Special article: contributions of medieval Islamic physicians to the history of tracheostomy

May 2013 • Volume 116 • Number 5 www.anesthesia-analgesia.org 1123

Copyright © 2013 by the International Anesthesia Research Society.DOI: 10.1213/ANE.0b013e3182884313

And now, by all the words the preacher saith,

I know that time, for me, is but a breath,

And all of living but a passing sigh,

A little wind that stirs the calm of death.

—Hakim Omar Khayyam (1048–1131 CE)

Tracheostomy has been known for millennia as an effec-tive procedure for establishing an emergency airway in patients with upper respiratory tract obstruction.

However, it was always a highly controversial procedure, with most scholars dreading it and even warning their successors not to perform it.1 According to tablets found in Egypt, tracheostomy is believed to have been first per-formed by Egyptians in 3600 BCE. However, the earliest ref-erences to tracheostomy have been made in the “Rig Veda,” the sacred book of Hindu medicine (ca. 2000–1000 BCE) and the Ebers Papyrus (ca. 1550 BCE).2 Around 1000 BCE Homer reported that Alexander the Great saved a soldier from suf-focation by making an opening in the trachea using the tip of his sword.3 Although Hippocrates (460–370 BCE) theoret-ically knew about tracheostomy, he avoided performing it due to the fear of carotid artery damage.4 Later, Asclepiades of Bithynia (ca. 100 BCE) and Antyllus of Rome (340 CE) were credited with the first surgical tracheostomies.5,6

At the start of the Middle Ages, Paulus of Aegina (ca. 625–690 CE) presented the first detailed surgical description of tra-cheostomy.7 Tracheostomy appeared in medical texts during the Islamic Golden Age (ca. 750–1257 CE), along with techni-cal innovations and changes. The history of tracheostomy in Renaissance and modern Europe has been extensively stud-ied, and readers are referred to the reviews by Szmuk et al.3 and Missori et al.8 Nonetheless, in these historical reviews, relatively little has been devoted to the topic of tracheostomy in Islamic medicine. Therefore, the aim of the present review is to describe how physicians during the Islamic Golden Age contributed to the development and progress of the procedure of tracheostomy. Their brief biographies highlight Islamic physicians’ leading roles in the evolution of medicine.

ABUBAKR MUHAMMAD IBN ZAKARIYYA AL-RAZI,

RHAZES (865–925 CE)Abubakr Muhammad ibn Zakariyya al-Razi (Fig. 1), known as Rhazes in the West, was born in Ray, a town in the vicinity of Tehran, in 865 CE.9 Until his thirties, Rhazes was a musician and a money changer. He wrote an encyclopedia of music (On the Beauty of Music) before pursuing his interest in science.10,11 Later, Rhazes studied philosophy, mathematics, literature, astronomy, and alchemy.12 Sometime after 30 years of age, Rhazes went to Baghdad, where he completed his medical education (probably) under the supervision of al-Tabari (807–870 CE).13 During his 10-year residence in Baghdad (895–905 CE), Rhazes was the head of the Bimaristan-i Muqtadiri (Al-Muqtadir Hospital) founded by Al-Muqtadir of the Abbasid caliphate. In 981 CE, the hospital was renovated by Emir Adud al-dowleh Fana Khusraw (reigning from 949 to 982 CE) of the Buyid dynasty and renamed as the Bimaristan-i Adudi (Al-Adudi Hospital).14 Although inspired by the theories of Galen, Rhazes primarily adhered to knowledge derived from his own observations and scientific experiments.15 Rhazes questioned many of Galen’s medical and philosophical theories in his book Al-Shukuk ala Jalinus (Doubts about Galen).9 Having written >200 books and treatises on a variety of subjects, Rhazes’ 2 major medical contributions are Kitab al-Mansuri (Liber Al Mansuri) and Kitab al-Hawi (Liber Continens). Combining ancient and contemporary knowledge of his era, Rhazes is considered one of the authorities who established the basis of

Contributions of Medieval Islamic Physicians to the

History of Tracheostomy

Samad E. J. Golzari, MD,* Zahid Hussain Khan, MD,† Kamyar Ghabili, MD,‡§ Hamzeh Hosseinzadeh, MD,║ Hassan Soleimanpour, MD,¶ Rasoul Azarfarin, MD,* Ata Mahmoodpoor, MD,║ Saeid Aslanabadi, MD,# and Khalil Ansarin, MD,**

From the *Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; †Department of Anesthesiology and Intensive Care, Tehran University of Medical Sciences, Tehran, Iran; ‡Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; §Young Researchers Club, Tabriz Branch, Islamic Azad Uni-versity, Tabriz, Iran; and Departments of ║Anesthesiology and ¶Emergency Medicine, #Pediatric Health Research Center, and **Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Accepted for publication January 8, 2013.

Funding: None.

The authors declare no conflicts of interest.

This report was previously presented, in part, at the III NWAC 2012 World Anesthesia Convention, Istanbul, Turkey, April 24–28, 2012.

Reprints will not be available from the authors.Address correspondence to Kamyar Ghabili, MD, Physical Medicine and Re-habilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. Address e-mail to [email protected].

Tracheostomy was irst described by Greco-Roman physicians, including Paulus of Aegina. Medieval Islamic clinicians extended the Greco-Roman ideas with substantial contributions to the ield of surgery, including tracheostomy. Although Al-Zahrawi (936–1013 CE) stated that he had not heard or read of any Islamic physicians having performed tracheostomy, there is evidence that many prominent Islamic surgeons did practice this lifesaving procedure during medieval times. Throughout the Islamic Golden Age, Muslim physicians advanced the practice of tracheostomy with many modiications of the procedure, instrumentation, and adjuvant medici-nal prescriptions. (Anesth Analg 2013;116:1123–32)

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medical theory and practice that guided subsequent scholars in the Islamic Golden Age and in Europe.10,16 Rhazes died a blind pauper at the age of 60 in Ray in 925 CE.17–19 Rhazes’ birthday (August 27) is celebrated each year as Pharmacists’ Day in Iran to honor his contributions to medicine.9

Of all the many works of Rhazes, by far the most volumi-nous is Liber Continens (The Comprehensive Book of Medicine) (Fig. 2). This medical masterpiece is a posthumous collection of Rhazes’ notes containing 24 volumes on different medi-cal issues roughly a capite ad calcem.14 The third volume of the book contains a chapter on the “inflammations, ulcers, and Eustachian tube in the larynx and asphyxia and tongue and epiglottis and diphtheria and arteries and dysphagia” in which Rhazes describes the procedure of tracheostomy to overcome asphyxia.20

“…the procedure (tracheostomy) is performed when the life of the patient is threatened with asphyxia death; the skin between larynx and windpipe is in-cised to maintain the inspiration. After eliminating the cause, the incision is closed to restore (the skin) to the pre-incisional condition. To perform this procedure (tracheostomy), the head is lifted, the skin is retracted, underneath the larynx ridge is incised, consequently the two parts are pulled upward and downward using two threads until the emergence of the windpipe, after the asphyxia and its cause subside; the skin is sutured while leaving some tiny openings inside it…”

Rhazes was believed to have performed tracheostomy on a patient named Wazir Ahmad Ibn Ismail who was suf-fering from diphtheria.21

ALI IBN ABBAS MAJUSI, HALY ABBAS

(930–994 CE)Ali ibn Abbas Majusi Arrajani (930–994 CE) was born to Zoroastrian parents in Ahwaz near Gondishapur

in southern Persia 5 years after the passing of Rhazes. Also widely known as Haly Abbas, he studied medicine under Shaikh Abu Maher Musa ibn Sayyar22 and became physician to Emir Adud al-dowleh Fana Khusraw of the Buyid dynasty and practiced in the Bimaristan-i Adudi (Al-Adudi Hospital).23 In Baghdad, Haly Abbas wrote a medical encyclopedia for the Emir called Kitab al-Maliki (The Royal Book) or Kamil al-Sinaat al-Tibbiya (The Perfect Book of the Art of Medicine).24 Haly Abbas was among the most prominent physicians and medical scholars in the era after the passing of Rhazes.25,26 He was one of the first to criticize the classical medical knowledge of preceding scholars, including Hippocrates (460–370 BCE), Paul of Aegina (625–690 CE), Serapion (second half of 9th century), and even Rhazes. Haly Abbas died in 994 CE at the age of 65 years in either Baghdad or Shiraz.27

Written in Arabic, Kamil al-Sinaat al-Tibbiya (The Perfect Book of the Art of Medicine) (Fig. 3), also known as Kitab al-Maliki (The Royal Book) is a medical encyclopedia believed to have influenced both Eastern and Western medicine.22,26 Being different from Rhazes’ Liber Continens and Avicenna’s The Canon of Medicine (see below), Kitab al-Maliki aimed to encompass all medical knowledge of his era.27,28 The ana-tomical section of the book (Pars Practica II and III) was the sole source of anatomy science between 1070 and 1170 CE.29 The first half of Kitab al-Maliki consisted of 10 dis-courses on the theory of medicine. The second half of the book consisted of 10 discourses on practical medicine.23 The ninth discourse, consisting of 111 chapters, was dedicated

Figure 1. Portrait of Abubakr Muhammad ibn Zakariyya al-Razi or Rhazes (865–925 CE).

Figure 2. The frontispiece of Al-Hawi by Rhazes (Bodleian version). Reproduced with permission from Middle Eastern and Islamic Manuscripts, Bodleian Library, Oxford.

Tracheostomy in Islamic Golden Age


to surgery. In the thirty-eighth chapter of the surgical dis-course titled “On treatment of pharyngitis,” Haly Abbas described the surgery of “Shagh al-hanjarah” (to incise the larynx, tracheostomy) in cases with asphyxia as follows:30

“…place the patient between your arms and lift the head and incise underneath the larynx ridge with three circular incisions around the windpipe or four [inci-sions] but tiny incisions on the membrane between the circular cartilages of the windpipe and do not enlarge the incisions as it is hazardous and the appropriate ap-proach would be to hold the skin in place using Son-nareh [a type of hook, Fig. 4], and to cut it until the carti-lage and underlying arteries appear and consequently incise the membrane between the windpipe and be cautious not to cut any vein or artery, then abandon it until the asphyxia and its cause subside; later pull the skin and suture it without touching the cartilages…”

ABUL QASIM KHALAF IBN AL-ABBAS AL-ZAHRAWI,

ALBUCASIS (936–1013 CE)Abul Qasim Khalaf ibn al-Abbas al-Zahrawi (Fig. 5), known as Albucasis in the West, was born in al-Zahra (near Córdoba, Spain) in 936 CE.31,32 He lived most of his life in Córdoba where he studied, taught, and practiced medicine and surgery.31,33 Al-Zahrawi became one of the most famous surgeons of the Muslim era and was a personal physician to Abd Al-Rahman III (912–961 CE) and his son Al-Hakam II (915–976 CE) of Spain, the Umayyad Caliphs of Córdoba.34 After a long medical career replete with great original con-tributions particularly in the court of Caliph, Al-Zahrawi died in 1013 CE.35–37

Completed in 1000 CE, Al-Zahrawi’s 30-chapter medical treatise, Kitab al-Tasrif Leman Ajiz an al-Taalif (The Arrangement of Medical Knowledge for One who is not Able to Compile a Book for Himself) (Fig. 6) covered a broad range of medical topics with 200 illustrations.33,38 Translated into Latin and most of the European languages, Al-Tasrif displaced Avicenna’s The Canon of Medicine as the textbook for medical education in many of the European universities between the 12th and 17th centuries of the Common Era.33,38 The most important part of the Al-Tasrif comprises 3 books on surgery: cauterization; incisions, venesection, and wounds; and bone-setting.31 These books contain various aspects of surgical treatment in details based on Al-Zahrawi’s personal experiences of the surgical operations.33 In the forty-third chapter of the second part of his book (On incising the pharyngitis), Al-Zahrawi states that although he is not aware of any physician performing the procedure, he interprets his predecessors’ descriptions of tracheostomy comprehensively:31

“…the interpretation of what was previously quoted is whenever a pharyngeal abscess obstructs the pha-ryngeal passage leading to cessation of breathing and posing the danger of death, it is advised to cut through the larynx so that the patient could breathe through the incision minimally and be released from death, there-fore the verdict has been to leave the incision open un-til the disease subsides, which would probably last for three days or so and consequently the incision should be sutured to achieve a complete healing…”

To this, Al-Zahrawi added his personal observation about a young girl’s self-inflicted neck wound:31

“…what I personally have observed was when a maid cut her throat with a knife and the windpipe partially. I was invited for her treatment and on ar-rival; I heard she was letting out noises like an ani-mal with a cut throat. After exploring the wound, I discovered that not much bleeding was present

Figure 3. A page of Kitab al-Maliki by Ali ibn Abbas Majusi or Haly Abbas (930–994 CE). Reproduced with permission from Wellcome Library, London.

Figure 4. A page of Al-Zahrawi’s Al-Tasrif depicting the Sonnareh (a variety of hook) devised or utilized by Al-Zahrawi (Sana Library version).

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therefore I realized that no artery or vein was cut and air passed through the wound. So I sutured the wound and started the treatment until the patient was healed. The only finding that remained was hoarseness and nothing of the wound could be ob-served. After a few days, the patient was in her best condition. Therefore, I concluded that laryngeal cut or incision would not be hazardous…”

ABU ALI HUSAIN IBN ABDULLAH IBN SINA,

AVICENNA (980–1037 CE)Abu Ali Husain ibn Abdullah ibn Sina (Fig. 7) was born to a Persian family on the August 23, 980 CE in Afshaneh, a vil-lage near Bukhara (now located in Uzbekistan), in Persia.39,40 He became known in the West as Avicenna, the “Aristotle of Islam” and the “Second Doctor” (after Aristotle, who was “the First”).41,42 At 5 years of age, Avicenna moved to Bukhara with his family. With the help of his father and religious teachers, Avicenna completely memorized the Quran when he was 8 years old. At the age of 10, Avicenna became well versed in various sciences including logic, geometry, and mathematics.13 When Avicenna was a teenager, Abu Sahl al-Masihi encour-aged him to study medicine. In 997 CE, Avicenna began his professional career as a physician.43 At the age of 17, Avicenna cured Nuh ibn Mansur, the Samanid ruler of Bukhhara, of an unknown illness that other physicians had failed to cure.28 Avicenna was subsequently rewarded with access to the royal library of Bukhara for his success in curing the Emir’s illness.

By the fall of the Samanid dynasty in 999 CE, Avicenna had left Bukhara for Gorganch of the Khwarizmi Kingdom, now known as Urgench in Uzbekistan, where he became acquainted with Al-Biruni (973–1048 CE), a great pharma-cist and polymath of the 11th century.28 Avicenna’s travels to different Persian cities continued in later years afford-ing him with precious opportunities to access libraries, such as the Buyid Libraries of Ray (1014–1015 CE) and Hamadan and the Kakuyid Library of Isfahan. While resid-ing in Hamadan, Avicenna became Shams al-Dawla’s vizier until 1021 CE. After the Emir’s death, the new Buyid ruler, Samaa al-Dawla, detained Avicenna on suspicion of disloy-alty. During his 4-month imprisonment, Avicenna wrote

his medical treatise, Kitab al-Qawlanj (The Treatise on Colic).44 After Alaa al-Dawla ibn Kakuya’s conquest of Hamadan, Avicenna was released from prison and left for Isfahan where he wrote the Kitab al-Shifa (Book of Healing).18 On the way back to Hamadan in 1037 CE, Avicenna suffered from a severe colic, perhaps due to stomach cancer, and died at 58 years of age.18,43

Avicenna’s medical masterpiece is Al-Qanun fi al-Tibb (The Canon of Medicine) (Fig. 8). He started work on this in Jorjan and completed it in Ray.18 The Canon of Medicine was such an influential treasure in the history of medicine that Nizami Aruzi, a Persian poet in the 12th century, wrote in his Chahar Maqala (Four Discourses) “…could Hippocrates and Galen return to life, it were meet that they should do rev-erence to this book [The Canon of Medicine]…”45 Translated into Latin, Hebrew, German, French, and English, The Canon of Medicine was the core of Western medical science between the 13th and 18th centuries.46 Indeed, lessons of Avicenna were taught at the University of Brussels until 1909 CE.18

The Canon of Medicine was divided into 5 parts, the first of which described general anatomy and principles of medi-cine. The second book was dedicated to materia medica; the third, to diseases of the special organs; the fourth, to general medical conditions; and the fifth, to formulary. In the ninth part of the third book, Avicenna’s sixth chapter “On treat-ment of croup and angina,” describes his method of per-forming tracheostomy and administering a yellow powder on the incision site:47

“…retract the head and hold it (the head), hold the skin and incise it. It would be more appropriate to

Figure 5. Al-Zahrawi or Albucasis (936–1013 CE) blistering a patient in the hospital at Córdoba while his students look on. Reproduced with permission from Wellcome Library, London.

Figure 6. A page of Al-Tasrif depicting the surgical tools devised or used by Al-Zahrawi (Sana Library version).



hold the skin in place using “Sonnareh” and pull the skin away until the trachea is visible, incise between the two rings (cartilages) from the middle of the in-cised skin and later suture it and apply some Zarur e Asfar (the yellow powder) on it, and the edges of the skin should be folded and sutured solely without touching the cartilage and the membrane…”

Clearly documented in later centuries by Muhammad Momen Hosseini (17th century), a Persian physician of the Safavid court, this yellow powder comprised: sarco-colla (Astragalus fasciculifolius Boiss), aloe (Aloe vera), saffron (Crocus sativus), rose seed (Rosa damascena), opium (Papaver somniferum), and horned poppy (Glaucium cornicolatum).48

HAKIM ESMAIL JORJANI (1042–1137 CE)Hakim Jorjani (Fig. 9) was born in Gorgan (situated on the southeast coast of the Caspian Sea in Persia) in 1042 CE.49,50 Jorjani learned jurisprudence and medicine in Neishabour (Khorasan Province) from Abolqasem Qushairi and Abd al-Rahman ibn Ali ibn Abi Sadegh, respectively.51,52 After having lived in Khorasan (presently a northeastern province in Iran), Hakim Jorjani departed for Khwarazm where he presided over a hospital and served as a physician in the court of Khwarazm Shah Qutb al-Din Muhammad ibn Anush Tigin, the governor of the Persian province of Khwarazm and his successor, Atsiz.18,51 In approximately 1112 CE, at the age of 70 years, Jorjani compiled his comprehensive 750,000-word textbook of medicine, Zakhireyei Khwarazmshahi (The Treasure of Khwarazm Shah). This is considered the oldest medical encyclopedia written in Persian.

Jorjani made significant contributions to medieval medi-cine and medical education. He translated his Treasure into Arabic, from which others translated the text into Urdu, Hebrew and Turkish. This resulted in Treasure becoming a major medical textbook consulted by medical scholars of the

era.53–55 He also wrote 2 précis of the Treasure, Al-Aghraz al-Tebbieh (Medical Goals), and Khofieh Alaii for use as a manual or handbook by medical students.56 Yadegar (Memorial) writ-ten by Jorjani was also a medical book in Persian.28 Despite receiving a high salary from the court of Khwarazmian dynasty, Jorjani left for Marv, located on the historical Silk Road near what is now Mary in Turkmenistan, to live his last years of life in peace and tranquility. Hakim Jorjani eventually died at 95 years of age in Merv in 1137 CE.57

The Treasure is composed of 10 books of which the sixth one describes and discusses a long list of localized diseases, roughly a capite ad calcem. In the sixth article of this book, the first chapter “On pharyngitis and asphyxia” describes tracheostomy as a last resort for treating the patient with pharyngitis who is suffering from impending death:58

“…and in whom [patient] no improvement is achieved following these measures and treatments and there is a threat of death, the only hope of the victim to be released from death would be to cut through the pa-tient’s larynx which could be achieved by extending the patient’s head and (later) remove the (covering) skin of the larynx using Sonnareh [see above], liberate it from the larynx, go through (deeper) and incise the membrane located between two laryngeal rings until the patient becomes aphonic... and then [after elimina-tion of the threat] the membrane should be sutured so that the membrane and cartilage would not be dam-aged…”

Figure 7. Portrait of ibn Sina or Avicenna (980–1037 CE).

Figure 8. The frontispiece of The Canon of Medicine by Avicenna. Reproduced with permission from Wellcome Library, London.

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ABU MARWAN ABD AL-MALIK IBN ZUHR,

AVENZOAR (1091–1162 CE)Abu Marwan Abd al-Malik Ibn Zuhr (Fig. 10), known as Avenzoar in the West, was born into a famous Andalusian family of physicians at Seville, Spain in 1091 CE. Ibn Zuhr learned medicine from his father, Abu al-Ala Zuhr Ibn Abd al-Malik al-Iyadi.59 At 17 years of age, Ibn Zuhr was first introduced to the Almoravides royal family. He was summoned from Córdoba to cure Ali Ibn Yusuf Ibn Tashfin, an Almoravid king reigning between 1106 and 1143 CE.60 Thereafter, Ibn Zuhr was appointed as a court physician to Almoravid prince Ibrahim Ibn Yusuf Ibn Tashfin for whom Ibn Zuhr compiled his medical book “Kitab al-Iqtisad” (Book of Moderation) in 1121 CE.61 Due to long-standing enmity toward Ibn Zuhr’s father, Ali Ibn Yusuf Ibn Tashfin imprisoned Ibn Zuhr in Morocco.60 After the victory of the Almohads over the Almoravides, Ibn Zuhr became the court physician and vizier to Abd al-Mumin, founder of the Almohad dynasty. Ibn Zuhr dedicated his medical book “Kitab al-Aghdhiya” (Book of Aliments) to Abd al-Mumin.13 It was during Abd al-Mumin’s long and successful reign that Ibn Zuhr met Abu al-Walid Muhammad Ibn Ahmad Ibn Rushd or Ibn Rushd or Averroes (1126–1198 CE).62 After a long medical career and writing numerous medical books, Ibn Zuhr died in Seville in 1162 CE.60,63

During the Almohad caliphate of Abd al-Mumin, Ibn Zuhr compiled his major book “Kitab al-Taysir fi al-Mudawat wa al-Tadbir” (Book of Facilitation on Therapeutics and Dietetics) on Ibn Rushd’s request.64 The Kitab al-Taysir served as a com-panion book to Kitab al-Kulliyat (Book of Generalities or Colliget) of Ibn Rushd. Including a vast materia medica, Kitab al-Taysir is principally a compendium of diseases and therapeutics written in 30 chapters. This book covers both Ibn Zuhr’s personal views and recollections of his exile in Morocco and

case histories in the manner of those written by Rhazes.59 Throughout the Kitab al-Taysir, Ibn Zuhr has described his several experiments on animals to find answers for clini-cal problems, hence his title as “The Father of Experimental Surgery.”64 Translated into Hebrew and Latin, Kitab al-Taysir was an essential textbook at European universities during the 18th century.65 In the first part of the book, in his chapter “On diseases of esophagus,” Ibn Zuhr describes his method of performing tracheostomy on a goat.66

“...earlier on in my training when I read those opin-ions (controversies), I cut on the lung pipe of a goat after incising the skin and the covering sheath under-neath. Then I completely cut off the substance of the pipe, an area just less than the size of a tirmisah (lu-pine seed). Then, I kept washing the wound with wa-ter and honey until it healed and it (the animal) totally recovered and lived for a long time. After integration and union of the wound, blow some ground cypress nuts [Cupressus sempervirens] on it until it heals…”

DISCUSSIONDuring the Middle Ages, Islamic, Christian, and Jewish scholars contributed to the development of Islamic medi-cine, later influencing the rise of European science during the Renaissance.67–70 Medieval Islamic physicians not only added to the general knowledge of medicine but also modi-fied and enriched it throughout this era. Whereas anatomy, as the major basis of surgery was primarily taught via books due to the fact that human dissection was generally disapproved of based on religious beliefs,71,72 most promi-nent Islamic physicians emphasized the necessity for more practical anatomical knowledge gained from dissection. For example, Albucasis stated “For he who is not skilled in as much anatomy as we have mentioned is bound to fall into error that is destructive to life,” and Ibn Rushd and Fakhruddin Razi (1149–1209 CE) believed that undertaking

Figure 9. Portrait of Esmail Jorjani (1042–1137 CE).

Figure 10. Portrait of Ibn Zuhr or Avenzoar (1091–1162 CE).



dissection deepened the appreciation of God’s wisdom and power.28,73 Surgery was further enhanced by innovative approaches and devices introduced by Islamic physicians. Evidence of this includes the surgical instruments first depicted in detail by Albucasis in his book of Al-Tasrif.21,37

Tracheostomy was first described by Greco-Roman physicians, in particular, Paulus of Aegina, whose medical compendium presented the first detailed surgical descrip-tion of tracheostomy.7 Although basing their descriptions of tracheostomy on those of their Greco-Roman predecessors, medieval Islamic physicians’ modification of the procedure, instrumentation, and personal experiences indicate their own approach to this procedure. For example and in con-trast to Paulus of Aegina who suggested using a hook only in case of cautious physicians performing the procedure,7 medieval Islamic physicians recommended using tools for skin retraction (e.g., threads, hook) during tracheostomy. Albucasis, who was familiar with Greco-Roman medical

writings and was able to apply the techniques in an emer-gency, stated that tracheostomy was unknown in his own time. However, his successful management of a suicidal lac-eration of the trachea suggested to him that tracheostomy might be practical. Moreover, Jorjani introduced aphonia as an indicator of successful tracheostomy, a “pearl of wisdom” neglected by his Greco-Roman predecessors and Muslim peers. In addition, Ibn Zuhr demonstrated the feasibility of the procedure in an experimental animal model of tracheos-tomy. Table 1 lists additional innovations in tracheostomy technique pioneered by medieval Islamic physicians.

Medieval Islamic practitioners introduced the concept of applying medicinal herbs during or after tracheostomy, suggesting some familiarity with pharmacology. In his Canon of Medicine, Avicenna prescribed Zarur e Asfar (the yellow powder) consisting of sarcocolla (Astergalus fasciculi-folius Bioss), aloe (Aloe vera), saffron (Crocus sativus), opium (Papaver somniferum), rose (Rosa damascene), and horned

Table 1. Details of the Tracheostomy Procedure by Medieval Islamic PhysiciansPhysician Book Geographical

region

Year/Century

(CE)

Contribution to tracheostomy Performed/not

performed

Rhazes Kitab al-Hawi (Liber Continens) Persia 865–925 Comprehensive description, using 2 threads

for skin retraction, leaving some tiny

openings inside the incision

Performed

Haly Abbas Kitab al-Maliki (The Royal Book) Persia 930–994 Accurate depiction of the number and

shape of the incisions, performing tiny

incisions to avoid any probable damage

to the vessels, using a special surgical

instrument for proper skin retraction,

advice on leaving the membrane and the

cartilages intact

Performed (?)

Al-Zahrawi Kitab al-Tasrif Leman Ajiz an

al-Taalif (The Arrangement of

Medical Knowledge for One

who is not Able to Compile a

Book for Himself)

Al-Andalus 936–1013 Adding his personal observations to

the experiences of his predecessors,

introducing hoarseness as a probable

complication, practice of a three day delay

on closing the tracheostomy incision

Not performed

Avicenna Al-Qanun fi al-Tibb (The Canon of

Medicine)

Persia 980–1037 Comprehensive description, using a

special surgical instrument for proper

skin retraction, emphasis on leaving

the membrane and cartilages intact,

application of a topical medication on the

tracheostomy incision

Performed (?)

Jorjani Zakhireyei Khwarazmshahi (The

Treasure of Khwarazm Shah)

Persia 1042–1137 Recommending the procedure to be

reserved as the last measure, introducing

aphonia as an indicator of successful

tracheostomy, emphasis on leaving the

membrane and cartilages intact

Performed (?)

Avenzoar Kitab al-Taysir fi al-Mudawat wa

al-Tadbir (Book of Facilitation

on Therapeutics and Dietetics)

Al-Andalus 1091–1162 Detailed description of the procedure, the

irst elective experimental tracheostomy

(on animal model), application of honey as

a wound healing substance

Performed (on

animal model)

Table 2. Natural Substances Used in Tracheostomy and Their Confirmed Effects in Modern Medicine Described in Medieval Islamic Medical Books

Traditional name Common name Scientific name Persian name Effects

Zarur e Asfar (yellow

powder)

Sarcocolla Astergalus fasciculifolius Bioss Anzarout Wound healing74,75

Aloe Aloe vera Sabr-e-zard Antimicrobial,76 wound healing77

Saffron Crocus sativus Zafaran Anti-inlammatory,78 wound healing79

Opium Papaver somniferum Afyoun Antinociceptive80

Rose Rosa damascena Gol-e-sorkh Antinociceptive,81 Anti-inlammatory,81 antimicrobial82

Horned poppy Glaucium cornicolatum Mamitha —

— Cypress Cupressus sempervirens Sarv Antimicrobial83,84

— Honey — Asal Wound healing,85 antimicrobial86

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poppy (Glaucium cornicolatum) to be applied on the sutured tracheostomy incision. Ibn Zuhr recommended applica-tion of honey and ground cypress nuts on the cut wound to facilitate the healing process. The efficacy of most natural substances prescribed in medieval Islamic medical books for tracheostomy has been subsequently demonstrated by modern medicine (Table 2). E

DISCLOSURES

Name: Samad E. J. Golzari, MD.Contribution: This author helped design and conduct the study and write the manuscript.Attestation: Samad E. J. Golzari approved the final manuscript.Name: Zahid Hussain Khan, MD.Contribution: This author helped write the manuscript.Attestation: Zahid Hussain Khan approved the final manuscript.Name: Kamyar Ghabili, MD.Contribution: This author helped conduct the study and write the manuscript.Attestation: Kamyar Ghabili approved the final manuscript.Name: Hamzeh Hosseinzadeh, MD.Contribution: This author helped write the manuscript.Attestation: Hamzeh Hosseinzadeh approved the final manuscript.Name: Hassan Soleimanpour, MD.Contribution: This author helped write the manuscript.Attestation: Hassan Soleimanpour approved the final manuscript.Name: Rasoul Azarfarin, MD.Contribution: This author helped write the manuscript.Attestation: Rasoul Azarfarin approved the final manuscript.Name: Ata Mahmoodpoor, MD.Contribution: This author helped write the manuscript.Attestation: Ata Mahmoodpoor approved the final manuscript.Name: Saeid Aslanabadi, MD.Contribution: This author helped write the manuscript.Attestation: Saeid Aslanabadi approved the final manuscript.Name: Khalil Ansarin, MD.Contribution: This author helped write the manuscript.Attestation: Khalil Ansarin approved the final manuscript.This manuscript was handled by: Steven L. Shafer, MD.

ACKNOWLEDGMENTS

The authors gratefully thank Professor Honorio T. Benzon (Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL), Professor Salim Hayek (Department of Anesthesiology, Case Western Reserve University and Division of Pain Medicine, University Hospitals, Cleveland, OH), and Dr. Mohammadali M. Shoja (Section of Pediatric Neurosurgery, Birmingham Children’s Hospital, University of Alabama at Birmingham, Birmingham, AL) for their valuable comments on the manuscript. The authors are also grateful to The Bodleian Library, University of Oxford (Ms. Gillian Grant), and The Wellcome Library, London, UK (Ms. Venita Paul) for providing permissions to use some library fig-ures in the present paper. The authors are also indebted to Mr. Ramin Abdollahzadeh for depicting the portraits of Rhazes and Ibn Zuhr.

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E SPECIAL ARTICLE


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Special article: contributions of medieval Islamic physicians to the history of tracheostomy