<Home> <Muslim Scientists> <Al-Zahrawi> <Surgery of Abul-Qasim Al-Zahrawi>

SURGERY OF ABUL-QASIM AL-ZAHRAWI
Dr. A.M. Mansour
EGYPT

While Arabic medicine was at its peak in the East, thanks to al-Razi (Rhazes) and Ibn Sina (Avicenna), it was achieving tremendous advances in the West, where a great surgeon, Abul-Qasim al-Zahrawi was born in Andalusia in 936 A.D. His name is associated with one of the great treasures in medical history "al- Tasreef". In the last section of this medical encyclopedia, he deals with many branches of surgery. It also contains detailed illustrations of many surgical instruments. It remained the backbone of surgical teaching and practice in European Universities, almost till the close of the 18th century and in fact it laid the solid foundations of what has become nowadays a monumentous achievement of the art and science of surgery.

Al-Tasreef contains about 200 surgical instruments clearly described and illustrated, many of which were of his own design, for he was a great advocate of creativity and invention.

His book is widely acclaimed to be the first illustrated treatise in the history of surgery. It is lucidly written, unambiguous and is an enjoyment to read even nowadays.

The first 56 chapters of al-Tasreef deal with cautery, but we will confine ourselves to very few examples, not only for their historical importance but also to dissipate many illusions which link all progress in medicine with the last 100 years.

In chapter 28, a specific clinical condition -Liver abscess, is described, for opening which al-Zahrawi describes an instrument designed in a particular shape together with its canula. In this way, al-Zahrawi combines the qualities of cauterization, piercing and drainage of pus in one instrument.   (Fig. 1)

As a matter of fact, no real improvement on this method of treatment of liver abscess was achieved till the beginning of the 2Oth century, when Rogers4 introduced emetine salts for its treatment.

In chapter 51 , al-Zahrawi establishes an important basic principle of surgery , and this is dependent drainage of pus, using for this purpose a specially designed cautery. (Fig. 2).

Chapter 56, "On Cauterization in haemorrhage arising from a cut artery" tells more than what the title denotes, for the author mentions ligature of blood vessels, for the first time in the history of medicine -as one of the methods of arresting haemorrhage. Harvey2 states that the most important reason for Ambroise Pare's fame in the sixteenth century was his invention of ligatures for arresting haemorrhage instead of cautery in amputations.

In the field of general surgery, al-Zahrawi in Chapter 40 deals with "Perforation and Incision of Tumours", basically he deals with inflammatory swellings and he establishes three important principles of surgery:

1) First, the importance of early incision of perianal suppurations.
2) Second, that incisions should be situated in the most dependent part of the swelling.
3) Third, The necessity of using a drain.

If we carefully read Chapter 44, "On cutting upon the tumour which occurs on the outside of the throat and called Elephant of the Throat", it becomes obvious that he deals with thyroid swellings, "for it may reach a large size, is of the same colour of the body", i.e. it is not an inflammatory swelling "and it commonly occurs in women", a statistical fact. "It is of two types, congenital and acquired. The acquired is of two kinds, one resembles lipomata, the other resembles a tumour arising from an arterial aneurysm and is dangerous to incise".

It is clear that the condition last described is that of thyrotoxicosis and he advises not to operate on it. From the text, it is also clear that he operated on thyroid nodules.

Samuel Cross, the famous Philadelphia surgeon wrote in 1866 "Can the thyroid gland in case of enlargement be removed? Emphatically experience answers No. If the surgeon is foolhardy to attempt it, lucky it would be for him, if his victim survives till the end of this horrid butchery. Any sensible and honest surgeon should avoid it."

Nine centuries elapsed since al-Zahrawi first operated on the thyroid gland, before any real progress occured in the field of thyroid surgery at the hands of Halstead who acknowledged his debt to al-Zahrawi and Theodor Kockher.

If we now move on to chapter 49, "On opening a tumour arising from a blood vessel, called aneurysm", we find that al-Zahrawi was aware that trauma can cause an aneurysm and that thrill is one of its signs. Al-Zahrawi also described in detail a method for proximal and distal ligation of arterial aneurysms. Eight centuries later, John Hunter became widely famous for a similar procedure.

Chapter 65 deals with treatment of intestinal hernias. As we go along it, we get surprised by his accuracy and attention to details. Soon it becomes obvious that he was able to distinguish between direct and indirect inguinal hernias. This, and his awareness that the contents may be intestine or omentum and that incarceration could cause obstruction, must have been attained through his vast experience.

Al-Zahrawi's description for the surgical treatment of hernia closely resembles the herniotomy of today, except that we do not remove the testis. Herniorrhaphy was introduced by Bassini in 1884, 9 centuries later, when the anatomy of the anterior abdominal wall became thoroughly understood.

In Chapter 54, we find an accurate description of tapping of ascites, using a pointed scalpel followed by the introduction of a canula (Fig. 4, 5, 6,). This description makes it clear that he intended a valvular incision.

Chapter 85 deals with " Abdominal wounds, protrusion of the intestine and suturing them". He advises using warm water sponges to facilitate reduction of bowel to the abdominal cavity, if this is still difficult he advises opening up the wound, with a curved scalpel (FIgure 7) whose sharp edge lies on the inner side.

For the first time in the history of surgery, al-Zahrawi describes bladder wash out and invents an instrument for this, made of silver or ivory, hollow with a long fine tube. "The hollow part containing the plunger is exactly of a size to be closed by it, so that any liquid is drawn up with it when you pull it up, and when you press it down it is driven in a jet, as is done by the projector whereby petrol is thrown in sea battles". (Fig. 9)

It is obvious that this instrument is the ordinary syringe, if a needle is added to it, it becomes possible to introduce drugs parentrally.

Al-Zahrawi, starts Chapter 60 "On extraction of stones" with very important clinical observations. "A bladder calculus most frequently occurs in boys, and of its signs is that urine may contain sand, the patient keeps on rubbing his penis and many of them get a prolapse of the rectum".

Then he proceeds to describe with great accuracy, the ideal position of the patient during the operation, and the role of assistants. Then he describes the details of the operation and locates the exact anatomical position of the perineal incision, he mentions the difficulties which may arise, and the precautions to avoid them.

It is no exaggeration to state that al-Zahrawi was the pioneer of Plastic surgery. Most of the instruments he invented, are still used, but under the name of Surgeons who followed him many centuries later.

Marking the procedure with ink prior to the actual operation is a must in this fine speciality. This step is almost a routine in many of the operations described by al-Zahrawi.

Furthermore, many operative procedures which he described in this field, are still used with some modifications and additions. His description of blepharoplasty, for example, resembles to a great extent what is being practiced nowadays. If we read his account, we immediately realize his honesty, for he acknowledges his debt to the ancients. Then he describes new surgical instruments like the eye speculum with 3 hooks (Fig.11) to hold up the upper eyelid. These hooks are characterized by olivary ends to avoid damage to the eye. Then he proceeds to describe a pair of fine scissors (fig. 12) This, according to Spink and Lewis,5 was the first drawing of a true pair of scissors in the history of surgical literature.

Al-Zahrawi also dealt with ectropion. He realizes that it may be congenital or acquired, and although the principle of his operation seems to be rather simple, and that is excision of a triangle of tissues whose apex is directed towards the fornix, yet, it is one of the important basic principles of plastic and reconstructive surgery. With a simple addition, the operation he described is now known under the name of Kuhnt-Szymanowski operation.6

In chapter 26 "On suture of nose, lip and ear, when there is discontinuity from a wound or the like" al-Zahrawi lays two important basic principles:

First, that recent wounds should be sutured primarily. Second, that in old wounds, the margins should be freshened before any attempt at suturing is made.

Illustrations of many different types of hooks (Fig. 31) abound throughout the book. As usual, these instruments are now known under other surgeons' names e.g. Gillies.

ENT SURGERY

In Chapter 6, many new instruments were described for removal of foreign bodies which may enter the ear. A forceps consisting of two levers connected at the base, with a sliding collar along them, to ensure the meeting of the tips when the collar is advanced away from base is illustrated (F. 16). With progress in industry and metal alloys it became possible to dispense with the collar and we get the ordinary toothed or nontoothed forceps. In the same chapter, he describes a fine scalpel to cut plant grains which may grow or swell inside the auditory canal (Fig. 17). Furthermore, a simple otoscope is illustrated (Fig. 18). The gentle curve proves his accurate knowledge of Anatomy.

He starts chapter 36 by differentiating between inflammatory and malignant swellings of the tonsils and advises not to open a tonsil or abscess until it becomes mature. Then he proceeds to describe tonsillectomy in much the same way as it was performed Just few years ago. For the procedure, he describes three important surgical instruments:
1) The Tongue depressor (Fig. 20)
2) The tonsil guillotine (F. 21 ), it is like a pair of scissors except that the extremities are curved, the beak of each, meeting the other and very sharp.
3) Then a hooked-scalpel is described if the tonsil guillotine is not available. (Fig. 22)

Oral and Dental Surgery For the first time in the history of surgery, scaling is described and a multitude of instruments illustrated for this purpose. (Fig. 24 )

Chapter 31 "On extraction of roots of teeth and of broken pieces of mandible" shows clearly al- Zahrawi's genius and creativity. According to Spink and Lewis,5 nobody before him wrote on this subject with such detail and accuracy which denotes a vast experience. He describes a very important instrument, the forceps or Kalalib (F. 25) "the point of which resembles a bird jaws having teeth fitting into each other, so that sure and firm grip may be obtained." This instrument he used for root extraction and for removal of broken teeth and sequestrum.

Other versions of it were used for extraction of arrows. Some were straight and others were curved. A glance at the illustrations is enough to realize that it was the prototype for the present day artery forceps, Kokher's forceps and many other pedicle clamps. Only minor adjustments e.g. the lock were introduced. However, they are known under the name of Spencer-Wells, Kokher's and many other surgeons. I believe that the word Clamp is derived from al-Zahrawi's Kalalib.

Over and over again, al-Zahrawi repeats his advise not to blindly follow the ancients but to think and try to invent the proper instrument which suits a particular situation. In this respect, I find his own words the best to bring this talk to an end. "You should know that dental instruments are very numerous, as are the other instruments, almost beyond reckoning, And the experienced worker with a knowledge of his craft may devise fresh instruments, as his work on actual cases suggests them to him. For there are certain diseases for which the ancients did not mention any instruments.

ACKNOWLEDGEMENT

The author wishes to acknowledge the courtesy of Bodleian Library for providing him with microfilms of two manuscripts of al-Tasreef:
1) H. Huntington 156
2) M. Marsh 54

I would also like to thank the Director General of the Egyptian National Library for providing me with a microfilm of the Oxford Edition (1778) of the same book (Tib-935).

REFERENCES

1) HALSTEAD, W.S., : "The Operative Story of goitre". Johns Hopkins Hosp. Rep. 19: 71, 1929
2) HARVEY, S.C.: "The History of Haemostasis". Ann. Med. Hist., 1: 127, 1929.
3) NYHUS, L.M., and BOMBECK, C.T.: "Hernias, historical aspects", In: Davis-Cristopher Text book of Surgery, 11th Ed., W.B. Saunders Co. pp.1335-1360, 1977.
4) ROGERS, L: "The Rapid Cure of Amoebic dysentry and hepatitis by hypodermic injections of soluble salts of emetine"., B.M.J.,1: 1424, 1912
5) SPINK, M.S. and LEWIS, G.L.: "Abulcasis on Surgery and Instruments. " University of California Press (1931 ).