Title: Drawings and Pharmacy in Al-Zahrawi's 10th-Century Surgical Treatise
Author: Hamarneh, Sami Khalaf, 1925-
Language: English
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                 Drawings and Pharmacy in al-Zahrāwī’s
                    10th-Century Surgical Treatise

                         _by Sami Hamarneh_

                     Paper 22, pages 81-94, from

                    CONTRIBUTIONS FROM THE MUSEUM
                      OF HISTORY AND TECHNOLOGY

                    UNITED STATES NATIONAL MUSEUM
                            BULLETIN 228

          SMITHSONIAN INSTITUTION    ·    WASHINGTON, D.C., 1961

  [Illustration: Figure 1.--Reproduction of a page from
  original Arabic manuscript indexed as "Cod. N.F. 476A" at
  Oesterreichische Nationalbibliothek in Vienna. Courtesy
  Oesterreichische Nationalbibliothek.]



Drawings and Pharmacy in al-Zahrāwī’s
10th-Century Surgical Treatise

_by Sami Hamarneh_


_Probably the earliest independent work in Arabic Spain to embrace the
whole of medical knowledge of the time is the encyclopedic al-Tasrīf,
written in the late 10th century by Abū al-Qāsim al-Zahrāwī, also known
as Abulcasis. Consisting of 30 treatises, it is the only known work of
al-Zahrāwī and it brought him high prestige in the western world._

_Here we are concerned only with his last treatise, on surgery. With its
many drawings of surgical instruments, intended for the instruction of
apprentices, its descriptions of formulas and medicinal preparations,
and its lucid observations on surgical procedures, this treatise is
perhaps the oldest of its kind._

_Scholars today have available a translation of the text and
reproductions of the drawings, but many of the latter are greatly
modified from the originals._

_This study reproduces examples of al-Zahrāwī’s original illustrations,
compares some with early drawings based on them, and comments on
passages in the treatise of interest to students of pharmacy and medical
therapy._

THE AUTHOR: _Sami Hamarneh undertook this research into the history of
medicine in connection with his duties as associate curator of medical
sciences in the United States National Museum, Smithsonian Institution._


THE INTRODUCTION OF THE WRITINGS of Abū al-Qāsim Khalaf ibn ʻAbbās
al-Zahrāwī--better known as Abulcasis (d. ca. 1013)--to Western Europe
was through the Latin translation of his surgical treatise (maqālah) by
Gerard of Cremona (d. 1187).[1] The response to this treatise,
thereafter, was much greater than the attention paid to the surgery of
any of the three renowned physicians of the Eastern Caliphate: al-Rāzī
(Latin, Rhazes, d. ca. 925), the greatest clinician in Arabic medicine;
al-Majūsī (Haly Abbās, d. 994), the author of the encyclopedic medical
work, _al_-_Malakī_;[2] and Ibn Sīnā (Avicenna, 980-1037), the author
of the famous _al-Qānūn fī al-Ṭibb_, a codification of the whole of
medical knowledge. Because of the widespread dissemination of this Latin
version in medieval Europe beginning with the latter part of the 12th
century, al-Zahrāwī attained more prestige in the West than he did in
Arabic Spain, his native country, or in any other part of the Islamic
world.[3]

  [Illustration: Figure 2.--The myrtle-leaf shape recommended
  for paper on which medicine is to be placed for cauterizing
  eyelid. _Top_, from original Arabic manuscript (Tüb. MS.
  91), courtesy Universitätsbibliothek Tübingen. _Bottom_,
  from Channing, _Albucasis_.]

The fame attached to this surgical treatise, the 30th and last in
al-Zahrāwī’s encyclopedic work _al-Taṣrīf Liman ‘Ajiza ‘an
al-Ta’līf_, is founded on certain merits. The text is characterized
by lucidity, careful description, and a touch of original
observation of the surgical operations to which the treatise as a
whole is devoted.[4] Al-Zahrāwī furnishes his own drawings of the
surgical and dental instruments he used, devised, or recommended for
a more efficient performance. The illustrations were intended to
provide instructional material for apprentices--whom al-Zahrāwī
calls his children--as well as for the benefit of those who would
read the work later on.[5] The treatise is probably the oldest one
known today that contains such instructive surgical illustrations
and text.[6]

  [Illustration: Figure 3.--Small funnel for pouring heated
  lead into fistula of the eye for cauterization. _Top_, from
  original Arabic manuscript (Vel. 2491), courtesy Süleymaniye
  Umumi Kütüphanesi Müdürlüğü. _Bottom_, from Sudhoff,
  _Chirurgie_, courtesy National Library of Medicine.]

  [Illustration: Figure 4.--Circular cauterization in stomach
  ailments. _Top_, from original Arabic manuscript (Tüb. MS.
  91), courtesy Universitätsbibliothek Tübingen. _Bottom_,
  from the 1531 Latin edition of Pietro d’Argellata,
  _Chirurgia Argellata cum Albucasis_, hereinafter cited as
  Argellata 1531, courtesy National Library of Medicine.]

This surgical treatise has been investigated, translated, and commented
upon by eminent historians of medicine and surgery to whose works I
shall refer in this article. However, the pharmaceutic and therapeutic
details of the treatise have been somewhat overlooked.

As to the various illustrations of the surgical instruments (over 200
figures in all), an almost complete representation of samples has been
introduced by Channing,[7] Leclerc,[8] Gurlt,[9] Sudhoff,[10] and
others. Nevertheless, a good number of the reproduced drawings are
greatly modified, most likely having been influenced by earlier
illustrations in several Latin and vernacular versions of the
treatise.[11] This becomes clearer on comparison with seven Arabic
manuscripts that have not been fully examined by Western scholars before
and that--in several instances--show more authentic drawings of
al-Zahrāwī’s surgical instruments than any heretofore published.[12]

  [Illustration: Figure 5.--Ink markings for identifying place
  of cauterization. _Top_, from original Arabic manuscript
  (Vel. 2491), courtesy Süleymaniye Umumi Kütüphanesi
  Müdürlüğü. _Bottom_, from Argellata 1531, courtesy National
  Library of Medicine.]

  [Illustration: Figure 6.--Cautery in hernia. _Top_, from
  original Arabic manuscript (Vel. 2491), courtesy Süleymaniye
  Umumi Kütüphanesi Müdürlüğü. _Bottom_, from Leclerc,
  _Albulcasis_.]

This article therefore, is an attempt to present a sample of these
illustrations with brief comments regarding certain figures and passages
of interest to pharmacy and medical therapy.

With much gratitude I express my indebtedness to Prof. G. Folch Jou of
Madrid, to Dr. A. Süheyl Ünver and Mr. H. Dener of Istanbul, and to the
librarians of the depository institutions for their cooperation in the
reproduction of the manuscripts on microfilm.

  [Illustration: Figure 7.--Fine tweezer for removing foreign
  bodies from the ear. _Top_, from original Arabic manuscript
  (Ali 2854), courtesy Süleymaniye Umumi Kütüphanesi
  Müdürlüğü. _Bottom_, from Leclerc, _Abulcasis_.]

  [Illustration: Figure 8.--Syringe with metal plunger-pump.
  _Top_, from original Arabic manuscript (Ali 2854), courtesy
  Süleymaniye Umumi Kütüphanesi Müdürlüğü. _Bottom_, from
  Channing, _Albucasis_.]

Al-Zahrāwī frequently introduces his treatises with brief instructive
and sometimes informative preludes. However, in launching the last
treatise of _al-Taṣrīf_ he expounded in a most interesting and
illuminating manner the status of surgery during his time. He also
explains the reasons that forced him to write on this topic and why he
wished to include, as he did, precautions, advice, instructional notes,
and beautifully illustrated surgical drawings. For example, the prelude
to the treatise mentions four incidents that he witnessed, all ending
with tragic results because of the ignorance of physicians who attempted
to operate on patients without the proper training in anatomy and
surgical manipulation. "For if one does not have the knowledge of
anatomy," al-Zahrāwī protests, then "... he is apt to fall in errors
that lead to death as I have seen it happen to many."[13]

Al-Zahrāwī divides his surgical treatise into three sections (abwāb). In
the first section (56 chapters)[14] he elaborates upon the uses and
disadvantages of cautery in general. And on the ground that "fire
touches only the ailing part ... without causing much damage to
surrounding area," as caustic medicine does, he prefers cautery by fire
(al-kay bi al-nār) to cautery by medicine (bi al-dawā).[15] This, he
adds, "became clear to us through lifelong experience, diligent
practice, and thorough investigations of facts."[16]

  [Illustration: Figure 9.--Metal nose dropper. _Top_, from
  original Arabic manuscript (Tüb. MS. 91), courtesy
  Universitätsbibliothek Tübingen. _Middle_, from Channing,
  _Albucasis_ (_Smithsonian photo 46891-C_). _Bottom_, from
  Sudhoff, _Chirurgie_, courtesy National Library of
  Medicine.]

He also proposes that instruments made of iron are more practical in
many ways than those made of gold, because often, when gold instruments
are put in fire, they either are not heated enough or are overheated,
causing the gold to melt.

  [Illustration: Figure 10.--Dental scrapers. _Top_, from
  original Arabic manuscript (Vel. 2491), courtesy Süleymaniye
  Umumi Kütüphanesi Müdürlüğü. _Left_, from Argellata 1531,
  courtesy National Library of Medicine. _Right_, from
  Channing, _Albucasis_.]

Al-Zahrāwī gently refutes the superstition that cautery is "good only in
springtime," and states that "under the right conditions of the body’s
humors it could be used in all seasons."[17] Although he recommends
cautery rather highly, he never minimizes the importance of treatment
by drugs. Actually, he encourages the use of drugs, before, with, and
after cauterization.[18] For example, in chapter 16 on "the
cauterization of eyelid when its hair grows reversedly into the eye," he
recommends treatment by cautery and by medicine. In cautery, the area
where fire is to be placed is marked with ink in the shape of a myrtle
leaf. In drug treatment, the caustic medicine is applied to the eyelid
over a paper in the shape of a myrtle leaf (fig. 2).

  [Illustration: Figure 11.--Dental forceps. _Top_, from
  original Arabic manuscript (Tüb. MS. 91), courtesy
  Universitätsbibliothek Tübingen. _Bottom_, from Leclerc,
  _Abulcasis_.]

In chapter 17 the author refers to an ancient method regarding cautery
of the fistula in the inner corner of the eye. After incising the
fistula, one "dirham" (derived from the Greek "drachma," which is equal
to about 2.97 grams)[19] of melted lead is poured into it through a fine
funnel used for cauterization (fig. 3).

  [Illustration: Figure 12.--Golden bridge to stabilize shaky
  teeth. _Top_, from original Arabic manuscript (Tüb. MS. 91),
  courtesy Universitätsbibliothek Tübingen. _Left_, from
  Argellata 1531, courtesy National Library of Medicine.
  _Right_, from Channing, _Albucasis_.]

In like manner, al-Zahrāwī discusses cautery of the stomach and the
"cold liver" in chapters 26 and 27, respectively. The drawings therein
represent shapes of the burns on the skin (fig. 4) and marks of ink to
be drawn beneath the cartilage of the ribs (fig. 5) for the purpose of
spotting the area of operation. Here also he describes carefully and
clearly the methods of applying cautery and the types, position, and
number of tools employed in each case. He likewise depicts (in chapter
45) instruments used in the treatment of hernia (fig. 6).

The second section (bāb), with about 99 chapters,[20] deals with
incision, puncturing, venesection, cupping, surgery on abscesses, and
the withdrawal of arrows from the body. Al-Zahrāwī warns that ignorance
in such operations may lead to damage of an artery or vein, causing loss
of blood "by which life is sustained."[21] Moreover, needle and thread
(more than one kind is mentioned) for the stitching of wounds are
repeatedly recommended.

According to al-Zahrāwī, foreign bodies that lodge in the ear (chapter
6) are of four origins: (1) "mineral stones" or substances resembling
mineral stones such as iron and glass; (2) plant seeds (chick-peas and
beans); (3) liquids, such as water and vinegar; and (4) animals, such
as fleas. Several instruments are recommended for the removal of such
foreign bodies--fine tweezers shaped like a dropper (fig. 7), a syringe
with plunger-pump, and a tube made of silver or copper (fig. 8). Also of
interest to pharmacy and therapy is the advice in regard to the use of
lubricants to be applied before administering these fine instruments
into the body’s cavities.

Chapter 24 is concerned with the treatment of the polypus that grows in
the nose. The various kinds (including cancer growth), shapes, and
colors of this type tumor and its treatment by surgery or medicine are
described. A hollowed nose-dropper made of metal in the shape of a small
kerosene lamp[22] is suggested (fig. 9). The dropper is held by its
handle while its contents are heated before use. Applying heat to nose
drops was probably proposed because it serves two purposes: it allows
easier flow of the "duhn," or the fatty substance used, and it raises
the temperature of the drops to that of the body.

In his discussion on dental hygiene,[23] al-Zahrāwī describes scrapers
and dental forceps for teeth cleaning and extraction (figs. 10, 11) and
brings in a few points of historical interest.[24] He warns of the
common error of extracting the adjacent healthy tooth instead of the
ailing one due to the patient’s sense deception. For a gargle he
prescribes salt water, vinegar, and wine (sharāb). To stop hemorrhage he
used blue vitriol (al-zāj)--copper sulfate in our modern terminology.

In chapter 33 al-Zahrāwī discusses bridge-making for the consolidation
of shaky teeth (fig. 12). He prefers the use of stable gold over silver
which, he says, putrifies and rots in a short time. In a rational
approach, he also suggests that the fallen tooth itself, or a similar
one shaped out of a cow’s bone, be installed and connected with
adjacent, stable teeth by a bridge.

Now, turning to chapter 36, we find al-Zahrāwī describing a knife-thin
tongue depressor (fig. 13) that he used to facilitate the examination of
inflamed tonsils and other swellings of the throat; it was made of
silver or copper. And in chapter 37 (chapter 34 in Bes. 503), he
describes the excision of an inflamed uvula by surgery. In the same
chapter, he also mentions the use of instruments made of steel. Of
pharmaceutical interest is the following free translation of the formula
he prescribes "as a milder treatment by fumigation ... to be resorted to
only when the swelling is subsiding":[25]

  Take pennyroyal [_Mentha pulegium_ Linn.], absinthe
  [_Artemisia maritima_ Linn.], thyme, rue, hyssop, camomile,
  abrotanum [_Artemisia abrotanum_ Linn.], and other similar
  herbs. Put all in a casserole and cover them with vinegar.
  Then close tightly with clay [_lutum-sapientiae_]--except
  for a small hole in the middle of the cover--and boil.
  Connect one end of a hollowed instrument, a crude form of an
  inhaler [fig. 14], with the hole in the cover and insert the
  other end, which contains the nozzle, into the patient’s
  mouth, allowing the vapor to rise up to the uvula. And if
  you are not able to secure this instrument, take a straw and
  attach its end to an egg-shell. The egg-shell will prevent
  burns in the patient’s mouth that might be caused by the
  heated vapor.

  [Illustration: Figure 13.--Metal tongue depressor. _Top_,
  from original Arabic manuscript (Ali 2854), courtesy
  Süleymaniye Umumi Kütüphanesi Müdürlüğü._ Bottom_, from
  Channing, _Albucasis_.]

  [Illustration: Figure 14.--Crude form of an inhaler. _Top_,
  from original Arabic manuscript (Tüb. MS. 91), courtesy
  Universitätsbibliothek Tübingen. _Bottom_, from Argellata
  1531, courtesy National Library of Medicine.]

Al-Zahrāwī repeats in chapter 53, on cancer, what Greek physicians had
said earlier, that cancer could be removed by surgery only at its first
stage and when found in a removable part of the body, such as the
breast. Therefore, he confesses that neither he nor any one else he
knew of ever applied surgery with success on advanced cancer.[26]

  [Illustration: Figure 15.--Metallic syringe for injecting
  solutions into the bladder. _Top_, from original Arabic
  manuscript (Bes. 503), courtesy Süleymaniye Umumi
  Kütüphanesi Müdürlüğü. _Bottom_, from Argellata 1531,
  courtesy National Library of Medicine.]

  [Illustration: Figure 16.--Metallic or porcelain syringes
  for injection of enemas. _Top_, from original Arabic
  manuscript (Ali 2854), courtesy Süleymaniye Umumi
  Kütüphanesi Müdürlüğü. _Bottom_, from Argellata 1531,
  courtesy National Library of Medicine.]

Of special interest in chapter 59 is the metallic "syringe" (fig. 15)
used to inject medicinal solutions into the bladder: "The hollow passage
[of the syringe] should be exactly equal to the plunger it contains and
no more, so that when such fluids from an excess of humors are aspirated
they will be drawn out, and likewise when the solutions are injected
they will be pushed in easily." Such description of the use of a
"bladder syringe" in the late 10th century clearly points to the
practical and interesting approach to surgery in _al-Taṣrīf_. Moreover,
his description of the removal of a stone from the bladder--an operation
we now call lithotomy--is considered a contribution to bladder surgery.

One of the earliest recorded operations for the extractions of two dead
fetuses from the womb is clearly described in chapter 76. The account of
this case shows not only al-Zahrāwī’s intelligent approach as a shrewd
observer but also his clinical and surgical ability.

Drawings of bulb-syringe instruments used for administering enemas in
ailments of the rectum and for the treatment of diarrhea and colic are
depicted in chapter 83. The text describes several kinds of syringes
made of silver, porcelain, and copper in various sizes (fig. 16). Of
particular interest is an illustration of a syringe, especially
recommended for children, to which a piece of leather (jildah) is
attached (fig. 17). This instrument is a precursor of our modern bulb
syringe.

In chapter 84 al-Zahrāwī turns to the treatment of various wounds. He
prescribes the following powder formula for use: "Take olibanum
[frankincense] and dragon’s blood,[27] two parts of each, and three
parts of slaked or unslaked lime. Pound them well, pass through a sieve
and apply the powder to the wound." In cases of damaged blood vessels,
he tied the arteries by ligature, a practice of which he was a pioneer.
In another chapter he describes four methods for suturing the
intestines.

Al-Zahrāwī, being associated with war casualties and writing his
treatise about the end of the 10th century, no doubt had the experience
of dealing with cases involving injuries caused by arrows. The text in
chapter 94 discloses his observations in elaborate investigations
regarding the extraction of various kinds of arrows from the body.[28]
Accordingly, several kinds of hooks and forceps for removing arrows are
described and depicted in the treatise (see fig. 18). Al-Zahrāwī’s
mention of Turkish bows and arrows led Freind to believe, erroneously,
that the author of the treatise must have lived in the 12th century,[29]
notwithstanding the fact that Turkish bows and arrows were in common use
in the latter part of the 10th century.

  [Illustration: Figure 17.--A crude form of bulb syringe
  recommended for use with children. _Top_, from original
  Arabic manuscript (Ali 2854), courtesy Süleymaniye Umumi
  Kütüphanesi Müdürlüğü. _Bottom_, from Leclerc, _Abulcasis_.]

The next chapter, on cupping, mentions the use of cups made of horns,
wood, copper, or glass, according to circumstances and the availability
of material. The methods of treatment are divided into two kinds: dry
cupping, with or without fire, and wet cupping (see fig. 19). He
prescribes ointments and aromatic and medicated waters to be applied
before and after cupping to facilitate healing. Only when cupping is not
possible, as on the nose, fingers, and similar parts of the human body,
does he propose the use of leeches for treatment.[30] Evidently this is
an indication that he did not, as generally supposed, encourage the
widespread use of leeches.

  [Illustration: Figure 18.--Hooks and forceps used for the
  extraction of arrows. _Top_, from original Arabic manuscript
  (Tüb. MS. 91), courtesy Universitätsbibliothek Tübingen.
  _Bottom_, from Channing, _Albucasis_.]

  [Illustration: Figure 19.--Cupping. _Top_, from original
  Arabic manuscript (Tüb. MS. 91), courtesy
  Universitätsbibliothek Tübingen. _Bottom_, from Argellata
  1531, courtesy National Library of Medicine.]

The third and final section, of 35 chapters, deals with the reduction,
luxation, and treatment of injured bones, including fracture of the
pelvis. The advices and warnings in the prelude of this section appear
to repeat some of al-Zahrāwī’s sayings that had been covered in his
previous introductions. The text, however, presents many facets of
interest to the health professions. It elaborates upon the application
of various forms of bandages and plasters in a variety of operations.
Al-Zahrāwī’s detailed description relating to fractures of bones is a
fine anatomical document of historical interest. He illustrates and
describes special methods for tying injured or broken bones, and he
suggests that bandages made of soft linen be less and less tight as
distance increases from the injured place (chapter 1). For the
protection of areas adjacent to the injured part against contact with
edges of splints he advocates padding with soft gauze and carded wool.
In some cases, to guard against swelling, he preferred a delay of one or
more days in applying bandages over splints. Al-Zahrāwī also devised
and depicted many kinds and shapes of splints for use in simple and
compound fractures of the head, shoulders, arms, fingers, etc. (see fig.
20). For example, in discussing the reduction of the humerus, he
recommends a splint consisting of a smooth, thin stick bent in the shape
of a bow with two strings, each attached to one end of the stick (fig.
21). The injured bone is then placed in the middle of the bent splint
for reduction while the patient is seated on a chair. Tying is applied
only when there is no "hot" swelling (chapter 11). One of the remarkable
observations made in this section is the description of the paralysis
caused by fracture of the spine.

  [Illustration: Figure 20.--Splint "in the shape of a spoon
  without a bowl." _Top_, from original Arabic manuscript
  (Tüb. MS. 91), courtesy Universitätsbibliothek Tübingen.
  _Bottom_, from Channing, _Albucasis_.]

Of interest to historians of medical therapy and pharmacy are the
recipes for poultices that al-Zahrāwī recommends for use over
fractured bones. For example, he gives the following recipe for one
such poultice: "Take the so-called 'mill’s dust' [ghubār al-rahā],
which is the part of the wheat flour that clings to the walls of the
mill during grinding [lubāb al-daqīq], and, without sifting away the
bran, knead with white-of-egg to a medium consistency, and apply."
Another, more elaborate, recipe calls for 10 dirhams each of the
roots of wild pomegranate [_Glossostemon bruguieri_ D.C.], chickling
vetch [the grass pea, _Lathymus sativus_], and white marshmallow; 5
dirhams each of myrrh and aloes; 6 dirhams of white gum Arabic
[_Acacia_]; and 20 dirhams of bole [friable earthy clay consisting
largely of hydrous silicates of aluminum and magnesium, usually
colored red because of impurities of iron oxide]. Procedure was to
pound all ingredients gently, pass them through a sieve, and knead
with water or white-of-egg (chapter 1).

  [Illustration: Figure 21.--A splint to support the arm.
  _Top_, from original Arabic manuscript (Cod. N.F. 476A),
  courtesy Oesterreichische Nationalbibliothek. _Bottom_, from
  Argellata 1531, courtesy National Library of Medicine.]

The question arises as to whether al-Zahrāwī did any human dissection.
The answer is uncertain because our knowledge of his life is
fragmentary. However, he gives no clue to the dissection of humans in
any of the 30 treatises of _al-Taṣrīf_--his only known writings--and
there is no evidence that he practiced it in secret. His upright
attitude as a Muslim who repeatedly emphasized his adherence to his
faith suggests that he relied completely on animal dissection and the
writings of his Greek-Roman and Islamic predecessors. Physicians in both
the Islamic domain and in Christendom for many centuries were hostile to
the idea of human dissection for any purpose because of their
traditional socio-religious convictions, considering it an unethical and
undignified practice. Perhaps it has been al-Zahrāwī’s original
contributions to surgery, his enthusiasm in emphasizing the value of
anatomical knowledge, and his recognition of the necessity that only
well-educated, well-trained doctors should perform surgery that have led
some medical historians to wonder whether he did human dissection at
some time in his long years of experience.


In Summary

The few examples of illustrations of surgical instruments given here
indicate that the Arabic manuscripts, in general, have preserved the
original, oriental, artistic features of the drawings in a way that has
been overlooked in Latin and vernacular versions of _al-Taṣrīf_.

In presenting his personal observations and original ideas on surgery
late in life, al-Zahrāwī, for the most part, was inspired by a thorough
acquaintance with Greek and Arabic medical literature supplemented by
lifelong intelligent observation and experience.

Through its descriptions and illustrations, the surgical treatise of
al-Zahrāwī very likely played a significant role in the designing of
improved surgical instruments in the Middle Ages. Also, the treatise no
doubt promoted the development of improved surgical techniques in Islam
and, through its translations, promoted these techniques to an even
greater extent in the West, a fact that justifies the fame of this
treatise as the highest expression of the development of surgery in
Arabic Spain--a treatise whose influence continued to the Renaissance.
It contributed in no small measure to the idea of equipping learned and
well-trained surgeons with the best surgical tools and techniques of the
time; moreover, it encouraged the invention of new instruments to meet
differing circumstances and special conditions. These tools no doubt
greatly facilitated the work of the surgeon.

Throughout the text of _al-Taṣrīf_ al-Zahrāwī gave careful attention
to the importance of pharmaceutical preparations in the healing art,
including cases requiring surgery.


  [1] George Sarton, _Introduction to the History of
  Science_, Baltimore, 1927, vol. 1, p. 681.

  [2] Mohammad S. Abu Ganima, in _Abul-Kasim ein Forscher der
  Arabischen Medizin_, Berlin, 1929, suggested that
  description of operations in al-Majūsī’s surgery is clearer
  than that in al-Zahrāwī’s--a statement which does not seem
  acceptable.

  [3] Max Neuburger, _Geschichte der Medizin_, Stuttgart,
  1911, vol. 2, pt. 1, pp. 178-179.

  [4] Heinrich Haeser, _Lehrbuch der Geschichte der Medizin
  und der epidemischen Krankheiten_, Jena, 1875, vol. 1, pp.
  578-584; and Donald Campbell, _Arabian Medicine and Its
  Influence on the Middle Ages_, London, 1926, vol. 1, p. 88.

  [5] See the prelude to the treatise.

  [6] Fielding H. Garrison (_An Introduction of the History of
  Medicine_, ed. 4, rev., Philadelphia, 1929, p. 132), states,
  in reference to "Sudhoff and others," that many drawings
  earlier than those of al-Zahrāwī have been discovered in
  medieval manuscripts. However, Garrison overlooked the fact
  that al-Zahrāwī’s surgical illustrations were mainly
  depicted for instructional purposes--a unique approach. It
  should be noted also that al-Zahrāwī died almost a century
  earlier than Garrison thought. See also Martin S. Spink,
  "Arabian Gynaecological, Obstetrical and Genito-Urinary
  Practice Illustrated from Albucasis," _Proceedings of the
  Royal Society of Medicine_, 1937, vol. 30, p. 654.

  [7] Johannis Channing, _Albucasis de Chirurgia. Arabice et
  Latine_, Oxford, 1778, 2 vols. (hereinafter referred to as
  Channing, _Albucasis_). The text has many errors in spelling
  and grammar, but Leclerc went too far in criticizing this
  edition, which has many merits. Moreover, the surgical
  illustrations (reproduced from the Huntington and Marsh
  manuscripts of the Bodleian Library) in Channing’s edition
  are of special interest.

  [8] Lucien Leclerc, _La Chirurgie d’Abulcasis_, Paris, 1861
  (hereinafter referred to as Leclerc, _Abulcasis_). This
  excellent French version was first published in a series of
  articles in _Gazette Médicale de l’Algérie_, and seems
  influenced by Channing’s edition more than Leclerc admits.
  Leclerc consulted several Arabic copies of the treatise as
  well as Latin and vernacular translations, but only a few of
  these Arabic manuscripts are considered complete. The Arabic
  manuscripts studied for the present article are not the same
  as those used by Leclerc. See also Leclerc’s monumental
  work, _Histoire de la Médecine Arabe_, Paris, 1876, vol. 1,
  pp. 453-457.

  [9] Ernst Gurlt, _Geschichte der Chirurgie und ihrer
  Ausübung Volkschirurgie-Alterthum-Mittelalter-Renaissance_,
  Berlin, 1898, vol. 1, pp. 620-649, with more than 100
  figures. In the text and illustrations, Gurlt relied upon
  Leclerc’s translation and modified drawings of the surgical
  instruments; nevertheless, he presents a brief, systematic
  study--probably the best so far--of the entire treatise.

  [10] Karl Sudhoff, _Beiträge zur Geschichte der Chirurgie im
  Mittelalter_, Leipzig, 1918 (hereinafter referred to as
  Sudhoff, _Chirurgie_), vol. 2, pp. 16-84, with a few plates.
  Although Sudhoff consulted the fragmentary Arabic manuscript
  indexed as "Cod. Arab. 1989" in Gotha, Germany, he relied
  mainly upon Latin versions of the treatise and the
  illustrations contained in them.

  [11] See Leclerc, _Abulcasis_, in introduction.

  [12] The seven Arabic manuscripts are indexed as "Berlin MS.
  Or. fol. 91," temporarily at Universitätsbibliothek
  Tübingen, in Germany; "Escorial MS. Arabe No. 876," at
  Biblioteca del Monasterio de San Lorenzo el Real de El
  Escorial, in Spain; "Wien MS. Cod. N.F. 476 A.," at
  Oesterreichische Nationalbibliothek, in Vienna; and "Ali
  Emiri Arabi No. 2854," "Beşir Ağa Nos. 502 and 503," and
  "Veliyyudin No. 2491," all at Süleymaniye Umumi Kütüphanesi
  Müdürlüğü, in Istanbul. Hereinafter these manuscripts are
  referred to, respectively, as Tüb. MS. 91; Esc. 876; Wien
  476 A; Ali 2854; Bes. 502; Bes. 503; and Vel. 2491. The
  Smithsonian Institution recently obtained a microfilm copy
  of Bankipore Manuscript No. 17 from the Khuda Bakhsh O. P.
  Library, Patna (Bihar), India. This manuscript, containing
  only the 30th treatise of _al-Taṣrīf_, was copied in 1189;
  therefore, it is the earliest dated Arabic manuscript of the
  surgical treatise known to exist. The surgical illustrations
  therein add weight to the belief that the Arabic manuscripts
  show more originality in the drawings than do the later
  copied versions, which often were inaccurate and possibly
  distorted. About ten other illustrations from the Arabic
  manuscript in Istanbul indexed as "Topkapi MS. No. 1990"
  (which contains 215 beautifully illustrated figures) were
  presented by A. S. Ünver and Hüseyin Usman in an extract
  titled "Meşhur Arab Cerrahi Elbülkasimi Zehravi ve onum
  Kitabül Cerrahiyesi," Istanbul, 1935. See also Ünver,
  _Şerefeddin Sabuncuoğlu: Kitabül Cerrahiyei Illhaniye_,
  Istanbul, 1939, pp. [5]-7.

  [13] See introduction to the treatise; for example, Bes.
  502, fol. 522v-523v and Vel. 2491, fol. 104r-105v. See also
  K. P. J. Sprengel, _Versuch einer pragmatischen Geschichte
  der Arzneikunde_, Halle, 1823, vol. 2, pp. 449-451. George
  J. Fisher, in "Abul-Casem Chalaf Ibn Abbas al-Zahrāwī,
  Commonly Called Albucasis," _Annals of Anatomy and Surgery_,
  July-December, 1883, vol. 8, pp. 24-25, gives a translation
  of only the first part of the introduction.

  [14] There are 56 chapters listed in almost all manuscripts
  and commentary works I checked except Tüb. MS. 91 and Esc.
  876, where only 55 chapters are listed.

  [15] Al-Zahrāwī mentions several caustic medicines used in
  cautery, among which are garlic, mustard, melted lead,
  slaked or unslaked lime with or without "common" soap,
  Thapsia (_Ruta graveolens_ Linn.), and juice of the Oriental
  cashew nut (_Senecarpus anacardium_ Linn.).

  [16] Vel. 2491, fol. 106; Bes. 502, fol. 523r-524v.

  [17] Al-Zahrāwī criticizes those who interpret the saying
  "cautery is the end of treatment" to mean that cauterization
  is the best and only conclusive treatment at the physician’s
  disposal. He points out that other treatments, such as
  drugs, should be resorted to first, and used until they
  prove of no avail; and he states that only after cautery
  proves to be the cure should it be considered the completion
  of medical treatment--"al-kay ākhir al-ṭibb." See Vel. 2491,
  fol. 106; and Bes. 502, fol. 524r-525v.

  [18] For healing, soothing, or emollient purposes,
  al-Zahwārī suggested medications, such as egg white, salt
  water (normal saline), sap of psyllium, several ointments,
  "duhn" of rose, and other "adhān" (plural of "duhn," the
  fatty or oily essences extracted from various substances
  through pharmaceutical processes).

  [19] For a more accurate estimate of the equivalence of
  "dirham" according to the area in which the measurement was
  taken, the reader may consult Walter Hinz, _Islamische Masse
  und Gewichte umgerechnet ins metrische System_, Leiden,
  1955, pt. 1, pp. 2-8; and George C. Miles, _Early Arabic
  Glass Weights and Stamps_, New York, 1948, p. 6.

  [20] The contents of several manuscripts (such as Ali 2854,
  Wien 476 A, Bes. 503, and Tüb. MS. 91) give different
  numbers.

  [21] See, for example, Tüb. MS. 91, fol. 45v; and Bes. 502,
  fol. 530v.

  [22] Sudhoff, _op. cit._ (footnote 10), p. 29, fig. 6.

  [23] For a more detailed and interesting discussion with
  beautiful illustrations included, the reader may consult Ch.
  Niel, "La Chirurgie Dentaire D’Abulcasis Comparée a celle
  des Maures du Trarza," _Revue de Stematologie_, April 1911,
  vol. 18, pp. [169]-180 and 222-229.

  [24] It is regrettable that Franz Rosenthal in his fine
  article "Bibliographical Notes on Medieval Muslim Dentistry"
  (_Bulletin of the History of Medicine_, 1960, vol. 34, pp.
  52-60) failed to refer to this or any other section of
  al-Zahrāwī’s work.

  [25] Bes. 502, fol. 538. See also Channing, _Albucasis_, pp.
  206-208. For the identification of the drugs and their
  botanical origins the author of the present paper consulted
  H. P. J. Renaud and Georges S. Colin, _Tuḥfat al-Aḥbāb,
  Glossaire de la Matière Médicale Marocaine_, Paris, 1934,
  pp. 133, 143, 193-194, and Max Meyerhof, _Un Glossaire de
  Matière Médicale Composé par Maimonide_, Cairo, 1940, pp.
  168-169.

  [26] Tüb. MS. 91, fol. 99v.

  [27] Dragon’s blood is a resin obtained from the scales
  covering the surface of the ripe fruits of "_Daemonorops
  draco Blume_" (Heber W. Youngken, _Textbook of
  Pharmacognosy_, ed. 6, Philadelphia, 1948, p. 175). See also
  Renaud and Colin, _op. cit._ (footnote 25), pp. 54-55.

  [28] Heinrich Frölich, "Abul-Kasem als Kriegschirurg,"
  _Archiv für klinische Chirurgie_, 1884, vol. 30, pp.
  365-376. This well-presented study was reviewed by Paul
  Schede in _Centralblatt für Chirurgie_, 1884, no. 38, pp.
  626-627.

  [29] Johannis Freind, _The History of Physick_, London,
  1726, vol. 2, p. 129.

  [30] In several manuscripts, the chapter on the use of
  leeches is the last one in the second section of the
  treatise.


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