Islamic Civilization

Surgery

According to Elgood, the position of the surgeon in the time of the caliphs was one of honour, and he was not looked down upon by the physicians as was the case in Europe during the Middle Ages.[1] Reflecting the high status of the science, nearly every single Muslim medical writer had a chapter on surgery, covering one aspect of it or another.[2] The primary role of surgery in terminating many cases of ill health was well understood. Al-Madjusi, in his Liber Regius, considered treatment with surgery as of equal importance as treatment with drugs.[3] In the surgical section of his work, he described many surgical conditions and gives sound advice on treatment.[4] For instance, he describes laryngotomy, advising the operator, after cutting the skin, to draw the tissues apart with hooks, and then, exposing the trachea, to open it between the cartilages.[5] When an artery is wounded, it should be dissected out and silk ligatures applied on either side;  and after these have been tied, the artery should be severed between.[6] He recommends excision in cancers of the breast and extremities.[7] Abu Mansur Muwafaq (fl. Late 10^th century) was the first to describe the use of plaster of Paris in the treatment of broken bones.[8] Through some mischance of history, this discovery never became widely known, and it was not until 1852 that the treatment was reintroduced into medical practice.[9] Ibn Sina ’s description of the treatment of malignant disease might have been penned today; the only hope of cure he says is to take the disease in the early stages. [10] The excision must be wide and bold; all veins running to the tumour must be included in the amputation, and even this is not sufficient; the affected area should be cauterized. Even then ...cure is not certain.[11]  The lesser known Muslim surgeon, Ibn al-Ayn Zarbi (d. 1153), who originally comes from the Seljuk Heartland, authored many works on the healing art, most of which are, unfortunately lost.[12] He describes many injuries such as stab wounds, injuries to the head, bones and skin and how to care for them.[13] Concisely and accurately, he describes methods and techniques for bone setting, suturing and bandaging, and he also makes useful observations of scrofula, especially the fugitive and ganglionic types of this glandular, lymphatic disease.[14]

The main Muslim surgeon, however, was Al-Zahrawi, whose work is examined below at some length.

The Surgery  of al-Zahrawi

The principal Muslim surgeon was Al-Zahrawi’s, whose al-Tasrif, known in Latin  as liber servitoris, is a rich  treatise, which describes many operations in great detail as the following extracts will show.[15] For his purposes, Al-Zahrawi constructed a great number of instruments and devised a number of surgical procedures. He explains with the aid of drawings the use of such instruments and surgical operations in great detail.[16] In fact, the surgical portion, produced separately, was the first illustrated work on surgery.[17] Al-Zahrawi’s descriptions of operations are clear and particularly valuable because they portray the figures of surgical instruments used in the Middle Ages, for there are few illustrations dating from the Muslim period.[18] Most  of the figures of medieval times were derived from those of Al-Zahrawi (and incidentally show no knowledge of perspective).[19] Indeed, Al-Zahrawi’s surgical tract was translated into Latin by Gerard of Cremona in the 12^th century in Toledo ,[20] and the Latin translation of  al-Tasrif was printed in Venice in 1497 (and reprinted in 1500); and also in Strasbourg in 1532 and Basle 1541.[21] The Basle edition is illustrated with woodcuts which are dissimilar to those in Channing’s translation, which also contains commentaries by Roland, Roger, Constantine, and Gasius.[22] The Basle edition is also of interest, as it formed the basis of the work of John Channing who published his Albucasis de Chirugia in 1778.[23] The reference to gynaecology in it was published by Gaspar Wolph in his Collectio Gynaeciorum.[24] This treatise, Al-Tasrif, because it is so rich, and because it is not often used by historians on the subject, deserves a lengthy summary here.[25]

It is appropriate to begin with a point that Al-Zahrawi raises towards the end of his work (P. 676), saying:

‘Whatever skill I have, I have derived for myself by my long reading of the books of the Ancients and my thirst to understand them until I extracted the knowledge of it from them. Then through the whole of my life, I have adhered to experience and practice. So now I have described for you in this book all that my knowledge has encompassed on the subject, and that my experience has encountered; I have made it accessible for you and rescued it from the abyss of prolixity; I have reduced it to a brief outline; and have explained it most clearly. I have made for you many drawings of the instruments that are used in it, which is an adjunct to explanation, as I did in the previous two books. And there is no power save in God the High, the Great.’

An absolutely faultless paragraph, catching the very essence of Islamic science in all its dimensions: the recognition of the works of the predecessors; the need for experiment; the legacy of knowledge to successors; the determined search for clarity; and the absolute and foremost faith in God, and His guidance.

The first practical matter to preoccupy Al-Zahrawi (p. 4 ff.) relates to the precautions a surgeon has to take in performing any surgical operation. He says he witnessed a surgeon incising a scrofulous tumour in a woman's neck, cutting arteries in the neck causing her to bleed to death. Another surgeon sought to extract a large stone from a man of advanced age, but rushed the operation and took out the stone but also part of the man's bladder; the man was dead three days later. Another surgeon bound a fracture over a wound of a boy very tightly with pads and splints, not allowing the wound to breathe, which eventually caused the leg and foot to swell. Al Zahrawi was called for help. He made the bandage loose, but gangrene had already appeared and spread; and the boy eventually died. Al-Zahrawi then relates another case:

‘I saw another Doctor incise a malignant tumour. After some days the place broke out in open ulceration; thereby adding to the misery of the patient. For a cancer that arises from a melancholic humour should never be touched by the knife unless it should happen to be in a part of the body which may be removed thoroughly and in its entirety.’

Extreme accuracy in diagnosis and treatment, but also treatment according to patients and particular situations, he insists, are fundamental (p. 128 ff.) He, thus, describes and prescribes cauterization for deformities, but insists that cauterization should be avoided if deformities arise from nervous spasms. Another precautionary measure (in Book One on cauterisation) is the need to consider the general state of the patient first; and that some operations under certain conditions should be avoided as much as possible. In Chapter I of Book Three he draws attention to the differences in patients imposed by their age and condition, and also to the difference in fractures either with respect to the limb affected, or the nature of the fracture itself. To each type, he gives detailed directions, and the way to bandage. In the cure of hydrocephalus (p. 170), he gives directions for surgery if the swelling is small. If on the other hand, it is large, he gives alternatives, and if the problem is not between the bone and skin, but beneath the bone, he advocates a further course of action. He concludes his directions with the usual procedures to follow after the operation, and what particular diet is suitable for the patient.

Al-Zahrawi was possibly the first surgeon to understand how malignant diseases spread wide and fast, and the need for radical surgery. Thus on cauterization of cancer (p. 150), he advises burning all around the circumference of the cancer. Some doctors, he says, only advise extensive cauterization in the middle, which is wrong as the cancer ulcerates out, which he had seen several times. The same with gangrene (p. 154,) where he advises cauterization all over till all corruption is eradicated and none remains. And on amputations of limbs from gangrene (pp. 576-8), he stresses radical, prompt surgery. However, he is careful to point that if disease had reached the shoulders, amputation like with other limbs (fingers, hand, arm etc..) will cause the death of the patient. Instead he recommends the use of other means as well as possible. Similarly (p. 460) a cancerous tumour arising on the uterus is under no circumstance to be treated with the knife.

Al-Zahrawi insists (as in p. 146) that operations should only be undertaken by experts. Hence on cauterization for numbness, he stresses that the operation could only be attempted by someone who has good knowledge of the anatomy of the limbs and of the exits of the nerves that move the body. And (p. 420) on the extraction of a stone from a female, he recommends, that when carrying out the operation female assistance is crucial.

Al-Zahrawi also gives great attention to teeth problems and diseases and ways of curing them. (Pp. 272-4) he draws attention to the corruption of the teeth by substances that attack the gums. He recommends scraping teeth with a metallic instrument. He also notes that the tool used for the inner surface of the tooth is different from that used for the outer surface, and another one for scraping between the teeth, and all instruments are illustrated. (P. 276), he insists that all must be done to keep the tooth (a noble substance) until there is no means of avoiding its extraction. (P. 292), he tells of interlacing loose teeth with silver and gold wire; preferably gold as it does not oxidize or corrode, and lasts for ever.

On circumcision (pp. 396-400) he recommends the use of scissors and ligature. He says that the small boy must be kept unaware of what was happening, amused and cheered as best as possible, and for the surgeon to keep the scissors out of the boy’s sight.

A whole chapter (46, pp. 346-61) includes descriptions and illustrations of instruments for incising and perforating. And from such illustrations can be noted the immense similarity with modern day instruments used for the same purposes. In the use of the scalpel and cutting instruments, Al-Zahrawi shows how incisions are to be made (as with the eyes, p. 188), the direction of the cut, depth, the care needed to avoid muscles etc. He also shows in detail how to use knives during surgery (pp. 644, 646, 650,) again how to cut, the direction, depth, length, nature of the cut etc. Towards the end (pp. 698-710), he deals with fractures of the head caused by swords or stones, haemorrhages, and what instruments to use in each situation, and what sort of bone is dealt with. He insists constantly on the extreme care to be taken in using instruments in sensitive areas.

Al-Zahrawi repeatedly insists on the precautions to be taken to avoid cutting veins and arteries, and not to injure badly the part being operated upon, especially the eye or the brain (p. 208). On the extraction of temporal arteries, where the risks of haemorrhage are high, the operation is looked at in every minute detail, every action carefully described, as well as ways of dealing with bleeding and healing the wounds. To perform such highly delicate operations, Al-Zahrawi insists very much upon the need for broad sunlight, and the operation to be carried out in the middle of the day.

Haemorrhages are of course frequent in surgery, and constitute a very important element of his care. Thus, (p. 162) he elaborates on how to deal with haemorrhage arising from a cut artery. Every single action is detailed (pp. 162-4): how to close arteries; use of cauterization; use of strong thread ligature and bandaging in extreme cases; the use of very cold water to thicken the blood and make it congeal; and so on and so forth.

On the use of diverse substances necessary to complement surgery, al-Zahrawi mentions treatments which generate flesh, such as the mixing of wheat flour, colophonia, and making a salve of them to encourage the growth of flesh. The use of plants and their derivatives, honey, and ointments are also considered for cleansing or healing wounds, stopping bleeding, helping skin regeneration, and even opening wombs (p. 496). He also (p. 694) describes a plaster made of mill dust which, he says was principally flour, made into a stiff paste with egg white. He directs its use in instances of fractures of the clavicle and forearm.

Suture captures Al-Zahrawi’s interest in all its applications. He decribes its use after operations and the material it is made of: ‘rubbed down and well cleansed gut' (pp. 266, 334, 450, 536 etc.).

The greatest merit of Al-Zahrawi is not what he says, but the way he says it, never refraining from being detailed, repetitive, and above all very precise. Thus, as an instance, his focus on blood vessels absorbs thirty pages (pp. 624-54); dealing with vessels that can be opened; describing precisely their location, the number of veins in each limb etc.

Al-Zahrawi uses countless examples throughout his work, describing what he saw, what happened, what he did, what precautions were taken, before, during, and after the operation; how to cover wounds and cuts; how to loosen the bandage, rinse the wound, apply balms and other treatments until the wounds heal and so on and so forth; a mass of details no surgeon can miss. He devotes, for instance, an extensive amount of writing (pp. 608-22) to the single operation of extracting arrows. He describes their wounds; the reactions according to each wound in any part of the body; when the wounded person should not be operated upon, accounts of arrows he has himself extracted from patients, and so on and so forth.

Throughout the work, Al-Zahrawi also insists on actions that today might be taken for granted, but which at the time were fundamental for the success of surgery, such as the time of the day when operations should be undertaken, and when to avoid performing surgery. He tells how to sit or place the patient for each operation, the diet before and after the operation, the work of the assistants, the ways to heal wounds, to regenerate skin, and care for bones, actions to take in case of haemorrhage, etc. (P. 324,) for instance, he explains that even when releasing the pus from an abscess or wound, great attention should be paid to the state of the patient: too much and too sudden evacuation, and the patient might die. He also draws attention to the simple and yet important acts of having ready sponge or linen towels to wipe the blood away; and wiping off continuously during operations.

Al-Zahrawi (pp.578-80), does not fail to narrate his own shortcomings such as when he amputated the foot of one of his patients, then refused to amputate the hand when the disease affected it despite the insistence of the patient, because he considered him too weak to withstand the new operation. The patient went back to his country and there he had his hand amputated, and recovered. Al-Zahrawi narrates this story to his sons (students) so that they would see in it guidance to take and act upon; and that however great the surgeon, there is always someone better.

Finally, relying on his experience, Al-Zahrawi does not hesitate to refute the Ancients’ methods, and he proposes better ways, such as here with regard to suture. The Greeks seem to have employed only wool or linen, whilst Al-Zahrawi uses gut for mending wounds of the intestine, but first he tells us of another technique (p. 550):

‘Some men of experience have said that when a wound occurs in the intestine and it is small, it should be sutured in this manner. Ants with large heads are taken, then the edges of the wound are brought together and one of these ants is applied by its open jaws to the two edges of the wound. When it seizes it and closes its jaws, the head is cut off. Then another ant is applied near the first, and so on. The heads will remain sticking to the intestine until it is healed, and no harm will come to the patient.’

Then he says:

‘The intestine may also be sewn up with the fine suture which is extracted from an animal's gut. The end is taken of this suture, well scraped, and to it is fixed a fine linen thread, twisted, which is passed through the needle. The intestine is sewn with the gut, then replaced in the abdominal cavity.’[26]

Al-Zahrawi also refutes the Ancients in relation to many other issues such as in the treatment of dislocations of the spinal vertebrae (p. 812):

‘If the curvature dates from childhood, there is no treatment or cure at all. As for the sort that occurs from a fall or a blow or the like, the Ancients indulged in lengthy disquisitions, giving many kinds of treatment, most of which are of no use. I have abbreviated, making a little which will serve in place of their much, consisting in my clarification and exposition of the sense. I have also depicted the instrument differently from theirs.’[27]

In view of these examples cited, and other extracts in his work, it is obvious that he is at odds with Greek surgery, and his surgery is much more advanced, closer to our modern surgery. Thus, the assertion made by Western historians (as seen in the first heading) that Al-Zahrawi’s surgery is Greek, is false. Similar conclusion is reached by Haddad, who answers the assertion that Al-Zahrawi’s surgery is based on Paul of Aegina’s by noting that ‘those who hold this opinion have not compared the works of the two men.’[28]

Eye Surgery

In eye surgery, the Muslims were not surpassed for several centuries.[29] Nearly every Islamic medical compendium covers some aspect of eye diseases, although the best are monographs solely dedicated to the subject.[30] Such works on ophthalmology were innovative in many ways.[31] One reason, possibly, for the advance of the science was its high incidence amongst the population, and the fact that Muslim eye surgeons were able to use freely available eyes for practice.[32] Another, very likely reason, is that, as with surgery in general, though the oculist was not regarded with much respect among the Greeks and Romans, in Islam, he was an honoured member of the medical profession and occupied a unique place in the royal household in the days of the caliphs.[33]

The first scientific treatise on ophthalmology was written by Yuhanna ibn Massawaih (777-85) under the title Daghal al-'Ain, or Disorder of the Eye, one copy of this manuscript is preserved in the Taimur Pasha Library in Cairo , while another copy of it is found in the Leningrad Library.[34] The other important early work on the subject is the Ashar Maqalat fi’l Ain or the Ten Treatises on the Eye by Hunayn Ibn Ishaq (809-77), which is duly illustrated with diagrams, and in which Hunayn discusses the anatomy of the eye, brain, and optical nerves, as well as physiology, diseases and treatment of the eye.[35] Max Meyerhof has made an excellent edition and translation of the work into English, accompanied by a glossary.[36]

Most famed of all Muslim oculists is Ali Ibn Issa (Jesu Haly) (d.1010), from Baghdad , who completed Tazkiratul-Kahhaleen (Notebook of the Oculist) on diseases of the eye.[37] The first part of it is devoted to anatomy, the second to the external diseases of the eye, and the third part to internal diseases of the eye which are not visible upon inspection.[38] When 'Ali speaks of internal diseases of the eye, he literally means diseases confined to the eye. The possibility of first diagnosing diabetes, kidney disease and cerebral tumour in the ophthalmic consulting room was not conceived of by the oculists of those times.[39] The nearest approach that 'Ali makes to the modern conception of eye disease as a manifestation of general disease is when he urges the practitioner to realise that defective vision may be due to a disease of the stomach or brain just as much as to an incipient cataract.[40] The book contains the first description of the disease of temporal/giantcell arteritis which causes severe headache, migraine, loss of appetite and inflammation of the temporal muscles.[41] These symptoms sometimes terminate in the loss of sight. Thus, he was also the first to note a relationship between inflamed arteries and visual symptoms, not only in the case of a migraine, but also in affections showing heat and the inflammation of the temporal muscles.[42] He suggests the removal and cauterisation of the artery as a treatment for this disease.[43] The credit for the discovery of this disease has wrongly been given to Sir Jonathan Hutchinson and James Horton. Hutchinson (1828-1913), an eminent British surgeon and pathologist, was an authority on eye and skin diseases,[44] while Horton served as a medical officer in the British Army between 1857 and 1871.[45] This error was first corrected by J.R. Hamilton and his colleagues in an article titled Giant Cell Arteritis including Temporal Arteritis’.[46]

A point of great importance in Ali Ibn Issa’s treatise relates to its use of the expression Tanwim (sedate) the patient.  According to Hirschberg Ibn Issa speaks of general anaesthesia in four places, in operations for hydatids of the eyelids, he remarks: In case the patient is one of those who can’t hold still and causes trouble, put him to sleep and let one assistant hold his head and the other his arm.’[47] This breakthrough (like many) was not accepted to be of Islamic origin by historians who claimed it might just mean asking patients to lie down.[48] The Muslims, however, knew a great deal about the issue. Baha-al-Dula wrote:

'Take care that the treatment (the anesthetic) is not more dangerous than the disease."[49]

Ali Ibn Issa’s work was translated once into Hebrew and twice into Latin , and was printed in Venice in 1497, 1499, and 1500.[50] Centuries later, it was translated with commentary into German by Hirschberg and Lippert (1904) and into English by Casey Wood (1936).

A contemporary of Issa Ibn Ali was Ali Ammar Al-Mosuli, whose Kitab-ul Muntakhab fi Ilaj-ul Ayn (Book of Choices in the Treatment of Eye Diseases) discusses forty eight diseases, clinical cases and adaptations of surgical instruments.[51] The book deals with the anatomy and pathology of the eye. It mentions six cases of operation for cataract, deals with diseases of the eyelid, the corner of the eye, the conjunctive, the cornea, the pupil, the albumen, and the visual nerves.[52] In discussing the treatment of a cataract, Al-Mosuli produces an instrument of his own design, a hollow needle, which he introduces through the sclerotic, extracting the lens by suction.[53] This avoided an incision into the anterior chamber and the consequent loss of aqueous humour.[54] The treatise of Ali Ammar on eye surgery, according to Meyerhof, is so rich, that only in the 19^th century did Western European treatises catch up with it. [55]

A  number of other medical authors dealt with the same subject. Ibn Sina ’s section dealing with ophthalmology has been a particular subject of interest on the part of modern medicine.[56] Al-Ghafiqi (d. 1165) wrote Al-Murshid fil Kuhl  (The Right Guide in Ophthalmology), also gives details of the head and diseases of the brain, which he illustrated with pictures of the surgical instruments he used in performing eye operations, a practice started by al-Zahrawi.[57] Salah Eddin of Syria  Kitab Nur al-uyun wa-Jami al-Funun (Light of the Eyes..) is a very good compendium on previous authorities in the field.[58] Another Syrian, Ibn Abi'l-Mahisin, who lived in Aleppo  until about 1256, was the author of al-Kafi fi 'l-Kuhl, or The Sufficient Manual on Collyrium.[59] His writings contain a useful introduction to eye surgery and descriptions of eye operations, side by side with diagrams and drawings of surgical instruments.[60] He mentions eighteen major ophthalmologic texts, where he makes good descriptions of cataract operations, and the instruments used, as well as the steps to be taken after operations.[61]  He was one of the foremost eye surgeons of his time, and was so confident in his skill that he did not once hesitate to operate, even upon a one-eyed patient to remove a cataract.[62]

A number of diseases, not yet cited, were dealt with by these eye-surgeons. Amongst these was pannus, the Muslims being the first to operate for the relief of its chronic form.[63] In his Diseases of the Eyes, Ibn Massawayh describes the surgical treatment of pannus, how the surgeon would lift the blood vessels over the pupil with a small hook, and then sever them.[64] Ibn Massawayh also describes surgical operations on the eyelids and the sutures that were used.[65]

Muslim surgeons also differentiated phlyctenulae from corneal ulcers, whilst circumcision of the conjunctiva as an operation was revived in 1862 by Funari, who was given credit for a new method of treatment, which was, in fact, centuries after the Muslims had used it.[66]

In respect to the cataract, finally, Muslim surgeons stated that it was due to a pouring out of humour into the eye. Before them, Celsus had stated that suffusion is characterized by corrupt humour, collected in the locus vacuus between the pupil and the lens, thus abstracting the visual power. By clearing this empty space vision could be restored.[67] The same attention to detail is found again with al-Zahrawi, for instance, who, on the couching of the cataract (pp. 252-6), says that, although the patient's sight can be tried, it must not be at the time of the treatment, or immediately after the perforation by the needle. Here again (p. 256), he mentions of the existence in Iraq  of the hollow needle to extract cataract (by sucking it out).[68]