Al-Zahrawi's vision of surgery
Al-Zahrawi's pioneering and monumental work, Al-Tasrif provides a clear exposition of his surgical thinking and philosophy. Undoubtedly, Al-Zahrawi drew on the medical observations and researches of the ancients, whom he mentions with great respect and advises his pupils to benefit from their wisdom. At the same time, as a practising surgeon he differed from the Greeks in respect of certain surgical theories and questioned their beneficial application. Moreover, he introduced new operations and devised innovative surgical techniques and instruments. For instance, while discussing the treatment for the abnormal curvature of the spine, he says: "the ancients indulged in lengthy dissertation there on giving many kinds of treatment, the greatest part of which is of no use" 1
While discussing difficult operative steps, Al-Zahrawi places great emphasis on a thorough grounding in anatomy, without which a surgeon will be greatly handicapped even today. In the opening part of Al-Tasrif, al-Zahrawi says: "He who is not skilled in anatomy ......is bound to fall into error that is destructive of life". Al-Zahrawi emphasises that a surgeon must ensure the safety of the patient in the course of any surgical procedure. He disapproves of surgical procedures that are rash and devoid of practicality. He says: "My sons! show caution and care for yourself and gentleness and perseverance for your patients". He asks his pupils to take the "best road that leads to health and a happy outcome". He advised them that it is preferable to cure a disease by medicine, and if that is not possible, through a surgical procedure that involves the least amount of pain and discomfort to the patient. At the same time, he cautions his pupils to be ready for any eventuality that might arise in the course of surgical interventions. He says: "The more instruments the practitioner has ready by him the more rapidly he operates and the greater his reputation amongst them. So do not neglect to have ready by you a single one of these instruments". 2
While discussing the treatment for malignancy, Al-Zahrawi points out that cancer should not be touched with a knife unless it is in a part of the body from where it can be removed thoroughly and in its entirety (as in the case of breast cancer). He emphasises that the excision should be done with the utmost thoroughness so that "not the least root of it remains" and that surgery should be done in the early stage of the malignancy as late cases with extensive involvement can never be cured.
Self-introspection and self-correction are of the utmost importance in scientific advancement. Al-Zahrawi openly acknowledged his occasional mistakes and failures in the course of surgical interventions, such as the amputation of a gangrenous limb or the failure of wound healing due to a left out sequestrum.
Al-Zahrawi had great concern for medical ethics. He ensured that when a female patient was being examined or operated, a trained midwife was also around. He emphasised that surgery should be patient-oriented. Cautioning his pupils, he says: "Do not embark upon anything unless you have positive knowledge of giving the patient a good outcome......Let caution be stronger than your greed and desire for gain". 3
Al-Zahrawi's work Kitab al-Tasrif liman ajiza al al-talif is universally acknowledged as the first systematic, comprehensive and illustrated textbook of surgery. The book, which runs into 30 volumes, is a veritable encyclopaedia of medicine and surgery. A major part of the book (some 45 per cent) deals with materia medica and the remaining parts with wide-ranging subjects such as anatomy, clinical medicine, human temperament, the relationship between diet and disease, and the naming and compounding of drugs. The last part of the book --the 30th Treatise--deals with surgery. Al-Zahrawi noted that the art of surgery was fading away and the "skilled practitioner of surgery today is totally lacking in our land". He quotes the famous words of Hippocrates, for whom he had great respect: "Though many are doctors in name, few are in reality, particularly on the surgical side". 4
Al-Tasrif was translated into Latin, as Liber al-Sahrawi de Chirugia, at Toledo by Gerard of Cremona in the 12th century. This translation was printed in Venice in 1497. A Turkish translation of Al-Tasrif, together with illustrations, was attempted by Sharaf al-Din ibn Ali al-Hajj Ilyas in the 15th century. In 1778 Johnnes Channing brought out an Oxford edition of Al-Tasrif, and a French translation of the book, La Chirurgie d'Albucasis, by Lucien Leclerc was published from Paris in 1961. 5 A lithographic Arabic edition with stylized figures was printed in Lucknow (India) in 1908. An English translation of the book together with the original text, drawings of surgical instruments, footnotes and commentary, edited by M. S. Spink and G. L. Lewis, was published by the Wellcome Institute for the History of Medicine in 1973. 6
The part of Al-Tasrif that deals with surgery is divided into three books or treatises. Book I deals with cauterization, Book II with general surgery, including traumatology, obstetrics, gynaecology and urology, and Book III with bone setting. For nearly five centuries, Al-Zahrawi's treatise on surgery had a profound influence on European physicians and surgeons, including William of Saliceto (d. 1277), Guy de Chauliac (1300-1367) and Fabricus Aquapendente (1533-1619), among others.
The Encyclopaedia Britannica, while noting that the earliest known description of haemophilia is to be found in the work of Al-Zahrawi, says that his book "stood for nearly 500 years as a leading textbook on surgery in Europe, preferred for its concise lucidity even to the classic Greek authority Galen". 7 In the Introduction to Book III, Zahrawi says: "I have described to you in this book all that my knowledge has encompassed on the subject and that my experience has encountered. I have made it accessible to you and rescued it from the abyss of prolixity. I have made for you many drawings of the instruments that are used in it which is an adjuvant to explanation".
As mentioned in the foregoing, Book I of Al-Tasrif is entirely devoted to cauterization, a surgical procedure that has nearly disappeared in modern surgery. As a matter of fact, most people today doubt its efficacy. Cauterization can be done by heat (where the tissue trauma is localised), or by chemicals such as caustics. Al-Zahrawi generally preferred the former. Depending on the nature of the disease, the patient's temperament and the weather condition, different kinds of metals such as bronze, iron and gold could be used. The important considerations in the procedure include the shape of the cautery, the site of cauterization and the number of exposures. Many of the cauteries were taken from the Greeks, but Al-Zahrawi takes an independent line while describing cauterization for hare-lip, entropion, pulmonary disease, anal and pre-anal fistula, dislocation of femur, caries spine and corns. He describes about 20 cauteries for specific indications. These include the olivary cautery for a variety of indications including headache, the bolt and tube cautery for migraine, the punctuate cautery for ptosis, the probe cautery for fistulae, the pronged cautery for humeral dislocation, the ring cautery for sciatica, and the quill cautery for corns.
Various types of cauterization, from head to the foot, are mentioned for every conceiveable disease. Only a small percentage of these cauterizations are truly sharp cutting cautery for a hare-lip, the cauterization of haemorrhoids, the crescentic cautery for ptosis of eyelids, the cauterization for enteropion, lacrimal and perianal fistule, are some examples of the beneficial and effective cauterization. The heated cautery for opening a liver abscess also seems to be an ingenious idea, considering the available amenities in those days. The cautery as a means of controlling hemorrhage is in principle being used today by every surgeon in the form of the electro-surgical unit.
Though the procedure of cauterization has generally been repudiated by surgeons, a few of them have appreciated its efficacy and have compared its effect to that of modern ionizing radiation. It is rather strange that procedures such as venesection, cauterization, leech application and cupping, which were universally accepted by the ancient Greek, Roman and Muslim physicians and surgeons, find no place in modern medical armamentarium and are now looked down upon.
Original Operations and Instruments
Undoubtedly, Al-Zahrawi was greatly influenced by the ancient Greeks as well as by other physicians and surgeons in other parts of the world, including those from India with whose works he was directly or indirectly acquainted. 8 Islamic medicine and surgery, which had attained great heights during his time, was the outcome of some of the greatest minds of the time, from Persia, Iraq and Syria to Egypt and India. Spink and Lewis and other historians of medicine have ascribed the invention of a large number of surgical instruments and their original operation to Al-Zahrawi. These include the finely pointed scalpel to cut up a swollen foreign body in the ear, eye speculum, fine conjectivital hooks, opthalmic scissors, respiratory for lachrymal fistulae, fine couching needles, scrappers for teeth, forceps for the removal of broken roots of teeth and for the wiring of teeth, and the use of ox bone for artificial teeth. The operative removal of a ranula and the use of a tonsil guillotine and mouth gag in a tonsillectomy are among the original discoveries of Al-Zahrawi.9
W. S. Halsted (1852-1922), the doyen of modern American surgery, credits Al-Zahrawi for performing the first successful thyroidectomy, and says: "The extirpation of the thyroid gland for goiter typifies, perhaps better than any other operation, the supreme triumph of the surgeon's art--which is indeed a very great attribute". 10
Al-Zahrawi has many originals to his credit in the genitor urinary side. The Greeks had described S-shaped catheters, but the catheters designed by Al-Zahrawi were better, more straight, "slender, smooth and hollow like a bird's quill," with a small funnel at the proximal end. Al-Zahrawi also describes a probe for locating a calculus in the female urinary bladder. The first use of a syringe for bladder irrigation in the cases of cystitis with haematuria and pyuria is credited to him. Although the Greeks were familiar with the piston and the cylinder, they did not use it for surgical ends. The credit for this goes to Muslim physicians and surgeons. Al-Zahrawi not only describes forceps for suprapubic systolithotomy but advises that unusually large stones may be crushed by them and the fragments then easily delivered, thus anticipating the modern lithotrite. For impacted stones in the urethra, he describes a fine steel drill which can pierce and fragment it, the particles being then flushed out during micturition. A number of obstetrical and gynaecological devices and instruments mentioned by Al-Zahrawi, such as the modified vaginal speculum, hooks, cephalotribe and obstetrical forceps for extracting an impacted dead foetus, bear ample testimony to his originality and genius.11
Al-Zahrawi made a highly significant contribution to the field of traumatology and war surgery, which is borne out by his remarkable description of wounds of the neck, tracheal injuries, and pleural, pulmonary and intestinal trauma with its subsequent grave progress. Similarly, he greatly advanced the frontiers of gastrointestinal surgery. He noted, with an exceptional acuteness of clinical observation and analysis, that colonic wounds healed more quickly than wounds of ilium, and that jejunal injuries were unlikely to heal at all and usually had a fatal outcome. He makes a mention of primary intestinal sutures for which cotton, silk and ant heads could be employed. 12 Muslim surgeons were the first to use absorbable catgut sutures and, as Harrison mentions, the original credit goes to Al-Zahrawi. 13 The problem of controlling haemorrhage and the factors that delay wound healing, along with the pathogenesis of chronic osteomylitis, are brilliantly discussed and analyzed by Al-Zahrawi. He was the first physician to describe the rare entity of thrombophlebitis migraines.
Although the plaster of Paris was discovered many centuries after Al-Zahrawi, he envisaged a similar kind of firm support in the course of surgical procedures, which is mentioned in the early part of Book III. Al-Zahrawi clearly mentions, in addition to individual fractures and dislocation of bones and their treatment, including the use of reducing tables, the neurological deficits following a spinal injury and its generally poor prognosis.
A Contemporary Appraisal
Today, Al-Zahrawi can be criticised on several counts, such as his insistence on suppuration as a part of natural healing, his advice on prolonged immobilization after operative procedures, the emphasis on venesection and purgatives, and the apparent lack of stress on physiotherapy following orthpaedic trauma. The instruments and devices designed by him certainly lack sophistication, and some of his diagrams and descriptions seem to be laced with a surplus of imagination. However, one may ask whether we are justified in evaluating Al-Zahrawi's surgical procedures and the devices and instruments designed by him in the light of modern medical technology and surgery. Medical technology and surgery have undergone a revolutionary transformation during the past few centuries. Therefore, one should look at Al-Zahrawi's multi-faceted contributions in the context of his time and, in particular, of the state of medical and surgical knowledge during the 11th century. A contextual appreciation of Al-Zahrawi's contributions will certainly make us realise the freshness of his vision, the novelty and innovativeness of his surgical procedures and instruments, and his clinical far-sightedness. His legacy in neurology, transplant surgery, opthalmology and gastroenterology will undoubtedly remain a magnificent chapter in the history of medicine and surgery.
However, certain questions are likely to remain unanswered. It is rather difficult to believe that certain major and complicated surgical procedures as described in Al-Tasrif could be carried out without employing some form of analgesia or anaesthesia. Unfortunately, the surgical chapters in the book tell us nothing about this matter. Another curious issue is the rather sudden decline of Islamic surgery. How was it that Islamic civilization's magnificent legacy in science, medicine and surgery, which was a major source of the European Renaissance, underwent a strange atrophy? 14 The question of the decline and fall of medicine and surgery in the Islamic world after the 15th century requires a thorough and detailed investigation.
1 Al-Tasrif, Book III, Chapter 30
2 Al-Tasrif, Book II, Chapter 77
3 Al-Tasrif, Introduction to Book II
4 Introduction to the 30th Treatise
5. Moulvi Azimuddin Ahmad: Catalogue of Arabic and Persian Manuscripts in the Oriental Public Library, Bankipur, Patna, India. Calcutta, 1910, p. 30.
6. M. S. Spink and G. L. Lewis: Albucasis on Surgery and Instruments. The Wellcome Institute of History of Medicine, London, 1973.
7. Encyclopaedia Britannica (Macropaedia), 15th edition. Chicago/London, 1980, p. 37
8. Sami K. Hamarneh, Studies in History of Medicine, 1 (1), 30 (1977)
9. Spink and Lewis, op. cit.
10. W. S. Halstad, 'The operative story of goiter' Surgical Paper 2. Johns Hopkins University Press, Baltimore, 1924, p. 257
11. Abdul Azim Al-Daib: Abul Qasin al-Zahrawi. Darul Ansar Abedin, 1979
12. Ahmad A. Hai and S. W. Ahmad, 'Islamic legacy to modern surgery'. Paper presented at the 1st International Conference of Islamic Medicine, Kuwait, 1981
13. Timothy S. Harrison and David Christopher: The Textbook of Surgery. 11th edition. Philadelphia, 1978, p. 675
14. Philip K. Hitti, 'Preface' Early Islam (The Great Ages of Man). Time-Life International. The Netherlands, 1978
A Supplementary Note
By Professor A. R. Momin
Complete or partial manuscripts of Al-Zahrawi’s magnum opus Kitab al-Tasrif are to be found in libraries in Turkey, Egypt, Morocco and India. The Khuda Bakhsh Oriental Public Library in Patna (India) has two valuable manuscripts of the book. One of them, which is dated to 1710 CE, has 27 (out of 30) treatises of the book in 494 folios, and is written in the Maghrebi script. The other manuscript contains only the last (30th) treatise and has 248 folios. This manuscript has nearly 200 drawings and illustrations of the clinical and surgical devices and instruments, most of which were designed by Al-Zahrawi himself. This is perhaps the earliest—written in 1188--and one of the finest manuscripts of Al-Tasrif.
The illustrations and drawings accompanying Dr Ahmad Abdul Hai’s valuable paper have been reproduced from the Patna manuscript.
More than a thousand years ago, Al-Zahrawi diagnosed and treated many diseases, which came to be confirmed in later centuries. He described what later came to be known as “Kocher’s method” for treating a dislocated shoulder, and the “Walcher position” in obstetrics. He described the method of ligaturing blood vessels almost six centuries before the French surgeon Ambroise Pare (1510-1590). He described turberculosis of the spine, which is now known as Pott’s disease (named after the English physician Percivall Pott, 1714-1788). He prescribed mastectomy for breast cancer. Al-Zahrawi described, for the first time in medical history, a genetic disease transmitted by an unaffected woman to her male children, which is today known as haemophilia. Al-Zahrawi described families whose male members died of bleeding only after minor traumas. The first modern description of haemophilia was made by an American physician, Dr John Conrad Otto, in 1803. Al-Zahrawi advised the use of catgut, a natural substance that is capable of dissolving and is acceptable by the body, which is still used in modern surgical procedures. He was the first to use silk sutures to close wounds.
For nearly five centuries, from the 11th to the 16th, Al-Zahrawi’s work on surgery had a profound impact on European physicians and surgeons. The celebrated French surgeon Guy de Chauliac (d. 1368) made repeated references to Al-Zahrawi in his writings and even appended the Latin translation of his surgical treatise to his book Chirurgia magna. Al-Zahrawi was hailed by the eminent Italian surgeon Pietro Argellata (d. 1423) as “the chief of all surgeons”. The renowned French surgeon Jaques Delchamps (d. 1588) made frequent references to Al-Zahrawi’s work in his writings. Almost all European writers of surgery in the Middle Ages made extensive references to Al-Zahrawi’s work and drew upon his clinical insights and surgical innovations. Al-Zahrawi’s surgical treatise remained a standard textbook on the subject in all leading European universities from the 15th to the 18th centuries. The renowned historian of science George Sarton has remarked, in his monumental An Introduction to the History of Science, that no single book, other than Al-Tasrif, influenced and revolutionised the art of surgery from the 11th to the 14th century (Vol. 1, pp. 338; see also A. J. Hayes: The Genius of Arab Civilization: Source of Renaissance, MIT Press, Cambridge, 1983, p. 200).
A significant aspect of Al-Zahrawi’s multifaceted contributions to medicine and surgery relates to the diagnosis and treatment of women’s problems and diseases. He instructed and trained midwives and wrote a section on midwifery in Al-Tasrif. Some of the clinical and surgical devices and instruments designed by him were meant to be used for women.
Gynaecological matters are often mentioned in medieval surgical tracts written by Muslim physicians, even though it is unlikely, considering the religious and moral norms and social mores of earlier times, that those physicians and surgeons dealt, directly or personally, with such cases. Al-Zahrawi, for example, noted in connection with lithotomy in a woman:
The treatment is indeed difficult and is hindered by a number of things. One
is that the woman may be a virgin. Another is that you will not find a woman
who will expose herself to a (male) doctor if she be chaste or married. A third
is that you will not find a woman competent in this art, particularly not in
surgery……..If necessity compels you to this kind of a case, you should take
with you a competent woman doctor. As these are very uncommon, if
you are without one, then seek a eunuch doctor as a colleague, or
bring a midwife experienced in women’s ailments, or a woman to whom
you may give some instruction in this art. Have her with you and bid her
to do all that you may enjoin. (Albucasis (Abul Qasim) on Surgery and Instruments,
Arabic text with English translation and commentary by M. S. Spink and G. L. Lewis,
Berkeley, 1973, pp. 420-421).
Al-Tasrif contains more than 200 illustrations and drawings of clinical and surgical devices and instruments. These include scalpels, probe syringes, curettes, hooks, rods, specula, the surgical needle and forceps. These devices and instruments were meant to serve a wide variety of clinical and surgical purposes. A few years ago, a Spanish medical historian made replicas of the surgical devices and instruments designed by Al-Zahrawi and had them exhibited in a museum. They are now on display at the Museo Vivo de Al’Andalus, in Cordoba, Spain. I had visited the museum and seen these replicas in May 1998. Replicas of these instruments are also on display at Madinat al Hikmat, Hamdard University, Karachi.
The learned author has raised an interesting question about the apparent lack of reference in Al-Zahrawi’s surgical treatise to the use of anaesthetic substances during surgical procedures. Miller’s Anaesthesia, a standard textbook on the subject, notes that in the Middle Ages the concept of inhalation to induce sedation before surgery with the use of the sleeping sponge, or spongia somnifera, was originated by Arab physicians and surgeons. With the Arab conquest of Sicily in the 9th century and the Latin translations of Arabic medical books that followed, Arabic medicine, including the sophorific sponge, took hold in southern Italy. From there it spread to other parts of Europe and was fairly widely used in the Middle Ages (Miller’s Anaesthesia, edited by Ronald D. Miller. 7th edition, Philadelphia, 2010, pp. 50-51).
Original and highly significant contributions to anaesthesiology were made by Abu Bakr Muhammad ibn Zakariya Al-Razi (865-925) and Ibn Sina or Avicenna (980-1037), who was Al-Zahrawi’s contemporary. Al-Razi described the pupillary reaction to light and the laryngeal branch of the recurrent laryngeal nerve. He was the first physician to have used anaesthetic sponges in surgical procedures. Ibn Sina enumerated several agents that alleviate pain in general and in the course of clinical and surgical procedures in particular, such as opium, henbane and mandrake. In his Canon of Medicine, Ibn Sina advocated oral intubation. He advised the use of the soporific sponge, which was a sponge soaked in aromatics, soporifics and narcotics and held to the patient’s nose. In all probability, Al-Zahrawi was aware of the use and efficacy of anaesthetic substances during surgical procedures (F. S. Haddad, ‘The spongia somnifera’ Middle East Journal of Anaesthesiology, 17: 321-27 (2003); F. S. Haddad, ‘Ibn Sina (Avicenna) advocated orotracheal intubation 1000 years ago: Documentation of Arabic and Latin originals’ Middle East Journal of Anaesthesiology, 17: 155-62 (2000); A. Baraka, ‘The contribution of Arabs to medicine’ Middle East Journal of Anaesthesiology, 15: 353-59 (2000).