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Contributions of Ibn al-Nafis to the Progress of Medicine and Urology - II

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6. Emphasis on the study of anatomy for physicians and further progress in anatomical drawings in medical textbooks

In his book Sharh Tashrih al-Qanun, Ibn al-Nafis, like previous Muslim scholars, emphasized ,that the doctor should have knowledge of anatomy in order to be able to identify the state of the organs and how they are related to each other. He allocated a special chapter entitled "on the benefits of studying the science of anatomy" and showed how essential this study is for reaching a diagnosis and for practicing medicine and performing different surgical, orthopaedic or ophthalmologic procedures [62]. Furthermore, in this book, he wrote a special chapter on the best mode for dissecting the following parts: bones, peripheral vessels and internal organs of the chest (heart, lung, big vessels and the diaphragm) [63].

Both Ibn al-Nafis in his book and Al-Razi (Rhazes) in his chapter on anatomy in his treatise Al-Mansuri, frequently mentioned the word Al-Musharrihun, which according to the etymology of the Arabic language is derived from the Arabic verb Yusharrih. According to Ibn Manzur's lexicon Lisan al-'Arab [64], this verb means dissecting the flesh and dissecting the flesh out of bones. Thus Musharrihun subsequently means the dissectors. Therefore, in contradiction to what Long [65] and many others state, the practice of dissection for medical teaching, was not prohibited in either the religion of Islam or the Islamic world. On the contrary, all the eminent Islamic physicians of that era stated that knowledge of anatomy leads to a deeper appreciation of God's wisdom and omniscience [66].

Furthermore, the presence of anatomical drawings within the text in Ibn al-Nafis' Sharh Tashrih al-Qanun is a further step forward in illustrating medical text books; a trend that started and flourished in the Islamic period reflecting the role of direct observations and experience. This illustration of the maxillary sutures (Figures 3 and 4) in Sharh Tashrih al-Qanun is more sophisticated than the anatomical illustrations we have shown before in the Canon of Ibn Sina and the Mansuri book of Al-Razi and the Al-Mukhtar of Muhadhdhab al-Din al-Baghdadi [67].

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Figure 3: Anatomical drawing of the maxillary sutures in one of the original manuscripts of Ibn al-Nafis' book Sharh Tashrih al-Qanun. Source: Ibn al-Nafis, Kitab Sharh Tashrih al-Qanun (Cairo, 1988).

7. Contributions to the progress of urology

All the previously-mentioned contributions of Ibn al-Nafis helped in the establishment of the foundation of urology, as well as all other branches of medical and surgical subspecialties. However, of particular urological interest are the advances made by Ibn al-Nafis in uro-physiology. Contrary to Galen who described the bladder wall as formed of only one layer [68], Ibn al-Nafis, in his book Sharh Tashrih al-Qanun described the bladder wall as consisting of two layers [69]. Continuing with this original observation made by Al-Razi, Ibn Sina, Al-Zahrawi, and Al-Baghdadi, his description of the anti-reflux and micturition mechanisms were also contrary to Galen but conform well with our contemporary understanding [70].

Ibn al-Nafis' full description of the vesico-ureteric anti-reflux mechanism is translated here:

"For this reason the base and back of the bladder is made of two layers and when the two canals known as ureters penetrate it, they first penetrate through the superior layer and continue for a distance then they penetrate the inferior layer opening into the bladder cavity. The benefit of that (arrangement) is that when the bladder is filled up and the inner layer presses upon the outer layer, the two canals (ureters) going in between the two layers will be compressed and thus occluded preventing the reflux of urine (retrogradely)… [71]"

In this description, Ibn al-Nafis differed from Al-Razi [72], Ibn Sina [73], Al-Zahrawi [74], and Al-Baghdadi [75] in specifying the base and back of the bladder as the regions where the bladder wall is made of two layers. This is another proof that he was not a copyist or a mere compiler and is further evidence of the scientific spirit that spread during the Islamic era and stimulated its scholars to rely on their own findings and describe their own observations.

With regard to urological practice, Ibn al-Nafis stressed as did all his predecessors in the Islamic era, the importance of clinical medicine. In the book Al-Mujaz, in addition to a general introductory chapter on physical signs, he started each of the chapters dealing with regional diseases by mentioning the specific related symptoms paying a lot of attention to differential diagnosis and prognosis. This illustrates Cumston's description of the Arabian physicians as keen observers who excelled in diagnosis and prognosis with their description of symptoms showing a precision and an originality that could be only obtained by direct study of the disease [76].

Accordingly, in his book Al-Mujaz, Ibn al-Nafis distinguished between kidney stones and bladder stones with regard to their pathogenesis and clinical picture. He discussed how to differentiate renal from intestinal colic, bladder infections from kidney infections as well as the different types of inflammatory and non-inflammatory renal swellings [77]. In the conservative management of renal stones Ibn al-Nafis, advised diuresis only for short periods of time; not constantly as recommended by Ibn Sina [78]. In line with his general policy in Kitab al-Mujaz fi al-Tibb, Ibn al-Nafis listed only the commonly used and well known lithontriptic medicaments. Among those medicaments, he included a medicament which is not mentioned in Ibn Sina's Canon of Medicine [79].

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Figure 4: Anatomical drawing of the maxillary sutures in another original manuscript of Ibn al-Nafis' book Sharh Tashrih al-Qanun. Source: Ibn al-Nafis, Kitab Sharh Tashrih al-Qanun (Cairo, 1988).

Both Ibn Sina and Ibn al-Nafis recommended the same dietary management for urinary stone patients. However, Ibn al-Nafis did not pay attention to the type of water intake whilst Ibn Sina advised avoidance of "turbid waters" [80]. This again proves the originality of Ibn al-Nafis and shows, in addition to many other pieces of evidence, that Al-Mujaz fi al-Tibb is not just a summary for the Canon of Medicine as claimed by some modern historians. He also disagreed with Hippocrate's statement that penetrating wounds of the urinary bladder are always fatal [81]. Moreover unlike Paulus [82], Ibn al-Nafis did not recommend venesection in the management of patients presenting with stone impaction and acute pain [83]. As planned by Ibn al-Nafis, the book Al-Mujaz does not contain any details on operative treatment or surgical instrumentation. These are to be found in volume 42 of his encyclopedia Al-Shamil fi al-Sinaaa al-Tibbyaa [84], a manuscript of which is still waiting for editing and publication.

In conclusion, it is evident from this study that Ibn al-Nafis is the greatest physiologist of the Middle Ages and the main forerunner of Servetus, Vesalius, Columbus and Harvey in the description of pulmonary circulation as we know it today. He was also the first to describe the coronary vessels and the true concept of the blood supply of the heart. Moreover he described the presence of connecting passages in the substance of the lung between the branches of pulmonary artery and tributaries of pulmonary veins and pointed to the greater systemic circulation of blood from the heart to all organs and vice versa.

Ibn al-Nafis was also a talented physician and a gifted medical writer. His discoveries and medical works, greatly contributed to the progress of medical knowledge and the advancement of medical practice. His influence on the generations of doctors and scholars who came after him, both in the East and West, is well documented up to the seventeenth century.

8. Supplement: Commentary and Response

8.1. [Ibn] Al-Nafis and Servetus by Giles N. Cattermole

To the editor

I very much appreciated Abdel-Halim's article about Ibn al-Nafis and his contribution to medicine and urology. Al-Nafis was certainly a great physiologist and physician, and is rightly credited with the discovery of the pulmonary circulation [85]. Michael Servetus (1511-1553) was the first writer in Christian Europe to describe the pulmonary circulation, although because Servetus was burned as a heretic along with his books, for many years it was Realdo Colombo (1516-1559) who was credited with the discovery. Both Al-Nafis and Servetus were neglected by Harvey when he applauded Colombo as his forerunner [86]. However, I would disagree with Abdel-Halim that Servetus included Al-Nafis'description of the pulmonary circulation "verbatim" in his book Christianismi Restitutio. The implication is that Servetus plagiarised Al-Nafis, whereas in fact, both men almost certainly described what they had found in their own anatomical investigations.

The idea that Servetus copied Al-Nafis derives from a comment by Haddad and Khairallah in 1936 [87], who noted the "striking parallelism" that both descriptions were published within a theological discourse, and also that they "made the same mistakes in practically the same phraseology." It is highly unlikely that this is the case, partly as one wrote in Arabic, and the other in Latin. More importantly though, each described very different reasons for their understanding of the pulmonary circulation. Al-Nafis realized, contra Galen, that the interventricular septum was too thick to allow blood flow, and that instead the pulmonary artery must connect in the lungs with the pulmonary vein. Servetus observed the difference in color of blood in those vessels, and that the pulmonary artery was too large merely to provide nourishment for the lungs themselves [88].

In addition, although Al-Nafis did recognize that there were "perceptible connecting passages" between artery and vein, it was Servetus who first unequivocally described capillaries (in the lung and the choroid plexus), using that very word: "a new kind of vessels… hairlike [capillaribus] arteries… woven together very finely… the termination of arteries [89]." Nothing can detract from Al-Nafis' position as the discoverer of the pulmonary circulation. However, for all his other faults, Servetus was not a plagiarist. He made the same discovery, independently although much later. And we should not detract from Servetus' distinction as the first writer clearly to describe capillaries.

8.2. Reply from the Author Rabie E. Abdel-Halim

I would like to thank Dr. Giles Cattermole for his comment. I do agree with him on the distinguished status of Servetus in the history of medicine during the 16th century. Certainly, he was one of the greatest physicians of his time. In our paper [90], the review of the evolution of knowledge on pulmonary circulation was never meant to accuse him of plagiarism; a scholar of his calibre and character is never expected to plagiarize.

On pulmonary circulation and on capillaries, Servetus, in his great work Christianismi Restitutio (1553), presented what he accepted of the knowledge already available at his time. Early in the 16th century, Andrea Alpagus (1450?-1522), a professor of Medicine in Padua University who spent 30 years in Damascus studying Arabic Medical manuscripts, translated into Latin sections of Ibn al-Nafis' Book Sharh Tashrih al-Qanun including his views on the pulmonary circulation. This translation, printed in Venice in the year 1547, helped to spread Ibn al-Nafis' description of pulmonary circulation to European scholars and, thus, raise their doubts about Galen's anatomy. According to Ullman, "Servetus' presentation of the lung circulation resembled Ibn al-Nafis' so strongly that one can hardly reject a direct influence" [91]. Ullman, in his comparative study quoted the text of both the Latin text of Servetus and the English translation of Ibn al-Nafis' description. Many other authors came also to the same conclusion [92]. It is well documented that Servetus was an expert in the Arabic language [93] which he mastered during his university years in Toulouse [94].

References

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[63] Ibn al-Nafis, Kitab Sharh Tashrih al-Qanun. Qattaya S, editor. Cairo: The Supreme Council for Culture and the Egyptian Book Bureau; 1988, p. 30.

[64] Ibn Manzur. Lisan Al-Arab. Alkabeer AA, Hasballah MS, Al- Shathly HM, editors. Vol. 4. Cairo: Dar Al-Maarif, pp. 2228.

[65] Long ER. A History of Pathology. New York: Dover Publications, Inc; 1965, pp. 22-27.

[66] Abdel-Halim RE, Abdel-Maguid TE. "The functional anatomy of the uretero-vesical junction. A historical review". Saudi Med J 2003; 24: 815-819.
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[67] Abdel-Halim RE. "Contributions of Muhadhdhab Al-Deen Al-Baghdadi to the progress of medicine and urology..." Saudi Med J 2006; 27: pp. 1631-1641.

[68] May MT. Translator. Galen on the uses of different parts of the body. Vol. II. Ithaca (NY): Cornell University Press; 1968, pp. 269 & 275.
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[69] Ibn al-Nafis. Kitab Sharh Tashrih Al-Qanun. Cairo, 1988, pp. 431-432.

[70] Abdel-Halim RE, Abdel-Maguid TE. "The functional anatomy of the uretero-vesical junction. A historical review". Saudi Med J 2003; 24: 815-819.

[71] Ibn al-Nafis. Kitab Sharh Tashrih Al-Qanun. Cairo, 1988, pp. 431-432.

[72] De Koning P. Trois Traites D'Anatomie Arabes Par Muhammad Ibn Zakariyya Al-Razi, Ali Ibn Al-Abbas et Ali Ibn Sina, Texte Inédit de deux Traités, Traduction de P. De Koning, Leiden: E.J. Brill, 1903; reissued in 1986 by Institut Fur Geschichte der Arabisch-Islamischen Wissenschaften an der Johann Wolfgang-Goethe Universitat, Frankfurt am Main, pp. 72, 82.
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[73] Ibn Sina. Kitab Al-Qanun fi al-Tibb. Cairo: Boulaq Ameereyyah Press; 1877, vol. 2, p. 507.

[74] Alzahrawi (Albucasis). Kitab Aa-Tasrif, Manuscripts No. 4009 and 4932. Dublin: The Chester Beatty Library.

[75] Al-Baghdadi Muhadhdhabul-Din. Al-Mukhtarat fi al-Tibb. Vol. 1. Hyderabad: Osmania Oriental Publication Bureau; 1940, p. 60.

[76] Cumston CG. "Islamic Medicine". In: Cumston CG, editor. An introduction to the history of medicine from the time of the pharaohs to the end of the XVIII century. London (UK): Kegan Paul, Trench, Trubner and Co. Ltd. New York: Alfred A. Knopf; 1926, p. 192.

[77] Ibn al-Nafis. Al-Mujaz fi al-Tibb. Al-Ezbawy A, editor. 4th ed. Cairo: Islamic Heritage Revival Committee, Supreme Council for Islamic Affairs, Ministry of Endowments; 2004, pp. 239-241.

[78] Ibn al-Nafis. Al-Mujaz fi al-Tibb. Cairo, 2004, pp. 239-241.

[79] Ibn al-Nafis. Al-Mujaz fi al-Tibb. Cairo, 2004, pp. 239-241.
- Ibn Sina, Al-Qanun fi al-Tibb. Vol. II. Cairo: Boulaq Ameereyyah Press; 1877, pp. 501-504.

[80] Ibn al-Nafis. Al-Mujaz fi al-Tibb. Cairo, 2004, pp. 239-241.
- Ibn Sina, Al-Qanun fi al-Tibb Cairo: Boulaq, 1877, vol. 2, pp. 501-504.

[81] Ibn al-Nafis, Sharh Fusul Abuqrat. Ziedan Y, Abdel-Qadir M, editors. Cairo: Al Dar Al-Masreyya Al Lubnaneyyah; 1991, pp. 436-439.

[82] Paul of Aegina. The Seven Books of Paulus of Aeginata. Translated from the Greek with a commentary. Vol. 3. London: Sydenham Society; 1844-47, pp. 541-543.

[83] Ibn al-Nafis. Al-Mujaz fi al-Tibb. Cairo, 2004, pp. 239-241.

[84] Iskander AZ. "The Comprehensive book on the art of medicine by Ibn al-Nafis". The second International Islamic Medicine Conference (Kuwait, 1982). Available here.

[85] In the original publication, this footnote refers to the article by Professor Abdel-Halim: "Contributions of Ibn al-Nafis (1210-1288 AD) to the progress of medicine and urology" republished here (added by the editor).

[86] Cattermole GN. "Michael Servetus: physician, Socinian and victim." J R Soc Med 1997; 90: 640-644.

[87] Haddad SI, Khairallah AA. "A forgotten chapter in the history of the circulation of the blood. Ann Surg 1936; 104: 1-8.

[88] Cattermole GN. "Michael Servetus: physician, Socinian and victim"; op. cit.

[89] O'Malley CD. Michael Servetus – a translation of his non-theological writings. Philadelphia (PA): American Philosophical Society, 1953.

[90] In the original publication, this footnote refers to the article by Professor Abdel-Halim: "Contributions of Ibn al-Nafis (1210-1288[CE]) to the progress of medicine and urology" republished here (added by the editor).

[91] Ullman M, Islamic Medicine. Islamic Surveys, Vol. 11, Edinburgh (IR): Edinburgh University Press, 1978, pp. 68-69.

[92] In the original publication, this footnote refers to the article by Professor Abdel-Halim: "Contributions of Ibn al-Nafis (1210-1288[CE]) to the progress of medicine and urology" republished here (added by the editor).

[93] Gier N, The 454th anniversary of burning of Michael Servetus. Online here.

[94] Goldstone L, Goldstone N. Out of the flames: The remarkable story of a fearless scholar, a fatal heresy, and one of the rarest books in the world. New York: Broadway Books; 2003. p. 56.
- Dibb AMT. Servetus, Swedenborg and the nature of God. University Press of America; 2005, p. 123. Read online (Google books).

by: Professor Rabie E. Abdel-Halim, Sun 12 June, 2011