CONTRIBUTIONS TO AND SURGERY*

By AMIN A. KHAIRALLAH, B.A., M.D., F.A.C.S.

BEIRUT, LEBANON, SYRIA

T HAS always been taught that where he was dean of the Mansuri Hos- the did not contribute pital of Cairo. He was a keen observer anything to our knowledge of and a careful recorder and did not ac- anatomy and surgery, as the Mos- cept established authority blindly. Sev- lem law prohibited of theeral books were written by him, the Ihuman body. The “Arabic” knowledge most important being “Al-Mujaz,” of anatomy was derived from the teach- which is the best compendium on the ings of and from animal dissec- Canon of . Another book was tion, especially of the special organs “Sharh Tashrih al-Qanun” from which such as the eye, the and the liver. the following quotations are taken: A more careful study of Arabic manu- We have relied chiefly on his (Galen) scripts and medical literature, however, teachings, except in a few details which shows that they did contribute to our we thought might be due to mistakes of knowledge of anatomy in several ways. copyists or due to the fact that his descrip- They classified and arranged the writ- tion had not been given after a thorough ings of Galen in a logical and tangible investigation. In describing the use of the wTay, making its acquisition much eas- organs we have depended on careful in- ier. Avicenna codified all the anatom- vestigation, observation and honest study, ical writings of Galen in his “Canon.” regardless of whether or not these fit the Ibn Nafis, in his book “Sharh Tashrih teachings and theories of those who have al-Qanun” (A Commentary on the An- preceded us.2 atomy of the Canon), commented on the In describing the anatomy of the anatomy of Avicenna. Again, the an- pulmonary vessels, Ibn Nafis also de- atomy of Galen was saved for future scribes, for the first time, the pulmo- generations by the Arabic translations nary circulation and declares, three cen- of his books.1 The Greek originals have turies before Servetus, that the blood is been lost and are only known through aerated in the lung. the Arabic translations. Further, the Arabs were not blind followers as is seen But between these two cavities (of the heart) there is no passage as that part of from a study of the writings of Ibn the heart is closed and has no apparent Nafis and Al-Baghdadi. openings as some believed and no non- Abi al-Hasan ’Ala’ al-DIn ’Ali ibn apparent openings fit for the passage of Abi al-Hazm, better known as Ibn this blood as Galen believed. The pores Nafis, flourished during the first half of the heart there are obliterated and its of the thirteenth century. He was born body is thick and there is no doubt that and brought up in Damascus, but spent the blood, when thinned, passes through most of his life practicing in the vena arteriosa (pulmonary artery') to * This article is taken from a book entitled “Arabic Contributions to ,” written by the same author. the lung to permeate its substance and is to nourish the heart is not true at all, mingle with the air, its thinned part puri- for the nourishment of the. heart is from fied. It then passes through the arteria the blood that goes into the vessels that venosa (pulmonary vein) to reach the left permeate the body of the heart.6 cavity of the two cavities of the heart; having mixed with the air and become fit Muwaffaq al-DIn ’Abd al-Latif al- for the creation of the spirit.3 Baghdadi, the noted Arabian and traveler, was born in Baghdad but Ibn Nafis reiterates the same thing traveled extensively all over Iraq, Syria, in his description of the lung4 In de- and Egypt. In his book on his travels scribing the anatomy and function of in Egypt, he describes his visit to a the heart he states: little hill where there was a big mound Therefore, for the nourishment of the of skeletons. After having studied hun- spirit that is in the heart, it is necessary dreds of these he wrote: for the blood to become attenuated in the Some find difficulty in un- heart and its consistency very much derstanding anatomy as they have not thinned, then pass to the lung and mix seen except the description in their books. with what there is of air there and be . . . We were told that on a certain hill cooked in it until it is tempered and be- there were many skeletons. . . . We went come fit for the nourishment of the spirit, out there and saw thousands of bones and and afterwards pass to the spirit that is in the heart and mix with it and nourish it. articulations. We studied their relations . . . And his (Avicenna’s) statement that carefully and gained a great deal of knowl- edge from studying them, a knowledge the heart has three ventricles ... is not that we could not get from studying books correct, as the heart has only two ven- only. . . . For while we have the greatest tricles, one on the right side filled with respect for Galen, what we see with our blood and one on the left side filled with spirit, and between these two there is ab- own eyes is more trustworthy. . . . Thus solutely no opening, for if there were, the while Galen taught that the lower man- blood would pass to the place of the spirit dible consists of two bones united by a and spoil its essence. Also DISSECTION suture, we examined over two thousand gives the lie to what they said, as the bones and did not see one that consisted septum between these two cavities is much of two bones. It is one with no suture.7 thicker than elsewhere, lest some blood ’Ali ibn al-’Abbas al-Majusi (Haly or spirit pass through and get lost. . . . Abbas) ought to be given the credit for The benefit of this blood (that is in the the closest description, prior to Harvey, right cavity of the heart), when it is of the capillary circulation. In speak- thinned and attenuated, is to pass up to the lung, mix with what is in the lung of ing of the animal functions of the body, air, then pass through the arteria venosa he discusses the functions of expansion to the left cavity of the two cavities of the and contraction and then states: heart. Of that mixture is created the ani- You must know that during relaxation mal spirit.5 (diastole) the pulsating vessels (arteries) In his description of the anatomy of that are near the heart draw the air and the heart, Ibn Nafis, further, gives the the thinned blood from the heart by the nearest description, of those times, of vacuum action, because during their con- the coronary circulation. He states: traction (systole), they empty themselves of the blood and air, and when they relax, And his (Avicenna’s) statement that the air and blood return to them and fill blood that is in the right side of the heart them. Those that are near the skin, draw air from the outside, while those that are contraction of the iris. Ibn Sina (Avi- in the middle between the heart and the cenna) give a perfect description of the skin, have the property of drawing the six motor muscles of the globe of the

thinnest blood from the non-pulsating eye. Four of these, he states, arc on vessels (veins). That is because the veins the four sides—above, below, inside have pores communicating with the ar- and outside—and each moves the globe teries. The proof of this is that if the ar- in its special direction. The other two tery is cut all the blood that is in the vein are oblique and rotate the eyeball. He is emptied through the cut* was the first to teach that the first four While it is true that the Arabs did muscles are inserted by a common band. little or no dissection of the human According to Portal, the Greeks did not body, they did a great deal of dissection write anything about that. Ibn Sina was of animals and of special organs such also the first to teach that hard tissue as the eye, heart and liver, and thus such as bone could be inflamed and gained a great deal of practical anatom- could swell and that it could be the seat ical knowledge, Yuhanna ibn Masa- of tumefaction and tumor formation, wayh (Mesiie Sr.) dissected a large contrary to the teachings of the Greeks. monkey that had been sent as a present Further careful study of the literature to the Caliph from his representative would probably reveal other contribu- in Nubia and wrote a book describing tions in anatomy and physiology. They carefully what he found, a book that often mention dissection as a proof for “was liked by his friends as well as by what they wrote but did not dare to his enemies.”9 Mesiie even threatened to dissect a weak-minded son of his.10 mention directly that they did dissec- Al-Razi was the first to describe the tion. laryngeal branch of the recurrent laryn- The first of the Arabic physicians to geal nerve. This nerve, he notes, is write comprehensively about surgery sometimes double on the right side, and was ’Ali ibn al-’Abbas al-Majusi (Haly all due honor should be given him for Abbas) in his book al-Maliki (Kamil this discovery which has long been con- al-Sina’ah al-Tibbiyah, Liber Regius). sidered as modern.11 The Arabs had I hc clarity and definiteness of his de- an exact knowledge of the movements scription would make excellent text- of the pupil caused by dilatation and book reading even today. Here arc a few examples. In describing how to the is in the bladder for you feel catheterize a patient al-Majusi states: as though you are in an empty space.12 Choose a catheter of the proper size and Here is his description for the re- lubricate it well with violet ointment. moval of cysts:

Introduce it in the meatus with the penis Incise the skin until you reach the sac, straight up until you reach the root of trying not to cut into the sac. Take hold the penis. Bend the penis and pull it to- of the sac with hooks which an assistant wards the umbilicus as the canal to the should hold. Dissect the sac gently taking bladder is bent at its root. Push the cathe- care not to open it and try to remove the ter as far as it goes and then turn the penis whole cyst with the sac intact. This is the down towards the rectum and push the best treatment. . . .If the sac should be catheter into the bladder. You know that torn, hold it with the hooks and remove it piecemeal. . . .If any piece of the sac that they were the first to advise crush- remains cauterize it . . . for if any piece ing of calculi in the bladder. In the use of the sac is left the cyst would recur.13 of they were the pioneers. Al-Majusi’s fine surgical technique Hashish, tares and hyoscyamus were is clearly seen in his description of the used. 1 hey perfected the pharmacology removal of tubercular glands: of and used it extensively. They also invented the anesthesia sponge If not cured by , tubercular which was used in the Middle Ages. glands should be removed, (ait the skin The greatest name in Arabic surgery longitudinally down to the gland. Retract was that of A bn al-Qdsim Khalaf ibn the skin with hooks. Dissect slowly and 'Abbas al-Zahrawi (Abulcasis, Albu- gently, freeing the glands from the tissues casis, Bucasis, Alzahravius). Al-Zahrawi around them. Take care not to cut any was born at al-Zahra’, a suburb of Cor- vessels or puncture any nerve. If a vessel dova, as the name indicates. He flour- is cut, ligate it, lest the hemorrhage ob- scure the field of operation and prevent ished in the second half of the tenth you from doing a proper operation. When century and was court physician to the the glands are removed, put your finger Caliph Hakam II. He died in 1013. in and feel for any small glands that are His book, Al-Tasrif liman ’Ajiz ’an left. If you feel any remove them. When al-Ta’lif (A Help to Those Who Arc all is clear get the skin together and sew Not Equal to the Large Treatises), es- it. If the skin is redundant, trim it prop- tablished his fame as the best erly with scissors and then sezv z7.14 produced by the Arabs and one of the best and most frequently quoted sur- The gravity of was well rec- ognized. In his description for the re- geons of the Middle Ages. It was the moval of superficial cancer he advises inspiration for the early European sur- complete removal with a large border geons of the . This book of clear skin: was used as a textbook until the be- ginning of the seventeenth century, be- Medicines rarely help in this disease. ing printed and reprinted several times. ... It occurs chiefly in the wombs of The most important part of the book is women and in their breasts. What is in the last section dealing with surgery. the womb there is no way of treating by It contained all the surgical knowledge operation. In the breast and in the other superficial organs, in the neighborhood of of the time—Greek, Indian, Greco- which there are no large vessels and no Roman and Byzantine—and laid great nerves, we should remove all the growth stress on cautery and venesection. Abul- from the organ by cutting at a distance casis used the cautery extensively for from the growth so that none of its roots opening abscesses and for removal of remain. Do not stop the bleeding but let cancer, in preference to incision as ad- the soiled blood run out.15 vised by . We consider this Al-Razi (Rhazes) was the first to de- as the best technique today. In describ- scribe the use of the seton. In the use ing the technique for opening liver of the cautery the Arabs were the great abscesses with the cautery, Al-Zahrawi masters. They developed a method for speaks of the necessity of having ad- the reduction of shoulder dislocations hesions between the liver and the peri- which is known even now as the Ara- toneum otherwise there would be the bian method. It is generally conceded danger of pus going to the general peritoneal cavity causing the of surgeon and operator. His precise de- the patient. scription of the symptoms and of the In the beginning of the book the operative technique show that he had author sets down that a knowledge of done the work and had done it well. anatomy is the basis of surgery and The last of the Arabic writings on strongly advises dissection. The unique surgery was by Ibn al-Qiff. His book, part of the book is the figures of the Al-’Umdah fi Sina at al-Jarrdh (The surgical and dental instruments used Dependable in the Art of Surgery), con- at that time. Rough and clumsy as they tained twenty sections on the theoret- were, they were expertly handled and ical and the practical side of surgery. advantageously used. The chief source of obstetrical knowl- rhe surgical part was translated by edge among the Arabs was Hunayn’s Gerard of Cremona and was used as a translation of Paul of Aegina. Paul was surgical text book in the universities of known among the Arabs as “the ob- Europe. Its great influence is shown stetrician.’’ Al-Biruni was the first to in that quotes Abul- describe monstrosities carefully. Al- casis over two hundred times. Majusi was the first to teach that the The work of Abulcasis was the first expulsion of the fetus was due to the in medical history to treat surgery as a contractions of the uterus. Craniotomy distinct science founded on the knowl- was performed by Abulcasis for large edge of anatomy and separate from the fetal head. He devised a special spec- other medical branches. Heller states ulum and was the first to teach and that Abulcasis advised ligature of ar- perform vaginal lithotomy. Al-Majusi, teries long before Ambroise Pare. Por- , Ibn Sina and Abu al-Qasim tal considers him as the first to use all wrote on uterine tumors, short and hooks in the extraction of polyps. long cervices and ulcerations and tu- Sprengel says that Abulcasis was the mors of the cervix and of the uterus. first to teach the method of vaginal In eye diseases the Arabs accom- lithotomy. He was the first to describe plished a great deal. Their knowledge the hemorrhagic diathesis, having noted of the anatomy of the eye was excel- several cases in one town and treated lent. Ibn al-Mawsili (Canamusali) de- them with cautery. He was the first vised an operation for cataract by suc- to write on orthodontia. It is probable tion with a hollow needle. Khalifah ibn that he did lithotrity. He performed Abi al-Mahasin was so confident in his transversal and reports a successful operation on one of his serv- skill as an operator that he never hesi- ants. tated to operate for cataract in a one- Abulcasis has been accused of blindly eyed person. Their books were skill- copying Paul of Aegina, but whoever fully illustrated with diagrams showing compares the two books sees that Paul the anatomy of the eye and with designs had merely copied from his predeces- of instruments used in eye surgery. sors, while Abulcasis had added a great During the period of Arab domina- deal from the wealth of his experience. tion, surgery was a despised art in His marginal notes and the personal Europe and were looked down observations he gives are very impor- upon as unclean. Surgery was in the tant and show that he was not a mere hands of barbers, butchers and mounte- copyist but a skillful and experienced banks. From the twelfth to the fifteenth century surgery teas avoided by the upheld the dignity of the scientific fart medical faculties and by decent physi- of medicine and considered surgery as cians. In 1163 the Council of Tours a separate and honorable part of medi- passed resolutions by which surgery cine. 1'he dignity of the Arab physician was to be abandoned by the schools of with his flowing beard and his bro- medicine and by all decent physicians. caded headdress became a password The Arabs during the whole period (hiring the Middle Ages.

1. The following six books of Galen were 5. Ibid., vol. 104, p. 7. translated by Hubaysh al-A’sham. The 6. Ibid., vol. 104, p. 7. Greek originals have been lost and 7. Al-Baghdadi, Al-Ifadah w-al-I’tibar fi al- are only known through the Arabic Umur al-Mushahadah w-al-Hawadith translations. (1) Dissection of Live al-Mu’ayanah bi Ard Misr. p. 61. Animals. (2) Dissection of Dead Ani- 8. Al-Majusi, Kamil al-Sina’ah al-Tibbiyah mals. (3) Hippocratic Anatomy. (4) (Liber Regius). Vol. I. p. 139. Anatomy of . (5) Anatomy 9. Usaybi’ah. Vol. I. p. 178. of the Womb. (6) Differences of Opin- to. Ibid. Vol. I, p. 180. ion in Anatomy. 11. Cumston. History of Medicine, p. 200. 2. Haddad and Khairallah. A Forgotten Chapter in the History of the Cir- 12. Al-Majusi, Kamil al-Sina’ah al-Tibbiyah. culation of the Blood. Ann. Surg., vol. Vol. II, p. 483. 104, p. 3. 13. Ibid., vol. II, p. 467. 3. Ibid., vol. 104, p. 5. 14. Ibid., vol. II, p. 451. 4. Ibid., vol. 104, p. 5. 15. Ibid., vol. II, p. 468.