Submitted by Prof. Dr. Ibrahim B. Syed, Clinical Professor and Director of Nuclear Medicine Sciences, University of Louisville School of Medicine, Louisville, Kentucky, USA
Abstract
Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi was born near Cordoba, Spain, when it was part of the Islamic Empire. He was a physician, surgeon and chemist. He is best remembered for his encyclopedia of medicine, the Al-Tasrif li man ajaz an-il-talif (An Aid for Those Who Lack the Capacity to Read Big Books), known as the al-Tasrif. This became a standard reference in Islamic and European medicine for over 500 years. In Europe, Al-Zahrawi was known as Albucasis, and was particularly famous for his surgical knowledge.
Al-Zahrawi’s encyclopedia included sections on surgery, medicine, orthopedics, ophthalmology, pharmacology and nutrition. In it he described over 300 diseases and their treatments. He also included detailed descriptions of numerous surgical procedures, and the use of over 200 surgical instruments, many of which he developed. The most famous section of the encyclopedia, on surgery, was translated into Latin by Gerard of Cremona in the 1100s. From this time it also became a standard text in Europe, and was still being reprinted in the 1770s. Considered the greatest surgeon of the Middle Ages, he has been described as the father of surgery
While famed for his writing, Al-Zahrawi was also a prominent practitioner and teacher. In recognition of his skills, he was appointed as the court physician to King Al-Hakam II of Spain.[1]
Early Life
Abū al-Qāsim Khalaf ibn al-‘Abbās al-Zahrāwī al-Ansari ( 936–1013), popularly known as Al-Zahrawi (الزهراوي), Latinized as Abulcasis (from Arabic Abū al-Qāsim), was an Arab Muslim physician, surgeon and chemist who lived in Al-Andalus. Considered the greatest surgeon of the Middle Ages, he has been described as the father of surgery.
Al-Zahrawi’s principal work is the Kitab al-Tasrif, a thirty-volume encyclopedia of medical practices. The surgery chapter of this work was later translated into Latin, attaining popularity and becoming the standard textbook in Europe for the next five hundred years. Al-Zahrawi’s pioneering contributions to the field of surgical procedures and instruments had an enormous impact in the East and West well into the modern period, where some of his discoveries are still applied in medicine to this day.
He was the first physician to identify the hereditary nature of hemophilia and to describe an abdominal pregnancy, a subtype of ectopic pregnancy that in those days was a fatal affliction.
Al-Zahrawi was born in the city of Azahara, 8 kilometers northwest of Cordoba, Andalusia. His birth date is not known for sure, however, scholars agree that it was after 936, the year his birthplace city of Azahara was founded. The nisba (attributive title), Al-Ansari, in his name, suggests origin from the Medinian tribe of Al-Ansar, thus, tracing his ancestry back to Medina in the Arabian Peninsula.
He lived most of his life in Cordoba. It is also where he studied, taught and practiced medicine and surgery until shortly before his death in about 1013(at the age of 77), two years after the sacking of Azahara.
He was a contemporary of Andalusian chemists such as Ibn al-Wafid, al-Majriti and Artephius. He devoted his entire life and genius to the advancement of medicine as a whole and surgery in particular.
Surgical career
Al-Zahrawi specialized in curing disease by cauterization. He invented several devices used during surgery, for purposes such as inspection of the interior of the urethra and also inspection, applying and removing foreign bodies from the throat, the ear and other body organs. He was also the first to illustrate the various cannulae and the first to treat a wart with an iron tube and caustic metal as a boring instrument.
While al-Zahrawi never performed the surgical procedure of tracheotomy, he did treat a slave girl who had cut her own throat in a suicide attempt. Al-Zahrawi sewed up the wound and the girl recovered, thereby proving that an incision in the larynx could heal. In describing this important case-history he wrote: So, I hurriedly sutured the wound and treated it until healed. No harm was done to the slave-girl except for a hoarseness in the voice, which was not extreme, and after some days she was restored to the best of health. Hence, we may say that laryngotomy is not dangerous.
Al-Zahrawi also pioneered neurosurgery and neurological diagnosis. He is known to have performed surgical treatments of head injuries, skull fractures, spinal injuries, hydrocephalus, subdural effusions and headache. The first clinical description of an operative procedure for hydrocephalus was given by Al-Zahrawi who clearly describes the evacuation of superficial intracranial fluid in hydrocephalic children.
Kitab al-Tasrif
Fig. 1. Title page from the first Latin translation of the Al-Tasrif, here called the Liber theoricae nec non practicae Alsaharavii (Theoretical and practical book by al-Zahrawi). (1599). (Public Domain) [2]
Al-Zahrawi’s thirty-volume medical encyclopedia, Kitab al-Tasrif, completed in the year 1000 CE, covered a broad range of medical topics, including on surgery, medicine, orthopedics, ophthalmology, pharmacology, nutrition, dentistry, childbirth, and pathology. The first volume in the encyclopedia is concerned with general principles of medicine, the second with pathology, while much of the rest discuss topics regarding pharmacology and drugs. The last treatise and the most celebrated one is about surgery. Al-Zahrawi stated that he chose to discuss surgery in the last volume because surgery is the highest form of medicine, and one must not practice it until he becomes well-acquainted with all other branches of medicine. Al-Tasrif is an illustrated encyclopedia of medicine and surgery in 1500 pages.
The work contained data that had accumulated during a career that spanned almost 50 years of training, teaching and practice. In it he also wrote of the importance of a positive doctor-patient relationship and wrote affectionately of his students, whom he referred to as “my children”. He also emphasized the importance of treating patients irrespective of their social status. He encouraged the close observation of individual cases in order to make the most accurate diagnosis and the best possible treatment.
Not always properly credited, modern evaluation of al-Tasrif manuscript has revealed on early descriptions of some medical procedures that were ascribed to later physicians. For example, Al-Zahrawi’s al-Tasrif described both what would later become known as “Kocher’s method” for treating a dislocated shoulder and “Walcher position” in obstetrics. Moreover, Al-Tasrif described how to ligature blood vessels almost 600 years before Ambroise Paré, and was the first recorded book to explain the hereditary nature of hemophilia. It was also the first to describe a surgical procedure for ligating the temporal artery for migraine, also almost 600 years before Pare recorded that he had ligated his own temporal artery for headache that conforms to current descriptions of migraine. Al-Zahrawi was, therefore, the first to describe the migraine surgery procedure that is enjoying a revival in the 21st century, spearheaded by Elliot Shevel a South African surgeon.
On Surgery and Instruments
On Surgery and Instruments is the 30th and last volume of Kitab al-Tasrif. It is without a doubt his most important work and the one which established his authority in Europe for centuries to come. On Surgery and Instruments is the first illustrated surgical guide ever written. Its contents and descriptions has contributed in many technological innovations in medicine, notably which tools to use in specific surgeries. In his book, al-Zahrawi draws diagrams of each tool used in different procedures to clarify how to carry out the steps of each treatment. The full text consists of three books, intended for medical students looking forward to gaining more knowledge within the field of surgery regarding procedures and the necessary tools.
He divided the surgery section of Al-Tasrif into three parts: 1. on cauterization (56 sections); 2. on surgery (97 sections), 3. on orthopedics (35 sections).[3]
Some of the procedures and techniques detailed in these chapters include the following:
- Surgery of the eye, ear, and throat. He fully described tonsillectomy and tracheostomy.
- He devised instruments for internal examination of the ear.
- He devised an instrument used to remove or insert objects into the throat.
- He described how to use a hook to remove a polyp from the nose.
- He described the exposure and division of the temporal artery to relieve certain types of headaches.
- He utilized cauterization, usually to treat skin tumors or open abscesses. He applied cauterization procedure to as many as 50 different operations.
- Application of ligature for bleeding vessels and internal stitching utilizing catgut. He preceded the famous French military surgeon Ambroise Pare (1510–1590), claimed to be the first European to utilize sutures, by five centuries.
- Treatment for anal fistulas.
- Setting dislocated bones and fractures. His method for setting and reducing a dislocated shoulder was centuries before Kocher introduced his similar technique to European medicine.
- Removal of urinary bladder calculi. He advised that the treating physician has to insert a finger into the rectum of the patient, move the stone down to the neck of the bladder, then make an incision in the rectal wall or the perineum and remove the stone.
- He devised instruments for inspection of the urethra.
- He is credited to be the first to describe ectopic pregnancy.
- He devised several dental devices and artificial teeth made of animal bones.
- Al Zahrawi is considered the father of operative surgery. He is credited with performance of the first thyroidectomy. The last chapter of his comprehensive book, named “On Surgery”, was dedicated to surgical instruments. He introduced over 200 surgical tools, a staggering number by all standards. He gave detailed descriptions of for using probes, surgical knives, scalpels, and hooks. He also devised and invented surgical scissors, grasping forceps and obstetrical forceps. His illustrations of surgical instruments were the earliest intended for use in teaching and in methods of manufacturing them. [4]
The book was translated into Latin in the 12th century by Gerard of Cremona. It soon found popularity in Europe and became a standard text in all major Medical universities like those of Salerno and Montpellier. It remained the primary source on surgery in Europe for the next 500 years, and as the historian of medicine, Arturo Castiglioni, has put it: al-Zahrawi’s treatise “in surgery held the same authority as did the Canon of Avicenna in medicine”.
In the beginning of his book, al-Zahrawi states that the reason for writing this treatise was the degree of underdevelopment surgery had reached in the Islamic world, and the low status it was held by the physicians at the time. Al-Zahrawi ascribed such decline to a lack of anatomical knowledge and a misunderstanding of the human physiology. He who devoted himself to surgery must be versed in the science of anatomy.
Noting the importance of anatomy, he wrote:
“Before practicing surgery one should gain knowledge of anatomy and the function of organs so that he will understand their shape, connections and borders. He should become thoroughly familiar with nerves muscles bones arteries and veins. If one does not comprehend the anatomy and physiology one can commit a mistake which will result in the death of the patient. I have seen someone incise into a swelling in the neck thinking it was an abscess, when it was an aneurysm and the patient dying on the spot.”
Al-Zahrawi introduced over 200 surgical instruments, which include, among others, different kinds of scalpels, retractors, curettes, pincers, specula, and also instruments designed for his favored techniques of cauterization and ligature. He also invented hooks with a double tip for use in surgery. Many of these instruments were never used before by any previous surgeons.
His use of catgut for internal stitching is still practised in modern surgery. The catgut appears to be the only natural substance capable of dissolving and is acceptable by the body. An observation Al-Zahrawi discovered after his monkey ate the strings of his oud. Al-Zahrawi also invented the forceps for extracting a dead fetus, as illustrated in the Al-Tasrif. [4]
Fig. 2. Albucasis blistering a patient in the hospital at Cordova. [5]
In addition to sections on medicine and surgery, there were sections on midwifery, pharmacology, therapeutics, dietetics, psychotherapy, weights and measures, and medical chemistry.
Fig. 3. Page from a 1531 Latin translation by Peter Argellata of Al Zahrawi’s treatise on surgical and medical instruments. [4]
Al Zahrawi is considered the father of operative surgery. He is credited with performance of the first thyroidectomy. [4]
Figure. 4. Two pages from a manuscript of Al-Zahrawi’s Al-Tasrif, preserved at the Azerbaijan National Academy of Sciences, Baku [6]
Abdel-Halim et al gave a detailed study of Al Zahrawi’s technique of cystolithotomy.
Al Zahrawi contributed early descriptions of neurosurgical diagnoses and treatment including management of head injuries, skull fractures, spinal injuries and dislocations, hydrocephalus, subdural effusions, headache and many other conditions.
In addition, he made significant contributions to pediatric surgery. In addition to his description of hydrocephalus, he described harelip, adenoids, ranula, imperforated external urinary meatus, perforated anus, hermaphrodites, gynecomastia, supernumerary and webbed fingers. He was the first to describe in detail the medical aspects of hemophilia.
Finally, he emphasized child education and behavior, school curriculum and academic specialization. He advised that gifted and intelligent students be encouraged to study medicine after completing their primary education in language, grammar, mathematics, astronomy and philosophy. [4]
CONCLUSION
Thus, in conclusion, Al-Zahrawi was not only one of the greatest surgeons of medieval Islam, but a great educationist and psychiatrist as well. He devoted a substantial section in the Tasrif to child education and behavior, table etiquette, school curriculum, and academic specialization.
The methods of Albucasis eclipsed those of Galen and maintained a dominant position in medieval Europe for five hundred years, i.e long after it had passed its usefulness. He, however, helped to raise the status of surgery in Christian Europe; in his book on fractures and luxations, he states that ‘this part of surgery has passed into the hands of vulgar and uncultivated minds, for which reason it has fallen into contempt.’ The surgery of Albucasis became firmly grafted on Europe after the time of Guy de Chauliac (d.1368), the 14th century, French surgeon. He quoted al-Tasrif over 200 times. Pietro Argallata (d. 1453) described Al-Zahrawi as “without doubt the chief of all surgeons”. Al-Zahrawi’s influence continued for at least five centuries, extending into the Renaissance, evidenced by al-Tasrif’s frequent reference by French surgeon Jacques Daléchamps (1513–1588). [5]
We can reasonably assume that Al-Zaharawi knew about Sushruta. In the eight century CE, Sushruta Samhita was translated into Arabic by Caliph Mamun as “Kitab Shah Shun al –Hindi” and “Kitab – I – Susurud.” Al-Zaharawi lived in the 10th Century. [7]
Fig. 3 in in this article appears similar to the instruments used by Sushruta. However, I made a comparison and found there is no resemblance. Actually, instruments used by Sushruta look modern. They are not the same. Sushruta (Sanskrit: सुश्रुत, lit. “well heard”) was an ancient Indian ayurvedic physician, known as the main author of The Sushruta Samhita (ca. 600 BCE), an important early medical text and the first text to represent the process of rhinoplasty. One of the earliest documented plastic surgeons, he also described procedures for treating hemorrhoids and fistulae, as well as cataract surgery. Sushruta has been called “father of surgery” and “father of plastic surgery”. Al-Zaharawi (936-1013) wrote Al-Tasrif (The Method of Medicine), a 30-part medical encyclopedia in Arabic wherein he introduced his collection of over 200 surgical instruments, many of which were never used before. He is the first to describe and prove the hereditary pattern behind hemophilia, as well as describing ectopic pregnancy and stone babies. He has been called the “father of surgery”.
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