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International Journal of Scientific & Engineering Research Volume 4, Issue3, March-2013 ISSN 2229-5518

Anesthesia Drugs in the Medieval Muslim Era Dr. Ali Muhammad Bhat Dept. of Islamic Studies IUST Awantipora Pulwama Srinagar Jammu and Kashmir 192122

Abstract
Pain is difficult to measure in humans because it has an emotional or psychological as well as a physical component. Some people express extreme discomfort from relatively small injuries, while others show little or no pain even after suffering severe injury. The signals that warn the body tissue damage are transmitted through the nervous system. In this system, the basic unit is the nerve cell or neuron. Each nerve cell meets other nerve cells at certain points on the axons and dendrites, forming a dense network of interconnected nerve fibers that transmit sensory information about touch, pressure, or warmth, as well as pain. Sensory information is transmitted from the different parts of the body to the brain via spinal cord. To overcome pain different types of drugs were used from the very earlier period to restrict the nerve signals for some time in order to provide relief to the patient. At present highly modified drugs are prescribed to ease pain whether at the time of surgery or feeling any kind of pain in the body. In order to highlight the significance of medieval medicine prescribed to ease pain and save human beings from side effects, this topic has great significance in the contemporary era.

Keywords: Pain, Anesthesia, Analgesic Surgery, Tabiaa (Physician), Lettuces, Mandrake (Hashish),
(El-Khishkash), Shweikran, Bhang and hyoscyamus.

Science and medicine belong to no ethnic or national group. Of the countless scientific discoveries made by man, medical discovery are the outline of the many partial contributions made by forerunners throughout the ages. These discoveries are related to universal facts. Countless human sufferings whether psychological or physical needs Medicare in order to provide relief to human beings. Pain is a one-sided occurrence which necessitates the presence of consciousness. It is the sensation which is experienced by Consciousness. From the ages people are in search of pain relieving drugs. Over the ages there has been a demand for techniques in order to endow with relief from different kinds of pains. This whole process has been entitled as anesthesia and analgesics. Anesthesia means absence of physical sensation in part or all of the body. The term more commonly refers to a reversible condition that is stimulated using anesthetic drugs. These drugs may be injected, gulp, or applied directly to the surface of the body. Each year about 40 million patients in

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International Journal of Scientific & Engineering Research Volume 4, Issue3, March-2013 ISSN 2229-5518

the United States receive anesthetic drugs for surgery, obstetrics, dentistry, or other medical procedures. Induced anesthesia may be local, involving only part of the body, or general, involving lack of sensation in the entire body as well as a loss of consciousness.1 Localized anesthesia can also be a result of natural causes, such as nerve injury, leprosy, or diabetes. An analgesic, or painrelieving drug such as aspirin, may relieve a headache, but a person who takes an aspirin still feels other physical sensations, such as pressure, heat, cold, and vibration. In contrast, anesthetic drugs block all physical sensations, though for medical purposes their ability to block pain is among their most important effects. Pain is a crucial warning system that tells us when our bodies are in danger, but without anesthesia, pain would make surgery and various other medical procedures much more difficultor even impossible. The various drugs used in anesthesia work by several different mechanisms to block the transmission or perception of pain and other sensations. Some sleepproducing drugs used as part of general anesthesia are injected into a patients veins. 2 These drugs are taken up by organs, muscles, and brain tissue and interfere with the complex and poorly understood biochemical mechanisms of consciousness. Anesthetic drugs that are inhaled dissolve in the blood and circulate to the brain. These drugs interfere with the chemicals inside nerve fibers that are involved in transmission of nerve impulses. Over the ages scholars like Celsus, Galen and Paulus proved us information about the drugs used as anesthetic drugs in order to relieve a patient from the pain. After Galen; Greek medicine produced four writers who did not contribute any advancement. Their works mainly consisted of quotations from Hippocrates and Galen3 . As a consequence, the strong narcotic drug mandrake used by Celsus 4 seems to have fallen into neglect; confirmation of this is that Paulus5 in the 7th Century, who is regarded as having summed up all medical knowledge accumulated up to his time, did not use it in his trochaics as an anodyne. Paulus did not give the toxic dose or details of the specific actions of either mandrake or opium. It

Myers L B, Cohen D, Galinkin J, Kurth D. Anesthesia for the fetal surgery. Peadiatric Anaesthesia 2002, Vol, P 269578
2 3

Stanley F. Malamed, Hand Book of Local Anesthesia, Elsevier - Health Sciences Division, 2012, p: 10-20 Campbell DC, Arabian medicine and its influence on the Middle Ages. Amsterdam: Philo Press, 1974, (reprint). 4 Celsus, De Medicina. London: Heinemann; Cambridge: Harvard University Press, 1938, vols 1-3. 5 Paulus Aegineta, The seven books of Paulus Aegineta, translated by F. Adams. London, Sydenham Society, 1844-1847, vols 1-3.
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International Journal of Scientific & Engineering Research Volume 4, Issue3, March-2013 ISSN 2229-5518

seems that there was no standardization or regulation of dosage 6. It was therefore impossible to standardize the results7 and, attempts at the conquest of pain were sporadic8. In the Middle Ages, Christian Europe was in a state of intellectual stagnation9 and the theological doctrine that pain serves God's purpose and must not be alleviated militated against the improvement in methods of narcosis. Nuland10 points out that the Middle Ages in Europe were dark ages so far as advances in the pharmacology of anesthesia were concerned. In Europe, that period is usually referred to as the Dark Ages when no progress was made in medical science. However, the situation in the East was different11 In the East, with the firm establishment of the Muslim supremacy between the 9th and 16th centuries; the study of medicine along with other branches of science revived and acquired a truly scientific nature. Many Muslim Scholars like Ibn Sina (Avicenna)12 Al-Razi, AlBaghdadi and Ibn al-Quff13, paid great attention to the phenomenon of pain. They attributed it not only to a breach of continuity, as stated by Galen, but also to a sudden change of temperament with or without abnormal humors. Hence, for pain relief, they stressed the treatment of the underlying cause and they subsequently developed a large number of analgesics with variable modes of action. The anesthetics they described included a wide range of medical plants as well as ice or very cold iced water as an efficient and safe mode of local anesthesia even though there might be an increase in the pain at the beginning. Refrigeration anesthesia which is considered by some to be a modern discovery, thus, had its origin in the medicine of the middle ages. They discovered the anesthetic action of the various medical plants used to a specific sensation property of variable strength, and thus according to Ibn Sina (Avicenna),14 opium is the most powerful, then mandrake, papaveris,

Keys T, The history of surgical anaesthesia, New York: Schuman's, 1945, Nuland SB, The origins of anaesthesia. Birmingham: The Classics of Medicine Library, 1983. 7 Keys T, The history of surgical anaesthesia, New York: Schuman's, 1945.Tallmadge GK, "Some anaesthetics of antiquity". J Hist Med All Sci 1946: 1: 515-20. Horine FE, "Episodes in the history of anaesthesia". J Hist Med All Sci 1946; 1: 521-6. 8 Kitz RJ, Vandam LD, "A history and the scope of anaesthetic practice". In: Miller RD ed., Anaesthesia vol 1, 2nd ed., New York: Churchill Livingstone, 1986, 3-25. 9 Nuland SB, The origins of anaesthesia. Birmingham: The Classics of Medicine Library, 1983. Cumston C G, An introduction to the history of medicine from the time of the Pharoahs to the end of the XVIII Century. London: Dawsons, 1968. Bickers W, "Adventures in Arabian Medicine". J Roy Coll Surg Ir 1969; 5: 5-14. Campbell DC, Arabian medicine and its influence on the Middle Ages. Amsterdam: Philo Press, 1974, (reprint). 10 Nuland SB, The origins of anaesthesia. Birmingham: The Classics of Medicine Library, 1983. 11 Cumston CG, "An introduction to the history of medicine from the time of the pharoahs to the end of the XVIII century". In: Islamic medicine, London: Dawsons of Pall Mall, 1968: 23-26, 185-212. Dickinson EH, The medicine of the ancients. Liverpool: Holden, 1875: 37-39. Kirkup JR, "The history and evolution of surgical instruments. Introduction". Ann R ColI Surg Eng 1981; 63: 279-285. Campbell DC, Arabian medicine and its influence on the middle ages. 1st edition (reprint), Amsterdam: Philo Press, 1974: pp. XI-XV. 12 Ibn-Sina, Kitab aI-qanun fi al-tibb, Beirut: Dar Sadir, reprint of Cairo Boulak edition, 1877. 13 Al-Razi, Kitab al-Hawi fi al-tibb (Rhazes Liber Continens), vol 23, 1st ed., Hyderabad: Osmania Oriental Publications, Osmania University, 1961. De Moulin D, "A historical phenomenological study of bodily pain in Western man". Bull Hist Med 1974; 48: 540-70. AI-Baghdadi, Kitab aImukhtarat fi al-tibb, vols 1-4, 1st ed. Hyderabad: Osmania Oriental Publications, Osmania University, 1942-1944. Ibn al-Quff, AI-'Umda fi al-jiraha, vol 1-2, 1st ed. Hyderabad: Osmania Oriental Publications, Osmania University, 1936. 14 Ibn-Sina, Kitab aI-qanun fi al-tibb, Beirut: Dar Sadir, reprint of Cairo Boulak edition, 1877.

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International Journal of Scientific & Engineering Research Volume 4, Issue3, March-2013 ISSN 2229-5518

henbane or hyocyamus, hemlock, solanum and wild lettuce. These drugs, especially opium, were used as local anesthetics in dental cases, earache, eye pain and joint pain (especially in gout). In dentistry, they used opium, mandrake root or henbane juice in the form of pastes, patches or fillings. Gargles from decoctions of mandrake root, henbane root or seeds or the root of solanum were also used. Opium drops in rose oil, infusion of root of solanum, decoction of papaveris, oil or juice of henbane and angelica juice were used for earache. The relief of eye pains was achieved by either using dressings from mandrake leaves or mixing the eye medicines with mandrake tears or juice of hemlock. Embrocations of the juice of henbane leaves or seeds were also used on the eye and, for joint pains, dressings from mandrake leaves or embrocations from opium, hemlock, henbane or cannabis. In addition, as it is seen that severe pain may lead to death, the soporific action of these drugs was employed especially pre-operatively in the cases of amputation, cautery, circumcision and lacerations. They were administered by ingestion, inhalation or rectally. Infusions of solanum, cannabis, opium and mandrake were given orally or rectally on a plug which has to be changed hourly. Opium, mandrake and henbane were also used by inhalation in the form of odorants. The wild lettuce has a mild soporific effect. It was used either fresh or boiled as an adjuvant to any of the previous medications or alone in cases of insomnia. The physicians of Islamic civilization were familiar with surgery and have practiced different kinds of surgical procedures such as amputation, tonsillectomies, excision of tumors, and in some instances describing technical details. 15 This extent of surgery was not performed without some kind of pain allayment. In addition, one of the reasons why the Muslims could make their way into the field of anesthesia was the fact that the concept of pain as a punishment from God had no place in their belief and tradition. There is evidence that the Muslims used to administer sedatives and analgesic mixtures before a surgical operation. A question from Avicenna reads "A patient who wants to have an amputation of one of his organs must have a drink prepared from a mixture of Mandagora and other sleeping

15

HADDAD, F.S.: "Alo-Aldeen Ibnul Nafiess", M.E.J. Anaesth. 4:223-224, 1974.

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International Journal of Scientific & Engineering Research Volume 4, Issue3, March-2013 ISSN 2229-5518

drugs". Other plants used for the same purpose were Indian cannabis (Hashish), Opium poppies (ElKhishkash), Shweikran (Hemlock), Bhang and hyoscyamus. 16 The Muslims scientists are also credited for the introduction of inhalational anesthesia by using the then called "Anesthetic sponge" or "Sleeping sponge". A quotation from Sigrid Hunke's book reads: The science of medicine has gained a great and extremely important discovery and that is the use of general anesthetic s for surgical operations, and how unique, efficient, and merciful for those who tried it the Muslim anesthetic was. It was quite different from the drinks the Indians, Romans and Greeks were forcing their patients to have for relief of pain. There had been some allegations to credit this discovery to an Italian or to an Alexandrian, but the truth is and history proves that, the art of using the anesthetic sponge is a pure Muslim technique, which was not known before. The sponge used to be dipped and left in a mixture prepared from cannabis, opium, hyoscyamus and a plant called Zoan"17. These physicians not only determined the required dose in each drug precisely but also were able to fix the length of time which the anesthesia was to last with great precision. Avicenna for example, gave the dose of one 'mithkal' of mandrake for 3-4 hours of general anesthesia. Unlike Paulus, Ibn Sina, AI-Razi, Al-Baghdadi, Ibn EI-Quff and Ibn al-Baytar in the light of their own experiments and observations, described the general and special botanical characters of the plants in detail as well as indicating their habitats and what was best selected from each. They also specified methods for obtaining the active ingredients whether as juice or in the various medical forms that can be prepared as infusions, decoctions or dressings. Both of the historians, Ibn Khallikan in the 13th century, and Ibn Kathir in the 14th century, documented that Urwa Ibn AI-Zubair in the beginning of the 8th century developed leg gangrene for which amputation was required. The doctors of the Ummayad Caliph Al-Walid Ibn Abdel Malek in Damascus offered him Al-Murquid to be put to sleep for the operation. Literally, the word 'Al-Murquid' in Arabic means a drug that induces deep sleep. Evidence

16 17

GRAY and NUNN: "General Anaesthesis". Third edition, Vol. I, PP. 708-710, Butterwerths, 1971. AVICENNA: "El-Kanun Fi'l Tibb". Vol. II -371, Vol. III-132, 134, 137, 229. A newly print by El-Musanna Bookshop, Baghdad, Offset from Boulak print (1294 A.H.) and 1877 A.C.).

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International Journal of Scientific & Engineering Research Volume 4, Issue3, March-2013 ISSN 2229-5518

about the popularity of this anesthetic comes from finding entries about Al-Murquid in four generalpurpose Arabic language dictionaries compiled during that era18. Al-Murquid was used either by ingestion or inhalation or rectally. In the form of infusion, they used particular types of solanum, cannabis, opium and mandrake by ingestion. The last three drugs were also administered rectally on a plug which had to be changed hourly. On the other hand, opium, mandrake and henbane were also used by inhalation in the form of odorants. As wild lettuce has a mild soporific effect it was used, whether fresh or boiled, as an adjuvant to any of the previous ones or in cases of insomnia19. They not only precisely determined the required dose of each drug but also they were able to fix the length of time which the anesthesia was to last with great precision, for example, Ibn Sina 20 gave a dose of one 'mithkal' of mandrake for 3-4 hours of general anesthesia . The knowledge and practice of anesthesia reached its peak in the beginning of the 14th century as evidenced in Ibn al-Quff's book on surgery Al-'Umda Fi-'l-Jiraha (the mainstay in surgery). Different than Paulus of Aegineta21, Ibn al-Quff gave detailed information in his book on the phenomenon of pain and clearly stated that pain relief during surgery should be the responsibility of a second medical man other than the surgeon performing the operation. In this regard physicians were called to look after the matter of surgery after giving the pain relieving drug Al-Murquid and its effect on the patient and the surgeon (Al-Jaraaehi) is then allowed to perform the operation without any hindrance. This represents the first report, in the literature, on the role of the anesthetists. They also described the specific actions and side effects on the various systems of the body and stated with great accuracy the required dosage from juice, bark or decoctions as well as the toxic dose. Finally, they outlined the action of antidotes, adjuvant and alternative remedies. The development of anesthesia during that period by reviewing the following books: Al-Hawi fit-tibb (The Continence, Al-Qanun fi-al-tibb (The Cannon of Medicine), Al-Tasrif, Al-Mukhtarat fit18

lbn Khallikan, Wafayat al-a'yan, ed. Mohamed Mohyuldeen, Maktabt al-Nahda, 1948: 418-428. lbn Khathir, Albidaya wa-'l-nihaya, 3rd ed. Abu Mohem A. et al. eds. Beirut: Dar al-kutub al-'ilmiya, 1987; 4: 108. Mohamed bin Yagab AI Firouz-Abadi, Al-Qamus al-muhit, 3rd ed. Cairo: AI-Matba'a al-Masriya, 1933; I: 295. Ibn Manzur, Lisan al'Arab, AI-Kabir A et al. eds. Cairo, Egypt: Dar aI-Ma'arif, 3: 1206; Ibn al-Jawzi, Sayd aI-Khatir, Abdul Kader A, ed. Beirut: Al-maktaba 'l-'ilmiya (undated): 18. Al-Razi, Muktamal-Sihah. Beirut: Dar al-kitab al-'arabi, 1981: 252. AIZamakhshari, Asas al-Balagha. Beirut: Dar al-fikr (undated): 244.
19

Al Mazrooa AA, Abdel-Halim RE. "Anaesthesia 1000 years ago". In: Atkinson RS, Boulton TB, eds. The history of anaesthesia. London, New York: Royal Society of Medicine Services and the Parthenon Publishing Group, 1989: 46-48. 20 Ibn Sina, Kitab aI-qanun fi al-tibb, op. cit., vol. 1: pp. 334; vol. 2: pp. 200-205. 21 lbn al-Quff, AI-'Umda fi 'I-jiraha, op. cit., vol. 2: pp. 104-105; vol. 1: p. 205. Paulus of Aegineta, The seven books of Paulus of Aegineta, 6th book. Adams F, trans. London: Sydenham Society, 1846: pp. 1-3.
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International Journal of Scientific & Engineering Research Volume 4, Issue3, March-2013 ISSN 2229-5518

tibb, Al-'Umda Fil Al-Jiraha, and Al-Taysir. The authors of these books are respectively Al-Razi, Ibn Sina, Al-Zahrawi, Al-Bagdagi, Ibn al-Quff and Ibn Zuhr. Those authors were medical scholars who lived in the period between the 9th and the 14th centuries. Their contribution to pain relief has been recently evaluated22. In the following section, we will evaluate their contributions to anesthesia and resuscitation. The Muslims must be given the credit for developing the science of botany23. Ibn al-Baytar is one of the greatest Arabi botanists24 his book Al-Jami' Al-Kabir is the most original among the Arabic materia medica texts of the mediaeval period. Arabic materia medica had a considerable impact on European herbal and antidotarium authors from the 12th to the 17th century. remedies reported by Dioscorides are thus of Islamic origin. 26 The same may be said of the work of Celsus which was hardly noticed by the Greeks and overlooked in the middle Ages27. In the section on emollients (vol. 2), Celsus describes one of them as the invention of a certain Arab, and some of his recipes are based on Arabic materia medica with its tables of weights and measures (pound, dirham and dinarium or dinarii). The only conclusion
25

The works of

Constantine are plagiarism or skillful disguised translations from the Arabic treatises. The medicinal

22

AI-Razi, Kitab al-Hawi fi al-tibb, op. cit., vol.3: pp. 225-233; vol. 23: pp. 225-242. Ibn Sina, Kitab aI-qanun fi al-tibb, op. cit., vol. 1: pp. 334; vol. 2: pp. 200-205. AI Zahrawi, Al-Tasrif liman 'agaz 'an-al-ta'lif. In: Spink MS, Lewis CL, eds and trans. Albucasis on surgical instruments. London: Wellcome Institute of the History of Medicine, 1973: 338-339. AI-Bagdadi, Kitab aI-mukhtarat fi al-tibb, op. cit., vol. 1: p. 141; vol. 3: p. 190. lbn al-Quff, AI-'Umda fi 'I-jiraha, op. cit., vol. 2: pp. 104-105; vol. 1: p. 205. Ibn Zuhr, AI-Taysir fi-'l-mudawat wa-'l-tadbir, Alkhoury M, ed. Damascus: The Arabic Organisation for Education, Culture and Science, 1983: 149-155. Al Mazrooa AA, Abdel-Halim RE. "Anaesthesia 1000 years ago". In: Atkinson RS, Boulton TB, eds. The history of anaesthesia. London, New York: Royal Society of Medicine Services and the Parthenon Publishing Group, 1989: 46-48.
23

Desnos E, "The history of urology up to the latter half of the thirteenth century". In: Murphy LJT, ed., The history of urology. Springfield: Thomas, 1972. Dickinson EH, The medicine of the ancients. Liverpool: Holden, 1875. Margotta R, in: Lewis, P, ed., An illustrated history of medicine. Feltham: Hamlyn, 1968. 24 Cumston C G, An introduction to the history of medicine from the time of the Pharoahs to the end of the XVIII Century. London: Dawsons, 1968. Ibn al-Baytar, Jami' mufradat al-adwia wa-'I-aghzia (A Dictionary of simple drugs), MS No. 3979, Chester Beatty Library in Dublin, Microfilm at Imam Ibn Saud University Library, Riyadh. Hamerna SK. "Tareekh Al-Tibb Wa Assaidala End Al-Arab". Vol 1-2. Cairo: 1967. Ibn Abi Usaybi'a, 'Uyun al-anba' fi tabaqat aIatibba' (The sources of the knowledge of classes of doctors). Beirut: Dar Maktabat al-Hayat, 1965. 25 Cumston C G, An introduction to the history of medicine from the time of the Pharoahs to the end of the XVIII Century. London: Dawsons, 1968. Campbell DC, Arabian medicine and its influence on the Middle Ages. Amsterdam: Philo Press, 1974, (reprint). Garrison FH, An introduction to the history of medicine, 3rd ed. Philadelphia and London: Saunders, 1924. Dunlop DM, "Arabic medicine in England". J Hist Med 1956; 2: 166-82. 26 Cumston C G, An introduction to the history of medicine from the time of the Pharoahs to the end of the XVIII Century. London: Dawsons, 1968. 27 Guthrie D, A history of medicine. London: Thomas Nelson, 1945. Dunlop DM, "Arabic medicine in England". J Hist Med 1956; 2: 166-82.
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International Journal of Scientific & Engineering Research Volume 4, Issue3, March-2013 ISSN 2229-5518

possible is that the writings of the Muslim scholars in their Latin form influenced European medical thought over a very considerable period. In that era they also realized the importance of monitoring during anesthesia as, a third medical man used to be present putting a finger on the pulse during the operation28. It is interesting to note this method of monitoring, by palpating the pulse is still practiced nowadays and is referred to in anesthesia text-books as a simple non-invasive method. Ibn Abi Usaybi'a in the 13th century in his book of medical biographies 'Uyun al-anba' fi-tabaqat aI-atibba' documented a case in which a critically ill patient already pronounced dead was successfully resuscitated by the physician Saleh Ibn Bahla who bring forth that the patient still responded to painful stimuli, then with the use of bellow, insufflated air and soap root powder into his nose. According to Jaser, this clinical case report documented the use of bellows for respiratory resuscitation 900 years before it was first reported in Europe. The contributions of the above mentioned authors were translated into Latin as early as the middle of the 12th century and greatly influenced the European mediaeval schools of medicine well into the 18th century29. Conclusion Science has no native home of its own and every person has the right to ask for it. When the talents and circumstances exist, new horizons can be discovered. The Muslims are first in the list of the nations who had the honour of holding the torch of civilization for quite a while and made a great contribution to basic sciences, upon which the modern technology and progress is raised. In the field of anesthesia and resuscitation, the contribution of Islamic civilization is enormous and its influence on the western civilization is profound and discoveries made have laid down the foundation of

28

Sigrid Hunke, Allah's sonne uber dem abendland unser Arabische erbe, 6th ed. Baidoon F, Dosoky K, Arabic trans. Beirut: Dar Al-afaq aI-jadida, 1981: 239. 29 Ibn Abi Usaybi'a, 'Uyun al-anba' fi tabaqat aI-'atibba', Nizar Reda, ed., op. cit., pp. 475-477. Jaser MT, "Anaesthesia in the history of Islamic medicine". In: Atkinson RS, Boulton TB, eds., The history of anaesthesia. London, New York: Royal Society of Medicine Services and the ParthenoQ Publishing Group, 1989: 48-50. Ullman M., Islamic medicine (Islamic Surveys Series, N 11). Edinburgh: Edinburgh University Press, 1978: 52-54. Freind J., Histoire de la mdecine depuis Galien jusqu'au commencement du seizime sicle. Etienne Coulet, trans. Leyden: Langerak 1727; 3: 1-80. Gruner OC. A Treatise on the Canon of Medicine of Avicenna incorporating a translation of the first book. London: Luzac, 1930: 18. Montagnani CA. "Paediatric surgery in Islamic medicine from Middle Age to Renaissance". In: Rickham PP, ed. Historical aspects of paediatric surgery. Progress in Paediatric Surgery 1986; 20,39-51. Radbill SX. "The first treatise on paediatrics". Am J Dis Child 1971; 122: 369-376. Shah MH. The general principles of Avicenna's Canon of medicine. Karachi: Naveed Clinic, 1966: iii

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modern practice. Today the Islamic nations are invited to contribute more and more and they are quite capable to do right that again.

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