In operative surgery, Arabs proposed five essentials for performing a successful operation: a knowledge of anatomy, a knowledge of infection and its prevention (antisepsis), anaesthetics to kill pain, methods for controlling bleeding (haemostasis). And proper instruments for surgical invention.
1. Anatomy- The work of Yuhannah Ibn Masawayh on animals won the admiration of Caliph Al-Mutasim around ‘AD 830, who was interested that he made a special dissection hall available for Yuhannah’s use on the Tigris river bank and provided him with apes specially brought for him from Nubia in Africa. Furthermore, Avenzoar performed the first experimental tracheostomy on a goat and noticed that it was alive many days after the procedure. Dead animals were extensively used by Avicenna, Rhazes and Ibn Tufail for experimental work. The story of Hai Ibn Yakthan, written by Ibn Tufail before 1185 AD, was a scientific masterpiece. It concerned a baby on an island where he was adopted by a deer which had lost its own young. The boy grew up among the animals and was shocked when his adopting ‘mother” died. He then dissected the deer’s body. The anatomical description of the dissected animal Ibn Tufails immense knowledge. The story was translated into Latin as Philosophus Autodidacs by Mirandola (1494 AD) and Pocock (1671 AD) and Pocock (1671 AD) and appeared in many languages. Both Robinson Crusoe by Daniel Dofoe and Tarzan by Edgar Rice Burroughs were corruptions of the Hai Ibn Yakthan story.
Furthermore, there is a plethora of Muslims books on animal kingdoms, animal anatomy and behaviour; they represent a remarkable wealth of scientific literature. Hayat Al-Hayaqwan Al-Kubra (The Life of Animals) by Al-Dumairi, Aja’eb Al-Maklokat Wal Hayawat Wa Ghara’eb Al-Mowioodat (Wonders of Creatures and Animals) by Al-Kizweeni, and Kitab Al-Hayawan (The Book of Animals) by Al-Jahidh are only a few notable examples.
The Qur’an (the backbone of Islam) urges its followers to look closely into the structure of the human body itself: “We shall show them Our portens on the horizons and within themselves’, Fusilat XLI, verse 53. ‘ And in yourselves, Can ye then not see? Al-Thari’at, verse 21. while unpurposeful handling of Muslim dead bodies was strictly forbidden, a purposeful dissection was mandatory in surgical practice and in surgical teaching and training; it was imperative in post-mortem examination for medico-legal reasons in suspicious cases of death, such as poisoning and assault cases; and finally, it was crucial in identifying the underlying causative agents in epidemics of infections diseases. In fact, there is strong evidence that it is the Arabs who actually established anatomy on extremely high standards and made it a prerequisite for surgical practice. They derived their extensive knowledge in anatomy from various sources, namely; Greek books on animal dissection, Egyptian embalming and taxidermy (Egyptian Mummies were known to Arab anatomists), careful observations of anatomical structures and skeletons of dead bodies from starvation and accidents in peace time, observation of underlying structures during surgical treatment of wounds in time of war, and dissection of pregnant mothers to extract living fetuses. However, human dissection of dead bodies was a reality. The fact that most surgeons, who were also the private doctors of the Calips, were vocal about the need for dissection as a prerequisite for surgical practice can only indicate that dissection was carried out publicly or secretly but with implicit blessing of the Caliphs themselves. Indeed, anatomy and dissection were extensively covered in Avicenna’s Al-Canon and Haly’s Liber Regius with unprecedented description, including many discoveries and pioneering works. Furthermore, there has never been a single reported incidence in history to indicate that a Muslim doctor has been punished for snatching a dead body or dissecting a cadaver, though reports of malpractices were documented thoroughly. There must have been precautions laid down for such a vital mission. These may have included cadaveric dissection of non-Muslims who died after being captured or during fighting with Muslims. Dissection of human fetuses was performed on a large scale. Dead bodies of insane Muslims with no relatives to claim them may have also been considered.
Ibn Al-Nafis was certainly a genuine anatomist; he vehemently attacked Galen’s and Avicenna’s concept of invisible interventricular pores of the heart, because dissection (as he said) refuted the presence of such pores; he also discovered the coronary blood vessels and pulmonary circulation.
Avicenna’s comments on optic chiasma and extraocular muscles were unprecedented and could only indicate a pioneering work based on his personal dissection of human bodies.
Arabs left indelible imprints in anatomical terms such as nucha (from Arabic nucha’ pertaining to spinal cord), saphenous (from Arabic safin, the conspicuous), cephalic and basilica veins (from Arabic al bazili, the draining, and al-kafli, the sponsoring), colon (from Arabic al colon) and cornea (from Arabic carania).
2. Infection and antisepsis Islam prevents the mixing of a diseased (infected) patient with a non-diseased; it instructs its followers to run from lepromatous patients the way they run from the lion; it also advises not to enter or leave a plague endemic area, thus introducing the quarantine principle in the control of infectious diseases. In fact, when Rhazes came to Baghdad, he was chosen by the Caliph (out of 100 doctors) to be the decision-maker on the location of the newly founded hospital, named after Calip Al-Muta’did (AD 892-902). Rhazes hung pieces of meat in various corners of Baghdad and the place of the last meat piece to decompose or to become rotten was selected as the site for the hospital foundation; he then became the head of its staff. Rhazes was a chemist too, he prepared alcohol by distillation (of fermented sweet juice) for the first time in history. Latterly, he used a alcohol as antiseptic for wounds. Furthermore, Arabs used crushed rotten bread for tonsillitis, thus wittingly or unwittingly taking the credit for introducing antibiotics long before Alexander Fleming.
3. Anaesthesia – Perioperative opium infusion was in common use for inflammatory conditions associated with severe pain as well as painful operative procedures, such as dental extraction and reduction of fractures. Poppy seeds were used in oral pre and postoperative analgesic syrups or paste; their boiled solution was often used for inhalation. The Arabian Nights (Sir R. Burton), however, contains reference to anaesthesia by inhalation. Theodoric of Bologna, (1206-1298), whose name is associated with the ‘soporific sponge, got his information from Arabic sources. The sponge was steeped in aromatics and soporifics and dried; when required it was moistened and applied to lips and nostrils. The Arabic innovation entails the immersion of the so-called ‘anaesthetic sponge’ in a boiled solution made of water with a unique mixture of hashish (from Arabic hasheesh), opium (from Arabic afiun), C-hyoscine(from Arabic cit al huscin), and Zo’an (Arabic for wheat infusion acting as a carrier for active ingredients after water evaporation). Arabs in Andalucia were the first pioneers of artificial ice-making. Freezing with ice was used for local anaesthesia in external operative procedures of a minor nature.
4. Haemostasis (see Albucasis, and the history of laparatomy).
5. Surgical instruments Arabs invented and perfected many surgical instruments illustrated in Albucasis’s Al-Tasrif Liman Ajaza An Ta’leef, Haly Abbas’s Kamil Al-Sina’ah Al-Tibbiah or Al-Kitab Al-Malaki or Liber Regius, and in Ibn Al-Quff’s Al-Omda Fi Sina’at Al-Jiraha. These instruments include tools for dissection and cutting; various ligatures using guitar strands, catgut, linen and silk. Ant jaws were innovatively used by Albucasis as mechanical clips after head application to wounds followed by dismemberment of the head discarding the body; ants’ oral secretion of formic acid made their jaws an ideal antiseptic device for suturing. Caustic substances and cautery were used for haemostasis, particularly in haemophiliacs. Catheters were invented by Arabs to serve as tools for drainage in patients with urinary retention. The word catheter is derived from Arabic catha tair (bird’s quill), which is a hollow tube with attenuated ends used initially for writing. Gauze (derived from Arabic Gazza where it wa manufactured) and bandages made of various textile materials were used by the Arabs for wound dressing, as a haemostatic (by pressure) and for cleanliness (protection). Occasionally, the bandage was used as a proximal tourniquet in snake bites. Wicks and tube drains were also used in abscess cavities. A leather bulb syringe (from Arabic zarrag) was used for rectal enema. Proctoclysis was invented by Avenzoar. Urethral dilators and sounds were also used by Ibn Al Thahabi while Albucasis used a lithotrite and metallic bladder syringe (litholapexy). Snares (from Arabic sinnara) were extensively used for removal of nasal polyps, enlarged tonsils, varicose veins and haemorrhoids. Tracheostomy was first referred to by Rhazes, experimentally applied by Avenzoar on goats, and practically performed by Albucasis on one of his servants successfully. Palliative treatment of oesophageal obstruction by intubation with narrow metallic tubes made of silver was first advocated by Avenzoar. Various glasses and optics were invented by Al-Hazen and extensively used in ophthalmology. Gypsum (from Arabic gyps, a powder hardened by was first used by Arabs in fractures. Wooden splints were chosen from special trees, such as pomegranates.
6. Caesarian section According to the manuscript of Shanama or “Book of Kings” written and illustrated by Ferdowski c. 1560-80 (in the Metropolitan Meseum of Art in New York), the earliest such operation was carried out on Rustam, a Persian hero (many centuries before the Roman Caesar). Such immaculate birth was even taken as a sign of a high destiny- kings and heroes tend to avoid the dark dirty confines of the natural channels of birth (inter faeceset urinas nascimur). It is evident that caesarian section was initially performed (for the lack of technical knowledge) only in the dead, if there was still hope of rescuing the full-term child (particularly, if it was a question of delivering a possible heir to throne, the ancient Persians- be fore Islam- seem to have allowed exceptions). Ferdowsi, however, however lived in the Islamic era, and he must have seen a ceasarian section performed before his eyes before illustrating it in the book.
Moreover, Edinburg University library has its possession an original manuscript by Al-Biruni, entitled ‘Al-Athar al-bagiya an al-qurun al-khaliyah’ (The Chronology of Ancient Nations) (manuscript 161, folio 6, verso).
It reveals that ceasarean section in the Islamic world not only continued to be performed under special circumstances on dead mothers, but was probably also performed on living wives of Muslims kings, sultans and amirs at their special request to rescue both the mother and the heir child. Plates illustrating Muslims surgeons performing caesarean section were gathered from Ferdowsi’s Shah-nama and Al-Biruni’s book by Brandenburg with excellent running commentary; (Brandenburg, D. (1982) Islamic Miniature Painting in Medical Manuscripts, Basle: Hoffman-La Roche); one can study Plate No. 65,73,81,82 carefully.
Furthermore, Arab surgeons, particularly, Albucasis (AD 936-1013) and Rhazes (AD 865-932), were aware of rescuing living mothers threatened by spread of sepsis from their dead fetuses; they had not only described the details of vaginal extraction of dead fetuses, but masterminded the manufacture of various instruments for such as job, i.e. Albucasis’ obstetric forceps (preceding Chamberlains). Arab surgeons were thus aware in their management of three predicaments namely, dead mother with a living fetus, and living mother with a dead fetus. Arabs, therefore, were the real founders of midwifery as a separate branch of the medical profession. For moral or doctrinal reasons, Islam upheld the principle that is still mandatory for every obstetrician today: first save the mother, even if the child has to be sacrified; only once hope has been abandoned for the mother should an attempt be made to save the child (if still alive).
