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Lecture to 2nd year medical students at the Kulliyah of Medicine, International Islamic University, Kuantan on 17th October 1998; by Prof Dr Omar Hasan Kasule, Sr.
SURGERY IN THE PRE-ISLAMIC PERIOD
Surgery in many pre-Islamic communities mixed medical treatment with magic. Much of surgery was practiced as part of religious rites by physician-priests. Muslims learned from the experiences of Greek, Persian, Indian, Egyptian, Roman, and Chinese surgeons. The remnants of the ancient knowledge from Assyrian, Babylonian, and Egyptian surgeons were also useful. The practice of embalming the dead gave Egyptians a lot of knowledge about anatomy. The Babylonians knew nasal tamponade for bleeding, cataract couching, blood-letting, and circumcision. The Hebrews made no original contributions to surgery; they learned from the Egyptians. Surgical knowledge in India was very advanced. The following operations were carried out by Indian surgeons: tonsillectomy, amputation, tumor excision, hernia repair, repair of harelips, removal of bladder stones, couching cataracts, nose repair, and caesarian section. They also developed surgical instruments. They knew the washing and bandaging of wounds. Hyoscyamus (Henbane) and cannabis indica were used as anesthetics. In some cases hypnosis was used as anesthesia. The Chinese developed acupuncture and castration of males who became eunuchs at the royal court. The Greek physician Hippocrates introduced rational/scientific medicine. Romans had advanced military hospitals called valetudinaria that were used to treat wounded soldiers on the battle-field. Galen is remembered as a skilled Roman military surgeon. Celsus described the cardinal signs of inflammation: rubor, tumor, calore, and dolore. He gave details of surgical procedures and ligation of blood vessels. He encouraged dissection. The Native Americans had developed sophisticated surgery at the time of Columbus' discovery of the Americas. They performed the following operations: massaging, tooth extraction, blood-letting, trepanning, bandaging, suturing, and amputation. Arabs in the pre-Islamic period practiced cupping and cauterization. These continued during the early Islamic period.
SURGERY IN THE EARLY ISLAMIC PERIOD
In the early Islamic period the knowledge of surgery existing in the Arabian Peninsula continued to be used. The prophet taught improvements as recorded in the books of hadith. He recommended and even practiced cupping and cauterization. During the era of the rightly-guided khulafa more surgical knowledge was acquired with the geographical expansion of the Islamic state and contact with other civilizations in West Asia, Central, North Africa, and South Europe. In the Umayyad period, translation of Greek and Roman medical texts started. This was continued vigorously under the Abbasid dynasty. The Muslims not only learned from others, they also added to the knowledge from their experiences. They developed new and improved procedures. The golden era of Islamic medicine witnessed a lot of developments. The Muslims not only preserved and improved the ancient Greek knowledge; they also passed it back to Europe through Andalusia. It was this knowledge that was responsible for the new developments in surgery in Europe during the renaissance. However while European surgical knowledge developed, the Muslim world was in decline.
2 FAMOUS MUSLIM SURGEONS and AUTHORS
Al Zahrawi (born 325 AH/976 CE, died 404 AH/1013 CE): His full name was Abu Al Qasim Khalaf Bin Abbas Al Zahrawi. He was an Andalusian born and worked in the city of Zahrah. He left a big mark on surgery and became very famous in Europe. His fields of interest were surgery, pharmacology, and anatomy. He designed over 200 surgical instruments. His book Kitaab al Tasriif Liman 'Ajaza 'an Ta'liif became a standard textbook of surgery in Andalusia and Europe for centuries. Al Zahrawi's book al Tasrif that took 30 years to compile is in 30 volumes. The last volume deals with surgery and is one fifth of the whole book. The volume on surgery is divided into three sections: (a) cauterization with 56 chapters (b) incisions, perforations, wounds & wound healing 93 chapters (c) bones setting and joints 36 chapters. The book contains anatomical details. It covered all branches of surgery.
Ibn al Quffi (born in 630 AH/1233 CE and died in 685 AH/1286 CE): His full name was Amin al Dawlah Ibn al Faraj Muwafiq al ddiin Ya'qub Ibn Ishaq Ibn al Quffi al Malaki al Karki. He wrote a surgical manual ' al 'umdat fi sina'at al jarahat'. The book consists of 20 maqalas of which maqala #17 is devoted to traumatology while maqala #19 discusses surgical problems and their treatment from head to foot.
Other famous books on surgery are: Al Jirahat Al Kaniya by Sharaf Al Dddiin Ali, The Ten Articles on the Eye by Hasan Ibn Ishaq, and A Manual for the Oculist by Ali Ibn Isa.
MUSLIM CONTRIBUTIONS TO SURGICAL KNOWLEDGE: GOLDEN ERA
Anatomy: Famous names in anatomy were: Ibn Masuwayh, Ibn Abi al Ash’th, al Majusi, Ibn Habal, Ali Ibn Abbas, Ibn Sina, Ibn al Quffi, Ibn al Nafiis, Ibn Ruhd, Abdul Lateef Baghdadi, and Zakariyyah Ibn Muhammad Ibn Muhammad al Qazweeny. Al Razi encouraged dissection and study of physiology. Al Zahrawi insisted on knowledge of anatomy before any surgery.
Ophthalmology: (Ibn Hytham d. 1040 AD, Hunain Ibn Ishaq, Al Razi, Ibn Sina, Al Zahrawi, Ali Ibn Isa, Ibn al Rushd, Abu al Qasim Ammar). Ibn Hytham (965-1040 CE) in his book 'Kitaab al Manadhir' disproved the extromission theories of Euclid and Ptolemy and instead advocated an intromission view. He described the optic pathways and the point-to-point projection of the visual world into the brain. He described how eye movements helped in visual perception. He also realized that several processes were involved in conscious visual experience. Jurjani (5th century AH) wrote about ophthalmology in his book 'Nur al 'Uyuun'. Al Zahrawi described many extra-ocular operations. Al Zahrawi described the posterior displacement of the lens in cataracts. He also discovered many ophthalmic instruments such as hooks, eye speculum, conjunctiva scissors for removal of panus, perforators and depressing needles for cataract surgery. Al Razi recommended tearing the capsule of the lens if it cannot be displaced and Ibn Sina described various needles that can be used for this. Ali Ibn Isa was another ophthalmologist who wrote the book 'Tadhkirat al Kahaaliin'. Both Al Razi and Ibn Sina described a procedure for operative decompression of glaucoma.
Anesthesiology: Al Zahrawi performed many of his operations under anesthesia: opium or mandragora.
Obstetrics: Al Baladi (circa 380 AH) wrote a complete discourse on midwifery called 'Kitaab Tadbir al Habala'. Al Zahrawi described normal and abnormal presentations and described instruments for craniotomy to deliver a dead fetus in case of obstruction. He also developed a vaginal speculum.
Infectious diseases: (smallpox, measles, epidemics). Ibn Khatima had mentioned minute bodies causing disease in the 14th century CE. Al Razi was aware of air-borne infection when he made an experiment to determine the site of a new hospital in Baghdad by putting meat in the air and waiting to see the site where it putrefied soonest.
General surgery: The famous names in general surgery were: Ibn Zuhr, al Shirazi, and Ibn Dhahabi. The most famous of them all was al Zahrawi. His book al Tasrif was used as a standard text in Europe and was translated into Latin in the 12th century CE. Al Zahrawi performed thyroidectomy in 952 CE. He is reported to have used catgut and cotton sutures in closing surgical wounds. He recognized pain as a symptom and not a disease. He performed tracheostomy as an elective procedure and described bandaging techniques. Among his inventions: the syringe for bladder irrigation, the vaginal speculum, and plaster for bone setting. Al Jurjani (d. 1136 CE) described the relation between goiter and exophthalmos. Al Razi was the first to use gut sutures for intestinal repair.
Traumatology & orthopedics: Al Zahrawi and al Quff described treatment of bone and joint trauma. Al Zahrawi wrote about osteomyelitis, amputations, and osteotomies for un-united fractures. Al Zahrawi cautioned against above-knee and above-elbow amputations.
Wound treatment: Famous names in wound treatment were: Ibn Sina, Al Zahrawi, Ibn Rushd, and Al Razi. Al Zahrawi taught the following methods of arresting hemorrhage: digital pressure, tourniquet, sponges, cauterization, hypothermia, and ligation of bleeding vessels by sutures of thread. He also advised against tight bandaging. Al Zahrawi emphasized the importance of cleanliness in wound treatment. Ibn Sina mentioned dry dressing. Al Zahrawi wrote about the drainage of abscesses describing in detail the site and shape of the incision, packing of the wound, excision of the skin edges, use of slow decompression of large cavities, dependent and counter drainage.
Urology: Al Zahrawi described bladder irrigation. He also developed original methods of lithotromy for impacted stones. He introduced a fine drill into the urethra that was rotated gently to break up the stone into small pieces that could be washed away by the urine. He also wrote about using a bladder sound to locate bladder calculi, control of post-operative hemorrhage, and removal of clots from the bladder.
Gastroenterology: Al Zahrawi used stomach tubes. He described paracentesis for ascites and intra-peritoneal abscesses. He mentioned use of the trocar and cannula to drain liver abscesses. He also described the use a heated cautery to open liver abscesses. Ibn Zuhr (1113-1162 CE) was the first to describe in detail the distinction between gastric ulcer and gastric malignancy. Ibn Sina wrote about colitis and its management by diet, drugs, and enema. Abu Imran Musa bin Maymun (1135-1204 CE) wrote about hemorrhoids and the role of diet and surgery in their treatment. Muhammad bin Mahmood Al-Qusum (circa 1525 CE) in his book ' Zad al Masir fi 'Ilaj al Bawasir' wrote about treatment of piles. Ibn al Quff wrote about complications of hemorrhoidectomy and post-operative anal stricture. Al Zahrawi originated cauterization treatment of fistula-in-ano and was aware of the complications of this treatment.
Plastic surgery: Al Zahrawi described the cauterisation treatment of harelip. He wrote that the edges must be freshened first before cautery.
Ear, Nose, and Throat: Al Zahrawi discovered the guillotine method of tonsillectomy as well as the complications of the operation. He described the tumors of the tonsil. Among other discoveries attributed to al Zahrawi are: use of special osteotomies for nasal operations and polypectomy, use of a marine sponge with an attached string for removal of foreign bodied from the throat, removal of foreign bodies from ears, treatment of nasopharyngeal tumors by repeated excision and cauterization.
Dentistry: Ibn al Quff described making artificial teeth from bone. A Zahrawi described several dental operations: wiring of loose teeth, extraction of roots of broken teeth and broken pieces of the mandible by use of special forceps.
Tumors: Al Zahrawi and Ibn Sina recommended wide excision including healthy tissue in removal of tunors. Use of cautery and drugs in treatment of tumors was also described. Another author on tumors was Abdul Malik Ibn Zuhr (d. 484 AH).
Neuro-surgery: Both al Zahrawi and Ibn Quff described in detail the various intra-cranial and extra-cranial hemorrhages due to arrow wounds and their respective treatments. Al Zahrawi described symptoms and signs of skull fracture. He also described the depressed fracture in children and recommended treatment by removal of a bone. In cranial operations, the drill may accidentally perforate the delicate intra-cranial structure; Al Zahrawi developed an instrument to prevent this accidental penetration. Al Zahrawi's craniotomy operations were remarkably like modern ones; using burr holes with a linking cut between them allowing to raise part of the cranial vault. Al Zahrawi described paralysis due to injury of the spinal cord. Haly Abbas described several types of fractures: simple, comminuted, displaced, and hairline. Ibn Sina classified fractures of the skull into two types: closed fractures and open fractures. He described treatment of skull wounds by relieving hematoma or removing pieces of bone that could hurt the brain. Baghdadi described the depression fracture found in children. He also described meningoceles that remained after skull surgery and appeared during coughing. Samarkandi described treatment of brain edema following skull trauma and its relief using dehydration, venesection, and enema.
DECLINE AND RENNAISSANCE
Following the golden era of Islam, the initiative for medical development was in Europe. Muslims can still be proud of this because Europeans learned from them. The subsequent growth of surgical knowledge in Europe and later America was very rapid and phenomenal. Muslim contribution to this development was minimal or absent. This rapid development was in marked contrast to Muslim stagnation.
Surgical development in Europe developed rapidly after the renaissance and the subsequent centuries. Leonardo da Vinci (1452-1519 CE) dissected and described human bodies. Andreas Vesalius (1513-1564 CE) dissected bodies and published De Humani Corporis Fabrica Libri Setem which corrected many anatomical mistakes. Ambrose Pare (1510-1590 CE) was an army surgeon who stopped use of hot oil to treat gunshot wounds, invented surgical instruments, used ligatures instead of cauterization of blood vessels in amputations, developed artificial limbs, and invented surgical instruments. Jean Baptiste Denis carried out the first successful human blood transfusion in 1667 using blood from a lamb. Obstetric forceps were developed by Peter Chamberlain in England in 1630. Santorio Santorio (1561-1636 CE) developed the thermometer and measured body weight. William Harvey (1578-1657 CE) rediscovered blood circulation that had been described centuries before by the Muslim physician Ibn Nafis. Marcello Malphigi (1628-1694 CE) described capillary circulation. Athanasius Kircher (1602-1680 CE) and Anton Van Leewenhook (1632-1723 CE) described micro-organisms seen under the microscope. Fransesco Redi (1626-1697 CE) disproved the theory of spontaneous generation. Daniel Fahrenheit (1686-1736 CE) developed the mercury thermometer. Stephen Hales (1677-1761 CE) was the first to measure blood pressure. William Hunter (1718-1783 CE) and his brother John Hunter (1728-1793 CE) dissected bodies and taught anatomy and surgery. Rene TH Laennec (1781-1826 CE) discovered the stethoscope. Claude Bernard (1813-1878 CE) introduced the scientific method in medicine. Herman von Helmholtz (1821-1894) invented the ophthalmoscope. Joseph Priestly discovered nitrous oxide in 1776 CE and it was later used as an anesthetic in operative surgery. Ignas Semmelweiss (1818-1865 CE) insisted on hand-washing in obstetric practice to prevent spread of infection. Oliver Wendell Holmes (1809-1894 CE) also wrote treatises on infections. Louis Pasteur (1822-1895 CE) laid the foundations of modern bacteriology but Robert Koch (1843-1910 CE) is considered the father of this discipline. William Roengten (1845-1922) discovered x-rays in 1895 CE. Madame Curie and her husband Peter discovered radium and its ability to destroy malignant cells in 1898 CE. Paul Erlich (1854-1915 CE) discovered Salvarsan in 1910 CE. Alexander Fleming (1881-1955 CE) discovered penicillin in 1929 CE. In 1901 Karl Landsteiner discovered blood grouping. In 1948 CE Dr Papanicoulus discovered the Pap smear. Since 1950 rapid developments have occurred due to growth in the basic sciences. The first heart transplant was carried out in 1967. In-vitro fertilization and genetic engineering are breaking new frontiers in surgery and medicine as a whole. The developments in the past 40 years are so many that it is difficult to document them in detail as was done for the earlier centuries.
Muslim medical renaissance: A real interest in reviving the Muslim heritage in medicine was noticeable with the start of the new hijri century 1400/1980. Medicine in the ummat is passing through a period of renaissance. There is pride in the past and a determination to excel in the present. This renaissance is manifesting as seminars, conferences, memorial buildings, books, and publications dealing with Islamic medicine. Islamic Medical Associations have been set up and are operating in the USA, S Africa, Pakistan, Egypt, Sudan, Malaysia, Indonesia, and Jordan. Among their activities are: journals, bulletins, conventions, research, direct care services, medicolegal fatwas, advocacy, Islamic clinics and hospitals. There is research on remedies in tibb nabawi and traditional medicine, clinical trials of the use of honey in treatment (diarrhea, ocular disease, and bladder schistosomiasis), chemical analysis of nigella sativa seed, experimental study of Qur’anic facts on menstrual hygiene, immunological and physiological properties of the black seed habba sauda, immunological and physiological impact of tilawat al Qur’an, use of dermatoglyphics to study hereditary disease, herbal drugs for intestinal infestations, analysis of herbal remedies mentioned by early physicians for pharmacological activity, and clinical trials of ancient remedies. In the practical arena Islamic relief agencies: medical services in war and devastated areas, medical services for the poor, medical services and dawa. Medico-legal fatwas are being made. Medico-fiqhi committees have been set up at the World Muslim League, Rabitat al Aalam al Islami, the Organization of the Islamic Conference, the Islamic Hospital in Jordan, the International Conferences on Islamic Medicine held in Kuwait, USA, S Africa, Egypt, Malaysia, and Pakistan.
THE CHALLENGE
Muslim physicians and surgeons must be motivated to open and expand new frontiers of knowledge. They cannot sit on their laurels and be proud of the achievements of the early Muslims. They will have to realize their present backwardness and make a resolution to break out of it. Muslims cannot reject the modern achievements in surgery. They have to build on them as the ancients did. They in addition will have to grapple with the legal and ethical issues that modern biotechnology has generated.