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The scientific and logical methods inaugurated by the Caliphs of the East were perfected in the medical colleges of Muslim Spain. The study of anatomy attained a development previously unknown to the traditions and experience of the profession. From the contemplation of bone-heaps in the cemeteries the student advanced to the performance of autopsies; to the determination, by actual survey, of the location and offices of the internal organs; to the vivisection of quadrupeds and criminals [52]. In etiology, pathology, therapeutics, great progress was made [53].

Surgery, whose practice had entailed reproach rather than distinction upon its Professors, was, by the removal of the prejudice attaching to anatomical demonstration, relieved of the obloquy with which it was generally regarded; a blind reverence for precedent and authority was not recognised by the practitioners of the Hispano-Muslim school [54]. They inculcated the paramount importance of a competent knowledge of the functions of the organs of the human body, which they well knew could only be obtained from the practice of dissection. They advised great caution in all operations, and every new theory was subjected to severe and exhaustive tests [55]. Their works were elucidated by the introduction into the text of drawings of instruments adapted to the removal of the morbid conditions described; and science is indebted to the Spanish Muslems for this innovation, now an essential part of all treatises on surgery [56].

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Figure 4: Detail from the Latin version of Haly Abbas's Liber Totius Medicine Necessaria (1523). (Source).

Perhaps the most famous physician and surgeon of the Umayyad age in Spain was Abul-Qasim Khalaf ibn Abbas al- Zahrawi, known to the West as Albucasis (A.H.318/A.D. 930 to A.H. 403/A.D. 1013). He gained great fame as a physician, and wrote a major compendium of extant medical knowledge entitled Tasrif, known in Latin as Liber Servitoris, which comprises thirty volumes [57]. The initial volumes dealt with general principles, the elements and the physiology of humours, and the rest dealt with the systematic treatment of diseases, from the head to the feet. The last volume is perhaps the most important in that it deals with all aspects of surgery [58]. Al-Zahrawi's al-Tasrif, includes many surgical instruments, which Al-Zahrawi devised and constructed, and a number of surgical procedures [59]. It was the first textbook of surgery with illustrations of the instruments used ever to be published [60]. He explains with the aid of drawings the use of such instruments, and surgical operations in great detail [61]. He then shows what a practical man he is by adding:

"Now I have arranged this Book on cauterisation by chapters, set in order from the head to the foot, to make it easier for the seeker to find what he wants." And that is the system he follows in the other two Books [62]. It gained such great fame that it became the standard textbook of surgery in important universities in Christian Europe, and was widely read. Al-Zahrawi emphasised that knowledge of anatomy and physiology was essential prior to undertaking any surgery [63].

"Before practicing surgery, he [the surgeon] 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 [64]."

Al-Zahrawi describes instruments designed and constructed by him, and their use. Here he tells of the tonsil-guillotine, and first describes a tongue-depressor made of gold or silver and slender like a knife:

"And when the tongue is depressed with its help, the tumour will be made manifest to you. Take a hook, fix it in one tonsil and pull it forward as far as it will go, but be careful not to pull any of the mucosa away with it. Then cut it with an instrument of this form; it is like scissors except that its extremities are curved, the beak of each meeting the other, and very sharp. It should be made of Indian iron or Damascus steel [65]."

He also gives what may be the first description of a true syringe. He calls it zarraqah, "shooter" projector:

"It is made of silver or ivory, hollow, with a long fine tube, fine as a probe; entirely hollow except for the end, which is solid with three holes in it: two on one side and one on the other. The hollow part containing the plunger (al-midfa) is exactly of a size to be enclosed 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 naphtha is thrown in naval battles [66]."

"With this stitch I once sewed up a wound that a man got in the belly. He had been wounded with a knife; the opening of the wound was more than a span long, and by that time there protruded some two spans length of his mid-gut… The wound healed in about a fortnight, and I treated him until he was better; he lived for many years after, carrying on as usual. The verdict of the doctors had been that he could not be healed [67]."

Some operations described by him are carried out even today in the manner he described almost one thousand years ago [68]. These include operations on varicose veins, the reduction of skull fractures, dental extractions, and the forceps delivery of a dead foetus, to mention just a few [69].

There is more than a touch of pride too when he explains the importance of knowledge of anatomy:

"He who is not skilled in anatomy is bound to fall into error that is destructive of life. I have seen many laying claim to this knowledge and boasting of it, but having neither knowledge nor experience [70]."

`I saw another doctor who had a regular salary from one of the high officers of our country for medical treatment. A black slave of the officer's suffered a fracture of the leg near the heel, together with a wound. The doctor rushed in, in his ignorance, and bound up the fracture over the wound, very tightly, not allowing the wound to breathe. Eventually the slave's leg and foot swelled and he was close to death. I was called in and made haste to loosen the bandage, but gangrene had already taken hold and it continued to extend until he perished [71]."

But he also records at least one instance where he was wrong and not another doctor but the patient was right:

"What I am going to tell you is exactly what happened to a certain man's foot. He had a blackening of the foot, with a burning like fire. When he saw the disease spreading in the limb, he hastened to amputate it himself, at the joint, and he got better. After a very long time had passed, the very same kind of disease arose in the forefinger of his hand. He came to me and I attempted to suppress the superfluity with remedies applied to the hand. But it was not to be suppressed and began to spread to the second finger and eventually to the whole hand. He urged me to cut off his hand but I did not wish to do so . . . for his strength was declining. When he despaired of me, he went back to his own country, and I then heard that he had gone and cut off his hand and had got well [72]."

In conclusion, as Nagamia notes, surgery in the Muslim world was raised by al-Zahrawi to the level of a high science at a time when in the Christian West, the Council of Tours declared, in 1163, "Surgery is to be abandoned by all schools of medicine and by all decent physicians [73]."

The treatment of the eye received more attention from the Muslims than any other branch of the profession [74]. From the very early stages, ophthalmology and eye surgery received focused attention, and Islamic ophthalmology is reckoned by many to be of the highest order [75] with Muslim oculists as the most accomplished operators [76]. One reason, possibly, for the advance of the science was its high incidence amongst the population, and the fact that Muslim eye surgeons were able to use freely available eyes [77]; the heat and dryness of the climate being favourable to ophthalmic affections and affording the surgeon varied and incessant practice [78]. Nearly every medical compodium covers some aspect of eye diseases, although the best is by monographs solely devoted to the subject [79]. They enumerate nine different forms of cataract, which they treated by couching and by puncture. Their needles were both round and triangular; some were hollow and made of glass [80].

By far, one of the earliest scholars in the field was Ali Ibn Issa (Jesu haly) (d.1010), from Baghdad. His Tadkiratul-Kahhaleen (Notebook of the Oculist) is the second oldest complete text extant in Arabic on the eyes, and is based on older texts as well as personal experience [81]. The book is in three parts, the first, devoted to anatomy, the second to the external diseases of the eye, and the third part to internal diseases of the eye which are not visible upon inspection [82]. We are interested in the third part which includes general ophthalmological medicine. He describes the effects of 143 drugs [83].

"Prescription for a collyrium which sharpens and strengthens the sight. Take equal parts of sagapenum resin, opopanax resin, saltstone, verdigris, white pepper, asafetida, balsam oil, gall of a bull, long pepper, and ginger. The number of drugs is ten. These are kneaded with fennel juice after which it is finely pulverised. The eye is rubbed with it."

Further, "when you dissolve a little opopanax resin in basil juice, it is useful when it is rubbed in the eye. Or one may take the juice of green, unripe pomegranates, it is cooked down to its half, then honey is added, and then it is left for 20 days in the sun; it is rubbed on to sharpen the sight [84]."

Issa's book was the most widely referred to text book by later ophthalmologists. First translated into Persian and then into Latin and printed in Venice in 1497, his work was used as a text book in Europe till the 18^th century [85]. It was translated with commentary into German by Hirschberg and Lippert (1904), as already noted, and into English by Casey Wood (1936).

Famous contemporaries of Isa Ibn Ali was Al-Mosuli from Mosul in Iraq. His Kitab-ul Muntakhab fi Ilaj-ul Ayn (Book of Choices in the Treatment of Eye Diseases) discusses forty eight diseases. The translation of this work has been accomplished in German, and it highlights many of the accomplishments of al-Mosuli [86].In the following are recipes by Al-Mosuli to heal eye disorders and diseases. Al-Mosuli states:

"In the treatment of ulcers, the best for treatment is the following collyrium. It effects healing and allows natural flesh to grow there so that, after the cure, no spot remains in the eye. Watch that when the ulcer is treated with anything else. The eye must be bound from the beginning of the ailment."

"Take 8 dirhams each of gold colored calamine, white lead and burnt copper, 4 dirhams of burnt lead, 30 dirhams of antimony sulfide, 8 dirhams each of strong gum arabic and tragacanth, 1 dirham each of myrrh and opium, and 5 dirhams of incense. These drugs are put together, pulverised, sieved, and kneaded with potable water. Small cakes are made of them which are dried in the shade, then used.

Watch that when using a mineral drug which has not been properly pulverised for the remedy which is used in ulcers it should not prick the eye. Be careful in the same way with other remedies. I myself have treated ulcers with this remedy all my life. It is the best."

"If a small spot remains, then prepare a calamine collyrium so that no other be used. Prescription [of the calamine collyrium]: Five dirhams of white lead, 2 dirhams each of gum and tragacanth and 1 dirham each of opium and silver colored calamine are gathered, pulverised and sieved, and kneaded with rainwater and egg white. A collyrium is prepared from it and some rubbed with milk when it is needed and dripped into the eye [87]."

In discussing the treatment of a cataract, Al-Mosuli presents four detailed cases and an instrument of his own design, a hollow needle to remove cataract by suction, inserted through the limbus (where the cornea joins the conjunctiva). Until the 20^th century, this work was only available in Arabic and a Hebrew translation of the 13^th century. The German translation is recent and is by J. Hirschberg (1905).

On this subject of the cataract, Al-Zahrawi tells us, in the course of some of the more horrendous operations, to give the patient a rest from time to time, for instance in couching for cataracts. The method is to insert the couching needle, miqdah, into the white of the eye and press the point down. The illustration shows the needle as broadening out from the tip, like a spatula. He goes on, and this is an interesting sidelight on the difficulties in the way of the transmission of information before the days of journals and international congresses:

"I have heard that a certain Iraqi has said that in Iraq he makes a hollow needle, miqdah manfud, by which the humour is sucked out. In our land I have never seen anyone do it in this fashion, nor have I read of it in any of the books of the Ancients; perhaps it is a new invention [88]."

Syria produced a number of eminent writers in the field. Salah al-Din wrote Kitab Nur al-uyun wa-Jami al-Funun (Light of the Eyes..), which is most particularly interesting in its mention of all preceding authorities and their works, including Ali.b. Isa, Ammar, Ibn Jazla...

Khalifa al-Halabi (mid 13th) of Aleppo, wrote his Kitab al-Kafi fi al-Kuhl (Book on the Adequacy in Ophtalmology) in which he mentions eighteen major ophtalmological texts. His work is very practical too, with very good descriptions of cataract operations, the instruments used, and also the steps to be taken after the operation [89].

Al-Mahasin (13^th century) also of Aleppo, is the author of a large work of 564 pages in which he describes and gives drawings of various surgical instruments including 36 instruments for eye surgery.

Completing this list of an otherwise longer one, are Al-Ghafiqi and Ibn Sina. Al-Ghafiqi (d. 1165), from Spain, wrote Al-Murshid fil Kuhl (The Right Guide in Ophthalmology). The book is not just confined to the eye but also gives details of the head and diseases of the brain. In the Kitdb al-murshid fi 'l-kuhl, al-Ghafiqi describes treatment for pustules of the eyelid, which is of interest when considered together with his great work on simple drugs [90]. Throughout this text on ophthalmology, the author is well oriented toward the use of drugs, both internally and externally. Al-Ghafiqi informs us that hard and small pustules appear especially on the eyelids of adolescents and young girls. They originate from a thick vapor. He gives the treatment:

`It is necessary to approach the eyes with two droppers. From one, there comes out very hot water in which has been boiled dill, camomile, and melilot. Then, the eyelid is coated with juice of wild cucumber or take finely powdered Yemenite alum. Then take after that terebinth gum; put it in a small fire and pour alum in it. Finally, put it on the pustules to extirpate them. Take some natron and gum arabic in equal parts. Pulverise them with a palm branch and apply. If that does it, it is good. If not, then open the cephalic veins [91]."

As for Ibn Sina, whilst his Qanun had more than thirty Latin editions since the 16^th century, its section dealing with ophtalmology has been the subject of special study on the part of modern medicine [92].

[57] H.F. Nagamia, "An Introduction to the History of Islamic Medicine", op. cit., p. 12.

[60] H.F. Nagamia, "An Introduction to the History of Islamic Medicine", op. cit., p.12.

[63] H.F. Nagamia, "An Introduction to the History of Islamic Medicine", op. cit., p. 12.

[68] H.F. Nagamia, "An Introduction to the History of Islamic Medicine", op. cit., p. 12.

[73] H.F. Nagamia, "An Introduction to the History of Islamic Medicine", op. cit., p.12.

[74] S.P. Scott, History of the Moorish Empire, op. cit., vol. 3, pp. 513-514.

[75] G.M. Wickens, for example, qualify it as "outstanding": see G. M. Wickens, "The Middle East as a world centre of science and medicine", in Introduction to Islamic Civilisation, edited by R.M. Savory, Cambridge: Cambridge University Press, 1976; pp 111-118; p. 116.

[76] S.P. Scott, History of the Moorish Empire, op. cit., vol. 3, pp. 513-514.

[77] G.M Wickens, "The Middle East as a world centre of science and medicine", op. cit., p. 116.

[78] S.P. Scott, History of the Moorish Empire, op. cit., vol. 3, pp. 513-514.

[79] E. Savage Smith, "Medicine", in Encyclopedia of the History of Arabic Science, edited by R. Rashed, London: Routledge, 1996, vol. 3, pp. 903-962; p. 948.

[80] S.P. Scott, History of the Moorish Empire, op. cit., vol. 3, pp. 513-514.

[81] M. Levey, Early Arabic pharmacology: An Introduction Based on Ancient and Medieval Sources, Leiden: Brill, 1978 (reprint 1997), p. 128.

[82] C. A. Elgood, A Medical History of Persia and the Eastern Caliphate, op. cit. p. 141.

[86] J. Hirscliberg, J. Lippert, and E. Mittwoch, Die arabischen Augenarzte nach den Quellen Bearbeitet, Leipzig, 1905, part II.

[87] These recipes are found in M. Levey, Early Arabic pharmacology, op. cit., pp. 127-128.

[91] J. Hirschberg and J. Lippert (Leipzig, 1904), Part I, p. 273; Al-Ghafiqi, Kitdb al-murshid fi ‘l-kuhl, Arabic text published by Sayyid al-Sharafi, Hyderabad, 1964.

[92] F. Gabrieli, "The Transmission of learning and literary influences to Western Europe", in The Cambridge History of Islam, vol 2, edited by P.M. Holt, A.K. S. Lambton and B. Lewis, Cambridge University Press, 1970, pp. 851-89; p. 862.

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