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Islamic ophthalmology

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Ophthalmology was one of the foremost branches in Islamic medicine. The oculist or kahhal (کحال), a somewhat despised professional in Galen’s time, was an honored member of the medical profession by the Abbasid period, occupying a unique place in royal households. As such, medieval Islamic physicians are considered founders of ophthalmology as an independent discipline in its own right.[1] The specialized instruments used in their operations ran into scores. Innovations such as the “injection syringe”, a hollow needle, invented by Ammar ibn Ali of Mosul, which was used for the extraction by suction of soft cataracts, were quite common.

Muslim physicians deserve much praise for their descriptions of ophthalmological pathology. They were the first to describe such conditions as pannus, glaucoma (described as ‘headache of the pupil’), phlyctenulae, and operations on the conjunctiva. They were the first to use the words 'retina' and 'cataract'. They also pioneered the field of optics. The list of Muslim contributions to Ophthalmology is anything but brief.

Fertile grounds for emergenceEdit

The scientific achievements of the late Abbasid period may perhaps be attributed to the worldview that had developed as a result of the establishment of the House of Wisdom, and intermingling of scholars from India, Persia, North Africa and the west, in Baghdad. There, an ideology began taking shape in which unlike their early Islam predecessors, did not recognize a disparity between faith and reasoning, though many doubtlessly continued to do so. The Moorish Lisan al-Din ibn al-Khatib, himself a great vizier and a man of medicine, is famous for once declaring that “whatever the traditions of the prophet might say, their remarks about exhalations from Hell cannot stand against the evidence of careful observation.” And put another way by Ibn Tufayl: “Faith is for the people. But its understanding in the light of reason, is the privilege of the intellectual elite.”

Education and historyEdit

Ali ibn Isa was born in Baghdad. His work, Tashkiratul-Kahhalîn (Notebook of the Eye Physician), the best and most complete text book on diseases of the eye. Ibn Isa's was the most widely referred to textbook by later ophthalmologists. It was first translated into Persian and then into Latin and printed in Venice in 1497 CE. Famous contemporaries of Isa Ibn Ali were Ammar Ibn Ali Al-Mosuli and Abul Hasan Ahmed Ibn Muhammad Al-Tabari who, in his work Kitâb-ul Mu'âlaja 'l-Buqratiyya (Book of Treatment), says that he wrote a long treatise on diseases of the eye.[2]

Ammar Ibn Ali Al-Mosuli, from Mosul in Iraq, flourished around 1010 CE. He wrote a book entitled Kitâb al-Muntakhab fî 'ilâj al-'ayn (Book of Choices in the Treatment of Eye Diseases) and practiced mainly in Egypt. His book deals with anatomy, pathology and describes six case histories for cataract operation and a case of optic neuritis. Ammar discussed some 48-eye diseases. Ammar was the inventor of the cataract operation by suction, using a fine hollow needle inserted through the limbus (where the cornea joins the conjunctiva). This was the best-performed operation of its time. This type of cataract operation among others is still carried out today. Ammar throughout his work, as a surgeon and researcher, never forgot his compassionate attitude towards his patients. On his travels he fulfilled his religious duties, visiting Medina and performing Hajj at Mecca.[3]

Abu Ruh Muhammad Ibn Mansur Bin Abdullah Al-Jurjani, an excellent surgeon from Persia who flourished around 1088 C.E., wrote a book, entitled Nûr-ul-'Uyûn (The Light of the Eyes). The book, much of which is original, was written during the reign of Sultan Malik-Shah I and consists of ten chapters. In the seventh chapter he describes some 30-eye operations including 3 types of cataract operation. He also deals with anatomy and physiology of the eye and eye diseases. One chapter is devoted to eye diseases which can be seen such as cataract, trachoma, scleral and corneal diseases and problems of the eyelids. Another chapter deals with diseases that lie hidden, third nerve paralysis, blood disorders, toxicity. The book mentions curable and incurable diseases and gives methods of treatment. A large section is about surgery of the eye. There is a section on drugs employed by the Ophthalmologists.[4]

Another name mentioned by Hirschberg in his address to the American Medical Association (1905) was Abu Muttarif from Seville (Spain) who flourished around the 11th century. Besides being an eye specialist he was also a Vizier (minister).

Muhammad Ibn Qassoum Ibn Aslam Al-Ghafiqi, a Muladi Muslim (died 1165 CE), also from Spain, wrote a book in the 12th century called Al-Murshid fî 'l-Kuhl (The Right Guide in Ophthalmology). The book is not just confined to the eye but gives details of the head and diseases of the brain. Al-Ghafiqi used Ammar's treatise as a reference for his work. Today a tourist visiting Cordoba can see the commemorating bust of Muhammad Al-Ghafiqi, a tribute paid from the people of Cordoba to an outstanding Muslim eye specialist. The bust with full Arab Ammama can be seen in the quadrangle of a municipal hospital in Cordoba, Spain.[5]

Kalifah Ibn Al-Mahasin of Allepo (Syria), who flourished around 1260 CE, wrote a book of 564 pages in which he describes and gives drawings of various surgical instruments including 36 instruments for eye surgery. He also discusses the visual pathways between the eye and the brain. He also writes about twelve kinds of cataract operations. The term for cataract in Arabic is Al-Mâ' Nazul 'Ayn. Mâ' means water or water descending onto the eye, water accumulates in the lens and it becomes "soggy" thus making it cloudy. This cloudiness is sucked out by the use of hollow needle, thus the cataract is removed and the patient is once again able to see.[6]

Salahuddin Ibn Yusuf from Hammah of Syria wrote in 1290 CE a book called The Light of the Eyes in which he discussed new work on the optical theory of vision. He also quoted many extracts from Ammar's treatise. He did work on the eye from a more general medical point of view, as did other notable physicians such as Abu al-Qasim al-Zahrawi, Ibn Zuhr and Ibn Rushd.

To become a practitioner, there was no one fixed method or path of training. There was even no formal specialization in the different branches of medicine, as might be expected. But some students did eventually approximate to a specialist by acquiring proficiency in the treatment of certain diseases or in the use of certain drugs. “The Prince of Physicians”, the Persian (Iranian) Avicenna, for example, was held to be more proficient than most others in his treatment of nervous diseases, and hence a large number of psychological cases were brought to him, the most famous being the Samanid prince Nooh ibn Mansur who thought of himself as a cow, and who was cured by Avicenna who was no more than 17 years of age. Avicenna himself benefited from the instruction of many teachers, ranging in subject from geometry to theology.

Nevertheless it was standard and necessary to learn and understand the works and legacy of predecessors, if one was to excel and surpass others in the field. Among those one can mention The alteration of the eye by Yuhanna ibn Masawayh, the great ethnic Assyrian Christian physician, whose work can be considered the earliest work on Ophthalmology, only to be eclipsed by that of none other but Hunain ibn Ishaq another Assyrian Christian physician, known in the west as Johannitius, for his work The ten treatises of the eye.

Cataract extractionEdit

The next major landmark text on ophthalmology was the Choice of Eye Diseases written in Egypt by the Iraqi Ammar bin Ali Al Mawsili[1] who attempted the earliest extraction of cataracts using suction. He invented a hollow metallic syringe hypodermic needle, which he applied through the sclerotic and successfully extracted the cataracts through suction.[7] He wrote the following on his invention of the hypodermic needle and how he discovered the technique of cataract extraction while experimenting with it on a patient:

"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."[8]

Physiological opticsEdit

See also: Book of Optics and Islamic physics

Ibn al-Haytham (965-1039) has been described as the father of ophthalmology.[9] He discussed the topics of medicine and ophthalmology in the anatomical and physiological portions of the Book of Optics and in his commentaries on Galenic works.[10] He accurately described the process of sight,[11] the structure of the eye, image formation in the eye and the visual system. He also discovered the underlying principles of Hering's law of equal innervation, vertical horopters and binocular disparity,[12] and improved on the theories of binocular vision, motion perception and horopters previously discussed by Euclid and Ptolemy.[13][14]

He discussed ocular anatomy, and was the first author to deal with the "descriptive anatomy" and "functional anatomy" of the eye independently.[15] Much of his decriptive anatomy was faithful to Galen's gross anatomy, but with significant differences in his approach.[16] For example, the whole area of the eye behind the iris constitutes what Ibn al-Haytham uniquely called the uveal sphere, and his description of the eye was devoid of any teleological or humoral theories associated with Galenic anatomy.[17] He also described the eye as being made up of two interesecting globes, which was essential to his functional anatomy of the eye.[18]

After describing the construction of the eye, Ibn al-Haytham makes his most original anatomical contribution in describing the functional anatomy of the eye as an optical system,[19] or optical instrument. His mulitple light-source experiment via a reduction slit with the camera obscura, also known as the lamp experiment, provided sufficient empirical grounds for him to develop his theory of corresponding point projection of light from the surface of an object to form an image on a screen. It was his comparison between the eye and the beam-chamber, or camera obscura, which brought about his synthesis of anatomy and optics, giving rise to a new field of optics now known as "physiological optics". As he conceptualized the essential principles of pinhole projection from his experiments with the pinhole camera, he considered image inversion to also occur in the eye,[15] and viewed the pupil as being similar to an aperture.[20] Regarding the process of image formation, however, he incorrectly agreed with Avicenna that the lens was the receptive organ of sight, but correctly hinted at the retina also being involved in the process.[21]

Surgical treatment HEYEdit

Edit

Being an ophthalmologist was not an easy profession then, for a license was required to be able to practice. The granting or withholding of this rested with the hakim-bashi, the chief physician to the Caliph. However, in addition to this test of certification, there was an additional means of checking for malpractice: Aside from the chief physician whom to which the Caliph delegated his powers to, there was another official known as the Muhtasib, or Inspector–General, who was appointed to oversee the practice of medicine by all physicians.

Before the year 931CE, there was hardly any means of professional certification, for in that year the Abbasid Caliph al-Muqtadir, was informed that the mistake of a private medical practitioner had resulted in the death of a patient. The Caliph therefore issued orders to the Inspector-General Ibrahim Muhammad ibn Abi Batiha to see to it that the practice of medicine by anyone who had not been examined and approved by Sinan ibn Thabit ibn Qurra be prohibited. Sinan thus only authorized physicians to practice whom he personally endorsed. He furthermore would suggest to each applicant what branch of medicine he ought to practice in. It is said that he examined a total number of physicians exceeding the number 860 in Baghdad alone during the first year.

The chairing of the board was later passed to Sinan’s son Ibrahim, who became chief physician of Baghdad, and Abu Sa’id Yamāni of Basra who certified the practice of 700 physicians through examinations. The board continued to function, being chaired by the likes of Ibn al-Tilmiz, court physician to caliph Al-Mustazhir.

Both the offices of the chief physician and the inspector general formed part of the royal caliphate. Among the Muhtasib’s duties were the administering of the Hippocratic Oath, which required physicians to swear that they would prepare, administer, or entrust no poisonous drafts to any unauthorized persons: that they would avoid gazing upon unrelated women folk within the sick household they visit: and that they would never reveal to any third person anything revealed to them in confidence by the patient. So important was this oath that Hunain ibn Ishaq was said to have reminded the Caliph of his oath when asked to prepare a lethal poison for an enemy of the Amir.

It was also the Muhtasib’s duty to see that physicians possessed proper instruments of his calling that were necessary and befitting for practice, as was with all the other branches of medicine. He would further, if he wished, require them to undergo a further examination. For example, physicians would be required to be thoroughly familiar with the ‘Ten treatises on the eye’, and were forbidden to practice unless they demonstrated knowledge of the gross anatomy of the eyeball. Rhazes, for instance, when about to undergo an operation for his deteriorating vision, orally examined his surgeon on the anatomy of the eye, and finding him lacking in knowledge refused to submit to his blade for the operation.

Ophthalmologists hence had to satisfy the examiner that they knew the principal diseases of the eye as well as their intricate complications, and were able to properly prepare collyria and ophthalmic ointments. Moreover they had to assert under oath not to allow unauthorized persons access to any surgical instruments, such as the lancet that was used for cases of pannus and pterygium, or the curette used for cases of trachoma.

The penalties for disregarding proper professional conduct varied from the warning of divine punishment on the Day of Resurrection, to more drastic measures such as the beating of the soles of the feet. The Muhtasib had such authority as to even inspect shops during after hours, as frequently and unexpectedly as he wished. He could enter shops and observe operations being performed. The inspector-general would oversee the preparation of certain ointments and destroy jars that he determined to be old or smelly. The rules for maintaining sanitary conditions were quite severe for such places including those of the druggists, public eating houses, and butchers. In earlier days, the Muhtasib had the right to punish, even by death, gross neglect of the health of the public. It was not uncommon to hear of a baker be thrown into his own furnace for selling poisonous corn, or for a cook to be boiled in his own cauldron for selling carrion or putrid meat.

Still, the sheer number of ignorant and fraudulent eye-charlatans caused many problems. So shocking was the conduct of these ignorant doctors that it was the declared duty of the Muhtasib to see that such men perform no operation upon the eyes, and never give a patient any preparation intended to be applied within the lids. Rhazes poured out his wrath when encountering quacksters and charlatans.

In the Ottoman Empire, and well into the Republic of Turkey of the 20th century, a class of ambulatory eye surgeons, popularly known as the ‘kırlangıç oğlanları’ (‘sons of the swallow’) operated on cataract using special knifes. From contemporary sources can be glimpsed that the reputation of these “blinding frauds” was far from spotless.[22]

Fees and incomeEdit

There was a good deal of drama surrounding the men of medical professions in those days. A physician could on the one hand receive no less than an astronomical sum of 4,000,000 dirhams a year, as did Bukhtishu ibn Jurjis, the Assyrian Christian chief physician to the great Caliph Harun al-Rashid; or pay for the unfortunate death of his patient or failure of his treatment with his own life, as was often the case with physicians treating many a royalty.

But in general, the fee varied according to the status of the physician and the patient. The life of Ibn Masawayh, can perhaps be quite instructive in this regard: When still unknown and still a so called “road-side” physician in Baghdad, in return for successfully treating a servant suffering from Ophthalmia, he was paid with a daily allowance of bread and meat and sweets and a promise of a monthly salary of a few silver and copper coins. When The Vizier fell ill and Ibn Masawayh achieved similar success with him, his salary rose to 600 silver dirhams a month, food for two mules, and the services of five servants. And when he finally obtained the rank of chief ophthalmologist to the Khalifah, his salary was fixed at 2000 dirhams a month plus gifts valued at 20,000 dirhams a year, including forage for his mules as well as the services of a number of servants.

However, fees paid to ophthalmologists were measly in comparison to the elephantine fees which others were apt to receive overall. At the time when Ibn Masawayh received 2000 dirhams a month as ophthalmologist-in-chief to the Caliph Harun al-Rashid, Jibrail the physician was receiving 10,000 dirhams per month.

As to the means of obtaining the fee, in cases deemed chronic requiring multiple visits, they would receive the fee only on the fair conclusion of the case. If the patient recovered, there was, in most cases, no question of refusal to pay. But if the case ended fatally, then the relatives could if they so choose, show the chief physician of the city a copy of all prescriptions and medicaments which he ordered for the sick person. If the Hakim-bashi determined they were proper and fitting for the case and that the physician was exempt of any negligence or fault, he could declare that the person’s life had reached its allotted span by the will of Allah, and that the fees had to be paid in full. If on the other hand, the chief physician found evidence of neglect, he would direct the relatives to collect dieh (or blood money) for their kinsman from the physician, ‘for it is he who slew him by his poor skill and negligence.’

Nevertheless, some ophthalmologists would be fortunate enough to work as personal ophthalmologist to an Amir of good heart and intellect, and some Caliphs were even known to have kept a personal ophthalmologist in addition to a personal physician.

So well ingrained did the science of ophthalmology become in medieval Islamic culture that the word used for "wisdom" in Arabic is "al-Basirah", meaning the ability to see. In fact, one refers to loved ones as "Nour al-Ayni" meaning the light of my eyes.

NotesEdit

  1. David C. Lindberg (1980), Science in the Middle Ages, University of Chicago Press, p. 21, ISBN 0226482332
  2. http://www.muslimheritage.com/topics/default.cfm?ArticleID=222
  3. http://www.muslimheritage.com/topics/default.cfm?ArticleID=222
  4. http://www.muslimheritage.com/topics/default.cfm?ArticleID=222
  5. http://www.muslimheritage.com/topics/default.cfm?ArticleID=222
  6. http://www.muslimheritage.com/topics/default.cfm?ArticleID=222
  7. Ibrahim B. Syed PhD, "Islamic Medicine: 1000 years ahead of its times", Journal of the International Society for the History of Islamic Medicine 2 (2002): 2-9 [7].
  8. Finger, Stanley (1994), Origins of Neuroscience: A History of Explorations Into Brain Function, Oxford University Press, p. 70, ISBN 0195146948
  9. André Authier (2013). "3: The Dual Nature of Light", Early Days of X-ray Crystallography. Oxford University Press, 23. ISBN 9780191635014. “Tables of angles of incidence and refraction were given by the famous Arab mathematician and physicist Alhazen, considered as the 'father of modern optics' and ophthalmology.” 
  10. Steffens (cf.)
  11. Bashar Saad, Hassan Azaizeh, Omar Said (October 2005). "Tradition and Perspectives of Arab Herbal Medicine: A Review", Evidence-based Complementary and Alternative Medicine 2 (4), p. 475-479 [476]. Oxford University Press
  12. Ian P. Howard (1996). "Alhazen's neglected discoveries of visual phenomena". Perception 25 (10): 1203–1217. doi:10.1068/p251203. PMID 9027923. 
  13. (Wade 1998)
  14. (Howard & Wade 1996)
  15. 15.0 15.1 Gul A. Russell, "Emergence of Physiological Optics", p. 689, in (Morelon & Rashed 1996)
  16. Gul A. Russell, "Emergence of Physiological Optics", pp. 689-90, in (Morelon & Rashed 1996)
  17. Gul A. Russell, "Emergence of Physiological Optics", p. 690, in (Morelon & Rashed 1996)
  18. Gul A. Russell, "Emergence of Physiological Optics", p. 692, in (Morelon & Rashed 1996)
  19. Gul A. Russell, "Emergence of Physiological Optics", p. 691, in (Morelon & Rashed 1996)
  20. Gul A. Russell, "Emergence of Physiological Optics", p. 695-8, in (Morelon & Rashed 1996)
  21. N. J. Wade (1998). A Natural History of Vision. Cambridge, MA: MIT Press. 
  22. Laban Kaptein (ed.), Ahmed Bican, Dürr-i meknûn, p. 31f. Asch 2007. ISBN 9789090214085

ReferencesEdit

  • Sadi, Gulistan.
  • Ibn al-Ukhuwwa, Ma’alim al-qurbah.
  • Ibn Abi Usaybi’ah, Uyun ul-Inba’ fi Tabaqat ul-Atibba, Cairo 1882.
  • Nizami Arudhi, Chahar Maqalah. Gibb Series. London, 1921.
  • Zeylessouf-ed-douleh, Matrah ul-anzār. Tabriz, 1916.
  • Bar Hebraeus, Historia Dynastiarum, Edward Pococke's edition, Oxford 1663.
  • Raphael du Mans, Estat de la Perse.
  • M. Brett, W. Foreman. The Moors: Islam in the west. 1980.
  • Cyril Elgood. A Medical history of Persia and the eastern caliphate : the development of Persian and Arabic medical sciences, from the earliest times until the year A.D. 1932. 1979.
  • Casey Wood. Memorandum book of a tenth-century oculist for the use of modern ophthalmologists : a translation of the Tadhkirat of Ali ibn Isa of Baghdad (cir. 940-1010 CE).

See alsoEdit

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