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Acupuncture points in the book of Şerefeddin Sabuncuoğlu, a 15th century Turkish physician
  1. H Volkan Acar
  1. Correspondence to Dr H Volkan Acar, Department of Anesthesiology and Intensive Care, Ankara Training and Research Hospital of Ministry of Health, Ankara 06340, Turkey; hvacar{at}yahoo.com

Abstract

Şerefeddin Sabuncuoğlu (1385–1468?), the author of Cerrahiyetü'l-Haniyye (Imperial Surgery), was a distinguished Ottoman Turkish surgeon. The first illustrated Turkish surgical textbook, Cerrahiyetü'l-Haniyye consisted of three chapters (ie, cauterisation treatments, surgical procedures and fractures and dislocations). Although the main source of the book was Al-Tasrif (Textbook of Surgery) by Albucasis (Abu al-Qasim al-Zahrawi; 936–1013 AD), Sabuncuoğlu added much new information, his clinical experiences and suggestions. The original illustrations and human figures made Cerrahiyetü'l-Haniyye the first illustrated medical textbook in Turkish and Islamic medicine literature. Cerrahiyetü'l-Haniyye was also a valuable source for acupuncturists. Some new sections and additions revealed that Sabuncuoğlu had knowledge of Chinese medicine. In four sections of Cerrahiyetü'l-Haniyye (ie, toothache, haemorrhoids, eczema and dermatophytosis) Sabuncuoğlu described acupuncture techniques and point locations. It is likely that the Chinese medicine content of Cerrahiyetü'l-Haniyye was derived from Central Asian roots of Anatolian Turkish people.

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Introduction

Şerefeddin Sabuncuoğlu (1385–1468? AD) was a distinguished Turkish surgeon who lived in Amasya, Turkey in the 15th century. He was the surgeon of Amasya Hospital (darüşşifa), which was a post for which only the best physicians of the time were eligible. Amasya was a city of commerce and the centre of culture and art in Anatolia, and in the 15th century 8% of the entire population of the city were college (madrasah) students.1

Sabuncuoğlu wrote three books: Terceme-i Akrabadin (Translation of Pharmacopoeia), Mücerrebname (The Book of Experiences) and Cerrahiyetü'l-Haniyye (Imperial Surgery).1 When he completed his most recognised book Cerrahiyetü'l-Haniyye in 1465, he was 80 years old. This was the first illustrated Turkish medical textbook and consisted of three chapters (ie, cauterisation treatments, surgical procedures and fractures and dislocations).

Currently, three copies of Cerrahiyetü'l-Haniyye exist; two are in Istanbul and one is in the Bibliotheque Nationale, Paris. Two of the three extant copies of this book were handwritten by Sabuncuoğlu. In 1992, İlter Uzel, a Turkish medical historian, examined all three copies and published a Turkish/English translation with an in-depth review.1

Scientific background

Cerrahiyetü'l-Haniyye is scientifically important for several reasons. First, it was written in Turkish rather than Persian or Arabic. In that era, Persian and Arabic were scientific languages in Islamic regions and were used for the majority of the literature and scientific articles. Sabuncuoğlu said, “Here is why I wrote this book in Turkish. All Roman people (in Anatolia) spoke Turkish at that time. Besides that, the majority of surgeons of our age were illiterate. They all read the books in Turkish even if they were literate. If they use this Turkish book as a source, they can understand things in detail and can solve their problems easily. Thus, they can protect themselves from malpractice and can protect their patients from complications.”1

Second, Cerrahiyetü'l-Haniyye includes more than 100 coloured surgical and interventional illustrations of the surgeon, the patient, the surgical instruments and surgical procedures. Both male and female figures were illustrated, and the book even included illustrations in gynaecological and obstetrical positions. Although Islamic religion did not formally prohibit the depiction of the human body, illustrations of any living creature were not accepted in Islamic culture for centuries. Therefore, one could not view illustrations in any books, including medical books such as the Al-Tasrif of Albucasis and the Canon of Medicine of Avicenna. Thus, it can be said that Cerrahiyetü'l-Haniyye is a coloured and illustrated surgical atlas and not simply a medical treatise.

Third, Cerrahiyetü'l-Haniyye contains medical devices and instruments that were used for cauterisation, surgery and therapeutic interventions.1–3 Some of these devices and instruments were designed by Sabuncuoğlu himself and some were taken from Albucasis's book. However, all of the illustrations were drawn by Sabuncuoğlu.1

Cerrahiyetü'l-Haniyye includes treatments of nearly all types of surgery including general, orthopaedic, paediatric, thoracic, gynaecological, plastic, vascular and neurosurgery. Some surgical procedures and therapeutic interventions he mentioned in his book, including ophthalmological, urological and paediatric otorhinolaryngological practices, correlate well with modern practices.2 ,4–6

It seems that Sabuncuoğlu was influenced by many medical textbooks in Arabic, Persian and Greek. However, the primary source of Sabuncuoğlu was the Al-Tasrif (Textbook of Surgery) by Albucasis (Abu al-Qasim al-Zahrawi; 936–1013 AD).1 Albucasis is considered to be the father of modern surgery.7 Although Al-Tasrif was accepted as an original textbook, the main source of Albucasis was Paul of Aegina's The Epitome of Medicine (625–690 AD).7

The main skeleton of Cerrahiyetü'l-Haniyye comes from Al-Tasrif by Albucasis. However, although some have suggested that Cerrahiyetü'l-Haniyye is a verbatim translation of Al-Tasrif,8 Cerrahiyetü'l-Haniyye is clearly more than a simple translation. Cerrahiyetü'l-Haniyye contains many original descriptions and observations that were not mentioned in Al-Tasrif. Additionally, Cerrahiyetü'l-Haniyye contains original illustrations and human figures that were not depicted in Abulcasis’s book or in any other manuscript that had been published in the Islamic world. Three new sections were added at the end of each chapter. Uzel said that 137 different clinical observations and recommendations were mentioned in Cerrahiyetü'l-Haniyye, which indicates a clear difference between the two books.1 In other words, Sabuncuoğlu first translated Al-Tasrif and then expanded it to contain more information. Citations from the other physicians that were based on his own experiences, the original illustrations of human figures and the new surgical instruments enriched this translation and made Cerrahiyetü'l-Haniyye, the first illustrated Turkish surgical atlas, a reference textbook.

The additions to the book that originated from his own experiences might be a reflection of Sabuncuoğlu's Anatolian Turkish identity. Anatolia is a melting pot of various cultures, including Sumer, Babylon, the Hittites and Assyria, and has been a settlement place for great empires such as the Romans, Byzantines and Ottomans. Additionally, Mongol Ilkhans and Turkic tribes that originated in Central Asia also made large excursions to Anatolia beginning in the 11th century. This Asian connection introduced new knowledge to Anatolia.

Cauterisation

The book contains three chapters concerned with cauterisation treatments, surgical procedures and fractures and dislocations. The first chapter of the book includes 57 sections and lists the disorders for which cauterisation was used as treatment.1

The methods of cauterisation differ with respect to the disease being treated. In some sections cauterisation is applied directly to the local area for abscesses and localised skin or mucosal lesions. Examples of such lesions include acute dacryocystitis with fistulae, cleft lips, intraoral fistulae, warts after excision and anal fistulae.1 The goal of cauterisation seemed to be the formation of scar tissue or shrinkage of diseased areas for three conditions: dermato/blepharochalasis or ptosis, entropion and trichiasis, and inguinal hernia.1 The use of cauterisation to stop bleeding from vessels following surgical incisions and subsequent cauterisation is described in one section.1

Over nearly 20 sections, cauterisation seems to be applied to local points. The cauterisations of areas of the liver for liver diseases, the stomach for stomach diseases, the spleen for splenic diseases, the hip joint for hip dislocations and around cancer tissues are described.1

Acupuncture points

Sabuncuoğlu suggested the use of cauterisation on specific points in more than 30 sections.1 One of the most popular points he used was the location of GV20. This point is suggested for use in the treatment of various disorders including headaches, chronic migraines, ‘forgetfulness’, acute stroke, epilepsy, ‘melancholiness’, cataracts, chronic dacryocystitis, ozaena (chronic nasal discharge) and leprosy. The localisation of this point is described in Cerrahiyetü'l-Haniyye as follows: “Put the heel of your hand on the notch of the nose of the patient. Thereafter, place your hand on the head of the patient posteriorly. The point where the tip of your finger reaches is the point of cauterization.”1

The described locations of other points of cauterisation might also be considered to correspond to acupuncture points; for example, the corner of the forehead (ST8), the temple (Taiyang), the corner of the mouth where the lips meet (ST4), just lateral to the outer canthus of the eyes (GB1), in the depression above the clavicle (ST12), directly between the nipples on the chest (CV17), two finger widths below the umbilicus (CV5) and other points are mentioned.1

Although the abovementioned points are well correlated with acupuncture points, we cannot state with certainty that Sabuncuoğlu suggested that cauterisation be applied to acupuncture points. The primary reason for this lack of certainty is the fact that Cerrahiyetü'l-Haniyye was largely based on Albucasis’s Al-Tasrif. A comparative analysis revealed that the descriptions of the locations of these points were exactly the same as those in Al-Tasrif, but the primary source of Albucasis was Paul of Aegina.7

Sabuncuog˘lu's own contributions

In contrast to the abovementioned examples, Cerrahiyetü'l-Haniyye contains several other strong lines of evidence that are suggestive of a possible connection with Chinese medicine. The most striking examples that illustrate that Sabuncuoğlu had knowledge of acupuncture are stated in the four sections discussed below.

Section 21 of Chapter 1 dealt with toothache. Sabuncuoğlu stated that, “if someone has a toothache on the right-hand side, cauterize the left wrist bone and vice versa”.1 He also noted that, “I suggested you use this method because I have treated 30 patients using this method”. It is well known that cross needling is one of the point selection methods in acupuncture practice and that LI4 is among the points that can be used for the treatment of toothache.9 This method did not appear in Abulcasis's book.7

In section 34 of Chapter 1 he first explained the treatment of haemorrhoids just as it is expressed in Al-Tasrif. Thereafter he added, “I, the writer of this book, Şerefeddin, state that I discovered a treatment for this disease. I have used this treatment for 113 patients and observed positive results, and I now describe it here. Cauterize the umbilicus with a big ‘punctate’ cauterization. However, do not apply hard pressure so that only half of the skin is cauterized. This method benefits haemorrhoids, umbilical hernia and chronic diarrhoea.”1 In acupuncture textbooks, moxibustion of CV8 (in the centre of the umbilicus) is indicated for diarrhoea, ‘prolapse of the rectum’ and ‘umbilical shan disorder’ (ie, protrusion).9 However, Albucasis did not mention the cauterisation of the umbilicus for the treatment of haemorrhoids in Al-Tasrif.7

In section 57 of Chapter 1 (dealing with eczema), the location of PC6 is illustrated bilaterally and described as follows: “You have to cauterize the point close to the proximal side of both wrists … The point is above two finger widths away from the wrist bone”1 (figure 1). Acupuncture textbooks describe the location of this point as follows: “two cun proximal to PC7 (at the wrist joint)”.9 The contents of section 57 are not present in Abulcasis’ book7; all contents of this section were added by Sabuncuoğlu himself.

Figure 1

Illustration showing the location of PC6 for the treatment of eczema. Reprinted with permission from the Turkish Historical Society.

Section 98 of the Chapter 2 was also written by Sabuncuoğlu. This section deals with dermatophytosis (ie, ringworm disease) and is not included in Al-Tasrif .1 ,7 Sabuncuoğlu told an anecdote that he was treating a patient with dermatophytosis with the needling method.1 Just then, a Tatar man came in and suggested a different therapeutic method for this condition. The Tatar first made a few incisions on the palate and the backs of the ears. Next, he made two more incisions bilaterally on the wrists and on the ankles. The incision lines on the wrists and ankles were described as follows: “You have to make incisions on the two vessels on the medial sides of the forearms that are located four fingers above the wrist joint. Then, you repeat the procedure on the two vessels on the medial sides of the feet that are located four fingers above the ankle joint.” Two different therapeutic approaches are noted in this section. The first is the needling of skin lesions, which is not mentioned in any other part of Cerrahiyetü'l-Haniyye or in Al-Tasrif.1 ,7 It seems that Sabuncuoğlu practised acupuncture (ie, local needling) in these areas. The second treatment method was suggested by the Tatar physician from Central Asia. This method included the use of specific body points for venesection. These points correspond to the PC5 and SP6 acupuncture points9 (figure 2).

Figure 2

Illustration showing the locations of PC5 and SP6 acupuncture points for the treatment of dermatophytosis. Reprinted with permission from the Turkish Historical Society.

History of cauterisation

Cauterisation has been widely used for various purposes including strengthening the body, treating diseases and curing skin lesions since ancient times. Traces of cauterisations have been found on the head of babies from the Calcolytic Age (5000 BCE–3000 BCE) in Anatolia.10 It is known that Hippocrates (460–377 BC) used cauterisation in medicine.11 Cauterisation has been used to eliminate noxious material via the application of heat.

Historically, cauterisation/searing has always been popular in medicine and veterinary medicine among Turkic tribes/states.12 Dunhuang medical manuscripts found in Central Asia contain evidence that Turkish people used cauterisation for medical purposes.13 ,14 Yoeli-Tlalim showed that the basic treatment method in Tibetan medicine was moxibustion, although several other techniques including bloodletting, massage and cupping were also used. A passage in one of these texts emphasises the tendency of Turkish people to apply cauterisation for medical purposes: “The Turkic method of [using] iron for cautery is also suitable”.13 ,14 This quotation is also accepted as evidence of the Turkish influence on Tibetan medicine.13 ,14

A careful analysis of the Cerrahiyetü'l-Haniyye reveals that the sentences in which Sabuncuoğlu discusses his own experiences were strongly influenced by the Central Asian roots of Turkish civilisation. This influence is particularly apparent in the sections related to toothache, haemorrhoids, eczema and dermatophytosis.1 In addition to the abovementioned data, two important sources provide theoretical background regarding the Anatolian Turks’ knowledge of Asian medicine practices—that is, the Uyghur medical texts and Tanksukname-i İlhan.

The Uyghur medical texts were among the 40 000 manuscripts found during German expeditions to Central Asia between 1902 and 1914 and date from the 9th and 14th centuries.15 These texts were first introduced to the scientific world by Arat in 1930.16 One of these texts contains illustrations of three human figures that include channels and points that are similar to those used in acupuncture and are accepted as evidence that acupunctural treatments were disseminated between Central Asian Turks (Uyghurs) and Anatolian Turks.16 We might expect that Turkic tribes carried their medical knowledge and practice to Anatolia when they migrated from Central Asia to Anatolia.

Tanksukname-i İlhan (Tansuqnamah) is a Persian compilation of a classical Chinese medical text (Mai Jing) written by Wang Shu He (201 BCE–280 BCE) and is the earliest translation of Chinese medical manuscripts to appear in the West.17 The book was prepared by Rashid al-Din Fadlallah (1247–1318) who was the prime minister of Ghazan Khan (ie, the King of the Ilkhans). Medical historians have stated that the reign of Ilkhanate and its powerful minister Rashid al-Din played a major role in the transmission of medical knowledge between the West (ie, Arabia, Persia and Europe) and the East (ie, China, India, Tibet and the Uyghurs).17 ,18

Although this book included four chapters, only the first is extant (ie, the Introduction section).19 A single handwritten copy from 1313 was kept in Istanbul. Tanksukname-i İlhan was a valuable source of Chinese medicine because it includes information about five elements, 12 meridians and pulse diagnosis. In the Introduction section, Rashid al-Din Fadlallah says that “Khitan people (ie, the Chinese) go too far in the application of cauterization. They even cauterize newborns”. Sentences from the book provide good examples that revealed the connection between the cauterization and acupuncture theories; for example, “Each meridian corresponds to an internal organ”; “Cauterization (along the meridians) can be seen as stopping the water flow from the fountain”; “(Harmful) bodily fluids (eg, blood, phlegm, etc) cannot move to a diseased organ when a specific meridian is cauterized”; “In some instances, they cauterize the left-hand side when the disease is on the right-hand side”; “They sometimes cauterize the diseased organs (areas)”; and “As we stated above, the Khitan people (ie, the Chinese) and Turks go too far in cauterization and they compiled books that illustrate exact cauterization points”.19 We might assume that Tanksukname-i İlhan was potentially a source for Sabuncuoğlu because the Amasya Hospital (darüşşifa) in Anatolia where he worked was founded in 1308–1309 during the Ilkhanate period.1

In conclusion, Sabuncuoğlu compiled the surgical knowledge of his day, which included both ancient Greek medicine and Central Asian medicine, in his book Cerrahiyetü'l-Haniyye. This book was the first illustrated Turkish surgical textbook. Some new techniques, suggestions and original illustrations that were not included in Al-Tasrif are contained in Cerrahiyetü'l-Haniyye, although the general outline of Cerrahiyetü'l-Haniyye came from Albucasis’s Al-Tasrif. These added portions reflect Sabuncuoğlu's own knowledge and experiences. It is highly likely that the content that brings acupuncture medicine to the reader's mind originated from the medical knowledge of Central Asian Turkish people.

Acknowledgments

The author thanks Associate Professor Dr Ahmet Acıduman for his valuable contribution to the analyses of sections of Cerrahiyetü'l-Haniyye, which was written in old Turkish.

References

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Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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