SHAH KHALID

Abu Al-Qasim and his Stupendous Contribution to Medicine

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Abu Al-Qasim Khalaf Ibn-Al-Abbas-Al-Zahrawi, popularly known as Al-Zahrawi Latinised as Abulcasis from Arabic Abu -Al-Qasim, was an Arab Muslim physician, surgeon and chemist. Al-Zahrawi was born in the city of Azahara in 936 CE, 8 kilometres northwest of Cordova, Andalusia. He was considered as greatest medieval surgeon of the Islamic World in middle age, and has been described as the father of surgery. His principal work is the Kitab al-Tasrif, a thirty-volume medical treatise.The surgery volume in this treatise was later translated into Latin where it received a popularity and became the standard text book on surgery in Europe for nearly 500 years.

He lived most of his life in Cordova. It is also where he studied, taught and practiced medicine and surgery until shortly before his death in about 1013, two years after the sacking of El-Zahra. Few details remain regarding his life, aside from his published work, due to the destruction of El-Zahra during later Castillian-Andalusian conflicts. His name first appears in the writings of Abu Muhammad bin Hazm (993–1064), who listed him among the greatest physicians of Moorish Spain.

Al-Zahrawi’s pioneering contributions to the field of surgical procedures and Instruments had an enormous impact in the East and West well into the modern period, where some of his discoveries are still applied in medicine to this day. He was the first physician to describe an Abdominal Pregnancy a sub type of ectopic pregnancy, and the first physician to identify the hereditary nature of haemophilia. Al-Zahrawi was a court physician to the Andalusian caliph Al-Hakam. He devoted his entire life and genius to the advancement of medicine as a whole and surgery in particular. His best work was the Kitab al-Tasrif.

Al-Zahrawi specialized in curing disease by cauterization. He invented several devices used during surgery, for purposes such as inspection of the interior of the urethra, applying and removing foreign bodies from the throat, inspection of the ear, etc. He is also credited to be the first to describe ectopic pregnancy in 963, in those days a fatal affliction. Al-Zahrawi was the first to illustrate the various cannula and the first to treat a wart with an iron tube and caustic metal as a boring instrument. He was also the first to draw hooks with a double tip for use in surgery.He was a contemporary of Andalusian chemists such as Ibn Al-Wafid, Maslamah Ibn-Ahmad Al-Majriti.

Al-Zahrawi’s thirty-volume medical treatise, Kitab Al-Tasrif, completed in the year 1000, covered a broad range of medical topics, including on surgery, medicine, orthopaedics, ophthalmology, pharmacology, nutrition, dentistry, childbirth, and pathology. The first volume in the encyclopaedia is concerned with general principles of medicine, the second with pathology, while much of the rest discuss topics regarding pharmacology and drugs. The last treatise and the most celebrated one is about surgery. Al-Zahrawi stated that he chose to discuss surgery in the last volume because surgery is the highest form of medicine, and one must not practice it until he becomes well-acquainted with all other branches of medicine.

The work contained data that had accumulated during a career that spanned almost 50 years of training, teaching and practice. In it he also wrote of the importance of a positive doctor-patient relationship and wrote affectionately of his students, whom he referred to as “my children”. He also emphasized the importance of treating patients irrespective of their social status. He encouraged the close observation of individual cases in order to make the most accurate diagnosis and the best possible treatment.

Not always properly credited, modern evaluation of Al-Tasrif manuscripts has revealed on interesting descriptions of medical procedures that were ascribed to later scholars. For example, Al-Zahrawi’s Al-Tasrif described both what would later become known as “Kocher’s method” for treating a dislocated shoulder and “Walcher position” in obstetrics. Moreover, Al-Tasrif described how to ligature blood vessels almost 600 years before Ambroise Pare, and was the first recorded book to explain the hereditary nature of haemophilia. He was also the first to describe a surgical procedure for ligating the temporal artery for migraine, also almost 600 years before Pare recorded that he had ligated his own temporal artery for headache that conforms to current descriptions of migraine. Al-Zahrawi was therefore the first to describe the migraine surgery procedure that is enjoying a revival in the 21st century, spearheaded by Elliot Shevel a South African surgeon.

Al-Zahrawi also pioneered Neurosurgery and Neurological diagnosis. He is known to have performed surgical treatments of head injuries, skull fractures, spinal injuries, hydrocephalus, subdural effusions and headache. He developed material and technical designs which are still used in neurosurgery. The first clinical description of an operative procedure for hydrocephalus appears in the Al-Tasrif which clearly describes the evacuation of superficial intracranial fluid in hydrocephalic children. He described it in his chapter on neurosurgical disease, describing infantile hydrocephalus as being caused by mechanical compression. He wrote: The skull of a newborn baby is often full of liquid, either because the matron has compressed it excessively or for other, unknown reasons. The volume of the skull then increases daily, so that the bones of the skull fail to close. In this case, we must open the middle of the skull in three places, make the liquid flow out, then close the wound and tighten the skull with a bandage.

On Surgery and Instruments is the thirteenth and last volume of Kitab al-Tasrif. Its contents and descriptions has contributed in many technological innovations in Medicine, notably which tools to use in specific surgeries. In his book, Al-Zahrawihe draws diagrams of each tool used in different procedures to clarify how to carry out the steps of each treatment. The full text consists of three books, intended for medical students looking forward to gaining more knowledge within the field of surgery regarding procedures and the necessary tools. The book was translated in the 12th. It soon found popularity in Europe and became a standard text in all major Medical Universities. It remained the primary source on surgery in Europe for the next 500 years. Arturo Castiglione, a historian on medicine has put it: “Al-Zahrawi’s treatise in surgery held the same authority as did the Canon of Avicenna in medicine”.

Al-Zahrawi claims that his knowledge comes from careful reading of previous medical texts as well as his own experience: “whatever skill I have, I have derived for myself by my long reading of the books of the Ancients and my thirst to understand them until I extracted the knowledge of it from them. Then through the whole of my life I have adhered to experience and practice…I have made it accessible for you and rescued it from the abyss of prolixity”.

In the beginning of his book, Al-Zahrawi states that the reason for writing this treatise was the degree of underdevelopment surgery had reached in the Islamic world, and the low status it was held by the physicians at the time. Al-Zahrawi ascribed such decline to lack of anatomical knowledge and misunderstanding of the human physiology.

Al-Zahrawi also mentioned that “before practicing surgery, one should gain knowledge of anatomy and the function of organs so that he will understand their shape, connections and borders. He should become thoroughly familiar with nerves muscles bones arteries and veins. If one does not comprehend the anatomy and physiology one can commit a mistake which will result in the death of the patient. I have seen someone incise into a swelling in the neck thinking it was an abscess, when it was an aneurysm and the patient dying on the spot.”

In Urology, Abulcasis wrote about taking stones out of the bladder. By inventing a new instrument, an early form of the lithotrite which he called “Michaab”, he was able to crush the stone inside the bladder without the need for surgical incision. His technique was important for the development of lithotomy, and an improvement over the existing techniques in Europe which caused severe pain for the patient, and came with high death rates.

In dentistry and Orthodontics, Abulcasis had the most significant contribution out of all Muslim physicians, and his book contained the earliest illustrations of dental instruments. He was known to use gold and silver wires to ligate loosened teeth, and has been credited as the first to use replantation in the history of dentistry. Abulcasis also invented instruments to scale the calculus from the teeth, a procedure he recommended as a prevention from periodontal disease.

Abulcasis introduced over 200 surgical instruments, which include among other different kind of scalpels, Retractors, curette and also instruments designed for his favoured techniques of cauterization and ligature. Many of these instruments were never used before by any previous surgeons.His use of catgut for internal stitching is still practised in modern surgery. The catgut appears to be the only natural substance capable of dissolving and is acceptable by the body. An observation Al-Zahrawi discovered after his monkey ate the strings of his Oudh. Al-Zahrawi also invented the forceps for extracting a dead foetus, as illustrated in the Al-Tasrif.

In pharmacy and pharmacology, Al-Zahrawi pioneered the preparation of medicines by sublimation and distillation. Throughout the text, Al-Zahrawi uses an authoritative tone to declare his expertise on the topic. For example, when introducing topics or describing procedures, Al-Zahrawi often warns the reader of the skills necessary to complete the task. In chapter forty-eight, “On cauterization for numbness”, he defines the required knowledge for the procedure in a commanding tone: “This should not be attempted except by one who has a good knowledge of the anatomy of the limbs and of the exits of the nerves that move the body”.He invents a criterion to generate a standard of skill level, indicating that he himself has surpassed it due to training and experience. As such, he reiterates his pre-eminence by implying that he is part of an exclusive group of learned surgeons capable of correctly completing this cautery. In another instance, he states that the procedure should be avoided completely by incompetent surgeons: “However, no one should attempt this operation unless he has had long training and practice in the use of cautery”.

Al-Zahrawi was not afraid to depart from old practice, for example, he openly disparages the opinion that cauterization should only be used in the spring season as the ancients affirmed that spring was the best. Four pages later, he again opposes the opinion that gold is the best material for cauterization, stating that iron is actually his preferred metal. In chapter twenty-nine, “On cauterization for pleurisy”, he states: “Now one of the ancients mentioned that there were some people who used an iron cautery shaped like a probe, and introduced it red hot into the intercostal space until it reached the abscess itself and evacuated the pus…but in this perforation with the cautery there is a danger either that the patient may die on the spot or that an incurable fistula may rise in its place”

Al-Zahrawi was the most frequently cited surgical authority of the middle Ages. Donald Campbell, a historian of Arabic medicine, described Al-Zahrawi’s influence on Europe as follows:

  • The chief influence of Abulcasis on the medical system of Europe was that his lucidity and method of presentation awakened a prepossession in favour of Arabic literature among the scholars of the West: the methods of Abulcasis eclipsed those of Galen and maintained a dominant position in medical Europe for five hundred years, i.e. long after it had passed its usefulness. He, however, helped to raise the status of surgery in Christian Europe; in his book on fractures and luxation’s, he states that ‘this part of surgery has passed into the hands of vulgar and uncultivated minds, for which reason it has fallen into contempt.’ The surgery of Abulcasis became firmly grafted on Europe after the time of Guy de Chauliac.

In the 14th century, the French surgeon Guy de Chauliac quoted Al-Tasrif over 200 times. Pietro Argallata described Al-Zahrawi as “without doubt the chief of all surgeons”. Al-Zahrawi’s influence continued for at least five centuries, extending into the Renaissance, evidenced by Al-Tasrif’s frequent reference by French surgeon Jacques Dalechamps (1513–1588).

The street in Cordova, where he lived is named in his honour as “Calle Abulcasis”. On this street he lived in House No 6, which is preserved today by the Spanish Tourist Board with a bronze plaque (awarded in January 1977) which reads: “This was the house where Al-Zahrawi lived.”He died in the age of 77 in 1013.

(Shah Khalid is a freelance Writer, having a Diploma in Journalism & Mass Communication. Presently a final Year Student of Department of Electrical Engineering IUST Campus Awantipora)

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