Anaesthesia
1000 Years Ago
A. A.
AI-Mazrooa, R. E. Abdel-Halim*
Saudi
Medical Journal 1991; 12(5): 351-353
In
this paper we review some of the medical texts written by Muslim scholars
during the period from the ninth to the fourteenth century and present evidence
that anaesthesia monitoring and resuscitation were practised by Muslim scientists
more than 1000 years ago.
Little is
known about the history of anaesthesia in the period of more than I000 years
between Graeco-Roman times and the sixteenth 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.1-4,7 However, the situation in
the East was different. 2,5,6,7 Therefore, in this paper, the
development of anaesthesia during that period is studied by reviewing the
following books: Al-Hawi fit-tibb, ( The Continence), 8 Al-Qanon
fit-tibb ( The Cannon of Medicine), 9 Al-Tasrif, 10
Al-Mukhtarat fit-tibb, 11Al-Omda Fil Al-Jiraha, 12 and
Al-Tayseer 13 by Rhazes, Avicenna, Albucasis, A1-Bagdagi, Ibn El
Quff and Ibn Zuhr respectively. Those authors were medical scholars who lived
in the period between the ninth and the fourteenth centuries.
Their
contribution to pain relief has been recently evaluated. 14 In this
paper we will evaluate their contributions to anaesthesia and resuscitation.
Anaesthesia
Documentation
of the use of AI-Murquid
Both of the
historians, Ibn Khalkan15 in the thirteenth century, and Ibn Katheer16
in the fourteenth century, documented that Urwa Ibn AI-Zubair in the beginning
of the eighth century developed leg gangrene for which amputation was required.
The doctors of Khalifa Al-Waleed 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. 17-20
Also in the literary book Sayd Ul-Khatir, Ibn ul Joozi in the
twelfth century referred to the anaesthetizing effect of Bhanj. 21
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 Sina9 gave a dose of one
'mithkal' of mandrake for 3-4 hours of general anaesthesia.
However, Ibn El Quff12 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.
Anaesthesia
personnel
The
knowledge and practice of anaesthesia reached its peak in the beginning of the
fourteenth century as evidenced in Ibn El Quff's book on surgery Al-Omda Fil
AI-Jiraha12 (the mainstay in surgery). Unlike Paulus of Aegineta,
22 Ibn El 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.
Monitoring
In that era
they also realized the importance of monitoring during anaesthesia as,
according to Sigrid Hunke23 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.
Resuscitation
Resuscitation
team
In the
memoirs of Prince Osama Ibn Al-Munquiz24 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.
Nutrition
For the
resuscitation of patients with severe weakness and cachexia due to dysphagia,
Ibn Zuhr, 13 in the twelfth 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.
Management
of upper airway obstruction
For the
resuscitation of suffocation due to upper airway obstruction Ibn Sina,9
in the tenth century recommended the introduction of a tube made of gold or silver, or similar metal, to
assist breathing. In agreement with Brendt & Georig25 this
represents the first reported use of an endotracheal tube. However, before
attempting intubation, Ibn Sina9 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 Adams26
and Spink & Lewis27 Aretaeus in the second century and
Caelius Aurelinus in the fourth century did not approve of tracheotomy.
Therefore, although Paulus22 (seventh century) quoting Antyllus
(second century), described the technique of tracheotomy, the operations
remained in disfavour. This state of affairs lasted until the Islamic era when
AI-Razi8(ninth century) and later Ibn Sina 9 (tenth
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-Zahrawy28 in the tenth to
eleventh century and Ibn Zuhr13 (twelfth century). Al-Zahrawy,
28 in his book Al-Tasrif Liman Ajaz An Al-Taalif 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
Zuhr13 in his book AI-Tayseer 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-Zahrawy and Ibn Zuhr such as AI-Bagdadi11
and Ibn El 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 El Quff's12 indications for tracheotomy
specifically included the failure to introduce cool air to the interior .
Use
of bellows
Ibn
Abi-Usaybia29 in the thirteenth century in his book of medical
biographies Uyunul-Anba Fi-Tabaqat AI-Atibaa 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 Jaser30 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 twelfth century31 and
greatly influenced the European mediaeval schools of medicine well into the
eighteenth century. 2-4,7,31-36
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*King Abdulaziz University Hospital
PO Box 5l20, Jeddah 21422, Saudi Arabia
Department of Anaesthesia
ADNAN ABDULLAH AL.MAZROOA
Department of Urology
RABIE EL-SAEED ABDEL.HALIM