Contributions of Medieval Islamic Physicians to the History of

E SPECIAL ARTICLE
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,**
Tracheostomy was first described by Greco-Roman physicians, including Paulus of Aegina.
Medieval Islamic clinicians extended the Greco-Roman ideas with substantial contributions to
the field 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 modifications of the procedure, instrumentation, and adjuvant medicinal prescriptions. (Anesth Analg 2013;116:1123–32)
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)
T
racheostomy has been known for millennia as an effective 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 performed by Egyptians in 3600 BCE. However, the earliest references 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 suffocation by making an opening in the trachea using the tip
of his sword.3 Although Hippocrates (460–370 BCE) theoretically 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
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 University, 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 Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz,
Iran. Address e-mail to [email protected].
Copyright © 2013 by the International Anesthesia Research Society.
DOI: 10.1213/ANE.0b013e3182884313
May 2013 • Volume 116 • Number 5
At the start of the Middle Ages, Paulus of Aegina (ca. 625–
690 CE) presented the first detailed surgical description of tracheostomy.7 Tracheostomy appeared in medical texts during
the Islamic Golden Age (ca. 750–1257 CE), along with technical innovations and changes. The history of tracheostomy in
Renaissance and modern Europe has been extensively studied, 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
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Figure 1. Portrait of Abubakr Muhammad ibn Zakariyya al-Razi or
Rhazes (865–925 CE).
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 voluminous 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 medical 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 incised 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 suffering 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
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Figure 2. The frontispiece of Al-Hawi by Rhazes (Bodleian version).
Reproduced with permission from Middle Eastern and Islamic
Manuscripts, Bodleian Library, Oxford.
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 alMaliki (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 anatomical 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 discourses 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
anesthesia & analgesia
Tracheostomy in Islamic Golden Age
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).
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.
to surgery. In the thirty-eighth chapter of the surgical discourse 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 [incisions] 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 approach would be to hold the skin in place using Sonnareh [a type of hook, Fig. 4], and to cut it until the cartilage 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 contributions particularly in the court of Caliph, Al-Zahrawi
died in 1013 CE.35–37
May 2013 • Volume 116 • Number 5
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 pharyngeal 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, therefore the verdict has been to leave the incision open until 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 arrival; I heard she was letting out noises like an animal with a cut throat. After exploring the wound,
I discovered that not much bleeding was present
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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.
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 observed. 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 village 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 encouraged 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 pharmacist and polymath of the 11th century.28 Avicenna’s travels
to different Persian cities continued in later years affording 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 residing 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 disloyalty. During his 4-month imprisonment, Avicenna wrote
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Figure 6. A page of Al-Tasrif depicting the surgical tools devised or
used by Al-Zahrawi (Sana Library version).
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 reverence 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 medicine. 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 treatment of croup and angina,” describes his method of performing 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
anesthesia & analgesia
Tracheostomy in Islamic Golden Age
Figure 7. Portrait of ibn Sina or Avicenna (980–1037 CE).
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 incised 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: sarcocolla (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 medicine 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
May 2013 • Volume 116 • Number 5
Figure 8. The frontispiece of The Canon of Medicine by Avicenna.
Reproduced with permission from Wellcome Library, London.
era.53–55 He also wrote 2 précis of the Treasure, Al-Aghraz alTebbieh (Medical Goals), and Khofieh Alaii for use as a manual
or handbook by medical students.56 Yadegar (Memorial) written 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 patient’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 elimination of the threat] the membrane should be sutured so
that the membrane and cartilage would not be damaged…”
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Figure 10. Portrait of Ibn Zuhr or Avenzoar (1091–1162 CE).
Figure 9. Portrait of Esmail Jorjani (1042–1137 CE).
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 companion 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
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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 clinical 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 opinions (controversies), I cut on the lung pipe of a goat
after incising the skin and the covering sheath underneath. Then I completely cut off the substance of the
pipe, an area just less than the size of a tirmisah (lupine seed). Then, I kept washing the wound with water 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…”
DISCUSSION
During the Middle Ages, Islamic, Christian, and Jewish
scholars contributed to the development of Islamic medicine, 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 modified 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 prominent 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
anesthesia & analgesia
Tracheostomy in Islamic Golden Age
Table 1. Details of the Tracheostomy Procedure by Medieval Islamic Physicians
Physician
Geographical
region
Persia
Year/Century
(CE)
865–925
Haly Abbas Kitab al-Maliki (The Royal Book)
Persia
930–994
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-Qanun fi al-Tibb (The Canon of
Medicine)
Al-Andalus
936–1013
Persia
980–1037
Jorjani
Zakhireyei Khwarazmshahi (The
Treasure of Khwarazm Shah)
Persia
1042–1137
Avenzoar
Kitab al-Taysir fi al-Mudawat wa
Al-Andalus
al-Tadbir (Book of Facilitation
on Therapeutics and Dietetics)
Rhazes
Avicenna
Book
Kitab al-Hawi (Liber Continens)
1091–1162
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 description 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 contrast 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
Contribution to tracheostomy
Comprehensive description, using 2 threads
for skin retraction, leaving some tiny
openings inside the incision
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
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
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
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
Detailed description of the procedure, the
first elective experimental tracheostomy
(on animal model), application of honey as
a wound healing substance
Performed/not
performed
Performed
Performed (?)
Not performed
Performed (?)
Performed (?)
Performed (on
animal model)
writings and was able to apply the techniques in an emergency, stated that tracheostomy was unknown in his own
time. However, his successful management of a suicidal laceration 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 tracheostomy. 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 fasciculifolius Bioss), aloe (Aloe vera), saffron (Crocus sativus), opium
(Papaver somniferum), rose (Rosa damascene), and horned
Table 2. Natural Substances Used in Tracheostomy and Their Confirmed Effects in Modern Medicine
Described in Medieval Islamic Medical Books
Traditional name
Zarur e Asfar (yellow
powder)
—
—
Common name
Sarcocolla
Aloe
Saffron
Opium
Rose
Horned poppy
Cypress
Honey
May 2013 • Volume 116 • Number 5
Scientific name
Astergalus fasciculifolius Bioss
Aloe vera
Crocus sativus
Papaver somniferum
Rosa damascena
Glaucium cornicolatum
Cupressus sempervirens
—
Persian name
Anzarout
Sabr-e-zard
Zafaran
Afyoun
Gol-e-sorkh
Mamitha
Sarv
Asal
Effects
Wound healing74,75
Antimicrobial,76 wound healing77
Anti-inflammatory,78 wound healing79
Antinociceptive80
Antinociceptive,81 Anti-inflammatory,81 antimicrobial82
—
Antimicrobial83,84
Wound healing,85 antimicrobial86
www.anesthesia-analgesia.org 1129
E SPECIAL ARTICLE
poppy (Glaucium cornicolatum) to be applied on the sutured
tracheostomy incision. Ibn Zuhr recommended application 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 figures 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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