with every difficult situation there is a relief” (94:6), or “And be patient in hardship: for, verily, God is with those who are patient in hardship” (8:46). The Prophet (PBUH) is reported to have said many sayings with regards to this, such as:

“Anas (RA) reported that the Prophet (SAW) said: “The amount of reward is in accordance with the amount of suffering. When Allah (SWT) loves some people, He tries them (with affliction). He who then is content (with Allah’s decree) has achieved the acceptance (of Allah), and he who is dissatisfied (with Allah’s decree) will attain the anger (of Allah).” [Tirmithee]

Abu Hurayrah (RA) reported that the Prophet (SAW) said: “Whenever a Muslim is afflicted by harm from sickness or other matters, Allah will drop his sins because of that, like a tree drops its leaves.” [Bukharee and Muslim]

Abu Sa’eed al-Khudree (RA) reported that the Prophet (SAW) said: “A Muslim is not afflicted by hardship, sickness, sadness, worry, harm, or depression - even if pricked by a thorn, but Allah expiates his sins because of that.” [Bukharee and Muslim]”

Confining myself to the two strictly monotheistic religions, we can see that the relationship between religion and medicine has taken many different complexions over the years – in many cases, it has been a positive and powerful one. But at other times it has been a very negative.

THE RELATIONSHIP OF TRADITIONAL ISLAM TO MEDICINE

Confining myself to what I know best, since I am not expert on the relationship of Christianity or Judaism to medicine, I will only discuss the relationship of traditional Islam to medicine here.

What I have just mentioned about Avicenna, Rhazes and others is of course a positive thing, and I think it should remain forever in the memory of all those who seek the truth. It is not enough however to remember their names – it is important to know of their actual contributions too. The reason for this is that those who counter truth have striven in recent times to denounce our religion using these things – foolish men like the militant Christian writer Robert Spencer, who wrote the strange (and I do not speak as a Muslim, but simply as a rational observer and reader) ‘Politically Incorrect Guide To Islam’ and said:

“Take, for example, the medical sciences, Muslims established the first pharmacies and were the first to require standards of knowledge and competence from doctors and pharmacists, enforced by an examination.' At the time of the fifth Abbasid caliph, Harun al-Rashid (763-809), the first hospital was established in Baghdad, and many more followed. Yet it was not a Muslim, but a Belgian physician and researcher, Andreas VesaIius (1514-1564), who paved the way for modern medical advances by publishing the first accurate description of human internal organs, De Humani Corporis Fabrica (On the Fabric of the Human Body) in 1543. Why? Because Vesalius was able to dissect human bodies, while that practice was forbidden in Islam, What's more, Vesalius's book is filled with detailed anatomical drawings—but also forbidden in Islam are artistic representations of the human body”.

Or the even more pathetic Pakistani atheist (ex-Muslim) Ibn Warraq, author of the rather biased ‘Why I Am Not a Muslim’ (I would like one day to write a one page rebuttal to that book and call it, ‘Do I Give a Toss’ but will leave that major project for the time being) who believes that ‘orthodox Muslims’ never contributed to medicine, or were even actively against it (I presume he believes that they all desired ill health), and that all valuable contributions that Muslims have made to medical science and practice throughout the ages came after they opposed the religion, or freed themselves from its beliefs. But unlike Spencer, at least Ibn Warraq admits to Muslim contribution to medicine, saying in his book, “Much original work was also done in medicine, algebra, arithmetic, geometry, mechanics and astronomy”.

Indeed, this is the case – to quote one source:

“The contributions of Ibn al-Haytham (Alhacen) to anatomy and physiology include his correct explanation of the process of sight and visual perception for the first time in his Book of Optics, published in 1021. Other innovations introduced by Muslim physicians to the field of physiology by this time include the use of animal testing and human dissection. Ibn Zuhr (Avenzoar) (1091-1161) was one of the earliest physicians known to have carried out human dissection and postmortem autopsy. He proved that the skin disease scabies was caused by a parasite, a discovery which upset the theory of humorism supported by Hippocrates and Galen. The removal of the parasite from the patient's body did not involve purging, bleeding, or any other traditional treatments associated with the four humours.In the 12th century, Saladin's physicians al-Shayzari and Ibn Jumay were also among the earliest to undertake human dissection, and they made explicit appeals for other physicians to do so as well. During a famine in Egypt in 1200, Abd-el-latif observed and examined a large number of skeletons, and he discovered that Galen was incorrect regarding the formation of the bones of the lower jaw and sacrum. Ibn al-Nafis, the father of circulatory physiology, was another early proponent of human dissection. In 1242, he was the first to describe the pulmonary circulation, coronary circulation, and capillary circulation, which form the basis of the circulatory system, for which he is considered the one of the greatest physiologists in history. The first European descriptions of the pulmonary circulation came several centuries later, by Michael Servetus in 1553 and William Harvey in 1628. Ibn al-Nafis also described the earliest concept of metabolism, and developed new Nafisian systems of anatomy, physiology and psychology to replace the Avicennian and Galenic doctrines, while discrediting many of their erroneous theories on the four humours, pulsation, bones, muscles, intestines, sensory organs, bilious canals, esophagus, stomach, and the anatomy of almost every other part of the human body.”

This belief that Muslims were merely transmitters, translators, and preservers of old medical practices, with no original contribution is completely unsubstantiated. I do not know why great thinkers, the like of Bertrand Russell were not aware of this fact. Russell made his opinion clear in his ‘History of Western Philosophy’, saying:

“Arabic philosophy is not important as original thought. Men like Avicenna and Averroes are essentially commentators. Speaking generally, the views of the more scientific philosophers come from Aristotle and the Neoplatonists in logic and metaphysics, from Galen in medicine, from Greek and Indian sources in mathematics and astronomy, and among mystics religious philosophy has also an admixture of old Persian beliefs. Writers in Arabic showed some originality in mathematics and in chemistry--in the latter case, as an incidental result of alchemical researches.

Mohammedan civilization in its great days was admirable in the arts and in many technical ways, but it showed no capacity for independent speculation in theoretical matters. Its importance, which must not be underrated, is as a transmitter. Between ancient and modern European civilization, the dark ages intervened. The Mohammedans and the Byzantines, while lacking the intellectual energy required for innovation, preserved the apparatus of civilization--education, books, and learned leisure.”

Perhaps it is we, those who believe in God, and have submitted to Him, are to blame for the skewed opinions of some of the world’s great thinkers on such things. We need to highlight their original contributions, and set an example ourselves too by making such contributions ourselves.

And it all happened because of, rather than in spite of, religious guidance. Warraq is obsessed with quoting orientalist scholars (indeed that is why his only book not attacking Muslims is an attack on the great Edward Said, the man who first exposed orientalism and its goals and intentions) such as Plessner, Grunebaum and Ernest Renan, and uses them to substantiate his argument that Muslim progress came in spite of, rather than because of Islam – submission to God.
The first point I would to make with regards to Warraq’s claims is not regarding those claims, but something he writes prior to that discussion. He says, in his aforementioned work:

“As Ibn Khaldun reminds us, Arabs did not play a great part in the original development of Islamic science. “It is strange that most of the learned among the Muslims who have excelled in the religious or intellectual sciences are non-Arabs with rare exceptions, and even those savants who claimed Arabian descent spoke a foreign language, grew up in foreign lands, and studied under foreign masters.” As Martin Plessner says, emphasizing the internationality and inter-religiousness of Islamic science, most of the credit must go to Persians, Christians and Jews”.

I write as an objective reviewer – firstly, I ask, is there any need for this statement, but an unfair critique of the Arabs. The book is entitled, ‘Why I am Not a Muslim’, and not ‘Why I am not an Arab’. But perhaps it is the publishers who are to reprimand, and not the Pakistani ex-zealot, who I hasten to add, admitted that he wished to volunteer for the Israeli army in the 1967 war. That says a lot I think.

Secondly, I ask him to think about his statement once again and see how it contradicts the thrust of his work (but to be fair to him, he appears to be incapable of original thought, admitting in the ‘Acknowledgements’ section of his book, “I am not a scholar or a specialist. I certainly do not lay claim to originality; I lean heavily on the works of real scholars…there is hardly an image or thought that I can claim to be my own creation”. The only word[1] that I can change in that line is ‘heavily’ – the correct word is ‘entirely’. The Jews, Christians and Persians had their own civilizations for hundreds (and in cases of the Jews and Persians, thousands of years) prior to the arrival of the Prophet Muhammad and his followers. If that were the case, why didn’t they precede Islam with such discoveries?

Moving on swiftly, Warraq’s first source is Martin Plessner, who wrote ‘The Natural Sciences and Medicine’ chapter in Joseph Schacht’s and C E Bosworth’s Oxford publication, ‘The Legacy of Islam’. He says:

“Science was perhaps the one cultural area that was at least accessible to ‘Islamisation’. Moreover, the continued and undiminished hostility of official orthodoxy against the ancient sciences remained as characteristic of Islam as it was of Christianity until deep into the Middle Ages, and of orthodox Jewry to the very threshold of our present time. Knowledge not founded on revelation and tradition was deemed not only to be irrelevant but to be the first step on the path to heresy”

He goes on to explain:

“The Muslims made a distinction between the native or Islamic sciences and foreign sciences. Islamic science consisted of religion and language (Koranic exegesis, the science of hadith, jurisprudence, scholastic theology, grammar, lexicography, rhetoric, and literature). The foreign sciences, or the ‘sciences of the ancients’ were defined as those common to all people and religious communities, as opposed to such sciences whose development was peculiar to Islam. As Grunebaum says, the foreign (ancient) sciences are primarily…the various branches of mathematics, philosophy, natural history (zoology, botany, etc), medicine, astronomy, music, magic and alchemy. But as Grunebaum says, the study of these foreign sciences was always looked upon with suspicion and even animosity, which increased in the later Middle Ages. A part of the hostility can be attributed to the fact that the ancient authorities were non-Muslim and foreign. All foreign sciences endangered the faith”.

Later on he quotes Grunebaum’s remark, “Those accomplishments of Islamic mathematical and medical science which continue to compel our admiration were developed in areas and in periods where the elites were willing to go beyond and possibly against the basic strains of orthodox thought and feeling,” and Ernest Renan, “Science and philosophy flourished on Musalman soil during the first half of the middle ages, but it was not by reason of Islam, it was in spite of Islam”, to support his belief.

Furthermore, in his very polite fashion, Warraq writes:

“There is a persistent myth that Islam encouraged science. Adherents of this view quote the Koran and hadith to prove their point: “Say, shall those who have knowledge and those have it not be deemed equal” (39:12), “Seek knowledge, in China if necessary”, “The search after knowledge is obligatory for every Muslim”. This is nonsense, because the knowledge advocated in the preceding quotes is religious knowledge. Orthodoxy has always been suspicious of ‘knowledge for its own sake’ and unfettered intellectual inquiry is deemed dangerous to the faith…All sciences are blameworthy that are useless for acting rightly toward God. Useful knowledge was that which was necessary or helpful for the practice of religion. Eventually the ancient sciences were to lose out in this perpetual battle between theological and the philosophico-scientific approach.”

I will not make any comments here about Warraq’s inefficient style, and annoying repetitiveness (the book can be shortened by at least a hundred pages if he stopped repeating himself), but have to point out how frequently he uses the words ‘This is nonsense’ in his interviews and articles. Such words are never used by serious writers. Instead, they rebute their opponents with logic and reason, which Warraq claims to defend.

Second, how did he, being neither a lexicographer nor Arab, come to the conclusion that the word ‘3ilm’, which is used in all the above statements, means ‘religious knowledge’? Why such dishonesty? Where did he get his reference from? Why does he not make reference when he makes such rash statements, and rather fill his pages with quotes from ‘scholars’ whose thoughts are quite lacking in value. The following is a copy of the word’s translation from the major Arab-English dictionary of our time, Al-Mawrid:

It is clear to everyone who has even passively read the Quran, the only Holy Book of Islam, that it encourages man to study everything, and see the signs of God in everything. Far from denouncing natural sciences, there are many verses in the Quran encouraging its study. Verses such as,“Will they not regard the camels, how they are created? And the heaven, how it is railed? And the hills, how they are set up? And the earth, how it is spread? Remind them, for thou art but a remembrancer” (88:18-22), and “And within yourselves; do you not see?” (51:21). True submission to God entails that we view the world as a book of God – where in He displays His signs and majesty.

The Egyptian scholar Sayyid Qutb explains:

“No doubt Islam permits a Muslim to learn chemistry, physics, astronomy, medicine, technology and agriculture, administration and similar technical sciences from a non-Muslim or from a Muslim who is not pious - and this under the condition that no God-fearing Muslim scientists are available to teach these sciences. This is the situation which exists now, because Muslims have drifted away from their religion and their way of life, and have forgotten that Islam appointed them as representatives of God and made them responsible for learning all the sciences and developing various capabilities to fulfill this high position which God has granted them.”

What a strong believer in God believes is that, such knowledge, regarding His Creation cannot be dissociated from Him. It is to be directly connected to Him whenever possible. As explained by Mustafa Mahmood:

“Knowledge of the sciences alone does not create a man of knowledge. Knowledge of the exterior of things, and their quantities, and their relationships is always a deficient knowledge, and it is only the ignorant ones who confine themselves to these exterior sciences. God says about such people, “They know but the outer (things) in the life of this world: but of the End of things they are heedless” (30:7). The same people who “when their messengers brought them clear proofs (of Allah's Sovereignty) they exulted in the knowledge they (themselves) possessed. And that which they were wont to mock befell them” (40:83), and who were eventually punished for their disregard of God’s signs. Knowledge can never be complete unless it leads you to a knowledge of yourself first, and then a knowledge of God. For that is the only true knowledge”.

Indeed this definition of science was very similar to that given by Albert Einstein himself in his brilliant essay, ‘Science and Religion’:

“The weak point of his (the rationalist’s) conception is, however, this, that those convictions which are necessary and determinant for our conduct and judgments cannot be found solely along this solid scientific way.

For the scientific method can teach us nothing else beyond how facts are related to, and conditioned by, each other. The aspiration toward such objective knowledge belongs to the highest of which man is capabIe, and you will certainly not suspect me of wishing to belittle the achievements and the heroic efforts of man in this sphere. Yet it is equally clear that knowledge of what is does not open the door directly to what should be. One can have the clearest and most complete knowledge of what is, and yet not be able to deduct from that what should be the goal of our human aspirations. Objective knowledge provides us with powerful instruments for the achievements of certain ends, but the ultimate goal itself and the longing to reach it must come from another source. And it is hardly necessary to argue for the view that our existence and our activity acquire meaning only by the setting up of such a goal and of corresponding values. The knowledge of truth as such is wonderful, but it is so little capable of acting as a guide that it cannot prove even the justification and the value of the aspiration toward that very knowledge of truth. Here we face, therefore, the limits of the purely rational conception of our existence”.

God enjoins us to, “Bow down, prostrate yourselves, and adore your Lord; and do good; that ye may prosper” (22:77), and, “And there may spring from you a nation who invite to goodness, and enjoin right conduct and forbid indecency. Such are they who are successful” (3:104). And is there a greater goodness than saving one’s life, or revealing God’s signs. Regarding the former, the Quran tells us, “Whosoever killeth a human being for other than manslaughter or corruption in the earth, it shall be as if he had killed all mankind, and whoso saveth the life of one, it shall be as if he had saved the life of all mankind” (5:32). Is there then a greater incentive to study and practice medicine I wonder?
Then again, I think – are the intentions of these orientalists who Warraq refers to endlessly pure; do they really write in the name of justice and truthfulness. Swiss journalist and author, Roger Du Pasquier, gives the answer:

“The West, whether Christian or dechristianised, has never really known Islam. Ever since they watched it appear on the world stage, Christians never ceased to insult and slander it in order to find justification for waging war on it. It has been subjected to grotesque distortions the traces of which still endure in the European mind....One is forced also to concede that Oriental studies in the West have not always been inspired by the purest spirit of scholarly impartiality, and it is hard to deny that some Islamicists and Arabists have worked with the clear intention of belittling Islam and its adherents. This tendency was particularly marked for obvious reasons in the heyday of the colonial empires, but it would be an exaggeration to claim that it has vanished without trace.”

I do not understand Warraq’s intentions, but to hear him admit on several interviews that he volunteered to join the Israeli army in 1967 to fight Arabs (and not just Muslims), for me, says a lot. The least I can say about them is that they are not pure – and he is likely to be another Zionist doll talking the talk they all like.

Having just defended Islam and Muslim contributions to medicine, I would like to now look at the negative aspect of this relationship, something that unfortunately, in our age of free information, the opponents of the religion have picked up on and spread.

The lesser criticism that one can level at the Muslim world with regards to their current perspective on medicine is that, most Muslims, and indeed one of the major failures of many Muslim physicians these days is to place too much emphasis on past history and so called ‘Islamic contributions to medicine’ while neglecting the true wonders of the human body in health and disease as revealed by current research methods. In addition, many have a major misconception that there is something called ‘Islamic medicine’. Medicine is a neutral subject, without nationality, colour or race. The discoveries made by Avicenna, Rhazes and others are Muslim, rather than Islamic contributions to medicine. That great Russian physician and novelist, Anton Chekhov put it well, “There is no national science, just as there is no national multiplication table; what is national is no longer science”. Likewise, there is no religious medicine.

My more important criticism is that of the very practice of medicine in many ‘Islamic’ countries. We all know how decadent medical systems are in every single Arab and Muslim state. Sami Jaboor, an assistant professor of medicine based in Beirut, puts the blame on the existence of Israel, saying, “The main external factor is the Arab-Israeli conflict. Military spending is a direct impediment to development, especially in countries directly bordering Israel”. While I agree with the gist of this, I don’t think it paints the full picture. The Arabs and Muslims have been victims of the poverty of their own culture – which is essentially opposed to progress, scientific and intellectual pursuits. In addition, medicine has been a victim of the religious monopoly over everything in life.

For instance, we hear that in northern Nigeria:

“…a country that had previously checked in as provisionally polio-free—a group of Islamic religious figures issued a ruling, or fatwa, that declared the polio vaccine to be a conspiracy by the United States (and, amazingly, the United Nations) against the Muslim faith. The drops were designed, said these mullahs, to sterilize the true believers. Their intention and effect was genocidal. Nobody was to swallow them, or administer them to infants. Within months, polio was back, and not just in northern Nigeria. Nigerian travelers and pilgrims had already taken it as far as Mecca, and spread it back to several other polio-free countries, including three African ones and also faraway Yemen. The entire boulder would have to be rolled back right up to the top of the mountain.” Also, we know that, as Christopher Hitchens describes, “In 1995, the Council of Ulemas in Indonesia urged that condoms only be made available to married couples, and on prescription. In Iran, a worker found to be HIV-positive can lose his job, and doctors and hospitals have the right to refuse treatment to AIDS patients. An official of Pakistan's AIDS Control Program told Foreign Policy magazine in 2005 that the problem was smaller in his country because of "better social and Islamic values." This, in a state where the law allows a woman to be sentenced to be gang-raped in order to expiate the "shame" of a crime committed by her brother. This is the old religious combination of repression and denial: a plague like AIDS is assumed to be unmentionable because the teachings of the Koran are enough in themselves to inhibit premarital intercourse, drug use, adultery, and prostitution. Even a very brief visit to, say, Iran, will demonstrate the opposite. It is the mullahs themselves who profit from hypocrisy by licensing "temporary marriages," in which wedding certificates are available for a few hours, sometimes in specially designated houses, with a divorce declaration ready to hand at the conclusion of business. You could almost call it prostitution ... The last time I was offered such a bargain it was just outside the ugly shrine to the Ayatollah Khomeini in south Tehran. But veiled and burqa-clad women, infected by their husbands with the virus, are expected to die in silence. It is a certainty that millions of other harmless and decent people will die, very miserably and quite needlessly, all over the world as a result of this obscurantism.”

Like the medicine man of old, the religious authorities want to display their power over human affairs, by controlling the practice of physicians, and those beneficiaries of their practice. They feel a need to express an opinion over everything in life, and they seem to have a ruling for everything. Is this the freedom that God wanted man to enjoy? I think not.

Of course, the correct religious perspective regarding something like what the Nigerians did goes along the lines of rationality, which is expressed by the Egyptian scholar Yusuf Al-Qaradawi, who said:

“In the context of caring about physical health, Islam stresses the importance of both preventive and therapeutic medicine. It particularly cares about preventive medicine because prevention is better than cure. These days are known for the discovery of many preventive vaccines, especially for infant diseases such as small pox, polio, and certain types of fever. It is not a matter of choice in Islam whether to take the vaccinations or not, they must be taken”

THE DANGERS OF PROPHETIC MEDICINE

However, the greatest danger lies when such ‘rational’ scholars lie in silence or even in praise of some of the most harmful ideas held by many in the Muslim world – namely what is called ‘Prophetic medicine’. They dare not speak analytically about it; and leave many Muslims, especially those within the medical profession confused and contradicting their belief and their practice, which is a far cry from that system. The result, to those who think about it, is a disharmony within the self, for no one can live happily believing two contradictory systems of thought.

Even if we put these ‘rational’ thinkers aside – we have many Muslim doctors who, with good intentions I have no doubt, wish to contribute to their religion through their expertise, not realizing that their very practice is the greatest benefit to others, and is of greater pleasure to God than such praise of such a deficient and ‘unprophetic’ medicine.

Prophetic medicine is, defined as:

“The words and actions of the Prophet with a bearing on disease, treatment of disease, and care of patients. Thus also included are words of the prophet on medical matters, medical treatment practiced by others on the prophet, medical treatments practised by the prophet on himself and others, medical treatments observed by the prophet with no objections, medical procedures that the prophet heard or knew about and did not prohibit, or medical practices that were so common that the prophet could not have failed to know about them.”

It is a system that is regarded by some (like Professor Omar Kasule, an epidemiologist trained in Harvard and working in Brunei University), “as an authentic and valid medical system. The general principles of this system are applicable at all times and all places. The specific remedies taught by the Prophet (PBUH) are valid and useful.”

Furthermore he says:

“Whatever the Prophet said or did was valid and must be followed because he never uttered any untruth even when joking. The ijtihad of the prophet even in worldly matters was protected (ma'suum). The Qur'an and hadith have records of divine intervention to comment on the prophet's ijtihad on worldly matters such his advice on some aspects of agriculture that he later withdrew. Thus the record of authentic hadith that we have is valid whether in 'aqidat or worldly matters. The attempt to distinguish between the medical teachings of the prophet-messenger and as a human living in Arabia at a particular historical epoch is not easy and is of no practical significance. The question is whether all or some of the tibb nabawi should be used today. If the diagnosis of a disease and all the circumstances surrounding it are exactly like those at the time of the Prophet, then we have no hesitation in saying tibb nabawi should be used.”

As a result of this confusion, which is the direct consequence of the equation of the Prophet Muhammad (PBUH)’s practice as a human being living his time, and his universal message, we are still living in awe of this ‘Prophetic medicine’. It is as if God never said in His Holy Book, "Say: 'I am but a man like yourselves, (but) the inspiration has come to me, that Your God is one God.'" (18:110) or "Say: 'Glory to my Lord! I am aught but a man,- a Messenger.'" (17:93).

I cannot for the life of me regard most of the ‘hadiths’ regarding health as genuine, no matter what authority has reported them, and feel that anyone who regards the specifics of prophetic medicine as of value, living in delusion. We can of course accept general, rational statements without a doubt that they are very possibly from a prophetic source. Statements that encourage the learning of medicine, such as, “The Prophet said, "There is no disease that Allah has created, except that He also has created its treatment", or the visiting of physicians, such as “On the authority of Hilal Bin Yassar that he said; "The Prophet (r) once paid a visit to a patient and said; ‘Send for the doctor.' A man said; 'O, Messenger of Allah! Do you say so?' The Prophet (r) replied; 'Yes, I do.'"”, or “respecting specialisation in the profession of medicine. On the authority of Zayd Bin Aslam that a man was injured and blood was congested. The Prophet (r) called two persons from the tribe of Bani Anmar and said; 'Whoever of you is more professional in medicine?' A man said; 'Is it good to take up medicine?' The Prophet (r) replied; 'That Who created disease, sent down treatment'"” – all of those statements, even if they did not come from the Prophet (PBUH) are useful and beneficial statements that come under the fold of religion – which can be defined as all that is good for mankind.

But I will never be convinced that the Prophet was a diagnositician, an anaethetist, a gastroenterologist, a cardiologist, a neurologist. I simply cannot believe he (PBUH) would make many of the ‘medical statements’ attributed to him by our ‘scholars’. And it is unworthy of us to say he made many of those statements. Lets look at some of those statements – which I am taking only from the ‘most authentic’ sources of Prophetic statements and Ibn Qayyim’s book, ‘Prophetic Medicine’.

How can one believe that the prophet Muhammad (PBUH) would restrict the whole of medicine to three things, "Healing is in three things: A gulp of honey, cupping, and branding with fire (cauterizing)." But I forbid my followers to use (cauterization) branding with fire." Is surgery or the whole of pharmacological medicine a waste of time? And if cauterization is forbidden, then how will all those who benefit from the procedure, which is “frequently used to stop bleeding of small vessels (larger vessels being ligated) or for cutting through soft tissue i.e. abdominal fat in a laparotomy or breast tissue in a mastectomy. It is a treatment for frequent nose bleeds” survive. Was religion designed to kill us, to forbid us all those things which God has created, directly or indirectly, for the sake of man? The answer is clear to he or she who has a mind to think with and a heart that feels, one who knows the greatest man to embrace the planet, who was sent a mercy for all of mankind.

In a similar fashion, I cannot believe that the prophet (PBUH) would have said anything like this:

“Narrated Abu Sa`id Al−Khudri: A man came to the Prophet and said, "My brother has some Abdominal trouble." The Prophet said to him "Let him drink honey." The man came for the second time and the Prophet said to him, 'Let him drink honey." He came for the third time and the Prophet said, "Let him drink honey." He returned again and said, "I have done that ' The Prophet then said, "Allah has said the truth, but your brother's `Abdomen has told a lie. Let him drink honey" (SB). So he made him drink honey and he was cured.”

I have not used the word nonsense once in this book, but this is the first time. It is nonsense – unworthy of the great prophet (PBUH). To prescribe based on hearsay is hardly ‘medicine’, and to call someone’s symptoms ‘a lie’ while he is suffering, is unethical.

Likewise, how can he believed to do anything like this:

“The climate of Medina did not suit some people, so the Prophet ordered them to follow his shepherd, i.e. his camels, anddrink their milk and urine (as a medicine). So they followed the shepherd that is the camels and drank their milk and urine till their bodies became healthy. Then they killed the shepherd and drove away the camels. When the news reached the Prophet he sent some people in their pursuit. When they were brought, he cut their hands and feet and their eyes were branded with heated pieces of iron.”

Is this worthy of the greatest man? To say he did this is an insult, to say assault on the religion and the prophet (PBUH). And the punishment – is this the same prophet I know, who was sent a mercy to mankind[2]?

I ask our wonderful scholars, if they think the consumption of waste products like urine is so wonderful, why do they not drink it themselves? Why do they simply pay lip service to these statements, and reap all the rewards of the hard work of the intelligent Western medical doctors?

Can anyone imagine the Prophet, on his deathbed, to have done the following:

“Narrated Ibn `Abbas and `Aisha: Abu Bakr kissed (the forehead of) the Prophet when he was dead. `Aisha added: We put medicine in one side of his mouth but he started waving us not to insert the medicine into his mouth. We said, "He dislikes the medicine as a patient usually does." But when he came to his senses he said, "Did I not forbid you to put medicine (by force) in the side of my mouth?" We said, "We thought it was just because a patient usually dislikes medicine." He said, "None of those who are in the house but will be forced to take medicine in the side of his mouth while I am watching, except Al−`Abbas, for he had not witnessed your deed" (SB).

This is not Islam, but evil.

What are we to make of the following statement, “`Abdullah bin `Umar said, "The Prophet said, 'Fever is from the heat of Hell, so put it out (cool it) with water'”? This goes against all that I know about the prophet (PBUH), who as is well known, died of a feverish illness; infact, “His fever increased in the first days of his sickness so that he felt as if he were on fire”. I cannot believe that the prophet is material of hell, which is what this hadith implies. Also, belief in a hadith like this, which attributes a physical thing to something completely ‘ghaib’ (unknowable in our world) is opposition to science and progress, which is not Islamic in the slightest.

I do not know what to make of statements like, “On the authority of Saad that he said; "I once got sick, and the Prophet (r) came to visit me. He (r) put his hand on my chest, till I felt its coolness on my heart. Then the Prophet (r) said; 'You have a cardiac ailment. Send for Al Harith Bin Kalda from Thoqaif, as he is a man who gives medical treatment.'"”, or that conjunctivitis should be treated by diet and rest, or that vomiting should be encouraged unless it is becoming a risk to breathing, or that epilepsy is due to spiritual possession. I will make no further comment.

ZAGHLOOL AL-NAJJAR – A 21ST CENTURY DERVISH

This ‘medicine’ is dead, sterile, and quite disgusting. And it is an insult to humanity to use it, and an insult to the intelligence of mankind to advocate it. Listening to the highly respected geologist Zaghlool Al-Najjar justify the following hadith (as if the truthfulness of the Message rested on the wings of a fly), “If a housefly falls into the drink of anyone of you, he should dip it (in the drink), for one of the wings has a disease and the other has the cure for the disease” [Sahih al-Bukhari vol 4:537] makes me want to cry. Why is such intelligence being wasted? Also, Najjar claims he is only relying on established science in his books, and correlating only established fact with the ‘Sunnah’. Why does he not reference his works? Surely he understands that science is not based on authority – or maybe his long contact with ‘authority’ has made him forget this basic principle of science. Does he not realize that science is only science if its results can be replicted many hundreds of times afterward, and the results established in good journals, not directed by the whims of their author or editor. Najjar fails miserably in this regard.

But of course, he has an answer to all those who try to convince him of his unscientific approach, which I regard as professional treason – he is using his stance as a world-famous geologist to propagate his own beliefs. He feels the West would not replicate these findings, and would not fund research into it, because they are opposed to Islam – they wouldn’t want to show Islam to be true, as if submission to God rested on the wings of a fly. Is this not madness itself. I quote Najjar[3] fully below, without any further comment.

“This Hadith means that the fly carries on one of its wings a disease, and on the other a cure from the same disease. When a fly falls into a container (of food or drink), it puts forward the wing carrying the microbe, as a self-defense. Imam Ibn Hajar said in his commentary on the hadith that one of the scholars observed that the fly protects itself with its left wing, so it can be deduced that it carries the cure or the antidote on the right wing. So if the fly is immersed in whatever it falls on, the antidote will destroy the venom or the microbe with the will of Allah. Some people are not pleased with the idea of immersing a fly in one's food or drink. However, this can be only applied in cases of emergency. When, for example, someone is in a desert, having only little water or drink. Such a person has no choice but to do as the Prophet recommended. Otherwise, he will die from thirst or infection. If someone disdains eating that food or drink, he does not have to do so, but he does not have the right to disclaim the authenticity of the hadith. The hadith is strongly authentic, as it is narrated by Imam al-Bukhari.

Flies are very common on earth. They are almost 87000 species. It has been scientifically proved that they feed on garbage and waste organic matter of the vast numbers of bacteria, viruses and other various microbes and germs.

Bacteria are very small living organisms. They live in billions in one gram of agricultural land and in millions in one drop of saliva. The effect of bacteria on the biological life on earth is unlimited, without it no crops could grow, and without crops there would be no life for man and animals on earth. Most of the bacteria are harmless, but some cause several diseases.

Viruses are, in fact, nucleic acids (either DNA or RNA). Allah the Almighty gave them the ability to enclose themselves by a protein coat, to form separate units called the "virion". The virus particle or the "virion" has the ability to invade living cells (host cell), inciting them to produce more viruses or destroying the tissues of this host cell. That is why viruses are responsible for many diseases, which affect plants, animals and man.

There is a type of virus, which infects, bacteria cells, known as "Bacteriophage." The killing type of these viruses is known as "Virulent Bacteriophage", while the non-killing type is known as "Temperate Bacteriophage". It is of the Divine Ability of Allah, Glorified be He, to create everything in this universe in pairs, so that, it is only Allah, Who is the One, Who has no partner. Thus, Allah created male and female, day and night, positive and negative, as He created the bacteria and the "Bacteriophage." It is only Allah, Who is the One, Who has no partner.

Allah, the Almighty, gave the fly the ability to carry the germ on one wing and its antidote on the other. Otherwise the fly species would have perished by now, exposed to all these germs. However, they still exist in more than 87000 species.

The fly carries the viruses of many diseases, which are consequently transferred to man's food, drink and body. Of these viral diseases are common flu, measles, mumps, chickenpox, warts, yellow fever, infectious liver diseases, some cases of paralysis, some types of cancer, and some chronic diseases of the central nervous system including multiple sclerosis.

Viruses also cause many diseases, which effect cattle, sheep and birds. Some of these diseases are encephalitis, aphthous fever (foot and mouth diseases) and duck plague, which could be transferred to man through the infected animal. Some crops such as potatoes, tomatoes, bananas and sugarcane can also be destroyed by viral infections.

"The virulent Bacteriophage" kills the bacterial cell that it invades in a very short time. While the "Temperate Bacteriophage" keeps the bacterial cell that it invades alive. It acquires a kind of immunity against the same virus or produce similar viruses. This explains why the fly carries pathogen on one wing and its antidote on the other.

A group of Muslim researchers in Egypt and Saudi Arabia carried several experiments on containers of water, honey and different juices. They exposed them to the flies. Then they immersed some flies in some of these containers. The microscopic examination showed that the liquids in which no flies were immersed were full of bacteria and viruses, while the others where the flies were totally immersed had none.

It was discovered that there are antidotes for pathogens, and that there are various types of bacteria and "Bacteriophages", only in the last decades of the 20th century.

The Prophet alluded to these 1400 years ago, when humans knew almost nothing of the facts of modern science. But given this type of information with such accuracy, that one wing carries the antidote to the pathogen carried by the other, could only be of the Divine Revelation taught to the Prophet.”

Najjar is also the first person to put a medical and scientific cloak on many aspects of traditional Islam that were never previously regarded as such. But he, as he says, “feels obliged to do so since the Western world only speaks the language of science now, and we need to address them with science to spread the message of Islam to them”. He seems to forget that the West that he is talking about here is the same West that brought forth the great skeptics, most importantly David Hume, who demolished the opinion that science can be a route to ultimate truth, which essentially is what religion stands for.

Focusing on the ‘medical’ aspect only, for example, we see Najjar’s madness on fire when he is commenting on the miraculous aspect of the tradition, "Five practices are characteristics of the fitrah: circumcision, shaving the pubic hairs, cutting the mustaches short, clipping the nails and plucking the hair of the armpits." (Reported in Sahih al-Bukhari and Sahih Muslim.)

Beginning with circumcision, he says “extensive research proved the medical benefits of circumcision, showing that uncircumcised males are more vulnerable to veneral diseases such as gonorrhea and syphilis, and also to penile cancer which is the most painful”, as if to say, get circumcised lest you commit adultery – that way you will not suffer as much. I hasten to add that circumcision remains a controversial topic among andrologists; unbiased sources say that:

“The American Medical Association stated in 1999: "Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice." The British Medical Association, states “there is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.” Cost-benefit analyses have varied. Some found a small net benefit of circumcision, some found a small net decrement, and one found that the benefits and risks balanced each other out and suggested that the decision could "most reasonably be made on nonmedical factors."

I remind him too of the low incidence of penile cancer, “Penile cancer is very rare in Europe and North America, occurring in about one in 100,000 men in the latter. It accounts for 0.2% of cancers and 0.1% of deaths from cancer amongst males in the United States.”. And these are incidences in largely uncircumcised men.

He moves on to talk about the benefits of circumcision, saying that this “circumcision of the husband protects his wife from this type of infections, which may lead to cancer of the uterus that is widely spread among prostitutes”. This is the first time I hear that infection is a risk factor for uterine (endometrial) cancer.[4]

I presume the geologist is referring to cervical cancer, which carries the risk factor of ‘promiscuity’ – but circumcision cannot be defended on this basis. Firstly, the evidence for circumcision (which is not mentioned once in the Quran) is, as we just saw, pretty inconclusive. Secondly, one cannot use this way of argument to defend ‘a good thing’ – which I presume is Najjar’s opinion of circumcision, as a way of attenuating the harms of sin.

Following this, Najjar makes the sweeping statement, “Physicians noticed that uncircumcised men are more vulnerable to reproductive system diseases than others”; this, and I say this as a medical doctor, is not true. Not once have we learnt this, or heard it from the urologists who look after ‘male reproductive organs’.

He then proceeds to talk about female circumcision:

“Regarding female circumcision, it is also a way of following the Sunnah of the Prophet. It is also more dignified for her, as this is a very sensitive part of her body. If there is an extraordinary elongation of the prepuce (foreskin) it may lead to her being sexually excited repeatedly, especially before marriage. This may also displease her husband or make sexual intercourse difficult after marriage”.

Is there anything more ridiculous than that? Is it not an insult to God, the creator to say that it is more dignified for the woman for woman to not have her external female genitalia or any part thereof, than it is to have them? Are they not attributing a fault in the Creation, He who says, “No fault wilt thou see in the creation of the Most Gracious. And turn thy vision upon it once more: canst thou see any flaw. Yea, turn thy vision again and yet again, and every time thy vision will fall back upon thee, dazzled and defeated” (67:3-4).

When they hear of criticisms of such practices, like the following one by Christopher Hitchens they become very defensive:

“Across a wide swath of animist and Muslim Africa, young girls are subjected to the hell of circumcision and infibulations, which involves the slicing off of the labia and the clitoris, often with a sharp stone, and then the stitching up of the vaginal opening with strong twine, not to be removed until it is broken by male force on the bridal night. Compassion and biology allow for a small aperture to be left, meanwhile, for the passage of menstrual blood. The resulting stench, pain, humiliation, and misery exceed anything that can be easily imagined, and inevitably result in infection, sterility, shame, and the death of many women and babies in childbirth. No society would tolerate such an insult to its womanhood and therefore to its survival if the foul practice was not holy and sanctified.”

This is how one scholar put it, "It is clear that Islamic law supports both male and female circumcision. Just because mistakes are sometimes made in the way in which it is carried out does not mean that the procedure is wrong in itself." How merciful.

Is it not madness to hear that, in 1994, Egyptian Mufti Sheikh Jad Al-Hâqq issued a fatwa stating, "Circumcision is mandatory for men and for women. If the people of any village decide to abandon it, the village imam must fight against them as if they had abandoned the call to prayer”, that another Egyptian scholar saysEven prominent gynaecologists such as Dr Munir Fawzi of the department of gynaecology at Cairo University “came out in favour of the procedure, saying: "Female circumcision is entrenched in Islamic life and teaching."”

What we have here is a deep irrationality, an opposition to World Health Organisation guidelines, a pathetic reverence to ancient ideas that are grounded in nothing but tradition, and a deep contempt for women, and an emphasis on patriarchy. I have said nothing about the practice being opposed to historical practice of the Prophet and his companions, something emphasized by Abu Ameenah Bilal Philips, among others, in his book, ‘The Clash of Civilisations – An Islamic View’, who remarked:

“There are other inherited practices that are quite harmful physically as well as spiritually. For example, the pharaonic circumcision of females (genital mutilation) as practiced in East Africa, the Sudan, and Egypt among Muslims and non-Muslim tribes of that region is another example of inherited un-Islamic practices. It is harmful to women in that infections from it can lead to sterility and even death. And even under hospital supervision, it robs the woman of some if not all of her right to enjoy a basic part of her marriage. Furthermore, under the feminist attack, some women reject Islam under the mistaken impression that it condones this form of oppressive disfigurement of women”.

Martin Fido, a fellow at Oxford University when he writes:

“Female circumcision…might well have struck the Prophet as absurd or indecent… the spread of Islam to Africa brought Muslims in contact with several several tribes who practiced various forms of genital mutilation, including labia stretching, male circumcision and clitoridectomy. Since Jewsih influence already proposed male circumcision as a religious rite, some Muslims enthusiastically adopted the female “equivalent”, which was carried out at puberty in some 30 countries, often without anaesthetics.”

On hearing things like this, can anyone blame an atheist like Christopher Hitchens to say that religion is, “Violent, irrational, intolerant, allied to racism and tribalism and bigotry, invested in ignorance and hostile to free inquiry, contemptuous of women and coercive toward children: organized religion ought to have a great deal on its conscience”.

He further adds:

“The attitude of religion to medicine, like the attitude of religion to science, is always necessarily problematic and very often necessarily hostile. A modern believer can say and even believe that his faith is quite compatible with science and medicine, but the awkward fact will always be that both things have a tendency to break religion's monopoly, and have often been fiercely resisted for that reason.”

I certainly cannot argue with Hitchens over this; he is speaking the truth. But this irrationality does not stop here. Najjar proceeds to talk about the benefits of the beard, the shaving of which (as well as trimming the moustache) is regarded by many as a compulsory act, or at least a virtuous one. He quotes the hadith reported by Ibn Umar that the Prophet said, “Trim the moustache and let your beard grow”, as well as another narrations, such as “Act differently to the polytheists; let your beards grow and shave your moustache” and “Act differently to the Magians; shave your moustache and let your beards grow” (as if God were concerned were to judge us according to our external appearance, neglecting the fact that He says, “Allah will not take you to task for that which is unintentional in your oaths. But He will take you to task for that which your hearts have garnered. Allah is Forgiving, Clement” (2:225)).

It is all about acting different, and being different; is it a surprise then that Muslims these days are being treated differently, segregared against, opposed, attacked and ridiculed – in many cases it is the indirect outcome of their own wishes. Of course, all such things are wrong, but we need to at least blame ourselves a bit for the current chaos afflicting Muslims.

In any case Najjar proceeds to say:

“It is obvious from these narrations that letting the beard grow is obligatory and so is trimming the moustache. Being under the nose and above the mouth, exposed to their various secretions, makes it easy for the moustache to be contaminated with these secretions in addition to remnants of food and drink. It is then difficult to keep it perfectly clean which may lead to the growth of germs and bacteria and may result in a bad smell originating from the person, or may even cause diseases”.

Even a first year medical student can respond to this. Which textbooks of dermatology and microbiology has our wonderful geologist consulted in the course of saying this? Furthermore, which school of trichology has he attended? Why does he not reference these sweeping statements? Najjar cannot accuse others of being unscientific, or accuse others of writing ‘empty works’, as he recently did on a television programme, picking up a valuable book of the great and rational linguist Abdel Saboor Shahin saying, “This book has no scientific or religious value”, before he looks into his own works, which are sometimes based on the most ridicilous suggestions, a prostitution of science for his own agenda.
Najjar’s ideas are dangerous, but I have not qualms about his intentions – he seems like an honest man. But he is guilty here not only of treason, but also of misinformation. He is guilty of what Stephen Hawking described, “The greatest enemy of knowledge is not ignorance, it is the illusion of knowledge”. Here is a geologist abusing the entire world of science and medicine to suit his ‘religious’ goals. It is corruption of the highest kind.

THE CONSEQUENCES OF PROPHETIC MEDICINE AND THEIR SOLUTION

Thus in all this we see certain common things. Although there are some good things in ‘Prophetic Medicine’ (and perhaps the best thing about it is its opposition to charms and superstition), we have just seen that in most cases it is a drain of resources (especially human intelligence and time), is unethical, dependent on the belief of the person using it, opposed to science, leading to paranoia and hypocritical practice (those who believe like the author of a recently published book entitled ‘Tibbe Nabwi Aur Jadid Science (Prophetic Medicine and Modern Science)’, who claims that “Prophetic treatment of heart attack by eating seven dates, as was suggested to Sa’ad bin Waqqas, is still the better treatment than modern by-pass surgery, provided people have faith in the treatment of the Prophet” are the first to jump on a plane and seek treatment with the latest triumphs of ‘Western’ medicine), and harmful to the intelligence – a rational Muslim medic cannot be expected to happily believe that epilepsy is the result of spiritual possession and physical abnormalities within the brain tissue). I cannot myself believe that much of ‘Prophetic medicine’ is ‘Prophetic’ – I don’t think such absolutism, as expressed in the above ‘traditions’, with regard to wordly affairs, is characteristic of a prophet, whose beliefs are grounded most firmly in wisdom. In case any of the readers are somehow absolutely convinced that the Prophet (PBUH) made the above remarks, I refer them to the great historians Ibn Khaldun’s opinion regarding this Prophetic medicine is extemely valuable too for those who think that Prophetic medicine is indispensible and utterly correct, that, “The Prophet’s mission was to make known to us the prescription of the Divine Law and not to instruct us in medicine of common practice of ordinary life.’” It would also be, in my opinion, a great thing if Muslims as a whole would listen to the very logical Islamic framework of the Syrian thinker Professor Mohammed Shahrour, who I regard as one of the lights of our age.

In listening to his great precision and discrimination between terms such as ‘nabbi’ and ‘rasool’. Following his analysis of all the verses containing the two words, he comes to the conclusion that there is, “a difference between the words ‘Prophecy’ and ‘Message’, between the functions of Muhammad (SAW) as messenger (Rasul) and as Prophet (Nabi). Muhammad (SAW) received a body of information having to do with prophecy, religion and the like. As a messenger, he was the recipient of a corpus of legal instructions in addition to that information he received as a prophet. The function of Prophet is religious whereas that of the Messenger is legal (and contemporary)”.

This is an extremely important point, and it highlighted to me that imprecision in thought is one of the biggest ills of our time. Bertand Russell said that, “Everything is vague to a degree you do not realize till you have tried to make it precise”. That is precisely what has happened with Islamic thought, it has become vague and a victim of this vagueness. Shahroor is trying to highlight the element of precision in God’s Holy Book, likening it to the universe, His other only work that is on daily display to all of us. This is an approach that ought to be welcomed intensely.

Shahroor belongs to a linguistic school of thought that says that there are no synonyms in the Arabic language. This is not a new belief. Many lexicographers and linguists throughout the ages have expressed the same belief with regard to their own language. For instance, Laurence Urdang begins his book, ‘The Synonym Finder’ with the statement, "Those who work with language know that there is no such thing as a true synonym. Even though the meanings of two words may be the same - or nearly so - there are three characteristics of words that almost never coincide: frequency, distribution and connotation." Theodore Sturgeon, an American science fiction novelist, explained this in more detail in an interview, “Here's the point to be made - there are no synonyms. There are no two words that mean exactly the same thing. I don't care about the dictionaries of synonyms and antonyms. If there were two words that meant exactly the same thing, there wouldn't be two words. That means that every word you use has a certain amount of semantic or psychological freight that it carries that makes it different from other words.”

After analysing all those verses that include the word ‘obedience’ ‘اطاعة’ and its derivatives, Shahroor comes to the comforting conclusion that absolute ‘obedience’ is to the ‘Prophet’ and not to the Messenger. He uses several convincing arguments to support this.

For example, the fact that whenever God reprimands the Prophet for something, He is reprimanding Him in the context of Him being a Messenger (nabi), and never in the context of him being a ‘Prophet’ (rasool); the prophet may err as a human messenger, living his times and circumstance, but not in any way with regards to the ‘Prophecy’. In fact he is immune to faults with regards to the Prophecy. He says, “O Prophet (rasool)! Make known that which hath been revealed unto thee from thy Lord, for if thou do it not, thou wilt not have conveyed His message (risala). Allah will protect thee from mankind. Lo! Allah guideth not the disbelieving folk” (5:67).

As a messenger, he erred. God reprimands Muhammad (PBUH), as a messenger in several verses, such as, “O Messenger (nabi)! Why holdest thou to be forbidden that which Allah has made lawful to thee? Thou seekest to please thy consorts. But Allah is Oft-Forgiving, Most Merciful” (66:1).

We are told in God’s Holy Book to obey God and obey the ‘Prophet’, and not the messenger. What is said above, that, “Whatever the Prophet said or did was valid and must be followed because he never uttered any untruth even when joking” is absolutely correct. But the professor, I am sure, means ‘messenger’ here.

In all the following verses, obedience is referred to the ‘Rasool’, and not the ‘nabi’ (the word ‘Rasool’ is mistakenly translated as ‘messenger’ here)

“Say, 'Obey Allah and the Messenger.' Then if they turn away, Allah does not love the disbelievers. (3:32)

Allah fulfilled His promise to you when you were slaughtering them by His permission. But then you faltered, disputing the command, and disobeyed after He showed you what you love. Among you are those who want this world and among you are those who want the hereafter. Then He turned you from them in order to test you-but He has pardoned you. Allah shows favour to the believers. (3:152)
These are Allah's limits. As for those who obey Allah and His Messenger, We will admit them into Gardens with rivers flowing under them, remaining in them timelessly, for ever. That is the Great Victory. (4:13)

As for those who disobey Allah and His Messenger and overstep His limits, We will admit them into a Fire, remaining in it timelessly, for ever. They will have a humiliating punishment. (4:14)

You who believe! Obey Allah and obey the Messenger and those in command among you. If you have a dispute about something, refer it back to Allah and the Messenger, if you believe in Allah and the Last Day. That is the best thing to do and gives the best result. (4:59)

We sent no Messenger except to be obeyed by Allah's permission. If only when they wronged themselves they had come to you and asked Allah's forgiveness and the Messenger had asked forgiveness for them they would have found Allah Ever-Returning, Most Merciful. (4:64)

No, by your Lord, they are not believers until they make you their judge in the disputes that break out between them, and then find no resistance within themselves to what you decide and submit themselves completely. (4:65)

But if anyone opposes the Messenger after the guidance has become clear to him, and follows other than the path of the believers, We will hand him over to whatever he has turned to, and We will roast him in Hell. What an evil destination! (4:115)

Obey Allah and obey the Messenger and beware! If you turn your backs, know that Our Messenger is only responsible for clear transmission. (5:92)

Children of Adam! If Messengers come to you from among yourselves, recounting My Signs to you, those who guard against evil and put things right, will feel no fear and will know no sorrow. (7:35)”

To those who believe the words ‘Apostle’, ‘Messenger’ and ‘Prophet’ are synonyms, who believe that, “While every rasul is a nabi, not every nabi is a rasul”, we ask, then why does God, whose book does not have an extra word, use both words together in verses like, “(Allah said, 'Believers are) those who follow the Rasool, The Nabi, the Ummi, whom they find written down with them in the Torah and the Gospel, commanding them to do right and forbidding them to do wrong, making good things lawful for them and bad things forbidden for them, relieving them of their heavy loads and the chains which were around them. Those who believe in him and honour him and help him, and follow the Light that has been sent down with him, they are the ones who are successful'” (7:157). If every prophet is a messenger, then why didn’t God use the single word, ‘Prophet’, which encompasses both? Is that not an inefficiency or words, or being verbose. Zafar Ansari’s translation, which is used in the very popular English translation of Abul Ala Mawdudi’s tafseer of the Qur’an, ‘Towards Understanding the Quran’, uses just the word ‘Prophet’, “Today, this mercy is for those who follow the Ummi Prophet”. Harun Yahya very conveniently, and in accordance with his belief in the synonymity of the two terms, uses just the word ‘Messenger’ to cover both terms. Fortunately, Pickthall and Abdullah Yusuf Ali use both terms, ‘Messenger’ and ‘Prophet’, but by doing this they unintentionally support the orientalist claim that the Quran is verbose.

My attack on this pretentious field of ‘prophetic medicine’ is motivated by several other factors beside a desire for truth and wisdom (which very little of it actually displays). Firstly, it is to stop such inhumane practices as those given above, like female circumcision. Secondly, at an intellectual level, it is to stop us from seeing the Prophet’s statements as ‘incorrect’ (that cure is one of those three things mentioned above).

Secondly, it is to stop the publication of unnecessary, false and useless books that remain until this day, circulating in Islamic bookshops. Ibn Al-Qayyim’s book on Prophetic Medicine, for instance, a book that carries absolutely no scientific medical value, which spreads the medical ideas prevalent 700 years ago, which is regarded by some as an “extremely valuable book”, “the panacea for those in search of good health. It is a magnificent work that is a treasure every Muslim household. Although it was written by the author, Ibn Al-Qayyim, over six hundred and fifty years ago, it is extremely timely work for our generation in which health and natural health care products have become an important aspect of the lives of so many.” Another reviewer regards it as “an invaluable reference guide for the Muslim of every land and every generation. May Allah bestow His mercy and blessings upon the author, Ibn Al-Qayyim, for surely his work will be cherished throughout time”. Such writers and publishers need to realize that the hallmark of medical science is progress, that, as the great William Mayo put it, “The glory of medicine is that it is constantly moving forward, that there is always more to learn”, that, “Medical science aims at the truth and nothing but the truth”, and not the use of the uninformed opinions of men who lived before the advent of experimental science and medicine.

The attack on this monolithic, unprogressive medicine comes under the umbrella of attack on the concept of alternative medicine, which it falls under. Prophetic medicine and its myths are advocated under the same idea; that of ‘avoiding the harms of Western medicine’. The translators of Ibn Al-Qayyim’s book, for instance, write in their introduction that they are so happy to translate the book, “which is one of the best books which saved us from treatment of chemicals and poisonings that may have got bad side effects”. By spreading ideas like these, scientific, rational medicine comes under threat, and with that the health and safety of the Muslims primarily, but also possibly the rest of mankind. I fear that the Muslims, under the cloak of ‘religious medicine’ will fall under a spell similar to the one Mother Teresa used in the spread of her ideas. As Christopher Hitchens says about her:

"The decision not to [fund a proper hospital], and to run instead a haphazard and cranky institution which would expose itself to litigation and protest were it run by any branch of the medical profession, is a deliberate one. The point is not the honest relief of suffering but the promulgation of a cult based on death and suffering and subjection." And of course, we all know, “when she got sick, she would check herself into the Mayo Clinic or some other temple of American medicine. As one who has visited her primitive "hospice" for the dying in Calcutta, I should call that a wise decision. Nobody would go there except to check out, in one way or another. (And please note, adds Hitchens, that Mother Teresa herself has checked into some of the costliest clinics and hospitals in the West for her own treatment.)”

I devote a separate chapter later to the many flaws of alternative medicine. Finally, it is part of the larger attack on the idea of ‘scientific miracles in religion’, which I find extremely uncomfortable. The links between science and religion are far more subtle and sublime than the ones provided by the likes of Maurice Bucaille and Zaghlool Al-Najjar. I find myself in agreement with those who understand the Quran as it is, without extrapolating ‘scientific miracles’ in every other verse. The following is an excellent summary of the reasons why one should believe that to be the case:

“This method of scientific interpretation did not find general approval among Muslim authors. Many classical Muslim commentators and scientists, notably al-Biruni, assigned to the Qur'an a separate and autonomous realm of its own and held that the Qur'an "does not interfere in the business of science nor does it infringe on the realm of science." These medieval scholars argued for the possibility of multiple scientific explanations of the natural phenomena, and refused to subordinate the Qur'an to an ever-changing science. Author Rotraud Wielandt summarizes the arguments of the modern Muslim commentators such as Mahmud Shaltut and Sayyid Qutb who reject a scientific method of interpretation of the Qur'an as follows:

§ It is lexicographically untenable, since it falsely attributes modern meanings to the quranic vocabulary.
§ It neglects the contexts of words or phrases within the quranic text, and also the occasions of revelation where these are transmitted.
§ It ignores the fact that, for the Quran to be comprehensible for its first audience, the words of the Qurʾān had to conform to the language and the intellectual horizon of the ancient Arabs at the Prophet's time — an argument already used by the Andalusian Mālikite scholar al-Shāṭibī (d. 790/1388) against the scientific exegesis of his time.
§ It does not take notice of the fact that scientific knowledge and scientific theories are always incomplete and provisory by their very nature; therefore, the derivation of scientific knowledge and scientific theories in qurʾānic verses is actually tantamount to limiting the validity of these verses to the time for which the results of the science in question are accepted.
§ Most importantly, it fails to comprehend that the Qur'an is not a scientific book, but a religious one designed to guide human beings by imparting to them a creed and a set of moral values.”

In summary, the greatest danger of expounding beliefs such as those above is that it impairs the practice of medicine, that it reinforces this mythical notion of ‘Islamic medicine’ and impedes progress and health. If medicine is to remain, as Osler put it, “the only worldwide profession, following everywhere the same methods, actuated by the same ambitions, and pursuing the same ends”, then the entire edifice of Islamic medicine ought to be discarded. We ought to base our practice on the power of reason and faith in God, submitting our will to Him, rather than the dubious accounts mentioned above. Alas, most of us are too emotionally attached to the books of our men of old[5]. I very much doubt that all that I have said here is not going to fall on deaf ears, but I feel obliged to state my belief. Otherwise we will continue in our medical, not to say moral and intellectual stagnation.

The best way of worshipping God through medicine is excelling in its practice, in accordance with the Quran’s statements, “And there may spring from you a nation who invite to goodness, and enjoin right conduct and forbid indecency. Such are they who are successful” (3:104), and, "Ye are the best of peoples, evolved for mankind, enjoining what is right and forbidding what is wrong, and believing in Allah." (3:110). the reported saying of the Prophet (PBUH), “God loves to see one’s job done to the level of itqan (excellence),” and the other quite beautiful one:

“On the authority of Abu Mousa that the Prophet (r) said; "It is indispensable for every Moslem to give charity." It was asked; "But if he has nothing to give?" The Prophet (r) replied; "If he has nothing to give, he must do a work with his hand, by which he benefits himself; and gives charity with the remainder." They said; If he is not able to do that work?" The Prophet (r) replied; "Then assist the needy and the oppressed." They said; "If he is not able to do this?" The Prophet (r) replied; "Then exhort people to do good." They said; "If he does not?" The Prophet (r) replied; "Let him withhold himself from doing harm to people; for verily this is a charity for him."

Muslims or those who have submitted to God therefore ought to be the natural advocates of the poor, a role that many physicians have assigned to doctors in the past. For example Sir Douglas Black, former president of the ‘Royal College of Physicians’, who believed:

“[Poverty] is basically a political problem, whose radical solution will require a return to distributive justice. Why write about it in a medical journal? Because doctors are also citizens; they have opportunities to observe and perhaps to mitigate the effects of poverty; and they should be, in Virchow’s words, “the natural advocates of the poor”.”

By being the carriers of the greatest and most simple message – Islam, or submitting to God, they are in a privileged position to help the rest of humanity, to emancipate them from the many socioeconomic and moral crises that exist in our world today. The relationship between these things and ill health is established beyond any doubt, which is why we have something called the ‘social history’ in medical clerkings (which alas is mostly poorly taken). A fantastic article in the ‘Annals of Internal Medicine’ (McCally et al, 1999) states the following:

“Poverty and social inequalities may be the most important determinants of poor health world-wide. Socioeconomic differences in health status exist even in industrialized countries where access to modern health care is widespread. In this paper, we make a formal argument for physician concern and action about poverty based on the following assertions. Physicians have a professional and a moral responsibility to care for the sick and to prevent suffering. Poverty is a significant threat to the health of both individual persons and populations; thus, physicians have a social responsibility to take action against poverty and its consequences for health. Physicians can help improve population health by addressing poverty in their roles as clinicians, educators, research scientists, and participants in policymaking.”

And the greatest healing is in correct belief and good practice, in submitting to God, who said about His Words, “O mankind! There hath come unto you an exhortation from your Lord, a balm for that which is in the breasts, a guidance and a mercy for believers” (10:57) and “Say unto them (O Muhammad): For those who believe it is a guidance and a healing” (41:44).

Also, by being the only true upholders of the idea of God (together with the deists, many of whom, much to my dismay, do not believe in a personal God), they are upholding the most significant foundation to ethics. Without belief in God, ethics is grounded in a vacuum, in the Leviathan of Hobbes. I will turn to this subject in the next section.

The other way in which we can practice and in singing His praises through its many signs. It is this that I aim to highlight, to the best of my ability, in most of the rest of this work.
[1] Warraq would be pleased to know that I have discovered that he has indeed made one original ‘thought’ or remark. On page 131, he argues against the existence of God, saying, “It is very odd that when God decides to manifest Himself, He does so to only one individual. Why can He not reveal Himself to the masses in a football stadium during the final of the World Cup, when literally millions of people around the world are watching?” Quality. I am yet to read a more comical statement than that. Alas, I can think of no others, unfortunately, and I have read his work quite a few times.
[2] The Quran puts it like this, “And We have not sent you except as a mercy to mankind." ( 21:107)
[3] I would love to see Najjar and others who believe this ‘hadith’ dip one side of a fly in his food and redip the other afterward. He would never do it, and I don’t know how he thinks the prophet (PBUH) could even consider us to do that; we do not observe flies in slow motion, and there is no way that we would know which wing is which!
[4] The risk factors I know are obesity, nulliparity, late menopause, PCOS, unopposed oestrogen therapy, tamoxifen, diabetes and personal or family history of breast or colon cancer
[5] As the Quran says,“Nay! They say: "We found our fathers following a certain religion, and we do guide ourselves by their footsteps." Just in the same way, whenever We sent a Warner before thee to any people, the wealthy ones among them said: "We found our fathers following a certain religion, and we will certainly follow in their footsteps." He said: "What! Even if I brought you better guidance than that which ye found your fathers following?" They said: "For us, we deny that ye (prophets) are sent (on a mission at all)." (43:22-4).