Anaesthesia 1000 Years Ago (II)

The following research article in a particular field of the history of medicine, written by two eminent experts, Drs Adnan A. Al-Mazrooa and Rabie E. Abdel-Halim, is composed of two parts. This first part surveys the use of narcotics for pain relief from Antiquity up to the Renaissance; the second part is a historical investigation in the contribution of the Islamic medical tradition to develop anaesthesia methods and uses. Reviewing some of the medical texts written by Muslim scholars from the 9th to the 14th century, the authors present evidence that anaesthesia monitoring and resuscitation were practised by Muslim scientists more than 1000 years ago.

Table of contents

1. Anaesthesia and resuscitation in the medicine of Islamic era
1.1. Anaesthesia
1.1.1. Documentation of the use of AI-Murquid
1.1.2. Anaesthesia techniques
1.1.3. Anaesthesia personnel
1.1.4. Monitoring
1.2. Resuscitation
1.2.1. Resuscitation team
1.2.2. Nutrition
1.2.3. Management of upper airway obstruction
1.2.4. Use of bellows
2. Notes and references

1. Anaesthesia and resuscitation in the medicine of Islamic era

Figure 1: Page from The Result of Thinking about the Cure of Eye Diseases (Natijat al-fikar fi `ilaj amrad al-basar) written in Cairo by Fath al-Din al-Qaysi (d. 1259/657 H). Copy finished by unnamed scribe on 16 November 1501 (5 Jumada I 907 H). National Library of Medicine, Bethesda, Maryland, MS A48, fols. 7b-8a (Source).

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Little is known about the history of anaesthesia in the period of more than 1000 years between Graeco-Roman times and the 16th century when the Renaissance started. In Europe, that period is usually referred to as the Dark Ages when no progress was made in medical science [1] [2] [3] [4]. However, the situation in the East was different [2] [5] [6] [7]. The following section is dedicated to survey the development of anaesthesia during that period by reviewing the following books: Al-Hawi fit-tibb (The Continence) [8], Al-Qanun fi-al-tibb (The Cannon of Medicine) [9], Al-Tasrif [10], Al-Mukhtarat fit-tibb [11], Al-‘Umda Fil Al-Jiraha [12], and Al-Taysir [13]. The authors of these books are respectively Al-Razi, Ibn Sina, Al-Zahrawi, Al-Bagdagi, Ibn al-Quff and Ibn Zuhr. Those authors were medical scholars who lived in the period between the 9th and the 14th centuries. Their contribution to pain relief has been recently evaluated [14]. In the following section, we will evaluate their contributions to anaesthesia and resuscitation.

1.1. Anaesthesia

1.1.1. Documentation of the use of AI-Murquid

Both of the historians, Ibn Khallikan [15] in the 13th century, and Ibn Kathir [16] in the 14th century, documented that Urwa Ibn AI-Zubair in the beginning of the 8th century developed leg gangrene for which amputation was required. The doctors of the Ummayad Caliph Al-Walid Ibn Abdel Malek in Damascus offered him Al-Murquid to be put to sleep for the operation.

Literally, the word ‘Al-Murquid’ in Arabic means a drug that induces deep sleep. Evidence about the popularity of this anaesthetic comes from finding entries about Al-Murquid in four general-purpose Arabic language dictionaries compiled during that era [17] [18] [19] [20].

Also in the literary book Sayd Ul-Khatir, Ibn al-Jawzi in the 12th century referred to the anaesthetizing effect of Bhanj [21].

1.1.2. Anaesthesia techniques

Al-Murquid was used either by ingestion or inhalation or rectally [14]. In the form of infusion, they used particular types of solanum, cannabis, opium and mandrake by ingestion. The last three drugs were also administered rectally on a plug which had to be changed hourly. On the other hand, opium, mandrake and henbane were also used by inhalation in the form of odorants. As wild lettuce has a mild soporific effect it was used, whether fresh or boiled, as an adjuvant to any of the previous ones or in cases of insomnia [14]. They not only precisely determined the required dose of each drug but also they were able to fix the length of time which the anaesthesia was to last with great precision, for example, Ibn Sina [9] gave a dose of one ‘mithkal’ of mandrake for 3-4 hours of general anaesthesia.

However, Ibn al-Quff [12] most probably in an attempt to reduce the dose used, and hence decrease the risks of toxic effects, advised care on the part of the surgeon to use operative techniques that minimized pain.

1.1.3. Anaesthesia personnel

The knowledge and practice of anaesthesia reached its peak in the beginning of the 14th century as evidenced in Ibn al-Quff’s book on surgery Al-‘Umda Fi-‘l-Jiraha [12] (the mainstay in surgery). Unlike Paulus of Aegineta [22], Ibn al-Quff gave detailed information in his book on the phenomenon of pain and clearly stated that pain relief during surgery should be the responsibility of a second medical man other than the surgeon performing the operation. Al- Tabaaei (meaning the physician) was to look after pain relief by giving AI-Murquid to allow Al-Jaraaehi (meaning the surgeon) to perform the operation. This represents the first report, in the literature, on the role of the anaesthetist.

1.1.4. Monitoring

In that era they also realized the importance of monitoring during anaesthesia as, according to Sigrid Hunke [23] a third medical man used to be present putting a finger on the pulse during the operation. It is interesting to note this method of monitoring, by palpating the pulse is still practiced nowadays and is referred to in anaesthesia text-books as a simple non-invasive method.

1.2. Resuscitation

Figure 2: Manuscript page of Kitab Kamil al-sina’ah al-tibbiyah al-ma’ruf bi-al-Malaki by Ali ibn al-‘Abbas al-Majusi (10th/11th centuries). This Arabic manuscript on general medicine in 497 leaves is held at Yale University Library, Historical Medical Library: Cushing Arabic Ms. 4 (Source).

1.2.1. Resuscitation team

In the memoirs of Prince Osama Ibn Al-Munquiz [24] we found evidence that the Tabaaei (physician) and Jaraaehi (surgeon) also worked together as a resuscitation team. Both were called for the resuscitation of a warrior who collapsed immediately after an arrow hit him.

1.2.2. Nutrition

For the resuscitation of patients with severe weakness and cachexia due to dysphagia, Ibn Zuhr [13], in the 12th century, recommended enteral feeding through a tube made of silver or strengthened tin introduced into the throat gently and gradually, to avoid its nauseating effect. Contrary to his predecessors, Ibn Zuhr also advocated rectal enteral feeding and described how the bladder of a goat filled up with the nutrient fluid and fitted with a silver tube tied to its mouth could be used for this purpose.

1.2.3. Management of upper airway obstruction

For the resuscitation of suffocation due to upper airway obstruction Ibn Sina [9], in the 10th century recommended the introduction of a tube made of gold or silver, or similar metal, to assist breathing. In agreement with Brendt & Georig [25], this represents the first reported use of an endotracheal tube. However, before attempting intubation, Ibn Sina [9] tried conservative measures including clearing the secretions using a wicker stick covered with a piece of cotton-wool. If such measures failed and the patient’s life was threatened, Ibn Sina recommended tracheotomy. According to Adams and Spink & Lewis [27], Aretaeus in the 2nd century and Caelius Aurelinus in the 4th century did not approve of tracheotomy. Therefore, although Paulus [22] (7th century) quoting Antyllus (2nd century), described the technique of tracheotomy, the operation remained in disfavour. This state of affairs lasted until the Islamic era when AI-Razi [8] (9th century) and later Ibn Sina [9] (10th century) spoke favourably of the operation and refined the technique.

Although AI-Razi spoke of tracheotomy as a drastic measure he reported seeing patients with wounds in the throat through which breath came out, yet the wounds eventually healed and patients survived. However, the credit for proving that tracheotomy is not a dangerous operation goes to Al-Zahrawy [28] in the 10th to 11th century and Ibn Zuhr [13] (12th century). Al-Zahrawi, in his book Al-Tasrif liman ‘ajaza ‘an al-ta’lif reported from his own experience the successful management of a suicidal cut wound of the trachea and concluded that tracheotomy is not a dangerous procedure. On the other hand, Ibn Zuhr [13] in his book AI-Taysir described in detail his animal experiment of performing tracheotomy on a goat that completely recovered following the operation and lived for a long period thereafter. Ibn Zuhr’s application of an experimental model to a clinical problem was the forerunner of the method by which many current surgical procedures were developed. The authors who came after AI-Zahrawi and Ibn Zuhr such as AI-Bagdadi [11] and Ibn al-Quff [12] 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. It is interesting to note that Ibn al-Quff’s indications for tracheotomy specifically included the failure to introduce cool air to the interior.

1.2.4. Use of bellows

Ibn Abi Usaybi’a [29] in the 13th century in his book of medical biographies ‘Uyun al-anba’ fi-tabaqat aI-atibba’ documented a case in which a critically ill patient already pronounced dead was successfully resuscitated by the physician Saleh Ibn Bahla who elicited that the patient still responded to painful stimuli, then with the use of bellows, insufflated air and soap root powder into his nose. According to Jaser [30], this clinical case report documented the use of bellows for respiratory resuscitation 900 years before it was first reported in Europe.

The contributions of the above mentioned authors were translated into Latin as early as the middle of the 12th century and greatly influenced the European mediaeval schools of medicine well into the 18th century [2] [3] [4] [7] [31] [32] [33] [34] [35] [36].

3. Notes and references

[1] Bickers W, “Adventures in Arabian medicine”. J R ColI Surg Irel 1969: 5: 5-14.

[2] Cumston CG, “An introduction to the history of medicine from the time of the pharoahs to the end of the XVIII century”. In: Islamic medicine, London: Dawsons of Pall Mall, 1968: 23-26, 185-212.

[3] Desnos E, “The history of urology up to the latter half of the nineteenth century, Chapter 3”. In: Murphy LJT, ed. and translator, The history of urology. Springfield: Charles C Thomas, 1972: 34.

[4] Margotta R, “The Dark Ages, the decline of Rome”. In: Lewis P, ed. An illustrated history of medicine. Middlesex: Hamlyn, 1968: 100-105.

[5] Dickinson EH, The medicine of the ancients. Liverpool: Holden, 1875: 37-39.

[6] Kirkup JR, “The history and evolution of surgical instruments. Introduction”. Ann R ColI Surg Eng 1981; 63: 279-285.

[7] Campbell DC, Arabian medicine and its influence on the middle ages. 1st edition (reprint), Amsterdam: Philo Press, 1974: pp. XI-XV.

[8] AI-Razi, Kitab al-Hawi fi al-tibb, op. cit., vol.3: pp. 225-233; vol. 23: pp. 225-242.

[9] Ibn Sina, Kitab aI-qanun fi al-tibb, op. cit., vol. 1: pp. 334; vol. 2: pp. 200-205.

[10] AI Zahrawi, Al-Tasrif liman ‘agaz ‘an-al-ta’lif. In: Spink MS, Lewis CL, eds and trans. Albucasis on surgical instruments. London: Wellcome Institute of the History of Medicine, 1973: 338-339.

[11] AI-Bagdadi, Kitab aI-mukhtarat fi al-tibb, op. cit., vol. 1: p. 141; vol. 3: p. 190.

[12] lbn al-Quff, AI-‘Umda fi ‘I-jiraha, op. cit., vol. 2: pp. 104-105; vol. 1: p. 205.

[13] Ibn Zuhr, AI-Taysir fi-‘l-mudawat wa-‘l-tadbir, Alkhoury M, ed. Damascus: The Arabic Organisation for Education, Culture and Science, 1983: 149-155.

[14] Al Mazrooa AA, Abdel-Halim RE. “Anaesthesia 1000 years ago”. In: Atkinson RS, Boulton TB, eds. The history of anaesthesia. London, New York: Royal Society of Medicine Services and the Parthenon Publishing Group, 1989: 46-48.

[15] lbn Khallikan, Wafayat al-a’yan, ed. Mohamed Mohyuldeen, Maktabt al-Nahda, 1948: 418-428.

[16] lbn Khathir, Al-bidaya wa-‘l-nihaya, 3rd ed. Abu Mohem A. et al. eds. Beirut: Dar al-kutub al-‘ilmiya, 1987; 4: 108.

[17] Mohamed bin Yagab AI Firouz-Abadi, Al-Qamus al-muhit, 3rd ed. Cairo: AI-Matba’a al-Masriya, 1933; I: 295.

[18] Ibn Manzur, Lisan al-‘Arab, AI-Kabir A et al. eds. Cairo, Egypt: Dar aI-Ma’arif, 3: 1206; Ibn al-Jawzi, Sayd aI-Khatir, Abdul Kader A, ed. Beirut: Al-maktaba ‘l-‘ilmiya (undated): 18.

[19] Al-Razi, Muktamal-Sihah. Beirut: Dar al-kitab al-‘arabi, 1981: 252.

[20] AI-Zamakhshari, Asas al-Balagha. Beirut: Dar al-fikr (undated): 244.

[21] Ibn al-Jawzi, Sayd aI-Khatir, Abdul Kader A, ed. Beirut: Al-maktaba Al-‘ilmiya (undated): 18.

[22] Paulus of Aegineta, The seven books of Paulus of Aegineta, 6th book. Adams F, trans. London: Sydenham Society, 1846: pp. 1-3.

[23] Sigrid Hunke, Allah’s sonne uber dem abendland unser Arabische erbe, 6th ed. Baidoon F, Dosoky K, Arabic trans. Beirut: Dar Al-afaq aI-jadida, 1981: 239.

[24] 0sama Ibn Al-Munquiz, Kitab al-I’tibar, Samaraaei Q, ed. Riyadh: Dar Al-assala for culture, Publication and Information, 1987: 75.

[25] Brendt L, Georig M. “Die Oeschichte der Tracheotomie”. Anaesthetist 1986; 35: 279-283.

[26] Adams F., Translation of: The seven books of Paulus Aegineta. London: Sydenham Society 1846; 2: 301-303.

[27] Spink MS, Lewis CL. Albucasis on surgery and instruments. London: Wellcome Institute of the History of Medicine, 1973: 336.

[28] Al-Zahrawi, AI-Tasrif liman ‘ajaza ‘an aI-ta’lif. Istanbul, Besiraga Collection Suleymaniye Library, MS 502. Reproduced and edited by Fuat Sezgin, Frankfurt: Institute for the History of Arabic-Islamic Science, 1986, vol. 2: p. 498.

[29] Ibn Abi Usaybi’a, ‘Uyun al-anba’ fi tabaqat aI-‘atibba’, Nizar Reda, ed., op. cit., pp. 475-477.

[30] Jaser MT, “Anaesthesia in the history of Islamic medicine”. In: Atkinson RS, Boulton TB, eds., The history of anaesthesia. London, New York: Royal Society of Medicine Services and the ParthenoQ Publishing Group, 1989: 48-50.

[31] Ullman M., Islamic medicine (Islamic Surveys Series, N° 11). Edinburgh: Edinburgh University Press, 1978: 52-54.

[32] Freind J., Histoire de la médecine depuis Galien jusqu’au commencement du seizième siècle. Etienne Coulet, trans. Leyden: Langerak 1727; 3: 1-80.

[33] Gruner OC. A Treatise on the Canon of Medicine of Avicenna incorporating a translation of the first book. London: Luzac, 1930: 18.

[34] Montagnani CA. “Paediatric surgery in Islamic medicine from Middle Age to Renaissance”. In: Rickham PP, ed. Historical aspects of paediatric surgery. Progress in Paediatric Surgery 1986; 20,39-51.

[35] Radbill SX. “The first treatise on paediatrics”. Am J Dis Child 1971; 122: 369-376.

[36] Shah MH. The general principles of Avicenna’s Canon of medicine. Karachi: Naveed Clinic, 1966: iii.