Ann Thorac Surg 1999;67:578-580
© 1999 The Society of Thoracic Surgeons
Our Surgical Heritage
Early Islamic physicians and thorax
Hasan F. Batirel, MDa
a Department of Thoracic Surgery, Marmara University Hospital, Istanbul, Turkey
Address reprint requests to Dr Batirel Gökay sok. No:7/22 81090 Erenköy, Istanbul, Turkey
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Abstract
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Modern anatomic knowledge has developed throughout centuries with transfer of knowledge from generations to generations. 
bn-i Sina (980–1037), Razi (850–923), Davud El-Antaki (?–1008), Ali ibn Abbas (?–982), Ahmed bin Mansur (14th century), 
emseddin-i Itaki (1570–1640), and Ibn-i Nafis (1210–1288) were Islamic physicians who all contributed to the understanding of anatomy. They benefited from Greek and Roman pioneers, as well as from each other. To show the situation of thoracic anatomy in early Islamic physicians, we analyzed two original manuscripts in the Süleymaniye Library and some contemporary texts. There were original drawings of the trachea, lung, and vascular system in emseddin-i Itaki’s and Ahmed bin Mansur’s anatomy texts. Ibn-i Nafis’s writings revealed that he was the first person to describe the pulmonary circulation. Also Ali ibn Abbas wrote that the pulmonary artery wall had two layers and these layers may have a role in constriction and relaxation of this vessel. He also stated that pulmonary veins branched together with the bronchial tree. Ahmed bin Mansur, Ali ibn Abbas, and Ibn-i Nafis each wrote that the heart has two cavities. They also added that the wall of the septum is very thick and there are no passages in between. These show that Islamic physicians had important contributions to thoracic anatomy and physiology. European physicians benefited from these contributions till the end of the 16th century.
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Introduction
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The development of modern anatomic knowledge dates back to the end of the 18th century. But until these times, classical Greek medical heritage and, later on, books of Islamic physicians constituted the main reference for the understanding of anatomy and physiology. Although anatomy and physiology was largely mastered in the 19th century, emergence of contemporary surgical practice had to wait for more than half a century.
In the early times, Greek philosopher and physician Aristotle (3rd century BC) and Galen (AD 129–201) of Rome had enormous contributions to medical knowledge. The Galenic doctrine had its long-lasting influence on Islamic and Western medicine until the early decades of the 17th century. Galen in his voluminous work put forth most of the principles of anatomy and physiology that were to be followed by many physicians [1].
After Islam strengthened as a religion and became a governmental power, the Islamic rulers and scientists put forth much effort in exploring the details of medical knowledge. As an initial step they benefited from those gifted Greek and Roman pioneers and translated their books to Arabic. In the following centuries, most of the Spanish and European physicians mastered the Arabic language as a result of relations in Al-Andalusia and hence conveyed the medical knowledge back to Europe. Ibn-i Sina (Avicenna) (980–1037) and Razi (Rhazes) (850–923) were two of these great physicians [2, 3].
We have gone through emseddin-i Itaki’s and Ahmed bin Mansur’s original manuscripts in the Süleymaniye Library and some other contemporary texts to figure out the explanations and original contributions of the early Islamic physicians to thoracic anatomy and physiology [4–8].
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Trachea and lung tissue
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Ibn-i Sina, a Turkish physician, in his famous book Canon of Medicine (Al-Kanun) analyzes and classifies every subject in medicine and makes original contributions and descriptions [2, 3]. In his anatomic writings, Ibn-i Sina mostly follows Galenic principles in the understanding of thoracic anatomy and physiology. Ibn-i Sina begins with the trachea and describes the semilunar tracheal cartilages and membranous part in detail. emseddin-i Itaki (1570–1640?) was a Turkish physician like Ibn-i Sina who wrote an illustrated anatomy book in 1632, namely Anatomy of the Body (Te
rih-ül Ebdan). In his book he mostly benefited from Ibn-i Sina and Vesalius (AD 1543), describing tracheal and thoracic anatomy concordant with Galenic principles and the writings of Ibn-i Sina (Fig 1) [4, 5].
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Fig 1. A drawing of tracheal anatomy by emseddin-i Itaki. This figure shows that he has been highly impressed from Vesalius’s De Humani Corporis Fabrica. (The figure has been copied with permission from the original book in the Suleymaniye Library.)
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The anatomy of the lungs was much more debated among Islamic physicians. Ibn-i Sina wrote about the lungs as five lobes. But this was incorrect knowledge, which classified the mediastinal lobe as the fifth lobe and assumed that its tissue character was different. This description is the same in emseddin-i Itaki. But Ali ibn Abbas (?–982) described the right lung as three lobes. He mostly followed Razi and Galen, but as will be stated later on, made other contributions to the understanding of thoracic anatomy. Regarding the lung tissue, he described it as somewhat dense, somewhat airy, like blood with bubbles and clots, but he added that pulmonary venous branching went hand in hand with the branching of bronchi [4–6]. His assumption had wide acceptance beyond Islamic physicians. Davud el-Antaki (David of Antioche, ?–1008) gives generally the same knowledge, and Razi and Ahmed bin Mansur (14th century) make brief descriptions of the lung tissue in their books.
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Pulmonary circulation
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Ibn-i Sina and most of the preceding physicians, as well as Vesalius, describe the pulmonary artery as having a venous structure. Ali ibn Abbas stated that pulmonary arteries have two layers, the inner layer consisting of oblique fibers and the outer layer, longitudinal fibers. He added that these fibers may have a role in relaxation and constriction of vessels [4–6].
All of the Islamic physicians accepted the concept of Galen and Aristotle in the explanation of the pulmonary circulation. They assumed that there was a passage between the right and left sides of the heart, and blood circulated through this route. But Ibn An-Nafis (1210?–1288) in his commentary on Ibn-i Sina’s Canon of Medicine made a very original contribution [7]:
"As the production of the [vital] spirit is one of the functions of the heart, and as the spirit consists of much refined blood with a large admixture of airy substance, it is necessary that the heart should contain both refined blood and air so that the spirit may be generated out of the substance produced by their mixture. ... The blood, after it has been refined in this (right) cavity, must be transmitted to the left cavity where the [vital] spirit is generated. But there is no passage between these two cavities; for the substance of the heart is solid in this region and has neither a visible passage nor an invisible one as was alleged by Galen. Therefore, the blood, after having been refined, must rise in the arterious vein to the lung in order to expand in its volume and to be mixed with air ... and may reach the venous artery in which it is transmitted to the left cavity of the heart."
This is the first statement about the pulmonary circulation, but we do not see this explanation in any other Islamic physicians after him. In 1553, Michael Servetus made a very similar explanation of the lesser circulation, but was burned alive in October 1553 because of his opposition to the scholastic theory [7].
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Heart
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The heart was regarded as the most important organ in history. Thus the explanation for its physiology and anatomy was detailed. Most of the Islamic physicians accepted the classical knowledge introduced by Aristotle and Galen. Ibn-i Sina, Ahmed ibn Mansur, Antaki, and Itaki all accepted that the heart was of three parts (cavities); right left, and a middle portion. The middle portion was said to be smooth and like a sponge [4–6]. The first contrary opinion was by Ali ibn Abbas. He and later on Ibn-i Nafis stressed that the heart had only two cavities. Ibn-i Nafis insisted that the tissue between the right and left cavities was very thick [7]. All of the Islamic physicians described the pericardium and added that it was continuing with the mediastinal pleura. emseddin-i Itaki also wrote about a nervous control on the heart [4, 5]. A primitive figure of the vascular system and heart exists in Ahmed bin Mansur’s anatomy book (Fig 2) [8].
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Fig 2. The drawing of the vascular system in Ahmed bin Mansur’s book. The names of most vessels are those of today (basilic, etc.) written in Arabic script. (The figure has been copied with permission from the original book in the Suleymaniye Library.)
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Comment
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The development of modern anatomy and physiology enabled surgery to handle complex clinical situations. It is a must for a surgeon to master anatomy and physiology of the organ he or she deals with. This development has been through continuous transfer of knowledge from generation to generation, and all of the pioneers benefited from each other.
The above-mentioned findings by Islamic physicians show that they made original contributions that shaped the path of medical thought in Europe. Ibn-i Sina was one of the most famous for this; his book was an essential part of medical education in Europe till the end of the 17th century. The heritage of Ibn-i Sina and his successors enabled Albucasis and erefeddin Sabuncuo
lu to be pioneers in surgery, like Ambrois Paré who learned much from the books of his Islamic colleagues [9, 10].
Ibn-i Nafis’s and Ali ibn Abbas’s explanations on thoracic anatomy and physiology are very original. Although Ibn-i Nafis’s explanations were not noticed by subsequent physicians, it is said that Servetus might have read of his book, but this is rather a weak theory. Ibn-i Nafis explains the pulmonary circulation on a logical basis and does not attribute these assumptions to experimental data or dissection.
The dissection of the human body is not allowed by Islamic rules, but it is also a fact that these physicians reached these assumptions through transfer of knowledge from preceding physicians, animal dissections, evaluation of human corpses and bones that were found accidentally, and surgical interventions on patients.
The drawings in the books of these early pioneers are primitive, because the art of drawing humans was not allowed in Islam, except in medicine. There was no scholastic fundamentalism in Islamic medicine. Most of the assumptions achieved by experiments and observations were welcome by colleagues. Ibn-i Sina was generally accepted as being in a different sect of belief to Islam, and most of his religious and philosophic ideas were opposed by religious authorities. But he has always been one of the greatest pioneers of Islamic medicine throughout all medical schools in Islamic countries.
The above-mentioned physicians in medical history made contributions to the development of anatomy and physiology to enable better care for their patients. They should be remembered with respect owing to their contributions to the development of medicine and their function as a bridge in the transfer of knowledge to Europe.
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Acknowledgments
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I am grateful to Professor Esin Kahya, Professor Nuran Yildirim, and Dr Gülten Dinç for their kind support during preparation of this article.
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References
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Hurt R. The history of cardiothoracic surgery from early times. London: Parthenon Publishing Group, 1996:3-5.
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Ibn-i Sina, El-Kanun Fi’t-Tibb. In: Kahya E. Atatürk Kültür Dil ve Tarih Yüksek Kurumu, Atatürk Kültur 1995.
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Ünver AS. slam doktoru Ebubekir Razi. stanbul belediyesi mecmuasi. 1931;87:2–7.
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Kahya E. emseddin-i Itaki’nin resimli anatomi kitabi, 1st ed. Ankara: Atatürk Kültür Dil ve Tarih Yüksek Kurumu, 1996.
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Itaki . Terih-i Ebdan ve Tercüman-i Kibale-i Feylesufan (1st manuscript). stanbul: Süleymaniye Library, 464.
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de Koening P. Trois traite d’anatomie Arabe. Leiden, 1903.
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Meyerhof M. Ibn an-nafis (13th century) and his theory of the lesser circulation. Isis 1935;23:100-120.
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Ahmed ibn Mansur. Terih-ül Ebdan (2nd manuscript). stanbul: Süleymaniye Library, 3555.
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In: Spink M.S., Lewis G.L., eds. Albucasis: on surgery and instruments. London: The Wellcome Institute of the History of Medicine, 1973.
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Uzel . Cerrahiyet-ül haniyye, 1st ed. Ankara: Türk Tarih Kurumu Yayinlari, 1992.
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Abstract
Introduction
