|Year : 2012 | Volume
| Issue : 2 | Page : 75-78
Light through the dark ages: The Arabist contribution to Western ophthalmology
Imran Haq1, Humayun A Khatib2
1 ST1 Ophthalmology, West Midlands Deanery, Cardiff, United Kingdom
2 Consultant Ophthalmologist, MDA Clinic, Cardiff, United Kingdom
|Date of Web Publication||4-Aug-2012|
Birmingham Midland Eye Centre, Dudley Road, B18 7QH
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Europe in the Middle Ages had descended into a dark period, and none more so than in the field of medicine. The rich heritage of the pagan Greeks had largely been ignored or forgotten by medieval Europe, and instead it was the early Arabist world that embraced and developed the Hellenistic medical teachings, emerging not only as guardians of the classical learning still existent, but also as pioneers and innovators, restricted only by the development in the associated fields. The Kahhal (), or Oculist or Eye Specialist, had a privileged place in royal households, especially during the Abbasid period, in contrast to the time of Galen, whose writings referred to ophthalmologists in a rather derogatory manner. This elevated standing in the medical profession allowed Arabist scholars to cultivate remarkably erudite techniques and exceptional texts, which were used until very recently.
Keywords: Arabist, medicine, ophthalmology, surgery
|How to cite this article:|
Haq I, Khatib HA. Light through the dark ages: The Arabist contribution to Western ophthalmology. Oman J Ophthalmol 2012;5:75-8
| Introduction|| |
Under the Islamic Prophet Muhammad (570-632), Arabia's many tribes first began to unite together under one state and one ideal. The Prophet Muhammad gave detailed guidelines on diverse aspects of well-being, oftentimes looking after patients himself, with an emphasis on sound health being the natural state of existence, and as a result medicine became a central aspect of early Islamic endeavors. 
Following the death of the Prophet Muhammad in 632, Islam spread rapidly, slicing through the Middle East into Africa, and as far west as France. This rapid expansion led to the rise of three fundamental dynastic caliphates: the Abbasids (750-1258) arose in Persian Baghdad; in the Spanish West, particularly at Cordova, the Umayyads (756-1031); and the Fatimids in Egyptian Cairo (909-1171). 
The Abbasid Dynasty heralded Islam's Golden Age, and it was during this period that the translation of writings from other civilizations, past and contemporary, blossomed. The Abbasid Caliph Al-Ma'mun (786-833) is usually ascribed with institutionalizing the translation of the ancient sciences, and setting these out systematically, with his Bayt al-Hikmah or The House of Wisdom situated in Baghdad.  This institution, which became the intellectual hub of Islamic scholarship, had, as its principal activity, the translation of many critical works from other civilizations into Arabic, preserving countless precious manuscripts. By the time this had started in the early ninth century, Islam had already spread to such an extent that contact with the West was widespread, and hence the Bayt al-Hikmah had the advantage of employing a very cosmopolitan blend of scholars of many different creeds and languages.
| Cataract|| |
Because blindness was a major cause of morbidity in the medieval Arab world, as is the case in the developing world today, Arabist physicians developed much exposure to ophthalmological conditions, and nearly every major medical work written at the time had a chapter on diseases of the eye. 
The first major contributor to Islamic ophthalmology was Yuhanna Ibn Masawaih or Mesue the Elder (777-857), an Assyrian physician who came to Baghdad and became one of the early directors of the Bayt al-Hikmah as well as the personal physician of four caliphs. He is attributed with many medical and anatomical works, the most notable being the Daghal al-'ain or Disorder of the Eye, the first systematic work on ophthalmology, discussing 48 conditions in detail, including the removal of cataracts with a hollow tube via suction (which he attributed to Antyllus, a Greek physician from the second century). This method that had never really taken on due to the popularity of the overriding form of cataract surgery at the time, a method known as couching.  This involved using a bent needle with a mild incline that drove the lens into the posterior chamber, and out of the line of sight, and was first described by the Indian physician Sushruta, in his work the Sushruta Samhita, as early as the sixth century BC.  Couching was very ineffective and dangerous.
The descriptions by earlier oculists of removing cataracts through the use of suction provided the backdrop for the Iraqi Ammar bin Ali Al Mawsili to attempt such an extraction in the tenth century by inventing a tubular metallic syringe with a hypodermic needle.  This was inserted through the sclera and thereby allowing successful removal of cataracts by suction. Al Mawsili wrote regarding his extraction:
"Then I constructed the hollow needle, but I did not operate with it on anybody at all, before I came to Tiberias. There came a man for an operation who told me: Do as you like with me, only I cannot lie on my back. Then I operated on him with the hollow needle and extracted the cataract; and he saw immediately and did not need to lie, but slept as he liked. Only I bandaged his eye for seven days. With this needle nobody preceded me. I have done many operations with it in Egypt." 
Unlike other methods from the Arabist civilization, this method only really took off in the eastern lands, and as a result remained largely unknown to the West where the technique of couching persisted until Daviel separately described lens extraction
| Ophthalmology as a Specialty|| |
Ibn Masawaih's work was outshone by that of his tutee Hunain Ibn Ishaq, otherwise recognized as Johannitus (808-873), who continued Ibn Masawaih's work and wrote several medical and ophthalmologic treatise, combining Greek doctrines and his own observations, which later circulated in Latin throughout Europe. 
Ibn Ishaq was the son of a Nestorian Christian chemist, who first went as a boy to a medical school at Gunde Shapur, an ancient Persian town, but asked so many questions that he was driven away by Ibn Masawaih, and he subsequently left for Greece, before returning 4 years later. 
During his life, Ibn Ishaq produced 36 books, describing cysts, tumors, and ulcers, as well as the contemporary theories behind their cause, in addition to detailing several surgical techniques.  One of the most notable of these was Ibn Ishaq's Ten Treatise of the Eye, which documented the work of scholars such as Aristotle, Galen, and Hippocrates, and also delineated the first detailed anatomical illustration of the eye.  There were originally just ten treatises, when Ibn Ishaq's nephew, Hubais, with whom he translated many of the works of earlier scholars, asked him to write one more:
- Nature of the eye and its structure.
- Nature of the brain and its use.
- Optic nerve and visual spirit.
- Conservation of health
- Causes of accidents to the eye
- Symptoms of diseases of the eye
- Virtues of all remedies
- Kinds of remedies and their species, particularly for the eye.
- Medical treatment of the eye.
- Compound remedies for eye diseases.
- Operative treatment for the eye. 
Ibn Ishaq and his tutor Ibn Masawaih represented a transitional period in Arabic medicine whereby physicians did not solely translate and interpret earlier works but also began to cultivate original medical works.  They maintained a link between Islamic and Western teachings and rather than only delving into academic, and at times rather speculative contemplations on disease, Arabic scholars began to cultivate more understanding of the scientific method, thereby also leading them to come up with practical techniques to treat illness. 
Al-Razi or Rhazes (860-932) was the next great contributor to Islamic ophthalmology. He was a recognized polymath,  making several important contributions to many fields in science and the arts, and especially to that of Islamic ophthalmology, documenting and advancing many surgical techniques in his famous theoretical Kitab Al-Mansouri; in essence, a medical manual, which was used widely in medieval Europe.  There is not much in the form of documented literature detailing the early life of Al-Razi, but Islamic legend tells the story of how he chose the site of his first hospital in Baghdad by suspending meat in different areas of the city, and finding the site with the least decay. ,
Al-Razi condemned the Hellenistic teachings as well as that of his predecessors for reaching conclusions, which did not correlate with clinical findings, and was an early proponent of experimental medicine.  He advanced and detailed many new surgical methods for repairing damage to the eye and also described more than 900 patient case reports in his Kitab al-Tajarib. 
| Optics|| |
Ibn Al-Haytham, known as Alhazen (965-1040), wrote Kitab al- Manazir or the Book of Optics, and this was a revolutionary work in the history of ophthalmology, containing detailed descriptions of the anatomy of the eye and theory on how the eye may function, as well as the behavior of light itself using a very scientific method in disproving the Greek theories on how the eye saw.
It was initially suggested by Hellenistic theories on vision that sight was a result of rays emanating from the eye itself (Euclid and Ptolemy) or the intromission theory, whereby an object somehow communicated its form to the eye (Aristotle). These views were rejected by the Islamic scholars, especially Al-Haytham, who postulated that the image of an object was actually a result of light reaching the eye from a source.  He wrongly however sided with Ibn Sina, or Avicenna, that an image is formed by the lens, but rightly suggested that a retina was critical for this to occur.  Of greater significance, however, was the manner in which Al-Haytham reached his conclusions, utilizing a very scientific method of disproving the inherited Greek literature via experimentation, and thereby leaving a lasting legacy on the work of Western scientists, being quoted by the likes of Roger Bacon and Johannes Kepler. 
Among the other distinguished figures was Ali Ibn Isa (940-1010) or Jesu Occulist. Ibn Isa is held by many to be one of the most celebrated clinicians of his time, and his greatest work was the landmark textbook on ophthalmology in medieval Islam, the Tadhkirat al-Kahhalin or Notebook of the Oculists. This described over 130 eye conditions (many of which have been described by the likes of Ibn Ishaq in the past, but now in more detail), with the book sorting them by their anatomical locations. Along with the works of Ibn Ishaq, it illustrated, for the first time, the anatomy of the eye, especially the optic chiasm and brain, and as a result accompanied Western anatomists for centuries. ,
| Ocular Surgery|| |
External diseases of the eye were very common in medieval Arabia, and many of the treatments pioneered then are still very much practiced today, albeit in a more refined and sanitized fashion. Ibn Isa described chalazions (cysts present in the eye lid) as "collections of a gross humour," and surgical treatment involved incision with a lancet, scraping out with a spoon, irrigation and suturing; contemporary management involves incision and curettage. Styes were treated by rubbing with hot bread; hot compresses are used today. Trachiasis was (and still is) a leading cause of blindness, and its sequelae were surgically treated by pulling out the ingrowing lashes, and cauterization of the roots with a needle held on an open flame till red-hot. The trachomatous pannus was recognized as a superficial vascularization of the cornea due to trachomal infection, and was surgically treated by hooking the pannus and raising it to cut away the layer with cataract needles or small scissors. This is similar to the modern-day 'Peritomy' procedure carried out by modern-day ophthalmologists. Pterygium (a benign growth of the conjunctiva) was treated in a similar method to that of pannus. 
Abul Kasim ben Abbas al Zarawi, known in the West as Abulcasis (936-1013), was an Andalucian whose great medical work Al Tasrif or The Explanation had within its bounds a collection of the cream of Arabic ophthalmic surgery. During his own time, he was little appreciated but it was when his comprehensive works were translated into Latin around 1500 in Venice that his fame spread, with frequent reprints and circulation within medieval Europe. He listed his ophthalmic procedures in his second volume: 
| Legacy|| |
The following two centuries heralded further unparalleled interest in the flourishing science of ophthalmology, with the Islamic caliphates funding greater scholarship, and as a result between 800 and 1300 more than 60 oculists, authors of textbooks or monographs on ophthalmology were produced.  The Spaniard Muhammad Ibn Qassum Ibn Aslam al-Ghafiqi (d. 1165) wrote Al-Murshid fi'l Kuhl or the Right Guide to Ophthalmology, which cataloged all the ophthalmological instruments available at the time. Not much else is known about this oculist, barring the fact that he lived and practiced in Cordoba. 
The Egyptian oculist Fath al-Din al-Qaysi (d. 1259) wrote Natijat al-fikar fi'ilaj amrad al-basar or The Result of Thinking about the Cure of Eye Diseases.  Al-Qaysi was appointed chief physician to two Abbasid Caliphs, including the famous Saladin, and was one of the most respected physicians in Cairo. His treatise comprised 17 chapters dealing with the basics of ophthalmology delineating the pathophysiology, symptoms, and treatment of almost 130 ocular diseases, with some seemingly documented for the first time. In much the same period, another comprehensive ocular manual was composed by the Syrian Khalifah Ibn Abi al-Mahasin al-Halabi, including very intricate charts of instruments. 
| Conclusion|| |
In 250 years, the Islamic Golden Age produced more than 18 written works on the flourishing science of ophthalmology, while the Greeks in more than a millennium produced just five and none by a specialist. , The earlier Greco-Roman oculists undertook practices that were very crude and had very little scientific basis behind them, and as a consequence were treated with contempt by their communities. This usually resulted in more harm than good, and this lack of a scientific method was very much frowned upon by many of the leading lights of the medieval Arabist age - and as a result a lot of their work acted as the foundation not only to ophthalmology, but also to that of European science and medicine well into Victorian times.
The prevalence of eye diseases in medieval Arabia allowed a very unique exposure to a burgeoning empire, and oculists of many different creeds and cultures found themselves amidst a background for discovery and were actively supported in their quest to not only solidify the body of knowledge available, but also elaborate and refine methods of their own, with many techniques fashioned in medieval Islamic times still recognizable to ophthalmologists today.
"As Professor Julius Hirschberg concluded in his 1905 address to the American Medical Association:
During this total darkness in medieval Europe they (the Arab Muslims) lighted and fed the lamps of our science (ophthalmology) - from the Guadalquivir (in Spain) to the Nile (in Egypt) and to the river Oxus (in Russia). They were the only masters of ophthalmology in medieval Europe." 
| References|| |
|1.||Khan MS. Islamic medicine. London: Routledge & Kegan Paul; 1986. |
|2.||Matthews RT, Platt FD. The Western humanities. Columbus, OH: McGraw-Hill; 2003. |
|3.||Dallal A. Science medicine and technology. In: Esposito JL, editor. The Oxford history of Islam. Oxford: Oxford University Press 1999. p. 155-213. |
|4.||Savage-Smith E. Islamic Medical Manuscripts at the National Library of Medicine. Bethesda, MD, U.S: National Library of Medicine; 2005. |
|5.||Savage-Smith E. The practice of surgery in Islamic lands: Myth and reality. Soc Hist Med 2000;13:307-21. |
|6.||Farhadi M, Behzadian Nejad G, Bagbanzadeh A. Papers of the international congress of the history of medicine in Islam and Iran [in Persian] Vol. 1. Tehran: Iranian Institute for Science and Research Expansion; 1994. |
|7.||Syed IB. Islamic Medicine: 1000 years ahead of its times. Journal of the Islamic Medical Association 2002;2:2-9. |
|8.||Finger S. Origins of neuroscience: A history of explorations into brain function. Oxford: Oxford University Press; 1994. |
|9.||Savage-Smith E. Europe and Islam. In: Western Medicine: An Illustrated History, Loudon I (ed). Oxford University Press: New York. 1997.p. 40-54. |
|10.||Pollock WB. Arabian ophthalmology Br J Ophthalmol 1946;30:445-56. |
|11.||Shafqat Azmi KA. Hunain bin Ishaq on opthalmic surgery. Bull Indian Inst Hist Med Hyderabad 1996;26:69-74. |
|12.||Sorsby A. A short history of ophthalmology. London: Staples Press; 1933. |
|13.||Hirschberg J. Arabian ophthalmology. J Am Med Assoc 1905;XLV:1127-31. |
|14.||Wakim KG. Arabic medicine in literature. Bull Med Libr Assoc 1944;32:96-104. |
|15.||Clifford E, Asimov M. History of civilizations of Central Asia (Vol. IV). Paris: Motilal Banarsidass Publ/UNESCO; 2003. |
|16.||Arrington G. A history of ophthalmology. New York: MD Publications; 1959. |
|17.||Hermann ET. Early Arabian medicine. Bull Med Libr Assoc 1936;25:113-7. |
|18.||Ligon B. Biography: Rhazes: His career and his writings. Semin Pediatr Infect Dis 2001;12:266-72. |
|19.||Alvarez-Millan C. Practice versus theory: Tenth-century case histories from the Islamic Middle East. Social History of Medicine 2000;13:293-306. |
|20.||Wade NJ. A natural history of vision. Cambridge, MA: MIT Press; 1998. |
|21.||Lindberg DC. Roger bacon and the origins of perspectiva in the middle ages. Clarendon Press: Oxford 1996. |
|22.||Wood CA. trans. Memorandum Book of a Tenth-Century Oculist by Ali ibn Isa. Chicago: Northwestern University; 1936. |
|23.||National Library of Medicine US. Islamic Culture and Medical Arts. Retrieved 2009, from National Library of Medicine: http://www.nlm.nih.gov/exhibition/islamic_medical/islamic_09.html. 2009. |
|24.||Blodi FC. Trans. The History of Medicine by Julius Hirschberg (Vol. II) Wayenborgh: Bonn 1982. |