By: Rabie El-Said Abdel-Halim

This unique experiment represents a further step in the development of the experimental school started by Al-Razi (Rhazes) of Baghdad in the 9th century who is known to have given monkeys doses of mercury to test it as a drug for human use[i]. Nevertheless, we think that Ibn Zuhr can be still given the title “The Father of Experimental Surgery.”

Ibn Zuhr’s application of an experimental animal model to a clinical problem was the forerunner of the method by which many current surgical procedures were developed. The authors who came after him in the 13th century such as AI-Baghdadi and Ibn Al-Quff recommended tracheotomy unreservedly, in life-threatening upper airway obstruction not relieved by other means, and described the technique with more refinements and in more detail.

The investigative mind of Ibn Zuhr and his reliance on experimentation in seeking evidence is, also, shown in other sections of his book Al-Taysir. Faced with the difficulty of having no good treatment for patients with severe lung ulceration, he heard from shepherds that sheep do also get a similar disease and there is a cure for it. The following translation from page 129 of Al-Taysir shows how he further investigated this clinical problem:

“Thus remedies for lung ulcerations are around in nature but are yet unknown to us. For (as) sheep when caught with a lung disease do leave the herd and wander about as if looking for something; shepherds say for a plant to eat and when they finish eating it their illness is relieved completely and are back to normal… I did inspect lungs of sheep with the evident effect of breach of continuity and with obvious evidence of healing and union. Up till now I did not know that medicine; and I do think no one before me knew it either.”

Therefore, Ibn Zuhr resorted to perform post mortems on sheep in the course of his clinical research on ulcerating diseases of the lung. From this quotation and from several other places in his book, it seems he was, also, an observant pathologist.

II. The second important contribution of Ibn Zuhr to the progress of surgery is his emphasis on the great importance of a practical knowledge of anatomy for the surgical trainee. Here is a translation of his own words on page 141 in the management of inflammatory swellings of the neck if ripe and ready for bursting or drainage:

“And in case you have mastered the science of dissection then drain by the scalpel in the way that you will not come across a vein, artery or a nerve or anything that its injury will lead to an extra harm to the patient. But if you were one of the group like me and did not practice dissection but knew it only by imitation, keep away from the knife as nothing you know by mere imagination will be the same in real life; especially in the case of small organs.”

This excerpt indicates that it is only the practitioner who practiced dissection himself and mastered the science who is entitled to do an operative intervention. Mastering anatomy, according to Ibn Zuhr, is an essential training for a surgeon.

The importance of anatomy for surgical training is, again, another salient feature of Medical Education during that Islamic Era. Al-Razi, in Baghdad, Ibn Sina in Hamadan and Al-Zahrawi in Cordova did stress its importance before. And, Ibn Rushd, the co author with Ibn Zuhr, stated that: “Anyone who practices anatomy will increase his faith in Allah”

From the religious point of view, this statement by Ibn Rushd is of particular significance because he was, at the same time, the Grand Qadi (Chief Magistrate) of Cordova and a well known authority on Islamic jurisprudence in the whole Muslim world; then, and up till now[k] Accordingly, his statement confirms that, contrary to Long, the practice of dissection for medical teaching was not prohibited in the religion of Islam.

III. Another important contribution of Ibn Zuhr to the progress of surgery is his insistence on an adequately supervised and structured training program for the surgeon-to-be, before allowing him to operate independently. This is again quite evident in many places of Al-Taysir book. Just as an example, here is the translation of page 27 in the section on head injuries after Ibn Zuhr stated the indications and technique of trephine operation[61]:

“However I did mention it hoping to see among people, practitioners who are good at it; having enough skill, experience and training. Indeed no one should consider doing it unless he has practiced it as a student under the direct supervision of his teacher (bayna yaday mu’allimehi) for a long time. Then practiced it on his own for sometime”.

IV. Furthermore, Ibn Zuhr drew, in an emphatic way, the red lines at which a physician should stop, during his general management of a surgical condition. This is a step forward in the evolution of general surgery as a specialty of its own. In all sections we find plenty of examples on that. Here is a translation of one example, page 27 in the same section on management of wounds of the head:

“If the wound caused by a sharp iron has taken into the bones and not extended to the interior, then the treatment I just mentioned is enough for you, so stick to it. However, if it did penetrate the bone then in such a case, the surgeon (sâni’ al-yad) should come and see.”

V. The reliance of Ibn Zuhr on his own clinical observations together with his skill in differential diagnosis and his interest in clinico-patholgical correlations shines through in all sections of the book. Based on his own experience, he staged and classified diseases in a practical way relevant to their management and prognosis. Furthermore, in agreement with all of his biographers, Western or Eastern, he did enrich surgical and medical knowledge by describing many diseases not ever described before him such as pericarditis, mediastinitis, mediastinal tumours, empyema, meningitis, intracranial thrombophlebitis, inflammation of the middle ear, pharyngeal and oesophageal paralysis, verrucous malignancy of the colon, fecal fistula, Peyronie’s disease, purpuric skin rash and scabies.

Accordingly, Ibn Zuhr is not a mere compiler; he was an original contributor and innovator.

V1. It is evident from many places in Al-Taysir that Ibn Zuhr was, by nature, primarily a physician. He abhorred cutting on the bladder stone, an operation which was made safer by points of technique introduced by his predecessors Al-Razi in Baghdad and later on Al-Zahrawi in Cordova[m]. He preferred medical treatment and described, in details, remedies to dissolve, disintegrate or help the spontaneous passage of the stone. He even described, on page 262, how to detect in normal persons a tendency to stone formation:

“Whenever you see, in a healthy individual, that his urine turns thin, looking like water you must fear the possibility of him forming stones.”

Henceforth, Ibn Zuhr advised to start that individual on a prophylactic regimen of diet and herbal preparations:

“Indeed if you managed him with this regimen I think that Allah will save him from stone formation.”

Therefore, Ibn Zuhr believed in prophylaxis against urinary stone disease and reported the importance of dietary management for that purpose.

In the management of a patient with acute urinary retention due to a stone impacted in the urethra, Ibn Zuhr, like Al-Razi and Al-Zahrawi, prescribed several conservative measures. If those measures failed, he did not hesitate to intervene following the same endourological principle introduced by Al-Zahrawi in order to avoid open urethrotomy[n]. However, instead of using Al-Mich’ab of Al-Zahrawi he devised a new lithotrite-idea for that purpose.

“And if a fine probe is introduced, in the urethra, till it reaches the stone and the probe is of the finest caliber, with a tiny piece of diamond-stone fitted to its end; that diamond upon touching into the stone will lead to its crushing”.

Ibn Zuhr ingenuity with instruments and planning of management lines is also evident in many other places of his book Al-Taysir. He modified an ophthalmic surgical instrument to serve better its purpose. He also designed tubes for orogastric feeding and tubes for rectal feeding in patients with oesophageal paralysis, rejecting the opinion of those who claimed that such a patient can be fed by immersing him in a container full of milk or soup.

Accordingly, in conclusion and in agreement with Ibn Khaldun, Ibn Said and Sarton, among the many distinguished physicians of the Muslim West, Ibn Zuhr was by far the greatest. He was perhaps the greatest clinician in Islam after Al-Razi. Furthermore, he was the most famous physician of his time, not only among Muslims, but in Christendom and his influence upon European Medicine was maintained until the end of the seventeenth century.