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Colored illustrations of obstetrics manipulations and instrumentation techniques of a Turkish surgeon Serafeddin Sabuncuoglu in the 15th century

Colored illustrations of obstetrics manipulations and instrumentation techniques of a Turkish surgeon Serafeddin Sabuncuoglu in the 15th century
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  Colored illustrations of obstetrics manipulations and instrumentationtechniques of a Turkish surgeon Serafeddin Sabuncuogluin the 15th century Hasan Kafali a,* , Sahin Aksoy b , Ferda Atmaca c , Imran San d a  Department of Obstetrics and Gynaecology, Harran University Medical School, Sanliurfa, Turkey b  Department of Medical Ethics and History of Medicine, Harran University Medical School, Sanliurfa, Turkey c  Department of Obstetrics and Gynaecology, Sanliurfa State Hospital, Sanliurfa, Turkey d  Department of Otorhinolaryngology, Harran University Medical School, Sanliurfa, Turkey Received 28 January 2002; accepted 16 May 2002 Abstract Serafeddin Sabuncuoglu (1385–1470) was the author of the first illustrated surgical textbook   Cerrahiyyet’u¨ l Haniyye  (Imperial Surgery) inthe Turkish–Islamic literature. In the obstetric section he gave detailed descriptions of normal and abnormal presentation, surgicalmanipulation of intrauterine foetal death and retained placenta. He wrote about previously described procedures and the obstetric cultureof his time. Some authors have claimed that he only translated Abu Kasim-al Zahrawa (Albucasis)’s  Al-Tasrif   (Textbook of Surgery) andaddedtheillustrationsofthesurgicaltechniques.Evenifthisis accepted,theillustrationsareenoughtoentitlethisworkasamilestone.Inthispaper, we describe the contributions of this pioneer in obstetrics and compare his recommendations with the current practice. # 2002 Published by Elsevier Science Ireland Ltd. Keywords:  Serafeddin Sabuncuoglu; Medical history; Pioneers in medicine; History of surgery 1. Introduction Medicine is the culmination of the efforts of millions of people and tens of different civilisations [1], some knownand others not.In the period between the ancient civilisations of Egypt,Greece, Rome, Persia and India, and the Renaissance periodin Europe, ‘‘the dark ages’’, the knowledge of medicine waskept alive by another culture, the Arabs and Muslims [2].The nomenclature, ‘‘the dark ages’’, reflects the state of civilisation in Europe between the 7th and 13th centuries butnot in the state of affairs in the Arab world where sciencewas active and healthy. The period has been unjustifiablyneglected.One of the famous Turkish surgeons was SerafeddinSabuncuoglu who lived in the 15th century in Amasya, asmall city in central Anatolia [3]. He wrote  Cerrahiyyet’u¨ l Haniyye  (Imperial Surgery), the first Turkish–Islamic sur-gical textbook in 1465 at the age of 80 years [4]. The book was rediscovered in 1936 by Suheyl Unver, a Turkishmedical historian, and its illustrations were published in aseparate volume [5]. There are three srcinal hand-writtencopies, two in Istanbul, in the Fatih Millet Library and theCapa Medical History Department of Istanbul University,and the third in the Bibliotheque Nationale in Paris. Eachcopy differs from the others, and none is complete [6–8]. Cerrahiyyet’u¨ l Haniyye  consists of three chapters total-ling 206 pages and covering 193 topics. These deal withobstetrics and gynaecology, general surgery, paediatric sur-gery, ophthalmology, thoracic surgery, orthopaedic surgery,and urologic surgery. The obstetric section is mainly con-cerned with normal and abnormal labour, delivery of thedead foetus, and management of retained placenta [4].In the following section, we describe some highlightsfrom the book, print some illustrations and comment onSabuncuoglu’s advice. 2. Selected recommendations Sabuncuoglu devoted one topic to midwifery, includingthe problems of difficult labour and ways to hasten and to European Journal of Obstetrics & Gynecology andReproductive Biology 105 (2002) 197–202 * Corresponding author. Present address: Harran Universitesi TipFakultesi Hastanesi, 63100 Sanliurfa, Turkey. Tel.:  þ 90-414-314-21-59. E-mail address: (H. Kafali).0301-2115/02/$ – see front matter # 2002 Published by Elsevier Science Ireland Ltd.PII: S0301-2115(02)00203-8  ease labour. He observed that patients who hold their breathfor a long period and exert some strength delivered the childfast. He advocated assisting delivery by gently pushingdownwards on the parturient abdomen. He believed thatdelivery was easier if the mother sits upright and sneezeswith her nose and mouth closed and he recommended herbaldrugs that cause sneezing to ease the labour. In patients withcephalic presentation and regular uterine contracted heurged the midwife to ease the labour with amniotomy byusing scalpels or hand. He suggested that the midwife easedlabour with gentle massage with warm essential oil over theabdomen and genital area.He described abnormal presentations as conditions underwhich the foetus itself caused difficult delivery, and gavedetailed instruction for handling various kinds of casesincluding those where the foetus was dead. He described‘podalic version’ for compound feet or hand presentations.He said ‘‘ . . .  push the presenting part into the uterus gentlyfirst,lifthimupandthenlittlebylittleturnthewholebodytoa normal position’’ [4]. In neglected transverse lie, heaugmented labour with amniotomy and if the foetal neck or face was encircled by the umbilical cord after amniotomyhe recommended immediate cord cutting [4]. He referred tothe multiple pregnancy section of Al-Zahrawi and said ‘‘inonly a few cases I have seen the foetus survived aftermultiple deliveries’’ [4].He pointed out the need for surgical manipulation anddestructive procedures in dead foetuses that could not beotherwise delivered [4] anddescribed the equipment in detail(Figs. 1–4). He said ‘‘ . . .  if patient shows serious signs likeunconsciousness, poor verbal response, weak pulse do nottouchthesepatientssincesomeofthesepatientmayprobablybe going to die’’ [4]. His technique for delivering the deadfoetus was mainly based on hook insertion for traction anddecompression of the foetal head, thorax and abdomen. Hedescribed feasible points on the body of the foetus for hook insertion to deliver the foetus with traction. He advised theoperator to use one hand to guide the hook insertion. If anypart of a dead foetus impacts at the pelvic inlet he recom-mends the operator encouraging the process of dilatation bygentle rubbing of the opening with an oiled forefinger.If hydrocephaly causes obstructed delivery in a deadfoetus, he suggests foetal head decompression by meansof transvaginal needle or scalpel. If the obstruction is due toa large size of foetal head other than hydrocephaly, hesuggested crushing the foetal skull. When the after-cominghead of a normally formed dead foetus is impacted at theinlet, he recommended fixation of the foetal head with theoperator’sotherhand,andhookinsertionintothe foetalheadfor traction. Sabuncuoglu suggests that after every foetaldeath the uterus should be evacuated as soon as possiblesince his master, Al-Zahrawi, had reported pelvic infectionsafter prolonged retention of a dead foetus.He also reports removal of retained placenta [4]. If thepatient has an open cervix, he recommended the adminis-tration of herbal drug which has sneezing effect with noseand mouth closed. If the cervix is closed, he used a kind of nebulizer probably devised by himself (Fig. 5). This wascomposed of a soil jug covered with a lid and with a reedpipe inserted. He says ‘‘ . . .  fill the jug with herbal drug andboil it, insert the other end of reed pipe into the vagina andkeep there till vapour of drug reaches cervix and uterus. Fig. 1. Instrument called ‘Midfa’ used for pushing foetal head into the uterus and instrument called ‘Mi dah’ used for crushing foetal body.198  H. Kafali et al./European Journal of Obstetrics & Gynecology and Reproductive Biology 105 (2002) 197–202  Then administer a herbal drug for sneezing. Despite theseefforts if placental delivery remains unsuccessful, use themanual delivery of placenta’’ [4]. He says ‘‘ . . .  if theplacenta is attached to cervical canal, do not apply too muchstrength to the placenta as it may cause catastrophe forpatients.  . . . shakethe placenta alloversideandpullitgentlylittle by little, perhaps it istheway of placental delivery.’’[4]As a final attempt he recommended the use of a cupper or asoil made device called ‘Mibhar’ which contained a herbaldrug and operated as a nebulizer. 3. Comments Cerrahiyyet’u¨ l Haniyye  does not include many obstetricinnovations. However, several observations and descriptions Fig. 2. Instruments used for foetal head crushing and hook for traction.Fig. 3. A kind of scalpel called ‘Mibza’ used for foetal cutting.  H. Kafali et al./European Journal of Obstetrics & Gynecology and Reproductive Biology 105 (2002) 197–202  199  remainvalid today. Recent research indicates that an uprightposition as opposed to a recumbent position is more com-fortable for parturition, and reduces the time of both labourand delivery [9]. Massage with essential oil used by Sabun- cuoglu may well be the equivalent of the modern practice of aromatherapy, which has been gaining in popularity over thelast 10–15 years. Some of the oils that are used in labour anddelivery are used as adjuncts to conventional pain relief measures. Some modern obstetricians still advise patients tohold their breath for a long period and exert their fullstrength to hasten delivery as suggested by Sabuncuoglu,and amniotomy is still used for augmentation of labour. It isdifficult now to determine how efficacious or harmful hisherbal treatments might have been, but we ought not tounderestimate the potential, at least, for a placebo effect of some of these treatments.The need for destructive procedures on a dead foetus israre today and most present day obstetricians are unfamiliarwith them. With proper medical care, obstruction of a deadfoetus is seldom encountered and the foetus who cannot bedelivered vaginally is delivered by caesarean section. How-ever, in developing countries obstructed labour remains aproblemandaskilfullyperformeddestructiveoperationmaybe far safer than caesarean section. External version hasbeen amatterofdebateformanydecadesandappearstobeasafe alternative for the management of breech presentationnear term. Internal podalic version in contrast is almostobsolete. There is no evidence that Sabuncuoglu had per-formed caesarean sections. Some of his practices are nowobsolete. Trying to hasten dilatation by rubbing the cervix isdangerous since the midwife’s finger is likely to introduceinfection. Cutting the umbilical cord if it encircles thefoetus’ neck or face is also dangerous. Our present methodof manipulation for the treatment of post partum retainedplacenta is not very different than the method employedby Sabuncuoglu. He offered a gentle traction on the umbi-lical cord in delivery of placenta and pointed out one of themost serious complications, ‘uterine inversion’, if strongtraction is applied before separation of the placenta. Inmodern practice manual removal is employed as it was bySabuncuoglu.He used a combination of mandrake root and almond oilas general anaesthetic and analgesic [10,11], but does notmention using these drugs during labour. He claimed to haveperformed therapeutic trials first on animals, then on him-self, and only finally on the patients [12]. Following the Fig. 4. A kind of hook used for foetal traction. Fig. 5. Nebulizer devised by Sabuncuoglu used for cervical ripening.200  H. Kafali et al./European Journal of Obstetrics & Gynecology and Reproductive Biology 105 (2002) 197–202  Muslim thinkers’ tradition he was open about his faults,and freely credited other writers from whom he obtainedknowledge, such as Hippocrates, Galen, Al-Zahrawi, aswell as others who are now forgotten [13]. Sabuncuogluwas the first to describe the classical position for gynae-cologic examination, and illustrated a ‘‘ tabibe ’’ (femalephysician) operating on a patient [3] (Figs. 6 and 7). Previously males had not been allowed to practise evenmidwifery in the West for centuries, let alone acknowl-edged as  tabibe  [14]. Sabuncuoglu did not hesitate toillustrate the details of obstetric and gynaecologic proce-dures or to depict women dealing with and performingprocedures on female patients. Although the Turkish lord-ships encouraged writing in the Turkish language, the factthat the Ottoman Empire was Islamic forced many scien-tists, theologians and philosophers to write in Arabic.On the other hand, painting, drawing and sculpture werefrowned on by Islamic rules. Sabuncuoglu was a pioneer inwriting in Turkish, although he knew Arabic and Persian aswell. He illustrated his surgical techniques with colouredminiatures, drawn modestly and in serious spirit accordingto Islamic rules.Despite all his merit, Sabuncuoglu was not widely knownin his time and his book was forgotten for centuries. Cerrahiyyet’u¨ l Haniyye  was rediscovered only 60 yearsago [15,16].One cannot help but admire Sabuncuoglu. He not onlypreserved, but also added to, earlier achievements in med-icine and was a pioneer surgeon and medical writer stillremembered 600 years later.  Fig. 6. Illustration of ‘‘ tabibe ’’ (female physician) operating on a patient.Fig. 7. Illustration of vaginal speculum devised by Sabuncuoglu.  H. Kafali et al./European Journal of Obstetrics & Gynecology and Reproductive Biology 105 (2002) 197–202  201
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