Core Tip: Medieval Islamic ophthalmological instruments are a rich, complex, and understudied subject. This topic is interesting and deserves more attention than it has had. The book of Al-Halabi is indeed one of the interesting books on ophthalmology written in Arabic. The ophthalmological instruments included in Al-Halabi’s table represent an untold story about the contributions of Muslim and Arab scholars in the field of ophthalmology. The aim of the present article is to fill in one of the gaps to some extent in biomedical engineering history. The ophthalmological instruments represent the biomechanics field.
INTRODUCTION
Studying the biomedical engineering history has greatly influenced the creative and inventive sense of biomedical engineering students[1]. Biomedical technologies have a very long history, among which are the ancient surgical instruments[2]. Bronze age epilation forceps were found in Ur, Iraq. The forceps, used in the treatment of trachoma, date back to ca. 2600 BC[3]. Other epilation forceps were discovered in tombs of the New Kingdom of Egypt (1570-1070 BC). Moreover, pots containing copper, zinc oxide, lead, and antimony sulphates were uncovered at the same tombs. These pigments were utilized for treating conjunctivitis[4]. It is argued that the first “book” on medicine in the world which is a medical papyrus (1553-1550 BC) was discovered in Luxor (Thebes), Egypt, in 1872 by the German archeologist Georg Ebers (1837-1898). In the eye treatment section, the only surgical procedure mentioned in the papyrus that has survived was applying to the eyelid onions, myrrh, gazelle excrement, and blood from lizards or bats after epilation through the use of feathers of a vulture[3].Furthermore, in Egypt, several surgical needles could be seen carved in stone from the relief on the internal facade of the second wall in Kom Ombo Temple, constructed during the Ptolemaic dynasty (180-47 BC). Moreover, W.M. Flinders Petrie (1853-1942) (English Egyptologist) has discovered a series of ancient cooper needles with no hooks or apertures in King Khasekhemwy’s tomb (ca. 2690 BC) in the Royal Necropolis at Abydos, Upper Egypt, in 1900. These needles represent the earliest known ancient surgical instruments for dislodging the cataract away from the pupil[5]. These needles could be found in the National Museums in Liverpool, England[6].Hippocrates (Greek physician d. 370 BC) recommended using wool rounded around a wooden rod soaked in a caustic solution for scraping the eyelids when treating trachoma. Celsus (Roman encyclopaedist d. 50 AD) included in the medical work of his encyclopedia the recommendation of using a hook, a threaded needle, and a scalpel in the treatment of pterygium. Galen (Greek physician d. 210 AD) utilized a cuttlefish bone for roughness in treating trachoma and as an agent to dissolve pterygium. Aëtius of Amida (Byzantine Greek physician, mid-5th century to mid-6th century) applied a blunt hook, a tiny hook, a horse-hair and linen thread through a needle, and a knife in the treatment of pterygium[7]. Numerous gaps exist in the biomedical engineering history, one of which the present article aims to fill in through providing an overview of Al-Halabi’s contributions.
AL-HALABI’S BIOGRAPHY
Al-Halabi (middle of the 13th century)[8,9] - whose full name was Khalifah ibn Abi Al-Mahasin Al-Halabi[10] and who was known as Khalifa Ben Abi Al-Mahassin[11], Khalifa ibn Abi Al-Mahasen Al-Halabi[12], Halifa B Abi L-Mahasin[13], and Halifa[14] for short - was named after Aleppo (Arabic: Halab), a city in the northern part of Syria, known for its thriving trades and wealth in the middle ages before the Mongol onslaught (in 1260 AD)[11]. It was mostly where he was born and died[15,16]. He mentioned two incidents that happened to him in Aleppo in 1252 and 1254 AD (650 and 652 AH)[11,15]. Aleppo was, as it has been for centuries, an important city and the capital of a principality[17]. It appears that Al-Halabi must have had a wide spectrum of knowledge about medical sciences as can be derived from the list of references that he cited. He was considered the first ophthalmologist to use a magnet in order to remove metallic foreign body from the eye by Wafai and Kalaji as well as Hirschberg, as he extracted a couching needle that was broken in a patient’s eye during the surgery[14-16,18]. He realized that an instrument may be substituted by another because of unavailability[15].
AL-HALABI’S BOOK
The Sufficient Knowledge in Ophthalmology (Arabic: Kitab Al-Kafi fi Al-Kuhl), expected to be written within the period from 1256 to 1275 AD, is the only known book by Al-Halabi[11,13,14]. It is one of the masterpieces of Islamic ophthalmological medicine and surgery. The book’s scientific value is incomparable to European manuscripts till the beginning of the nineteenth century[14]. The book describes in a separate chapter the measurements, weights, and sizes used at that time by physicians. It quotes 73 authors and 41 books before its time[9,18]. He referenced famous Arabian or Muslim authors such as Al-Razi, Ibn Sina (Avicenna), Al-Tabari, Hunayn ibn Ishaq, Al-Ghafiqi, Ibn Zuhr (Avenzoar), and Al-Zahrawi; Greeks such as Galen, Hippocrates, and Oribasius; and Indians[15,16].The two copies of the book are to be found in the Bibliotheque Nationale in Paris, France (under the number 1043d. Arabe), and the Süleymaniye Kütüphanesi in Istanbul, Turkey (under the number Yeni Jami 924). The Paris manuscript was written by the Christian copyist Abd Al-Aziz ibn Abi Saeed Al-Masihi Al-Mawsili Al-Mutatabbeb in 1277 AD, meaning that it is very close to the time of the author. The Istanbul manuscript was written by the Muslim copyist Ahmad Al-Wali in 1560 AD, meaning that the manuscript was written around 300 years after the death of the author[15].The book was disappointingly ignored until the French medical historian Lucien Leclerc (1816-1893) had described it briefly for the first time in 1876 in his book “Histoire de la Médecine Arabe”[19]. In 1905, the German ophthalmologist and historian Julius Hirschberg (1843-1925) with the orientalists J. Lippert (1839-1909) and E. Mittwoch (1876-1942) wrote a book entitled “Arabian Ophthalmologists” in which they studied the book with great detail[15,16,20].The present article depends basically on the reproduction of Al-Halabi’s book edited by M. Z. Wafai and M. R. Kalaji. They produced Al-Halabi’s book within the combined series “The Islamic Heritage in Ophthalmology” in which they unearthed the Islamic glorious heritage and its valuable knowledge that served humanity for over thirteen centuries. They compared the two copies of the book (in Paris and Istanbul) and put in the text the most accurate words. They explained in the footnotes some words that could contain more than one meaning. They gave the modern names of the diseases that Al-Halabi described. The book was published by the Islamic Educational, Scientific and Cultural Organization, Rabat, Morocco in 1990[15].
THE INSTRUMENTS TABLE
Al-Halabi’s book is the first book to place thirty-six surgical instruments in a very elegant table[9,21]. This table is considered to be well organized as each surgical instrument was placed in a special frame with the name of the instrument on the top and the way to use it underneath it, as shown in Figure 1[16,22]. This was the first time that an author put a table for the surgical instruments, unlike his predecessors who used to put the drawing of the instrument within the text[15].
‘Foreign body’ fallen into the eye (p.215), Stye (p.279), Hordeolum (p.287),
Gatherer
28
Distichiasis, ‘foreign body’ fallen into the eye
Cautery
29
Supraorbital vein, superficial temporal veins
Superficial temporal artery (pp.300-301)
Cautery
30
Dacryocystitis
Cautery
31
Distichiasis
Small drill
34
Dacryocystitis
Awn-tongs
35
‘Foreign body’ fallen into the eye
The descriptions of the uses of the instruments[15]
CONTRIBUTIONS IN EYELID DISEASES
Al-Halabi utilized a needle in the treatment of trachoma (called granular conjunctivitis or Egyptian ophthalmia, which is a contagious, chronic inflammation of the mucous membranes of the eyes, caused by Chlamydia trachomatis; it is characterized by swelling of the eyelids, sensitivity to light, and eventual scarring of the conjunctivae and corneas of the eyes). The patient was lied down and Al-Halabi stayed beside the diseased eye. A nurse stayed beside Al-Halabi for handing him the required surgical instrument. The shape of the tip of the needle resembled the rose leaf with a small, short, pointed end, as illustrated in Figure 2[22]. He started stripping the scabies by the needle from the medial canthus to the lateral canthus. He noted that the ophthalmologist should preserve mildness and tranquility to prevent eye damage. As an alternative to the needle, a scraper can be used. It looks like a right-angled bolt extrator, as seen in Figure 3[22]. It is utilized for scratching scabies[15].
Al-Halabi used annexation technique in the treatment of distichiasis (congenital, abnormal, accessory row of eyelashes, often causing severe discomfort from contact with the eye). If the eyelashes number was from one to five, a very thin tailor’s needle could be used. A thread was twisted through the needle hole and around itself to make a buttonhole. Another thread was entered in the buttonhole to make it ready for annexation. The needle was applied at the margin of the eyelid from its inner side to the center of the distichiasis. The abnormal eyelashes were entered in the buttonhole with the aid of a tip of a gooseneck speculum (instrument number 24 in Figure 1). Then, the needle was pulled slowly and carefully to tighten the buttonhole on the eyelashes. Finally, the needle was extended quickly away of the eyelid, and the eyelashes were epilated at the middle of the buttonhole[15].Another technique for treating distichiasis was the use of glue. If the abnormal eyelashes were long enough and their number was from one to five, they were pasted to the nearest normal eyelashes. The components of the glue are listed in Table 2[31,32]. First, the glue was placed on a plate made of bronze. Second, the glue was melted on a soft flame. He noted that the flame should be near the ophthalmologist and ready to be used in order to prevent the glue from cooling down while being used. Third, an eye stick or a tip of a hook was utilized for applying the glue on the misdirected eyelashes. Finally, these eyelashes were extended to allow them to paste to the normal eyelashes for preventing the irritation of the eyeball. If the glue reached undesired normal eyelashes, it was removed by rubbing[15].
Table 2
Medicinal natural products used in distichiasis treatment[15,31,32]
Medicinal natural products used in distichiasis treatment[15,31,32]Moreover, distichiasis could be treated by cauterization. If the aberrant eyelashes number was from one to five despite being long or short, they should be plucked out first through the use of the gatherer. It could also be used in pulling out any “foreign body” that has fallen into the eye, as shown in Figure 9[22]. Then, a cautery was applied to the position of the pulled-out eyelashes. The cautery was pointed to be appropriate for the narrow places, as seen in Figure 10[22]. Al-Halabi preferred gold as a material of the cautery as the disease was cleared quickly and blisters did not appear at the cauterized position. When the eyelash was plucked out, the cautery was heated till its color turned red. Then, it was directed to the position of the pulled-out eyelashes. It should be slightly deeper to destroy the lash follicle[15].
Al-Halabi used a hook and scissors (Miqrad) in treating lacrimal caruncle swelling. The hook was utilized for hanging up the swelling. Then, the swelling was excised by the scissors. Finally, he warned the ophthalmologists that they should be cautious of the excision of a normal part of the lacrimal caruncle causing epiphora[15].In case of dacryocystitis (congenital displacement of lacrimal tissue results in subconjunctival cysts), he placed a cautery that looks like a right-angled screwdriver, as shown in Figure 12[22]. Its shape is appropriate for the target with a smooth rounded tip contact. This cautery was used to cauterize the lacrimal gland fistula after its rupture until the vessels stop bleeding. He preferred gold as a material of the cautery. The cautery was heated till its color turns red. Then, it was directed to the position of the fistula till boiling. The cauterized position was wiped with a rag. Next, cauterization was repeated several times till the crust on the lacrimal bone was peeled. Finally, the cauterized position was cleaned from rot[15].
Al-Halabi used eye speculums, hooks, scissors (Miqrad), couching needle with a rounded tip, dove’s feather, and eye stick in the treatment of pannus (membrane of fine blood vessels and fibrous tissue that spreads down over the peripheral cornea in trachoma and other inflammatory corneal disorders causing loss of vision)[34]. The patient was lied down, and he stayed behind the patient. A sessile pillow was put under the patient’s head to make it slightly declined[15].A tool, which looks somewhat like the eye speculum nowadays (instrument number 3 in Figure 1), was used to keep the patient’s diseased eye open. Al-Halabi expressed his preference of using two thumbs of a skilled nurse instead of two eye speculums. The disadvantage of using the eye speculums from Al-Halabi’s viewpoint was the obstruction of the eye speculums to the movement of the scissors (Miqrad) while cutting off the pannus. Three hooks were applied to hang up the pannus, one from the medial canthus, one from the center of the conjunctiva, and one from the lateral canthus. The hooks were applied near the upper eyelid[15].A tip of the scissors (Miqrad) was utilized for cutting off a part of the membrane from the lateral canthus. Then, the couching needle was introduced to saw off the pannus. Al-Halabi recommended that the couching needle should be made of red bronze (instrument number 16 in Figure 1). A dove’s feather might substitute the couching needle. The Miqrad scissors were used again to pick out the membrane until reaching the medial canthus. At this part, the three hooks were applied near the lower eyelid, and the same procedure was repeated till the pannus was completely removed. He noted that the ophthalmologist should watch out the cornea while performing this procedure[15].A tiny eye stick was wrapped in cotton which should be soaked in egg yolk and rose oil (calms painful sores and constricts and cools wounds). He recommended that the rose oil should not be used after two years of its manufacture date as it got expired. The eye stick should be applied at the middle of the eye and extended in the directions of the two eyelids in order to prevent any adhesions that might occur[15].Al-Halabi described another way to get rid of the pannus. One hook was applied to hang up the pannus. The scissors (Arabic: Kaz) were used to make a cut in the membrane. The Kaz scissors were thinner than the Miqass scissors and thicker than the Miqrad scissors, as shown in Figure 14[23]. Consequently, the hook was raised up while connected to the membrane, another hook was inserted, and the Kaz scissors were applied again. This procedure was repeated many times until the membrane was gathered by the Kaz scissors as one piece[15].
Al-Halabi used a hook, a smooth dove’s feather, myrtle leaf needle, Miqrad scissors, and Kaz scissors in treating pterygium (a pink, fleshy tissue that grows on the conjunctiva)[33]. The hook was utilized for raising the pterygium from its center. If the pterygium loosely adhered to the conjunctiva, a smooth dove’s feather was inserted under the hook to saw off the pterygium. If the pterygium hardly adhered to the conjunctiva, two or three hooks could be added to the sides of the pterygium. Then, the myrtle leaf needle was used for sawing off the tissue. Finally, the Miqrad scissors or the Kaz scissors were used for cutting off the pterygium[15].Al-Zahrawi used a horse-tail hair to saw off the pterygium. The dove’s feather and the horse-tail hair were utilized due to the inability of the technology of that era to manufacture a man-made instrument with the required thickness and sharpness[24]. Al-Halabi stated that the ophthalmologist should use extreme delicacy in order to avoid penetrating the cornea or the medial canthus. He asked the ophthalmologist to beware of the total removal of the pterygium to avoid its reappearance. Furthermore, he asked the ophthalmologist to take care of the adhesiveness of the pterygium with the conjunctiva. If the pterygium extremely adhered to the conjunctiva, the surgical instruments should not be applied at all in order to avoid eye damage[15].Al-Halabi used a hook, a couching needle, the half of the rose leaf needle, and the Miqrad scissors in treating hemangioma at the conjunctiva. The hook was applied to raise up the hemangioma. He stated that the ophthalmologist should use tremendous delicacy while raising up the hemangioma because it has a spongy consistency, and the hook might turn up during the treatment. The couching needle was inserted under the blood vessels, and he started sawing off the hemangioma. The half of the rose leaf needle could replace the couching needle in sawing off the hemangioma. Finally, the scissors were utilized for uprooting the hemangioma[15].Al-Halabi used a hook and the scissors (Kaz) in the treatment of granuloma at the conjunctiva (growth appearing like a nodule, consisting essentially of granulation tissue, and occurring as a result of localized inflammation). The hook was utilized for holding up the granuloma. If the size of the granuloma was large, two or three hooks should be applied. The Kaz scissors were applied to eradicate the granuloma[15].He used a Raven’s beak in the treatment of conjunctival wound (presence of wound or laceration of the conjunctiva with swelling and edema of the wound edges). The Raven’s beak is a slim gatherer with two heads, as displayed in Figure 15[22]. The Raven’s beak was used to extract an extremely small piece of wood that penetrated the eyeball and was fallen between the sclera and the eye bones. In addition, the Raven’s beak could be used for removing whatever sticks to the eye or the inner side of the eyelid. The awn-tongs (see Figure 16) were utilized when an awn (either a hair- or bristle-like appendage) or a similar object fell down into the eye[15,22].
Al-Halabi used a scalpel and a lancet in treating hypopyon (inflammatory cells in the anterior chamber of the eye). The scalpel was applied between the cornea and the conjunctiva to make an incision. He noted that the ophthalmologist should be cautious of the penetration of the iris. The lancet was applied at the position of the incision for the expulsion of the inflammatory cells. He used a needle, a thread, and scissors (Miqrad) in the treatment of the iris prolapse. A needle with a thread was inserted beneath the protrusion from the medial canthus and extracted from the lateral canthus. The two ends of the thread were drawn out of the eye. Then, the scissors were used to cleave the protrusion[15].
CONTRIBUTIONS IN HEADACHE AND MIGRAINE TREATMENT
In case of pain in the temporal muscles, headache, and migraine due to eye diseases, Al-Halabi used scissors (Miqrad), a hook, a lancet, and a cautery in the bloodletting and cutting the superficial temporal arteries and the posterior auricular veins[13]. A cord was tightened around the patient’s throat with great mildness. Then, the patient was asked to throttle himself/herself with leniency. This procedure was conducted to make the arteries and the veins of the head visible and to target them. In case of the superficial temporal artery, he suggested shaving the temple, and spotting the artery with ink—this made the artery visible. After targeting the artery, the patient was asked to stop throttling himself/herself, and the cord was released to reduce the amount of the seepage blood while working[15].Then, he attracted the skin over the artery using two fingers of his left hand. At this point, an incision was performed in the skin through the use of scissors (Miqrad). Consequently, the artery was extracted from its position and eradicated through the use of a hook’s tip. In case the artery was slim, a lancet was inserted under it to cut it off. Equally, the artery might be cut off using the scissors (Miqrad) instead of the lancet. In case the artery was thick, Al-Halabi used a needle and a thread made of silk or linen so that the artery would be tied in two places. Then, the lancet was utilized for opening an aperture between the two ligatures so that the desired amount of blood would flow out. After bloodletting, the artery was ligated and the blood flow was controlled[15].Al-Halabi provided the cauterization by a flathead cautery instead of the eradication of the artery through the use of the lancet or the scissors. The same procedures were conducted for the posterior auricular vein except that the cautery was smaller than that for the superficial temporal artery. His usage of smaller cautery for the posterior auricular vein is in line with modern knowledge, as the thickness of the outer walls and the layers of muscle and elastic fibers of the veins is less than that of the arteries. As a disinfection procedure, he recommended the use of medical packs made of cotton after cauterization[15].In case the previous procedures were unfruitful in treating migraine and headache, the supraorbital vein and the superficial temporal veins should be cauterized. First, the head was shaved from the middle of the scalp towards the forehead. Al-Halabi described how to know the position of the supraorbital vein in the forehead. The patient was asked to put the nail of his/her thumb of the right hand on the apex of the nose. Then, his/her forefinger was extended on the nasal septum towards the forehead. The maximum point the forefinger could reach was the position of the supraorbital vein. Next, this position was massaged using rough linen pack until it became red. At this point, a cautery was applied on the position longitudinally and horizontally in order to make a cross-shaped cauterization. The cautery looks like a fleshy olive and was made of iron, as shown in Figure 17[22]. The same procedures were performed on the superficial temporal veins. A knife that resembles to some extent an extremely small axe (see Figure 18) might replace the cautery for the supraorbital vein[22]. The knife was utilized for bloodletting the supraorbital vein. It was placed lengthwise on the vein, and the severing was conducted with the middle finger of the right hand[15].
Al-Halabi’s book was the first book to give a remarkable illustration of the anatomy of the brain, the eyes, and the visual pathway among them, as displayed in Figure 19[9,22]. The illustration presented the eyes, the optic chiasm, the cerebral ventricles, the pericranium, the dura mater, the pia mater, the olfactory nerves, and the petrosal bone[34]. The illustration showed that the left eye is controlled by the right part of the brain, and vice versa. All the ocular coats (cornea, sclera, choroid, zonules, and the retina) and the three humidities (vitreous, crystalline lens, and aqueous) are clearly illustrated and labelled. In this drawing, the conjunctiva seemed to originate from the pericranium and the sclera from the dura mater[16].
Al-Halabi detailed cataract operation representing twelve sorts of cataract in a table[14]. He dedicated a chapter of his book to the surgeries for removing the cataract. He described cataract operations, the required instruments, and the steps to be taken after the operation. He included his own experience which was described in good detail. He is so confident in his own talents that he had the courage to operate the cataract surgery on a one-eyed man for forty days[11,13]. Moreover, he surprisingly reported that he performed a successful cataract surgery for a predatory bird that was owned by his servant. However, the bird’s head movement after the surgery allowed the reappearance of the cataract[15].He preferred the use of the hollowed cataract needle for aspiration[33], on the solid three-edged couching needle or the rounded couching needle for its safety in the operation. First, a lancet with a rounded tip (instrument number 14 in Figure 1) was utilized for puncturing the outer coats. Then, the hollowed needle (instrument number 22 in Figure 1) was applied to the iris without perforating the cornea. Extracting the lens by suction, using the hollowed needle that resembles to some extent the aspirating syringe nowadays as what could be understood from Al-Halabi’s description has the benefit of excluding the possibility of the lens falling back into the eye[8,15].
CONCLUSION
Al-Halabi is an early biomedical engineer who invented various ophthalmological instruments. He is the first ophthalmologist to use a magnet for removing metallic foreign body from the eye. He utilized his instruments in the treatment of different eye diseases such as trachoma, lagophthalmos, chalazion, chemosis, symblepharon, ectropion, hordeolum, distichiasis, pannus, pterygium, and cataract. Al-Halabi’s book was the first to give a remarkable illustration of the anatomy of the brain, the eyes, and the visual pathway among them. Al-Halabi detailed cataract operation representing twelve sorts of cataract in a table.
ACKNOWLEDGEMENTS
The current research article could not come to light without the reproduction of Al-Halabi’s book edited by Wafai MZ (MD, FACS, FICS, and FRCOphth) and Kalaji MR (PhD). Dr. Wafai is a chief of Vitreo-Retina Division, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia, and a former instructor in ophthalmology, Harvard Medical School, Boston, Massachusetts, United States. Dr. Kalaji is a professor of Islamic Studies, King Saud University, Riyadh, Saudi Arabia, and a former professor of Islamic Studies, Damascus University, Syria.Finally, recognition must be given to the Frankfurt and Istanbul Museums for the History of Science and Technology in Islam. The Istanbul Museum has copies of the instruments that are in the Frankfurt Museum, and both museums are founded by the same person, Professor Dr. Fuat Sezgin. Institute for the History of Arab-Islamic Sciences, which runs the Frankfurt Museum, kindly and generously authorized the reproduction of the photos in this article.
Figure 1