Neurosurg Focus 23 (1):E14, 2007 Medieval neurosurgery: contributions from the Middle East, Spain, and Persia

SCOTT Y. RAHIMI, M.D.,1 DENNIS E. MCDONNELL, M.D.,2 AMIR AHMADIAN, B.S.,1 AND JOHN R. VENDER, M.D.1 1Department of Neurosurgery, Medical College of Georgia, Augusta, Georgia; and 2Department of Neurosurgery, Gunderson Lutheran Medical Center, Lacrosse, Wisconsin

PModern neurological and spinal surgical techniques have been developed on the foundations estab- lished by predecessors. Modern 21st century neurosurgery begins in the Babylonian period, with the Edwin Smith papyrus. Throughout history, periods of enlightenment have resulted in advances in knowl- edge and understanding that have served as stepping stones for generations to come. As in other fields, in neurosurgery these periods of “enlightenment” have occurred in a variety of civilizations and time peri- ods. (DOI: 10.3171/FOC-07/07/E14)

KEY WORDS • ancient neurosurgery • history of neurosurgery • Middle Eastern neurosurgery

NE OF THE MOST well known and widely accepted by providing descriptions of vertebral anatomy and clini- works on neurosurgical medicine, both technique cal annotations. In one of his annotations he describes O and management, was written in Persia between making a cranial incision: AD 900 and 1200. This period of enlightenment followed that of the Greek civilization and the era of Hippocrates When one decides to make an incision or opening one and Galen. Galen’s neuroanatomical observations and should take into consideration the various small and larger folds pathophysiological correlations served as pillars on which of the skin. In the case of the forehead however one would act Arabic knowledge was built. otherwise, because an incision along the folds there would Three of the most significant and influential medieval divide the muscles and cause drooping of the eyelids. Similar care must be taken in the case where the muscular fibers take a scholars responsible for the advances in medical knowl- different course to the surface folds. The surgeon must there- edge during this era were Avicenna, Abulcasis, and Rha- fore know the anatomy of the nerves, the veins, and the arter- zes. These physicians thrived between the 10th and 12th ies, so as not to sever them by mistake.6 century, and have been revered into the modern era for their consolidation, interpretations, and preservation of Because of Avicenna’s understanding and depiction of medical literature of the Greek and Roman periods. Al- the relationship between anatomy, function, and clinical rel- though there were other medical philosophers during the evance, both The Canon of Medicine and Avicenna himself same era, these three were among the few that contributed have survived the test of time. to the advancement of neurological and general surgical Avicenna dedicated numerous chapters of The Canon of practices in an environment of religious constraints. Medicine to the depiction of the spinal cord and the verte- brae. His descriptions—detailed, precise and at times poe- Abu Ali al-Husayn ibn Abd tic—were composed at a time and place in which religion Allah ibn Sina (Avicenna) prohibited human dissections. Though Islamic law forbids surgical investigation of cadavers, it does not restrict sur- Avicenna (AD 980–1037), a Persian physician, was the geons from performing operations on patients in need. Al- most prominent and famous intellectual of his time. His though not specifically documented, it is probable that contributions spanned philosophy, astronomy, mathemat- Avicenna made his observations through the many correc- ics, and medicine. His most renowned work was the book tive surgeries he performed. Al-Qanun fi al-Tibb (The Canon of Medicine), which Avicenna described the spine as having four functions: served as the primary textbook of medicine in Europe well protecting the spinal cord, protecting the organs of the tho- into the 18th century.6 His complete systematic anthology racic cavity, providing structural support for the entire of medicine was founded on previous works by Galen as skeletal system, and allowing movement. He described well as his own clinical observations of physiology, pathol- the vertebrae of the cervical, thoracic, and lumbar spine as ogy, and anatomy. Avicenna contributed to neurosurgery well as the sacrum and coccyx in great detail. He illustrat-

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Unauthenticated | Downloaded 10/07/21 10:45 AM UTC S. Y. Rahimi et al. ed the various processes, foramina, facets, and ligaments. In his description of the anterior and posterior longitudinal ligaments, he stated that the former is stronger than the lat- ter because anterior movement is needed more than poste- rior movement. After regional analysis of vertebrae and their presumed functions, Avicenna provided treatment options for back complaints. In the first book of The Canon of Medicine, there are many considerations of spinal injuries and their treatment. For example, Avicenna describes different ma- neuvers to treat thoracolumbar back pain (Fig. 1). Avicenna’s depth of understanding of spinal anatomy allowed him to be one of the first to provide ways of sta- bilizing the spine. In The Canon of Medicine, Avicenna provides treatment options for spinal deformities such as kyphosis as well as for dislocations and fractures of the vertebrae.1 He not only described what he observed, but also tried to provide a rational explanation for the anato- my. He argues that without the spinal cord:

Nerves innervating the hands and feet would travel a longer distance and, thus be more prone to injury...Therefore, God cre- ated the spinal cord below the brain. The spinal cord is like a channel coming out of a fountain in the way that nerves emerge from both sides and go down, thus putting the organs closer to 9 the brain.” FIG. 1. Avicenna demonstrating reduction of a tho- racic dislocation using a ratchet/lever system. Illustra- Although Avicenna’s greatest contribution to modern tions from the 1608 Latin edition of The Canon of neurosurgery was his depiction and explanation of the Medicine, published in Venice. spine, he also contributed observations on intracranial an- atomy and pathology. His assessment of intracranial ana- tomy divided the brain into the cortex and medulla. He had an in-depth understanding of the brain as described by his predecessors, specifically Galen, who went so far as to type of skull fracture as what one would see when a dent attempt to number the cranial nerves. Avicenna described is made in a metal bowl from an object falling on it. Al- intracranial disease, like meningitis, and conditions such bucasis was a pioneer in developing surgical instruments. as hydrocephalus. He also performed cranial and intracra- He was the first to introduce a nonsinking trephine for nial surgeries and interventions such as bur hole trephina- 12 skull access, using a circular margin beneath the sharp tion (Fig. 2). head in order to avoid plunging into brain tissue with the The Canon of Medicine by Avicenna chronicles major trephine.5 Albucasis discussed spinal injuries extensively advancements in the field of neurosurgery, which—along in his works. He described immobilization and traction for with the contributions of other intellectuals of the time, spinal dislocations. He accurately stated that severe dis- like Albucasis and Rhazes—distinguishes the medical and locations lead to bowel incontinence and limb paralysis, surgical enlightenment achieved at this time. with death ensuing shortly after injury. Albucasis includ- ed hydrocephalus and its treatment in his writings. He wrote that fluid may collect between the bone and meninges and that a deep incision below the bone could Abul-Qasim Al-Zahrawi (Albucasis) relieve this pressure. Albucasis was the first physician to No discussion of medieval medicine would be complete explain a surgical treatment option for the temporal without mention of the physician and scholar Al-Zahrawi headache syndrome now known as temporal arteritis. He (AD 936–1013). Known in the Western literature as Al- explained that relief from headaches could be provided by bucasis, he was born in Al-Zahra, a royal city near Cor- cauterizing the superficial temporal artery or ligating it doba, Spain. By the beginning of the ninth century Moor- with thread.13 In addition to contributing his extensive dis- ish culture was flourishing following the movement of cussion of brain and spine anatomy, he also contributed North African armies into southern Spain.11 immensely to surgical technique. He advocated the use of Albucasis was a scholar and compiler who wrote more cauterization in a wide variety of surgical procedures. He than 30 volumes on all subjects pertaining to medicine. was well aware of the need for aseptic technique and used His final volume, a treatise on surgery, includes several alcohol from wine during surgical procedures.8 chapters devoted to neurological surgery.2 He addressed a Albucasis was ahead of his time in the realm of neuro- wide variety of neurosurgical issues including head in- surgery. His contributions were crucial in bridging the juries with skull fractures, spinal injuries, hydrocephalus, knowledge gap in the world of medicine from the Middle and cauterization. He described skull fractures as pene- Ages to the more modern period following the 15th cen- trating or crushing. He accurately described a “ping-pong” tury.

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FIG. 2. Avicenna performing bur hole trephination. Part of a miniature copper engraving.

Abu Bakr Muhamed Ibn revered Galen’s work and frequently referenced it in his Zakaria Al-Rhazes (Rhazes) treatises such as Kitabal-Mansuri, he also respectfully criticized some of his theories. For example, contrary to Rhazes (AD 864–930) was born in Rayy, a city that was Galen’s belief that the brain, spinal cord, and ventricular near modern Tehran. His work included over 200 scientif- system were single structures, Rhazes correctly hypothe- ic documents in which he catalogued and elaborated on sized that these were paired structures.3 the works of Hippocrates and Galen. In addition to being Historically, Rhazes has not received the same recogni- a dedicated teacher, Rhazes was a master clinician. Both tion as Albucasis or Avicenna as a pioneer in neuroanato- students and patients sought his help for the most ad- my and neurology. Nevertheless his descriptions and un- vanced cases that puzzled many others. derstanding of cranial and spinal anatomy along with their After establishing himself as a prominent physician, clinical applications will always be remembered in the Rhazes was appointed a court physician in Baghdad in annals of medicine. AD 907. Over the course of his life Rhazes wrote many treatises on various medical subjects.10 The best known of these is Kitab al-Hawi fi al-Tibb, also known as Liber Conclusions Continens, a 25-volume encyclopedia that includes trans- In the beginning of the eighth century, the intellectual lations of the work of Greek, Indian, and Arab physicians center of the world shifted eastward and flourished until as well as anecdotes from Rhazes’ own personal experi- the beginning of the 13th century. During this period, the ences. Rhazes’ contribution to neuroanatomy is well doc- work of Middle Eastern physicians such as Avicenna, umented in his works in Kitab al-Hawi fi al-Tibb and Ki- Albucasis, and Rhazes was of paramount importance in tab al-Mansuri fi al-Tibb. He described nerves as having guarding the knowledge that had been accumulated both motor and sensory functions and as originating in throughout history, particularly the contributions of Greek pairs from the brain and spinal cord with membrane cov- and Roman scholars. In addition to preserving this wealth erings. Rhazes also stated that there were seven cranial of knowledge, these Middle Eastern scholars made signif- and 31 peripheral nerves, assigning them the order initial- icant contributions of their own to both medicine and neu- ly given by Galen.4 He divided the peripheral nerves into rosurgery. eight cervical pairs, 12 thoracic pairs, five pairs in the lumbar spine, and three in the sacral spine, and he used this knowledge of segmental nerve innervations to local- References ize lesions in patients. He described a man who became paraplegic as a result of a back injury with sparing of the 1. Aciduman A, Belen D, Simsek S: Management of spinal disor- 14 ders and trauma in Avicenna’s Canon of Medicine. Neuro- upper extremities due to sparing of the cervical spine. surgery 59:397–403, 2006 Rhazes was also the first physician to describe concussion 2. Al-Rodhan NR, Fox JL: Al-Zahrawi and Arabian neurosurgery, as it is recognized today and distinguished the term from 936–1013 AD. Surg Neurol 26:92–95, 1986 severe brain injury.7 3. Awad IA: Galen’s anecdote of the fallen sophist: on the cer- Some have argued that Rhazes lacked new ideas, im- tainty of science through anatomy. J Neurosurg 83:929–932, plying that his work mirrored Galen’s. Although Rhazes 1995

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4. Flamm ES: Historical observations on the cranial nerves. J and its breakup. Microsoft Encarta Encyclopedia Deluxe. Neurosurg 27:285–297, 1967 Redmond, WA: Microsoft, 2005 5. Goodrich JT: History of surgery in the ancient and medieval 12. Sarrafzadeh AS, Sarafian N, Gladiss AV, Unterberg AW, worlds. Neurosurg Focus 16(1):E2, 2004 Lanksch WR: Ibn Sina (Avicenna). Historical vignette. Neu- 6. Gruner OC: A Treatise on the Canon of Medicine of rosurg Focus 11(2):E5, 2001 Avicenna. London: Luzac, 1930 13. Savage-Smith E: The practice of surgery in Islamic lands: myth 7. McCrory PR, Berkovic SF: Concussion: the history of clinical and reality. Soc Hist Med 12:307–321, 2000 and pathophysiological concepts and misconception. Neu- 14. Souayah N, Greenstein JI: Insights into neurologic localization rology 57:2283–2289, 2001 by Rhazes, a medieval Islamic physician. Neurology 65: 8. Nabri IA: El Zahrawi (936–1013 AD), the father of operative 125–128, 2005 surgery. Ann R Coll Surg Engl 65:132–134, 1983 9. Naderi S, Acar F, Mertol T, Arda MN: Functional anatomy of the spine by Avicenna in his eleventh century treatise Al-Qanun fi al-Tibb (The Canons of Medicine). Neurosurgery 52: Manuscript submitted April 11, 2007. 1449–1454, 2003 Accepted May 24, 2007. 10. Richter-Bernburg L: Abu Bakr Muhammad al-Razi’s (Rhazes) Address reprint requests to: Scott Y. Rahimi, M.D., BI-3088, medical works. Medicina Nei Secoli 6:377–392, 1994 1120 15th Street, Medical College of Georgia, Department of Neu- 11. Rosenwein BH: The early Middle Ages: the Carolingian world rosurgery, Augusta, Georgia 30912. email: [email protected].

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