Islamic Physicians (2/4)

Al-Zahrawi (Abulcasis, Bucasis, Alzahravius) 930-1013 A.D.

His full name is Abu-Al-Qasim Khalaf Ibn'Abbas Al-Zahrawi. He had been known in the Western World as Abulcasis, Bucasis or Alzahravius. He is the famous surgeon of the Arabs. In 930 A.D., he was born in Al-Zahra, a suburb of Cordova. He attended the University of Cordova which had been established for one and a half centuries. At that time Cordova had a population of one million (Hitti 1977). It was the magnificent capital of Al- Andalus where culture and science were at their peak in Europe. In military power the Moslems also reached their zenith, not only in Spain but also throughout Europe after King Abdel-Rahman III defeated the Spanish kings of Navarre, Castile, and Leon at the north in 997 A.D.

Al-Zahrawi became an eminent surgeon lie was appointed as the Court-Physician of King Abdel-Rahman III. He spent a productive life in practicing medicine, especially in surgery and medical writings. He died at the age of 83.

He wrote mainly four books. One of them is "Al-Tastif Liman Ajiz'an Al-Ta'lif' which is the best medieval surgical encyclopedia. It was used in Europe until the 17th century. He stressed the importance of basic sciences: "... Before practicing, one should be familiar with the science of anatomy and the functions of organs so that he will understand them, recognize their shape, understand their connections, and know their borders. Also he should know the bones, nerves, and muscles, their numbers, their origin and insertions, the arteries and the veins, their start and end.

These anatomical and physiological bases are important, and as said by Hippocrates:

'There are many physicians by title and a few by practice.’... If one does not comprehend the anatomy and physiology, he may commit a mistake that can kill the patient. I have seen someone, who pretended to be a surgeon, incised an aneurysm in the neck of a woman, mistaking it for an abscess. The woman bled to death."

Heller stated that Al-Zahrawi described the ligature of arteries long before Ambrose Pare (Khairallah 1942). Al-Zahrawi also used cautery to control bleeding. He used wax and alcohol to stop bleeding from the skull during cranial surgery. Sprengel said that Al-Zahrawi was the first to teach the lithotomy position for vaginal operations (Khairallah 1942).

Al-Zahrawi also described the tracheotomy operation and performed it as an emergency on one of his servants. He was the first to write on orthodontia. He showed evidence of great experience from details of clinical picture and surgical procedures e.g. his description of varicose veins stripping, even after ten centuries, is almost like modern surgery (Al-Okbi 1971): "... Have the leg shaved if it is much hairy. The patient gets a bath and his leg is kept in hot water until it becomes red and the veins dilate; or he exercises vigorously. Incise the skin opposite the varicose vein longitudinally either at the ankle or at the knee. Keep the skin opened by hooks. Expose, dissect, and separate the vein. Introduce a spatula underneath it. When the vein is elevated above the skin level, hang it with a blunt rounded hook. Repeat the procedure about three fingers from the previous site and hang the vein with another hook as previously done. Repeat the procedure at as many sites along the varicose vein as necessary. At the ankle, ligate and strip it by pulling it from the incision just above. When it reaches there, repeat at the higher incision until all of it is stripped. Ligate the vein and then excise it. If difficulty is encountered in pulling it, ligate its terminal part with a string and pass it under the spatula and dissect it further. Pull gently and avoid its tearing because if it does, it becomes difficult to strip all of it and can cause harm to the patient. When you have stripped it all, put alcohol sponges at the sites of the skin incisions and take care of the incisions until they heal. If the varicose vein is tortuous, you have to incise the skin more frequently, at each change of direction. Dissect it and hang it with the hooks and strip it as previously described. Do not tear the vein or injure it. If this happens, it becomes difficult to strip it. The hooks used should be blunt, eyeless, and rounded; otherwise it can injure the vein".

He also wrote about fracture of the skull (Al-Okbi 197 1): "... The types of skull fractures are numerous, their shapes are different, and their causes are many. For example, some skull fractures are due to a blow by a sword that splits the whole skull and reaches the dura, the same as the ax does to the wood, therefore it is called axial fracture. Sometimes the sword does not split the skull completely, it is thus called incomplete axial fracture. Such a fracture can be small or big. Another type is comminuted fracture, which can be due to a hit by a stone or a fall on a stone; and this fracture can reach the dura or only be limited to the outer part of the bone. This fracture can also be small or big. A third type is the hairy type of skull fracture which is so tiny and linear like a hair. A fourth type is the depressed fracture which occurs due to a fail or a blow so the bone is depressed like a brass jar when hit by a blunt instrument. This usually happens when the bone is soft as children.

The types of these fractures are diagnosed by examining the wound, removing the debris and contused pan of the scalp, exposing the skull, and feeling it by the spatulas.

The hairy fracture is difficult to discover and can be diagnosed by exposing the skull, and smearing it with ink; the linear fracture thus appears stained." In the treatment of fractures of the skull, Al- Zahrawi wrote: "... If the patient shows serious signs such as high fever, repeated vomiting, exophthalmos, convulsions, and coma, do not touch him because he is probably going to die. Otherwise, treat him as follows: first shave the patient's head. In comminuted depressed fractures, these pieces of bone should be removed as will be explained. If in the process of the patient's examination or during surgery bleeding occurs, it can be controlled by pressure using towels soaked in alcohol and by wax. Then after control of the bleeding, the small pieces of bone are removed using special forceps.

To remove the depressed fracture, first, make trephines in the healthy bone around it.

These trephine instruments should not penetrate beyond the skull into the soft tissues underneath, thus they are called non penetrating trephines. They have a rounded ring in their proximal end to prevent them from penetrating beyond certain depths. You should have a number of these trephines that can stop at different depths depending on the thickness of the skull. Connect the holes in the skull using special saws. First, use a fine small saw, then larger ones. These should be sharp and made of steel. Avoid cutting the dura by the trephine or saw. Once the depressed bone is freed, remove it gently, then smoothen the edges of the skull by special instruments. Wash with alcohol and treat the wound with packs soaked with ointment."

Al-Zahrawi described many dental operations such as dental extractions, fixation, re implantation, and artificial teeth. He described referred tooth pain and cautioned the physician against removal of the healthy tooth to which pain is referred. He used gold threads to fix teeth because other metals would tarnish and cause a reaction. Chapter 6 of his book was all devoted to foreign bodies of the ear and their treatment.

He also devoted one whole chapter to mid wifery, giving tips to midwives, and describing the problems of difficult labor and obstetrical man oeuvre.

He recommended decompression of the fetal head for obstructed labor and described the instruments used. He described the management of liver abscess by treating it into two stages (Khairallah 1942). The first stage was to allow adhesions around it and to close it from the peritoneal cavity. The second stage was to incise it. "... If the procedure is done in one stage, the pus may spread to the whole abdomen and the patient may die." He described a total of 200 surgical and dental instruments most of them were original. He said "... Choose your instruments carefully beforehand according to the operation. However, you should design other devices if needed." Thus he encouraged the physician to be innovative.

During the time of Al-Zahrawi, surgery in the Islamic world became a respected specialty practiced by reputable physicians. On the contrary in Europe, surgery was belittled and practiced by barbers and butchers. In 1163 A.D., the Council of Tours declared the following resolution "Surgery is to be abandoned by the schools of medicine and by all decent physicians."

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