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A RECENT LOOK AND STUDY OF SOME PAPERS OF AL-ZAHRAWI'S BOOK "AL-TASRIF"

INTRODUCTION

In this article we are going to present a shot review on the story of evolution of the Arabic medicine. This will be followed by readings in few selected papers from al-Zahrawi's book "al- Tasrif" with some explanations and comments.

Medicine started to develop as early as man started to exist. It showed rapid progress with ancient Egyptians and Babylonians. Whereas the Egyptian medicine was based on experimental bases in most of its phases, the Babylonian medicine was dependent on magic and religious prayings.

WERE, NOT SOLOMON, BUT THE EVIL ONES, TEACHING MEN MAGIC, AND SUCH THINGS AS CAME DOWN AT BABYLON TO THE ANGELS HARUT AND MARUT             (Quran 52: V 102)

In Greece they selected and quoted many of the Egyptian medicine. They reformed it in a philosophic form which is characteristic of their way of thinking Hippocrates dominated medicine in the Western world for many centuries. Hippocrates and his students gave rise to the "Four Humors Theory".

By the four1h century (B.C.) with the invasion of Egypt and Asia by Alexander of Macedon, the Greek civilization followed him and dominated the thinking in the East as far as India and other Eastern countries. Alexandria by that time had got an important position becoming the centre of all cultural and other activities.

Galen's work represents a synthesis of all Western medical knowledge, and as such it was to be the authority for many centuries. But his coherent philosophical system led him into a finalist interpretation of the human organism. Nature, or God, does nothing in vain; every organ is destined for a precise function, has a special use preordinated by God's supreme wisdom.

ARABIC-ISLAMIC MEDICINE

With the beginning of the Islamic civilization, when the Arabs started to get in contact with other people, the Arabs started to comprehend all available knowledge at that time. They got their information from the invaded countries as well from the Nestorian Christians who had been expelled from the Byzantine Empire.

Medical knowledge grew up at Gondi- Shapur in Khuzustan. Here the main works of Greek science were translated and elements of the Iranian tradition were also adopted, together with certain ideas from India. Moreover, the Caliphs of Baghdad ordered translations to be made of as many of the Greek scientific works as could be found, and built spacious hospitals in Baghdad at a time when nothing comparable existed in the West. Not content with imitations of the Greek authors, they often added clinical observations of their own to the medical treatises inherited from the Greeks. Their vast knowledge in chemistry and Botany has helped much in prescribing many medicaments. To the Arabs all owe the final systematization of the theory of the four temperaments (melancholy, sanguine, choleric, and phlegmatic) which profoundly influenced the Renaissance, and is by no means dead 'today. The medical knowledge of the Arabs was handed to posterity in encyclopedic compendia by Rhazes, Avicenna, Abulcasis and the great philosopher Averroes. In his De Pestilentia, Rhazes included one of the first descriptions of smallpox, which he carefully distinguished from measles. In Cairo in 1270 Ibn al-Nafis described pulmonary circulation (lesser circulation) for the first time. Three centuries later Miguel Serveto made it known to the West in his Christianismi restitutio on 1553.

AL-ZAHRAWI AND HIS BOOK "AL-TASRIF"

Abul Qasim Ibn Khalaf al-Zahrawi (Abulcasis) was one of the first, if not the first, genius Arabic , surgeons and one of the most famous Arabic medical men; Rhazes, Avicenna and Abulcasis. He was born in Andalusia in 936 A.C. and died in 1013 A.C. He has many treatises, the most famous of which is the large book "al- Tasrif". This book remained as an important reference of the surgeons in the East and West for many centuries. This book has been referred to and was translated several times under various titles because of the difficulty in translating the original name. The most famous one is: "Concessio et daraguicomponere head valet".

This large book comprises thirty articles. The first one includes an introduction on the aim of writing the book, some of his personal experience of the fifty years of medical practice, some anatomical descriptions, few articles on what we call nowadays as Physiology, signs and causes of diseases, examination of urine and pulse and he concluded that article by stating that time is an important item in ; treating diseases after thorough contemplation and interrogation of the patient. And more important is ' strict observation of the patient, since many patients cannot express their troubles, even if he is of the highly intellectual group.

The second chapter of the book includes classifications of diseases, their signs and management from head down to the foot.

From the third chapter to the twenty fifth are descriptions of diets of some diseases and foods which should be avoided. About alcohol he says "..and of its complications, in general, especially for those who become addicted to it, are many chronic diseases as convulsions, melancholy, dementia, paralysis, tremors, general weakness of most of the nerves of the body, difficulties in articulation, weakness of voluntary movements, arthralgias, gout, etc.. disturbances of the liver which causes tumours and obstructions which is a definite cause of ascites and general ill health".

However, the last chapter of the book, is the most famous one. It is concerned with surgery. In its introduction he advices anyone who wants to practice surgery that he must be acquainted with anatomy, physiology, writings of philosophers interested in that subject, together with continuous trial.

DESCRIPTION OF THE PAPERS FOUND IN THE LIBRARY OF AL-HARAM, EL-SHARIF, MECCA

These papers comprise four hundred papers of the (30 x 20cm), every page includes 23 lines; the average number of the words in the line is eight words. The pages are not numbered. It begins by introduction showing the advantages of medical sciences over other branches of science.

We have selected several paragraphs from the first chapter about some diseases of the nervous system because of its easy understanding by the readers and because of its similarity in many aspects to our recent views.

SELECTIONS FROM AL-ZAHRAWI'S BOOK "AL-TASRIF":

Apoplexy:

This usually presents in three forms; either strong and chronic which is non-curable, or mild which is curable, and this is rare, or very strong and rapidly fatal. It arises from either cold tenacious phlegm or humid tenacious blood. If the brain ventricles become full with any of these fluids, this humidity prevents the spirit from reaching the body. The patient lies down in deep sleep and he does not respond to pain. In the chronic and severe stroke the patient respires with difficulty and the respiration may be interrupted. However, the patient may be still alive. In mild strokes the respiration is easy and regular.

The signs of severe stroke is the absence of intellectual functions i.e. imagination, memory, sensation, paralysis of all the body, weak respiration and presence of froth in the mouth. The prodromata of the stroke are sudden severe headache, visual hallucinations, swollen face and neck, sense of rotation, coldness of the extremities, difficulty in movements, amnesia and mental apathy.

The signs of phlegmatic stroke are obesity, faint colour of the skin, senility, excessive mucoid sputum, slow motion, physical inactivity, and craving for eating cold foods.

The signs of sanguinous stroke include plethoric face, congested neck vessels, the patient's appearance as if he is chocked, and usually the patient is of the type which prefers highly nutrient foods, alcohols and thick syrups containing large amounts of sugar.

Treatment of phlegmatic stroke is to look to the general condition of the patient at first. If his general condition is good give him cathartics as hiera mixed with fat of colocynth or compound purgative pills. Also inject him (most probably rectal enema) with fluids made of centaurium and fat of colocynth, together with gurgling with any substance which helps excretion of sputum. Also give him sernutatories and try as much as possible to open his mouth to help him to vomit, then give the patient small amount (4.4g.) of theriacum mixed with anise water together with honey. The patient is given nutrients as chopped white meat with cinnamon and coconut oil. Also a warm plate is put near to his head to become more hot and his head is bandaged by a mixture of cotton, Myristica officinalis, mecer and cinnamon. After twenty-one days the patient is bathed with massage of all his body and he is encouraged to move if possible. If you find froth coming out from the patient's mouth it is better not to treat him. Similarly do not treat the apoplexy which occurs in young persons particularly if it occurs during the summer months.

As regards treatment of the sanguinous apoplexy if the patient is fit and he is much stuffed with blood, do venesection to him either from the cephalic veins or from the lower limbs. Restrict his food intake and put on his head oil of violet with vinegar. If this is sufficient continue on this treatment. Otherwise, give him rectal enemas and give him cold nutrients until he is cured.

Hemiplegias:

It is obstruction of the nerve pathways in which the spirit passes by tenacious phlegm. If the obstruction occurs on one side of the brain, this side becomes paralysed, either left or right, and the paralysis is called according to the paralysed side. If the obstruction is allover the brain apoplexy will result and all the body becomes paralysed.

Hemiplegia is of two types of origin; either from tenacious phlegm or due to trauma. The signs of hemiplegia caused by phlegm is complete flaccidity of the paralysed side together with other signs of apoplexy. The sign of traumatic cases is complete flaccidity of many limbs of the body if not all of them.

Treatment of phlegmatic cases is hot enemas to withdraw the phlegm downwards. Then give him cathartics mixed with strong aromatic decoction, to be repeated every four days if the patient could withstand. In the other days you give the patient anacardia paste (made of one weight "4.4g." of anacardia mixed with three ounces of anise water together with theriacum of sabin. On the whole these patients are treated as those with apoplexy.

Treatment of traumatic cases includes bandaging with castoreum bandage on the sites of trauma together with hot pastes.

Facial Paralysis:

It arises from either tenacious phlegm obstructing the apertures through which the nerve passes or due to spasm in that nerve. In the former condition the muscles of the face become flaccid and the face is deviated to the healthy side and the patient cannot close his eye on tied paralysed side together with inability of blowing the face of that side. In cases of spasm of the nerve the muscle is deviated to the diseased side.

The signs of paralytic cases are flaccidity of the paralysed side, difficulty in its movement, downward position of the lower eye lid and excessive salivation. In cases of spasm of the nerve the face is withdrawn towards the affected side and diminised salivation, and the patient is usually thin.

Treatment of phlegmatic facial paralysis is emesis and other lines of treatment which has been described in hemiplegia. The face is tied on the paralysed side by a bandage to prevent filling of the mouth and the patient is given gargles made of mustard, piper or pyrethrum. The patient is advised to masticate one piece of Myristica officinalis or of castoreum and is given any of the snuffs which has been mentioned before. His neck is greased with oil of castoreum or oil of cuphorbeum. Treatment of cases caused by spasm of the nerve is to grease the affected side with oil of norcissi together with other lines of treatment which have been metnioned in convulsions.

Convulsions:

It is drawing of one or many organs to their origin. If it occurs in the eye lids, closure of the eye will occur; if in the eye muscles, squint will result; in the seminal vessels insemination could occur; in the whole body, epilepsy will result. If it occurs involuntarily it is called tetany. It results from two causes either from excessive humidity or dryness. The signs of convulsions due to humidity is its sudden onset. when the patient is indulged in overeating or alcohol or long recumbency in bed, physical inactivity or  luxurious life. It occurs most commonly in those of humid temperament. The signs of convulsions due to excessive dryness is its gradual onset following exhaustion, excessive vomiting, diarrhoea, haematemesis or melaena or fevers.

Treatment of convulsions due to excess humidity is to give hiera together with hot oils, strong emesis and other lines of treating phlegmatic facial paralysis. Treatment of dry convulsions, but its treatment is difficult and its prognosis is very bad, is to bathe him with lukewarm water with greasing of his spine with warm oils as oil of narcissi, oil of chickens or sesame oil. His nutrition includes she-ass milk with almond oil, syrup of barley with sugar, tender meat, chopped white meat and all fatty foods. Dry or acidic foods should be avoided.

Tonic Spasms:

It is a type of convulsions and comprises three types; either in the nerve and the flexor muscles, in Ithe nerve and the extensor muscles or in both. This latter type is which we mean in fact. The cause is either from inside the body or from outside. The former type arises from either excessive fullness or , humidity, excessive emesis or dryness. That arising from outside the body is due to many causes; either trauma to the nerve, burning of the nerve., excessive fatigue or carrying heavy objects or excessive lying on hard ground.

Tonic spasms occuring due to excessive humidity are sudden in onset whereas those occurring due to dryness are of gradual onset. In those due to external causes, the cause is usually evident.

General features of tonic spasms:

Breathelessness, prolonged expiration, spasm of muscles of mastication, abnormal facial appearance, i.e. as if the patient is laughing with exposure of the teeth, flushed face, swollen eyes, retention of urine or incontinence of urine which may be associated with blood, retention of stools, severe pains which may prevent the patient from sleeping, tremors and may be convulsions. This disease occurs frequently in children. If the patient is above twenty years of age the hope of cure is minimal. If the convulsions are associated with fever the patient may be cured. But if tonic spasms and convulsions occur following a fever the patient is never cured and is mostly fatal.

Treatment of tonic spasms includes warm enemas and warm ointments, as those made of oil of rul together with castoreum, honey, gum (Assu fortida) and other nutrients as coconut oil, mustard an, piper. Treatment of tonic spasm due to dryness is to grease his body with milk together with sesame oil oil of violet and is given 4 ounces of she-ass milk daily with almond oil and sugar. He is put in a bat! containing warm milk. The nutrition of the patient includes barley, sugar and almond oil. Also choppel white meat, made of tender meat and flesh, is given together with honey. Other lines of treatment are, similar to that of convulsions.

Flaccidity:

This occurs due to disease affecting the nerves which emerge from the brain or the spine. It is either due to causes from inside or outside the body. The former one arises from four causes: overfillin and excessive humidity, excessive vomiting and dryness, an abscess emerging from any of the variol humours. In case arising from outside the body there may be cutting of the nerve, trauma or laceratic of the nerve. This type of flaccidity is difficult to treat. The manifestations of flaccidity of dryness underweight and dry temperament. In cases of tumours it is usually palpable.

Treatment of the humid type is to give drugs which cause dryness together with cathartics or oils; otherwise cautery on the site of exit of the nerve or on the flaccid organ as will be mentioned; the chapter of surgery .

Treatment of the humid type is to give drugs which cause humidity. In cases due to abscesses treatment could be given.

Diminished or absent power of smelling (Anosmia):

This is either congenital, and is uncurable or acquired. The acquired type results from either cause inside the body or from outside. That from inside arises from dyscraisia of the four humors or obstructi (in the cerebral ventricles similar to that occuring in apoplexy and hemiplegia. The obstruction arises fro viscid chyme or gases or obstruction of the cribriform plate of the ethmoid bone (it simulates the strain and is present on the uppermost part of the nose). The obstruction may be due to a fistula or a cacerous tumour or other similar tumours or swellings. Those due to causes from outside the body a either from contact with cold anaesthetic materials, fractures of the skull of trauma of the nose its which damages the sense of smelling.

In congenital cases the eyes are congested and the patient does not smell from the beginning ar this is worst type and no treatment is available. Some patients may smell certain substances only which he cannot smell the others. The manifestation of anosmia due to hot humours is severe inflamation the front of the head, with fever and preference of cold substances. In cases due to thick humor there difficulty in blowing of the nose with heaviness of the front of the head. In cases of obstruction of cribriform bone there is absence of nasal discharge with nasal tone of speech and is usually difficult treat. If the obstruction is in the nasal passages themselves there is difficulty in the flow of air from the nasal passages and you may meet the swelling itself if you put a probe in the nose. In cases due contact with anaesthetics the history is usually evident. In cases of fractures the cause is usually evident. If the trauma is associated with soft wound, it may be followed by fever and he may be deliriou In other traumas of the nose the cause is usually evident.

Treatment of cases due to thick humor is venesection from the cephalic veins if there is no contra -indication. Cathartics are also given as myrobalans and Cassia fistula it the predominant humor is the bile. Foments, made of camomile, violet and barley, are put on the head. The face is exposed to various of highly acidic venegar several times. The diet is preferably to be of the cold humidifying foods cases of cold humors we give cathartics as compound pills or by giving hiera and is given gurgles which withdraw the phlegm from the head as oxymel and marrubium. Headfoments, made of camomile, malrubium, alum, worm seed, thymus serpyllum and oil of rue. Hot applications are also put on the head with hot substances such as hot salt and millot. Irritant snuffs are given such as sruthium and piper. Cauterization on the occiput and parietal eminences may be of value. Treatment of obstruction secondary to thick chyme is strong cathartics to clean the head together with other lines of treatment mentioned before appoplexy & hemiplegia. Also cauterization over the head is of marked value.

Treatment of obstruction of the cribriform bone is to clear head together with snuffing with nigella dissolved in oil after filling the patient's mouth with water. The patient should put his head as far backward as possible and he take a deep breath until he feels the drug inside his head. This is to be repeated for three consecutive days. Also the patient must snuff oil of violets or norcissi.

Treatment of obstruction secondary to tumours will be described in the chapters of tumours. Treatment of anosmia due to anaesthetic snuffs is sniffling by castoreum, musk, oil of rue, nigella or almond oil. Treatment of traumatic cases will be described in the chapters of traumas.

COMMENTS ON THE SELECTED PAPERS OF AL-ZAHRAWI's BOOK

In these selected papers from al-Zahrawi's book we notice the great influence of the "four humors theory" on all of his writings. He is not unique in that respect because this theory predominated the medical thinking for many centuries. He tried to ascribe all the causes of diseases according to the speculations of this theory. Consequently he tried to treat these diseases according to these presumed causes, such as diminishing the severity of the excess humor by venesection, emesis, cathartics, drugs or foods according to the case. If we exclude this obstacle in our evaluation of these articles, we are going to notice a great accuracy in describing the clinical signs of various diseases. Actually their clinical descriptions are very near to the recent classifications and observations. Also many anatomical findings have been referred to accurately, which may impress us that he may have dissected some parts of the body.

In the chapter dealing with apoplexy (he called it the major stroke or major hemiplegia), he classified it into three main forms; the first is the chronic and uncurable, the second is the curable one, and the third which is rapidly fatal. If we compare this classification with the recent thinking we would not find a great difference. Still we classify the cerebral strokes into three types: the chronic type of gradual onset which is usually due to a thrombus in any of the cerebral vessels or atherosclerosis, the curable type which may be due to spasm of any of the cerebral vessels due to either sudden rise of the blood pressure or small vessels thrombus which may be dislodged into a smaller vessel, and the last one is the fatal one which is usually due to cerebral haemorrhage.

Also we notice the accurate clinical description of some important clinical signs as the regularity of the respiration as an indication of the severity of the stroke, his definition of coma as that in which there is absence of the mental faculties i.e. imagination, thinking, memory together with absence of sensation and power of voluntary movement. He also described the prodromata of stroke as sudden severe headache, vertigo, visual hallucinations and presence of froth around the mouth (he considered the latter sign as bad prognostic sign). He also descriminated between simple hemiplegia and that associated with loss of consciousness.

He also described facial palsy, but unfortunately he was unable to discriminate between the sensory nerves of the face and the motor nerve. Nevertheless he described accurately the clinical signs of facial paralysis. He mentioned that the face is deviated towards the healthy side. He also discriminated between facial paralysis and facial spasm. In the latter type he mentioned that the face is deviated to the diseased side.

As regards his descriptions of various types of convulsions he differentiated between convulsions and other types of involuntary movements. He also differentiated between the various types of convulsions and tonic spasms. In this latter type he described a case very similar to cases of tetanus and he referred to the important sign (risus sardonicus), which is an essential diagnostic sign of that disease.

Also he could diagnose causes of flaccid paralysis and ascribed them to cutting of the motor nerves what we call nowadays as lower motor neurone lesion. He also described several causes of interruption of the nerve function including the abscesses of the spine which is usually due to tuberculosis of the vertebral column and we call it Pott's disease of the spine.

In the last paragraph, on anosmia, we notice a very accurate and reasonable classification of the various causes, which closely simulate the recent thinking. He could differentiate between the congenital type of anosmia and acquired forms. He could also follow the olfactory pathway from the orbital surface of the frontal lobe down to its termination in the nasal mucosa. He also described the cribriform plate of the ethmoid bone in which the olfactory nerve fibres pass. This may show that he dissected this complicated part of the head. During his description of the method of putting nasal snuffs and other nasal medicaments he referred to the importance of positioning the head as backward as possible together with deep and strong inspiration until he feels the drug inside this head. This in accord with our recent understanding of the anatomical position of the nasal sinuses and our advice to patient on using nasal drops to adopt this position.