The fundamental inspiration and impetus for the development of medical sciences, including surgery, in the Islamic world came from the Holy Quran and the Traditions (Hadith) of the Prophet Muhammad (SAAW), which took the medical sciences away from the realm of superstition and fantasy and led to their establishment on a rational foundation.
The incredibly rapid spread and expansion of Islam since its inception in the 7th century has no parallel in the annals of human history. In the span of a century, it reached the foothills of the Pyrenees, the Iberian Peninsula and the valley of the Indus. In the course of its onward expansion, Islamic civilization came in close contact with a variety of ancient cultures and ethnic groups.
The ancient Greeks had undoubtedly made an outstanding contribution to science, medicine and philosophy, but with the passage of time the Western world lost touch with the Greek legacy. In fact medieval Europe was by and large buried in superstition and cultural backwardness. Muslim thinkers and scientists discovered the Greek treasure house of learning, translated the Greek works in science, medicine and surgery into Arabic and transmitted it to Europe during the Middle Ages. As Sir William Oslar put it, “The medical profession reached among them (the Arabs), a position of dignity and importance, to which it is hard to find a parallel in history”1.
In addition to drawing on the medical knowledge of the ancient Greeks, Muslim physicians and surgeons also benefited from the researches and experiments of Indian scientists and physicians. Significant strides were made by Indian physicians and surgeons in respect of rational observations, experimentation, and innovation and use of medical and surgical instruments. Muslim physicians and surgeons had no hesitation in drawing on the medical legacy of ancient India. At the same time, they enriched the medical sciences with their own observations, researches and experiments.
The seminal and wide-ranging contributions of Abu Bakr Muhammad ibn Zakaria al-Razi (856-925 AD) mark a glorious chapter in the history of Islamic medicine and surgery. His magnum opus Kitab al-hawi fit-tibb2, which deals with diseases ranging from the head to the foot and encompasses the sciences of physiology, anatomy and pharmacology, has been hailed as “the greatest medical work”3 of all times. A distinctive feature of al-Razi’s great work is that, while discussion a particular disease, he cites the opinions of Greek, Persian, Indian and other physicians and then offers his own observations and experiences. It should, however, be pointed out that Al-Razi was not a blind follower of his predecessors. His other work Al-Shukuk ala-Jalinus, wherein he critiques some of the medical observations of Galen, bears ample testimony to this fact.
Al Hawi and Al Mansuri 4 were certainly the greatest medical and surgical works of their time.
Half a century later, we come across another towering figure in Islamic medicine in the person of Ali ibn al-Abbas al-Majusi (d. 994 AD). His major work, Al-Maliki, which runs into 20 volumes, remained a standard medical text for nearly a century. The second and third volumes of the book deal with anatomy and the nineteenth volume with surgery5.
The greatest surgeon of the Islamic world was undoubtedly Abul Qasim ibn Abbas al-Zahrawi al-Andalusi (912-1013 AD). His monumental work Kitab al-Tasrif liman ajiza an al-talif 6 was held in great esteem not only across the Islamic world but also in Europe, and it continued to be taught in European universities until the 18th century. It was translated into Latin in the 12th century and was considered an authoritative source of surgical observations and innovative surgical procedures for a long time. Scott7 described al-Zahrawi as the originator of modern surgery, and Guy de Chaulliac 8, the most celebrated European surgeon of the 14th century, ranked him with Hippocrates and Galen. His work Al-Tasrif had the distinction of being the first illustrated textbook on surgery.
Another illustrious name in the history of Islamic medicine is Abul Ali al-Husain ibn Abdullah Ibn Sina. He was born in the famed city of Balkh (now in Afghanistan) in 980 AD. Ibn Sina made original and outstanding contributions to not only medicine and surgery but also to philosophy, mathematics, logic and musicology. His celebrated work Al-Qanun fit-tibb9 (known as The Canon of Medicine in the West) became so popular in Europe that its Latin and Hebrew 5 translations were published 16 times during the 15th century. He passed away in 1037 AD.
During the heyday of Islamic science and medicine, nearly 400 Muslim scientists, physicians and surgeons made highly significant contributions and advanced the frontiers of science and medicine. One of these illustrious physicians and surgeons was Ibn Zuhr (1113-1162 AD). In his monumental work Al-Taysir10, Ibn Zuhr added considerably to medical and surgical knowledge. He disagreed with some of the medical observations of his predecessors, notably Galen and Ibn Sina. In addition to being a physician, Ibn Zuhr was also a practicing surgeons, and his works had a great impact not only on Muslim physicians and surgeons but also on Europe11.
Ibn Rushd or Averroes (d. 1199 AD), who is generally known as a great philosopher in the intellectual world, was also a reputed physician and a keen student of anatomy and surgery. He believed that the knowledge of the human body “demonstrated and strengthened faith in the greatness of the Creator”12. Another monumental work of surgery was Kitab al umdah fi sin’at al-jaraha 13, authored by Amin al-Dawlah Abul Farj al-Quff (1233-1286 AD). Ibn al-Quff was a renowned anatomist and surgeon. His celebrated work discusses in great detail traumatology as well surgical problems and procedures relating to the whole human organism.
As early as in 742 AD, Caliph Harun al-Rashid sent a delegation to the Roman Emperor Charlemagne, which included some renowned physicians of the time. Contacts and interactions between the West and the Islamic world were facilitated through trade, the Crusades and through Jews who often acted as intermediaries between European rulers and merchants and their counterparts in the Islamic world.
Bacteriology and Wound Infection
Although the concept of bacteria as the principal causal factor in the aetiology of disease was established by Pasteur in the second half of the 19th century and was subsequently elaborated by Lister, Muslim physicians in the medieval period made a notable contribution to this idea. When al-Razi was asked to select a site for the establishment of a hospital in Baghdad, he carried out an interesting experiment. Pieces of meat were hung out at various sites in the city, and when they were examined a few days later by him, the site where the meat showed the least putrefaction was selected for constructing the hospital building 14 In the beginning of the 14th century, Ibn Khatima had written about “minute bodies causing disease”.
Control of Haemorrhage
Haemorrhage remains a basic problem of surgery even today. Surprisingly, modern science has hardly added anything new to the techniques developed by Muslim physicians and surgeons centuries ago. The use of digital pressure, tourniquet, sponges, cauterization, the use of cold water (hypothermia), the division of vessels when imcompletely divided and the ligation of the bleeding points by sutures of thread and other materials have all been described in detail by al-Zahrawi. He also made some reference to the disordered coagulation of blood and warned against the danger of tight bandaging.
The method of suturing of wounds was employed by many Muslim surgeons pf earlier centuries. Ibn Sina mentioned, for the first time in medical history, the use of dry dressing.
Drainage of Abscess
Al-Zahrawi’s Kitab al-Tasrif describes in detail the drainage of abscess, the site and shape of incision, packing of wounds, the excision of the skin edges, the significance of dependent and counter drainage and the use of slow, gradual decompression of large cavities, especially during pregnancy and old age.
TRAUMATOLOGY AND ORTHOPAEDICS
Since ancient times, war surgery has been a training ground for surgeons. Muslim surgeons had a mastery over this branch of surgery. They described in great detail the penetrating war injuries and their management. The Third Book of al-Zahrawi’s Kitab al-Tasrif offers a comprehensive description of bone and joint trauma. Similarly, Chapter 17 of Ibn al-Quff’s Kitab al-Umdah is devoted to a description of the trauma of soft tissues and bones and the injury caused by animals. Al-Zahrawi was the first to describe and suggest treatment for the wounds of the neck and tracheae.
Al-Zahrawi describes in great detail oesteomyelitis, amputation and the corrective osteotomies for mal-united fractures. As Spink and Lewis15 point out, the orthopaedic instruments devised by al-Zahrawi show a far greater variety of saws, robes, osteotomes, respiratory, hammer, drill and scapper, as compared to the ancients.
Muslim surgeons greatly improved on the knowledge of genitor urinary surgery, which they had imbibed from the ancients. Although mechanical pumps were known to the ancient Greeks, they were first used for medical purposes, in the shape of syringes and especially for the irrigation of bladder, by Muslim surgeons. A great surgical feat of earlier times was the removal of massive bladder stones. Al-Zahrawi devised large forceps for the purpose, which could crush the stones and then remove the smaller pieces. He can therefore be regarded as the father of modern lithotrites. Al-Zahrawi described a novel and original method for impacted urethral stones. A fine drill was introduced per urethra and when it came in contact with the stone it was rotated gently until the stone broke up into fine pieces and was flushed out by the urine. Al-Zahrawi also mentioned the use of bladder sound for locating vesical calculi, the problem of post-operative haemorrhage and the importance of removal of clots from the bladder.
Ibn Sina was perhaps the first physician to describe at great length the three varieties of icterus and the use of stomach tubes. Muslim surgeons of earlier centuries employed the procedure of abdominal paracentesis for ascities and intra-peritoneal abscess. They were also aware of the dangers associated with sudden abdominal decompression. While speaking of ascities associated with hepatosplenomeqaly, al-Zahrawi made a reference to advanced cases of portal hypertension, although his understanding of the problem was different from that of present times.
Tropical liver abscesses (amoebic) are a problem with us even today. Al-Zahrawi mentioned the use of trocar and cannula for their evacuation. One of his original contributions is the use of a heated cautery of opening such an abscess. The credit for first using the gut sutures for the repair of intestine goes to al-Razi. However, Harrison16 credits al-Zahrawi with the first surgical use of catgut and cotton suture. Al-Zahrawi also stressed the importance of separate stitching of vaious layer for an abdominal wound. Muslim surgeons were aware of the use of hot fomentation over the strangulated intestine, the problem of foecal fistulae and the bad prognosis associated with jejunae injuries. Ibn Zuhr was the first physician and surgeon to describe in detail the distinction between gastric ulcer and gastric malignancy. A number of medical treatises written by Muslim physicians in earlier times, such as Ibn Sina’s Al-qulanj anwah wa mudawah, were devoted to the problem of colitis and its management through diet, drugs and enema.
Haemorrhoids were apparently a major surgical problem of earlier centuries. A number of medical treatises, such as Fil bawasir17, written by Aby Imran Musa ibn Maymun (1135-1204), and Zad al-masir fi ilaj al-bawasir 17, written by Muhammad ibn Mahmud al-Qusum (d. 1525 AD), were exclusively devoted to the subject. Ibn Maymun emphasized the role of diet and of surgery in selected cases. In his book Kitab al-Umdah, Ibn al-Quff focused on the complications arising from haemorrhoidectomy and post-operative anal stricture. He also made a passing reference to portal pyaemia as one of the complications of haemorrhoides. Al-Zahrawi cautioned against the late drainage of ischio rectal abscess and is regarded as the originator of the cauterization treatment of fistulae in ano. He also makes a reference to the dangers of this procedure, including that of damaging the intestine, bladder, major blood vessels, nerves and the internal sphincters leading to incontinence. He also pointed to the problem of recurrence following an incomplete excision.
One frequently comes across references to the planning of surgical incisions, repair of the palate, ear, nose and gynaecomastin in the works of Muslim physicians and surgeons. Surgical procedures such as the cauterization of warts and corns by heated metals and chemicals have been known since ancient times. But the credit for the cauterization treatment of hare-lip, with the sharp edge of the cautery used for freshening of the edges and the subsequent cicatrisation causing union of the two edges goes to al-Zahrawi.
E. N. T. SURGERY
The life-saving operation of tracheostomy was perhaps performed for the first time in medical history by Muslim surgeons. The credit for the procedure of tonsillectomy by the quillotine method and for devising special forceps and mouth gag for throat surgery goes to al-Zahrawi. Al-Zahrawi’s monumental work Al-Tasrif contains an amazingly perfect drawing of these instruments. Al-Zahrawi also described the complications in tonsillectomy and tumours of the tonsils. Al-Zahrawi recommended the use of special ospeotomes as well as a funnel for the installation of drugs. The first mention of a marine-sponge with an attached string for the removal of foreign bodies in the throat is to be found in Al-Tasrif. Al-Zahrawi describes in considerable detail paracentesia of the ear and foreign bodies in the area. Al-Tasrif contains a detailed description of the surgical removal of a ranula and a tumour (massive recurrent naso-pharyngeal fibroma) and their treatment by repeated excisions and cauterization.
The credit for establishing the relationship between a goiter and exhphthalmos goes to al-Jurjani (d. 1136 AD)18. The doyen of American surgery, Halsted, has stated that the extirpation of the thyroid gland for goiter typifies “perhaps better than any operation, the supreme triumph of the surgeon’s art”. The first successful thyroidectomy in medical history was performed by al-Zahrawi in the city of Madinat al-Zahra in 952 AD19.
Muslim surgeons of earlier times wrote a number of treatises dealing with dentistry. For the first time in the history of dentistry, al-Zahrawi used such procedures as the wiring of loose teeth, extraction of the roots of broken teeth and pieces of mandible by special forceps and fixing artificial teeth made from ox bone. Ibn al-Quff also makes a mention of artificial teeth made from bone.
Al-Jurjani, who lived during the 5th century AH, was an accomplished ophthalmologist. His book Nur al-Uyun 20 is considered a masterpiece on the subject even today. The book Al-Tasrif contains a detailed description of a large number of extra ocular operations as well as some original surgical devices and instruments such as hooks, eye speculum and conjunctival scissors for the removal of panus. Ali ibn Isa al-Kahhal’s book Tadhkirah al-kahhalin21, written in the 4th century AH, also mentions these special instruments.
The posterior displacement of the lens in cataract was known to ancient Grek physicians, but al-Zahrawi devised new techniques and surgical instruments such as perforators and depressing needles. Al-Razi recommended the tearing of the capsule of the lens if it could not be displaced, while Ibn Sina described the various types of needles for this purpose. Both al-Razi and al-Zahrawi described a procedure for the operative decompression of the glaucoma, which was fairly widely employed in Mesopotamia.
OBSTETRICS AND GYNAECOLOGY
Al-Baladi (d. c 380 AH) 22 wrote a comprehensive treatise, known as Kitab al-tadbir al-habala, on midwifery. Al-Zahrawi discussed normal and abnormal presentations as well as the destructive operations together with the relevant surgical instruments for the delivery of a dead foetus. He devised a cephalotribe for crushing the massive head of a dead foetus and described the varieties of the vaginal speculum.
Most Muslim surgeons cautioned against the use of the knife for the removal of malignant growth. Both Al-Zahrawi and Ibn Sina specifically mention that if a malignant tumour is to be removed, it should be done through excisional surgery with a good margin of healthy tissue. They also dwelt on the treatment of malignant tumours through drugs and, in certain cases, through cauterization.
Both al-Zahrawi and Ibn al-Quff described and recommended specially designed surgical instruments for neurosurgical procedures.
Unfortunately, most Western historians of medicines have not adequately acknowledged or highlighted Islamic civilization’s splendid legacy of surgical arts. Furthermore, with the passage of time surgery fell into the hands of incompetent physicians, which led to its decline and decay. Let’s hope that, in the years to come, there will be a greater appreciation of this glorious chapter in the history of Islamic medicine.
The authors place on record their gratitude to the Director of Khuda Buksh Library, Patna for help and guidance in the preparation of this paper.
- SIR WILLIAM OSLAR, As quoted by W.H. Shehadi “The billiary system through the ages” International Surgery, 64, 6. 1969
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