Drawings and Pharmacy in Al-Zahrawi's 10th-Century Surgical Treatise

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 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, al-Zahrāwī describes scrapers and dental forceps for teeth cleaning and extraction (figs. 10, 11) and brings in a few points of historical interest. 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":

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.

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.

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, 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. 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, notwithstanding the fact that Turkish bows and arrows were in common use in the latter part of the 10th century.

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. Evidently this is an indication that he did not, as generally supposed, encourage the widespread use of leeches.

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.

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).

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