Airlangga University, Surabaya, Indonesia (Winter 2015)
|Figure 1: Abu Al-Qasim Khalaf bin Abbas Al-Zahrawi
Abu Al-Qasim Khalaf Ibn Al-Abbas Al-Zahrawi (936-1013 AD), also known in the West as Abulcasis, was one of the most renowned surgeons of the Muslim era.1 Born in Zahra, six miles northwest of Cordova, he studied there, taught, and also practiced medicine and surgery.2 In addition to his knowledge of medicine and surgery he was skilled in using simple and compound remedies and therefore was also known as the “Pharmacist Surgeon.”3 His greatest contribution to history is the Kitab Al-Tasrif, a thirty-volume encyclopedia of medical practice, of which the most important part comprised three books on surgery: on cauterization; on incision, perforation, venesection, and wounds; and on bone-setting.3,4
In the section on pharmacology and therapeutics, Al-Zahrawi discussed cardiac drugs, emetics, laxatives, cosmetology, dietetics, weights and measures, and drug substitution.1,3 He also wrote “Liber Servitoris,” how to prepare simple and compound complex drugs used in those days.1,3
In the section on surgery, Al-Zahrawi covered all its aspects: eyes; ear, nose and throat; head and neck; general surgery; obstetrics and gynecology. He included military medicine, urology, orthopedics – even what later became known as “Kocher’s method” for reducing a dislocated shoulder. Almost six hundred years before Ambroise Paré, he described how to ligate blood vessels;3 expose and divide the temporal artery to relieve certain types of headaches; effect the diversion of urine into the rectum; perform reduction mammoplasty for very large breasts; and extract cataracts.5 He wrote extensively about bones and joints, even mentioning fractures of the nasal bones and vertebrae.1 He also described the tracheotomy operation and performed it as an emergency on one of his servants.6 He is the first to detail the classic operation for cancer of the breast, lithotripsy for bladder stones, techniques for removing thyroid cysts, treatment of sebaceous cysts using an exploratory needle, and treatment of lachrymal fistula by converting it to a fistula into the nasal cavity using cautery.7 He had a sound knowledge and understanding of the relevance of anatomy in surgical procedures, stating in the introduction of Al-Tasrif that learning the art of surgery is lengthy and that good practice of surgery required a sound knowledge of anatomy. “He who devoted himself to surgery must be versed in the science of anatomy.”3
In obstetrics and gynecology he described several instruments used for delivery.8 He was the first to describe the “Walcher position” in obstetrics,1,3,9 and the first to teach the lithotomy position for vaginal operations.2 His book contains pictures of gynecological instruments used in the tenth century e.g. vaginal specula and instruments to perform craniotomy for bringing out the dead fetus.3 He also described the surgical options of treating gynecomastia,4 “On the treatment of male breast when it resembles the female,” he recommended removing the glandular tissue by a C-shaped incision. For large breasts with excess skin that cannot be corrected with glandular excision he recommended making, “two incisions so that the edges join each other, then remove the skin and glandular tissue in between and suture the edges of the defect.”2 This technique is still considered for such conditions nowadays.
|Figure 2: Two pages from a manuscript of Al-Zahrawi’s Al-Tasrif,
preserved at the Azerbaijan National Academy of Sciences, Baku11
Al-Zahrawi was one of the early leading “plastic surgeons,” as he performed many plastic surgery procedures and outlined many principles in that surgical field. He used ink to mark the incisions in his patients preoperatively, now a routine standard procedure. In chapter twenty-six, he explained the differences between primary and secondary wound closure and the importance of wound debridement before closure.2 He was the first surgeon to use cotton (which itself is derived from the Arabic word qutn) as a medical dressing for controlling hemorrhage.6 He also used wax and alcohol to stop bleeding from the skull during cranial surgery.6,10
In urology, Al-Zahrawi converted the ritual circumcision to an art of surgical dissection, using scissors he designed especially for it.2 His contribution on bladder stone was remarkable. Extraction of stones from the urinary bladder is one of the oldest surgical operations in history. The operation was done through a perineal incision down to, then through, the bladder neck to reach the stone and extract it. He was the first to use a forceps to extract a bladder stone. Before him, extraction of the stone was with an instrument similar to a small spoon and used to scoop it out.5 But he introduced for that purpose a new instrument with a better grasp on the stone, improving the technique of this operation and reducing its risks. He invented Al-Mirwed, a metal probe or a sound used to confirm the presence of the stone before proceeding with perineal cystolithotomy. He also designed a special forceps (lithotrite) named Kalalib for crushing large vesical stones through a perineal cystotomy.2 He was the first to invent a fine pointed instrument (a drill) to pierce impacted urethral stones. He also used a syringe to irrigate the bladder and cleaning the ear.3
In orthopedics, Al-Zahrawi wrote on back pain, sciatica, hunchback, gout, arthritis, gangrene, tumors, ganglion, fistulae, paronychia, broken nails, and webbed fingers. He described cauterization as a treatment for recurrent dislocation of the shoulder or hip; amputations, compound fractures, bone setting, fracture of the head, broken nose, broken lower jaw, wiring teeth with silver or gold wires, fractures of female pudenda and the male organ; fracture of collar bone, chest, ribs, scapula, vertebrae, hip, femur, forearm, palm and fingers, patella, leg, feet, and toes. For fractures he advocated manipulative reduction with external immobilization if the bones were parted, saying that “reduction was to be effected by traction and counter-traction, using diligent manipulation in order to secure exact reposition of the bones and avoiding violent compression.”7 His remarkable conclusion that cranial and extremity bones healed differently is in concurrence with our understanding of cartilaginous and membranous bone healing. He described patelectomy one thousand years before Brooke reintroduced it in 1937.2
He outlined detailed procedures for various ophthalmic operations, including “cataract;”1,3 had a special interest in eyelid surgery; gave sensible suggestions on using fine instruments, of which he had a wide variety; and described the surgical management of entropion, ectropion, trichiasis, and symblepharon.9 For the treatment of entropion, Al-Zahrawi advised everting the eyelid with the fingers or with a traction suture. “An incision under the eyelashes from medial to lateral is then carried out so that the skin is separated from the lid margin. A leaf-shaped piece of eyelid skin is excised, and lash eversion is achieved as the defect is sutured primarily.” He also classified ectropion as congenital and acquired, and he advised eversion and resection of a base-down triangular segment from the inner layers for lower lid laxity to treat to eye ectropion.2
Al-Zahrawi also invented several surgical instruments.5 He introduced his famous collection of over two hundred surgical instruments such as scalpels, curettes, retractors, spoons, sounds, hooks, rods, and specula in the last volume of Al-Tasrif.1,7,9,11 He also invented the forceps for extracting a dead fetus.1 Most of these instruments were designed by Al-Zahrawi himself and had never been used before. He included illustrations of the surgical instruments, probably the first of their kind and a unique contribution to the history of surgery.3
|Figure 3: Al-Zahrawi’s lithotrite2|
A special medical instrument called a cauter was used for cauterizing arteries. He also introduced the use of a ligature to control bleeding from arteries in lieu of cauterization;3,4,5 a scalpel (Mibdla) for incising and removing tumors; a saw (Minshar) for dead bones and amputation; a raspatory (Mijrad) for scraping infected bones; a gouge for cutting pieces of infected bones; an osteotome (Miqta) for cutting protruding fractured ends or dead bones; wood blocks to put under the bone to be cut off safely; a drill (Mithqab) for making holes; a bone lever to reduce fracture; a ball splint for fracture of the small bones of the hand; a trapeze for reducing fractures of the humerus; a pestle for reducing shoulder dislocation; a catheter to treat urinary retention; a syringe (Mihqan) for the ear, vagina, rectum, and sinuses; a cephalotribe (Mishdakh) to crush and extract the head of the fetus in obstructed delivery; a couching needle (Miqdah) and a fine scalpel (Barid) for extracting cataracts; a lancet (Mibdah al-nash) for venesection and cutting nasal polypi; a blade that could be concealed between the fingers for use in nervous patients; forceps (Jift) for extracting teeth, leeches, and calculus; cautery instruments (Mikwa) used for sixty-five different problems from pain to hemorrhage; and a Mikhda, an instrument for deceiving by concealing the instrument from patients in order to allay their fears.7
Al-Zahrawi also described various types of thread (including catgut) for stitching of wounds. He found a monkey eating the bow strings of a musical instrument, made of sheep gut. He examined the monkey’s excreta and could not recover the “gut strings” so he concluded that those were absorbable, hence he used them as sutures.7 His use of catgut for internal stitching is still practiced in modern surgery. The catgut appears to be the only natural substance capable of dissolving and accepted by the body.1 He showed evidence of great experience from details of clinical picture and surgical procedures, e.g. his description of varicose veins stripping, even after ten centuries, is almost like modern surgery:
Have the leg shaved if it is much hairy. The patient gets a bath and his leg is kept in hot water until it becomes red and the veins dilate; or he exercises vigorously. Incise the skin opposite the varicose vein longitudinally either at the ankle or at the knee. Keep the skin opened by hooks. Expose, dissect, and separate the vein. Introduct a spatula underneath it. When the vein is elevated above the skin level, hang it with a blunt rounded hook. At the ankle, ligate and strip it by pulling it from the incision just above. Ligate the vein and then excise it. If difficulty is encountered in pulling it, ligate its terminal part with a string and pass it under the spatula and dissect it further. Pull gently and avoid its tearing because if it does, it becomes difficult to strip all of it and can cause harm to the patient. When you have stripped it all, put alcohol spanges at the sites of the skin incisions and take care of the incisions until they heal. Dissect it and hang it with the hooks and strip it as previously described. Do not tear the vein or injure it. If this happens, it becomes difficult to strip it. The hooks used should be blunt, eyeless, and rounded, otherwise they can injure the vein.2,6
Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi transformed the art of surgery, from small things such as marking his incisions with ink to big procedures such as treating people with gynecomastia. His contributions are legion and his contributions to surgery immense.
- Azizieh F. Abu Al-Qasim greatest medieval surgeon. Arab Times. November 1, 2013. https://www.gust.edu.kw/sites/default/files/Abu%20Al-Qasim%20by%20Dr.%20Fawaz%20Azizieh%20.pdf.
- Elgohary MA. Al-Zahrawi: The Father of Modern Surgery. Annals of Pediatric Surgery. 2006; 2(2): 82-87. http://www.aps.eg.net/back_issue/vol2/issue2_april2006/pdf/1-Al%20Zahrawi.pdf.
- Ahmed B. Abu Qasim Al-Zahrawi Albucasis The Father of the Surgery. Journal of the Tarrant County Medical Society. 2009. http://www.mcc-hs.org/Articles/Abu%20Qasim%20Al-Zahrawi.pdf. Chavoushi SH, Ghabili K, Kazemi A, et al. Surgery for Gynecomastia in the Islamic Golden Age: Al-Tasrif of Al-Zahrawi (936–1013 AD). ISRN Surgery. 2012. doi:10.5402/2012/934965.
- The CSS Point. Muslim Scientist & Their Contribution (Complete). http://csspoint.yolasite.com/resources/Muslim%20Scientist%20%26%20Their%20Contribution.pdf.
- Qari M. Abul Qasim Khalaf ibn al-Abbas al-Zahrawi (Abulcasis). Journal of Applied Hematology. 2010; 1(1): 66-67. http://appliedhematology.org/home/volumes/volume1issue1/pioneerofhematology/5373Volume%201%20-%20Issue%201%20-%20Sep%202010.pdf.
- Booz MK. Albucasis Bone Surgery in Antiquity. Pan Arab J Orth Traum. 1997; 1: 73-77. http://www.pajot.eg.net/pdf/f1_1997/f1a3b3.pdf.
- Syed S & Akhtar KAK. Ancient History of Obstetrics & Gynaecology. JSOGP. 2011; 1(1): 4-5. http://www.jsogp.net/Volumes/Volume1-1/ANICIENT%20HISTORY%20of%20Obstetrics%20and%20Gynaecology%20AL-%20Zahrawi.pdf.
- Al-Ghazal SK. Al-Zahrawi (Albucasis) – A Light In The Dark Middle Age In Europe. JISHIM. 2003; 1: 37-38. http://www.ishim.net/ishimj/3/08.pdf.
- Shuriye AO & Othman R, Ed. Contributions of Muslim Scientists to Medicine and Related Sciences. Batu Caves: HUM Press; 2011. http://irep.iium.edu.my/21116/1/CHAPTER_23.pdf.
- Minaret Research Network.The Patna Manuscript of Al-Zahrawi’s Al-Tasrif. http://iosminaret.org/vol-8/issue14-15/Al-Tasrif.pdf.
Highlighted in Frontispiece Winter 2015 – Volume 7, Issue 1