Al-Zahrawi, the Cordoba surgeon who taught surgery through pictures of instruments

In the operating theatre of any hospital, silver-bright instruments lie in order: forceps, scalpels, needles, thread. A new surgeon learns their names and uses from pictures in books. The tradition of teaching instruments through pictures is more than a thousand years old. A surgeon of Cordoba in Andalusia laid a major foundation for it. His name was Abu al-Qasim Khalaf ibn Abbas al-Zahrawi, and in Europe he became famous as “Abulcasis”.

The surgeon of Cordoba

Very little is known about al-Zahrawi’s life. In 1961 Sami Hamarneh, associate curator of medical sciences at the Smithsonian Institution in the United States, wrote a research paper on him. According to Hamarneh, al-Zahrawi died around 1013 AD. According to Dr Fadlurrahman Manaf, writing in the medical journal “Hektoen International”, he was born in 936 AD at Zahra, about six miles north-west of Cordoba, and was called “Zahrawi” after it. Hamarneh does not give a year of birth.

Hamarneh writes that his book “Al-Tasrif liman ajiza ‘an al-ta’lif”, written in the late 10th century, was probably the first independent work written in Andalusia to gather all the medical knowledge of its time. It consists of 30 treatises and is the only known work of al-Zahrawi.

The 30th treatise: surgery

The best-known part of the book is its 30th and last treatise, which is entirely about surgery. According to Hamarneh, its merits are its clarity, carefully given detail and personal observation. In it al-Zahrawi included his own drawings of surgical and dental instruments that he used himself, that he had designed himself, or that he recommended. According to Hamarneh, there are more than 200 such drawings of instruments in all.

The drawings were meant to teach his students, whom al-Zahrawi fondly calls his “children”. According to Hamarneh, this is probably the oldest known book in which such pictures and text appear together for the teaching of surgery.

In the preface to the treatise, al-Zahrawi described four incidents he had witnessed himself, in which inexperienced practitioners operated without training and the patients died. In Hamarneh’s translation he writes that a man who does not know anatomy, the structure of the body, makes mistakes that lead to death.

Three sections, hundreds of chapters

According to Hamarneh, the treatise on surgery has three sections. The 56 chapters of the first section deal with cautery, the treatment of a wound or diseased part with hot metal. Al-Zahrawi says the fire should touch only the diseased part. He advises that the instruments for this work be of iron, not gold, because gold either does not heat fully in the fire or melts.

About 99 chapters of the second section deal with incisions, opening veins, cupping and operations on abscesses. It contains drawings of fine forceps and a syringe for removing objects lodged in the ear, a silver or copper tongue depressor for examining the throat, and instruments for cleaning and extracting teeth. He warns that the healthy tooth next to the diseased one is often pulled out by mistake. It also describes joining loose teeth to firm neighbouring teeth with a gold bridge, and replacing a fallen tooth with one made of cow bone.

The same section mentions a metal syringe for putting medicine into the bladder, an operation to remove stones from the bladder, and a leather syringe for children, which Hamarneh calls a forerunner of today’s rubber syringe. According to Hamarneh, al-Zahrawi was among the first to adopt early methods of tying cut arteries with thread. According to Manaf, he used several kinds of thread to stitch wounds, including catgut, made from animal intestine. According to a paper by researchers at Heidelberg University in Germany, al-Zahrawi also gave the first detailed description of draining superficial fluid in children with hydrocephalus, the build-up of water in the head.

The 35 chapters of the third and last section deal with broken and dislocated bones. Al-Zahrawi drew several kinds of splints and advised that the bandage be tight at the site of injury and grow looser further away. According to Hamarneh, a notable observation in this section is his description of paralysis caused by a broken spine.

The Latin translation and Europe

According to Hamarneh, al-Zahrawi’s writings reached Europe through the Latin translation of Gerard of Cremona. Gerard died in 1187, and from the later part of the 12th century the translation spread across Europe. Hamarneh writes that for this reason al-Zahrawi won greater fame in the West than in his homeland, and that his treatise remained influential until the European Renaissance.

The lesson for today

Al-Zahrawi’s greatest lesson is that good treatment comes not from good intentions alone but from training. He stressed knowing the structure of the body. He preserved his instruments in drawings so that those who came after could learn, and he wrote down the incidents he had seen as a warning. Today, from Bolan Medical College to every medical college in the world, the pictures of instruments in surgery books continue that old tradition.