Acupuncture points in the book ofŞerefeddin Sabuncuo�glu, a 15thcentury Turkish physician

H Volkan Acar

Correspondence toDr H Volkan Acar, Departmentof Anesthesiology and IntensiveCare, Ankara Training andResearch Hospital of Ministry ofHealth, Ankara 06340, Turkey;hvacar@yahoo.com

Received 1 October 2014Accepted 21 October 2014Published Online First7 November 2014

To cite: Acar HV. AcupunctMed 2015;33:72–76.

ABSTRACTSerefeddin Sabuncuo�glu (1385–1468?), theauthor of Cerrahiyetü’l-Haniyye (ImperialSurgery), was a distinguished Ottoman Turkishsurgeon. The first illustrated Turkish surgicaltextbook, Cerrahiyetü’l-Haniyye consisted ofthree chapters (ie, cauterisation treatments,surgical procedures and fractures anddislocations). Although the main source of thebook was Al-Tasrif (Textbook of Surgery) byAlbucasis (Abu al-Qasim al-Zahrawi; 936–1013AD), Sabuncuo�glu added much new information,his clinical experiences and suggestions. Theoriginal illustrations and human figures madeCerrahiyetü’l-Haniyye the first illustrated medicaltextbook in Turkish and Islamic medicineliterature. Cerrahiyetü’l-Haniyye was also avaluable source for acupuncturists. Some newsections and additions revealed thatSabuncuo�glu had knowledge of Chinesemedicine. In four sections of Cerrahiyetü’l-Haniyye (ie, toothache, haemorrhoids, eczemaand dermatophytosis) Sabuncuo�glu describedacupuncture techniques and point locations. It islikely that the Chinese medicine content ofCerrahiyetü’l-Haniyye was derived from CentralAsian roots of Anatolian Turkish people.

INTRODUCTIONŞerefeddin Sabuncuo�glu (1385–1468?AD) was a distinguished Turkish surgeonwho lived in Amasya, Turkey in the 15thcentury. He was the surgeon of AmasyaHospital (darüşşifa), which was a post forwhich only the best physicians of thetime were eligible. Amasya was a city ofcommerce and the centre of culture andart in Anatolia, and in the 15th century8% of the entire population of the citywere college (madrasah) students.1

Sabuncuo�glu wrote three books:Terceme-i Akrabadin (Translation ofPharmacopoeia),Mücerrebname (The Bookof Experiences) and Cerrahiyetü’l-Haniyye

(Imperial Surgery).1 When he completedhis most recognised book Cerrahiyetü’l-Haniyye in 1465, he was 80 years old. Thiswas the first illustrated Turkish medicaltextbook and consisted of three chapters(ie, cauterisation treatments, surgical proce-dures and fractures and dislocations).Currently, three copies of Cerrahiyetü’l-

Haniyye exist; two are in Istanbul and oneis in the Bibliotheque Nationale, Paris. Twoof the three extant copies of this book werehandwritten by Sabuncuo�glu. In 1992, İlterUzel, a Turkish medical historian, examinedall three copies and published a Turkish/English translation with an in-depthreview.1

SCIENTIFIC BACKGROUNDCerrahiyetü’l-Haniyye is scientificallyimportant for several reasons. First, itwas written in Turkish rather than Persianor Arabic. In that era, Persian and Arabicwere scientific languages in Islamicregions and were used for the majority ofthe literature and scientific articles.Sabuncuo�glu said, “Here is why I wrotethis book in Turkish. All Roman people(in Anatolia) spoke Turkish at that time.Besides that, the majority of surgeons ofour age were illiterate. They all read thebooks in Turkish even if they were liter-ate. If they use this Turkish book as asource, they can understand things indetail and can solve their problems easily.Thus, they can protect themselves frommalpractice and can protect their patientsfrom complications.”1

Second, Cerrahiyetü’l-Haniyye includesmore than 100 coloured surgical andinterventional illustrations of the surgeon,the patient, the surgical instruments andsurgical procedures. Both male andfemale figures were illustrated, and thebook even included illustrations in

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gynaecological and obstetrical positions. AlthoughIslamic religion did not formally prohibit the depictionof the human body, illustrations of any living creaturewere not accepted in Islamic culture for centuries.Therefore, one could not view illustrations in anybooks, including medical books such as the Al-Tasrif ofAlbucasis and the Canon of Medicine of Avicenna.Thus, it can be said that Cerrahiyetü’l-Haniyye is a col-oured and illustrated surgical atlas and not simply amedical treatise.Third, Cerrahiyetü’l-Haniyye contains medical

devices and instruments that were used for cauterisa-tion, surgery and therapeutic interventions.1–3 Some ofthese devices and instruments were designed bySabuncuo�glu himself and some were taken fromAlbucasis’s book. However, all of the illustrations weredrawn by Sabuncuo�glu.1

Cerrahiyetü’l-Haniyye includes treatments of nearlyall types of surgery including general, orthopaedic,paediatric, thoracic, gynaecological, plastic, vascularand neurosurgery. Some surgical procedures andtherapeutic interventions he mentioned in his book,including ophthalmological, urological and paediatricotorhinolaryngological practices, correlate well withmodern practices.2 4–6

It seems that Sabuncuo�glu was influenced by manymedical textbooks in Arabic, Persian and Greek.However, the primary source of Sabuncuo�glu was theAl-Tasrif (Textbook of Surgery) by Albucasis(Abu al-Qasim al-Zahrawi; 936–1013 AD).1 Albucasisis considered to be the father of modern surgery.7

Although Al-Tasrif was accepted as an originaltextbook, the main source of Albucasis was Paulof Aegina’s The Epitome of Medicine (625–690AD).7

The main skeleton of Cerrahiyetü’l-Haniyye comesfrom Al-Tasrif by Albucasis. However, although somehave suggested that Cerrahiyetü’l-Haniyye is a verba-tim translation of Al-Tasrif,8 Cerrahiyetü’l-Haniyye isclearly more than a simple translation. Cerrahiyetü’l-Haniyye contains many original descriptions andobservations that were not mentioned in Al-Tasrif.Additionally, Cerrahiyetü’l-Haniyye contains originalillustrations and human figures that were not depictedin Abulcasis’s book or in any other manuscript thathad been published in the Islamic world. Three newsections were added at the end of each chapter. Uzelsaid that 137 different clinical observations andrecommendations were mentioned in Cerrahiyetü’l-Haniyye, which indicates a clear difference betweenthe two books.1 In other words, Sabuncuo�glu firsttranslated Al-Tasrif and then expanded it to containmore information. Citations from the other physiciansthat were based on his own experiences, the originalillustrations of human figures and the new surgicalinstruments enriched this translation and madeCerrahiyetü’l-Haniyye, the first illustrated Turkish sur-gical atlas, a reference textbook.

The additions to the book that originated from hisown experiences might be a reflection ofSabuncuo�glu’s Anatolian Turkish identity. Anatolia is amelting pot of various cultures, including Sumer,Babylon, the Hittites and Assyria, and has been a settle-ment place for great empires such as the Romans,Byzantines and Ottomans. Additionally, MongolIlkhans and Turkic tribes that originated in CentralAsia also made large excursions to Anatolia beginningin the 11th century. This Asian connection introducednew knowledge to Anatolia.

CAUTERISATIONThe book contains three chapters concerned with cau-terisation treatments, surgical procedures and fracturesand dislocations. The first chapter of the bookincludes 57 sections and lists the disorders for whichcauterisation was used as treatment.1

The methods of cauterisation differ with respect tothe disease being treated. In some sections cauterisa-tion is applied directly to the local area for abscessesand localised skin or mucosal lesions. Examples ofsuch lesions include acute dacryocystitis with fistulae,cleft lips, intraoral fistulae, warts after excision andanal fistulae.1 The goal of cauterisation seemed to bethe formation of scar tissue or shrinkage of diseasedareas for three conditions: dermato/blepharochalasisor ptosis, entropion and trichiasis, and inguinalhernia.1 The use of cauterisation to stop bleedingfrom vessels following surgical incisions and subse-quent cauterisation is described in one section.1

Over nearly 20 sections, cauterisation seems to beapplied to local points. The cauterisations of areas ofthe liver for liver diseases, the stomach for stomachdiseases, the spleen for splenic diseases, the hip jointfor hip dislocations and around cancer tissues aredescribed.1

ACUPUNCTURE POINTSSabuncuo�glu suggested the use of cauterisation onspecific points in more than 30 sections.1 One of themost popular points he used was the location ofGV20. This point is suggested for use in the treatmentof various disorders including headaches, chronicmigraines, ‘forgetfulness’, acute stroke, epilepsy, ‘mel-ancholiness’, cataracts, chronic dacryocystitis, ozaena(chronic nasal discharge) and leprosy. The localisationof this point is described in Cerrahiyetü’l-Haniyye asfollows: “Put the heel of your hand on the notch ofthe nose of the patient. Thereafter, place your handon the head of the patient posteriorly. The pointwhere the tip of your finger reaches is the point ofcauterization.”1

The described locations of other points of cauterisa-tion might also be considered to correspond to acu-puncture points; for example, the corner of theforehead (ST8), the temple (Taiyang), the corner ofthe mouth where the lips meet (ST4), just lateral to

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the outer canthus of the eyes (GB1), in the depressionabove the clavicle (ST12), directly between the nippleson the chest (CV17), two finger widths below theumbilicus (CV5) and other points are mentioned.1

Although the abovementioned points are well corre-lated with acupuncture points, we cannot state withcertainty that Sabuncuo�glu suggested that cauterisa-tion be applied to acupuncture points. The primaryreason for this lack of certainty is the fact thatCerrahiyetü’l-Haniyye was largely based onAlbucasis’s Al-Tasrif. A comparative analysis revealedthat the descriptions of the locations of these pointswere exactly the same as those in Al-Tasrif, but theprimary source of Albucasis was Paul of Aegina.7

SABUNCUOGLU’S OWN CONTRIBUTIONSIn contrast to the abovementioned examples,Cerrahiyetü’l-Haniyye contains several other stronglines of evidence that are suggestive of a possible con-nection with Chinese medicine. The most strikingexamples that illustrate that Sabuncuo�glu had knowl-edge of acupuncture are stated in the four sections dis-cussed below.Section 21 of Chapter 1 dealt with toothache.

Sabuncuo�glu stated that, “if someone has a toothacheon the right-hand side, cauterize the left wrist boneand vice versa”.1 He also noted that, “I suggested youuse this method because I have treated 30 patientsusing this method”. It is well known that cross need-ling is one of the point selection methods in acupunc-ture practice and that LI4 is among the points that canbe used for the treatment of toothache.9 This methoddid not appear in Abulcasis’s book.7

In section 34 of Chapter 1 he first explained thetreatment of haemorrhoids just as it is expressed in

Al-Tasrif. Thereafter he added, “I, the writer of thisbook, Şerefeddin, state that I discovered a treatmentfor this disease. I have used this treatment for 113patients and observed positive results, and I nowdescribe it here. Cauterize the umbilicus with a big‘punctate’ cauterization. However, do not apply hardpressure so that only half of the skin is cauterized.This method benefits haemorrhoids, umbilical herniaand chronic diarrhoea.”1 In acupuncture textbooks,moxibustion of CV8 (in the centre of the umbilicus) isindicated for diarrhoea, ‘prolapse of the rectum’ and‘umbilical shan disorder’ (ie, protrusion).9 However,Albucasis did not mention the cauterisation of theumbilicus for the treatment of haemorrhoids inAl-Tasrif.7

In section 57 of Chapter 1 (dealing with eczema),the location of PC6 is illustrated bilaterally anddescribed as follows: “You have to cauterize the pointclose to the proximal side of both wrists … The pointis above two finger widths away from the wristbone”1 (figure 1). Acupuncture textbooks describe thelocation of this point as follows: “two cun proximalto PC7 (at the wrist joint)”.9 The contents of section57 are not present in Abulcasis’ book7; all contents ofthis section were added by Sabuncuo�glu himself.Section 98 of the Chapter 2 was also written

by Sabuncuo�glu. This section deals with dermato-phytosis (ie, ringworm disease) and is not included inAl-Tasrif .1 7 Sabuncuo�glu told an anecdote that hewas treating a patient with dermatophytosis with theneedling method.1 Just then, a Tatar man came in andsuggested a different therapeutic method for this con-dition. The Tatar first made a few incisions on thepalate and the backs of the ears. Next, he made twomore incisions bilaterally on the wrists and on the

Figure 1 Illustration showing the location of PC6 for the treatment of eczema. Reprinted with permission from the TurkishHistorical Society.

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ankles. The incision lines on the wrists and ankleswere described as follows: “You have to make inci-sions on the two vessels on the medial sides of theforearms that are located four fingers above the wristjoint. Then, you repeat the procedure on the twovessels on the medial sides of the feet that are locatedfour fingers above the ankle joint.” Two differenttherapeutic approaches are noted in this section. Thefirst is the needling of skin lesions, which is not men-tioned in any other part of Cerrahiyetü’l-Haniyye orin Al-Tasrif.1 7 It seems that Sabuncuo�glu practisedacupuncture (ie, local needling) in these areas. Thesecond treatment method was suggested by the Tatarphysician from Central Asia. This method includedthe use of specific body points for venesection. Thesepoints correspond to the PC5 and SP6 acupuncturepoints9 (figure 2).

HISTORY OF CAUTERISATIONCauterisation has been widely used for various pur-poses including strengthening the body, treating dis-eases and curing skin lesions since ancient times.Traces of cauterisations have been found on the headof babies from the Calcolytic Age (5000 BCE–3000BCE) in Anatolia.10 It is known that Hippocrates(460–377 BC) used cauterisation in medicine.11

Cauterisation has been used to eliminate noxiousmaterial via the application of heat.Historically, cauterisation/searing has always been

popular in medicine and veterinary medicine amongTurkic tribes/states.12 Dunhuang medical manuscriptsfound in Central Asia contain evidence that Turkishpeople used cauterisation for medical purposes.13 14

Yoeli-Tlalim showed that the basic treatment method inTibetan medicine was moxibustion, although severalother techniques including bloodletting, massage andcupping were also used. A passage in one of these textsemphasises the tendency of Turkish people to apply

cauterisation for medical purposes: “The Turkicmethod of [using] iron for cautery is also suitable”.13 14

This quotation is also accepted as evidence of theTurkish influence on Tibetan medicine.13 14

A careful analysis of the Cerrahiyetü’l-Haniyyereveals that the sentences in which Sabuncuo�glu dis-cusses his own experiences were strongly influencedby the Central Asian roots of Turkish civilisation. Thisinfluence is particularly apparent in the sectionsrelated to toothache, haemorrhoids, eczema anddermatophytosis.1 In addition to the abovementioneddata, two important sources provide theoretical back-ground regarding the Anatolian Turks’ knowledge ofAsian medicine practices—that is, the Uyghur medicaltexts and Tanksukname-i İlhan.The Uyghur medical texts were among the 40 000

manuscripts found during German expeditions toCentral Asia between 1902 and 1914 and date fromthe 9th and 14th centuries.15 These texts were firstintroduced to the scientific world by Arat in 1930.16

One of these texts contains illustrations of threehuman figures that include channels and points thatare similar to those used in acupuncture and areaccepted as evidence that acupunctural treatmentswere disseminated between Central Asian Turks(Uyghurs) and Anatolian Turks.16 We might expectthat Turkic tribes carried their medical knowledge andpractice to Anatolia when they migrated from CentralAsia to Anatolia.Tanksukname-i İlhan (Tansuqnamah) is a Persian

compilation of a classical Chinese medical text (MaiJing) written by Wang Shu He (201 BCE–280 BCE)and is the earliest translation of Chinese medicalmanuscripts to appear in the West.17 The book wasprepared by Rashid al-Din Fadlallah (1247–1318)who was the prime minister of Ghazan Khan (ie, theKing of the Ilkhans). Medical historians have statedthat the reign of Ilkhanate and its powerful minister

Figure 2 Illustration showing the locations of PC5 and SP6 acupuncture points for the treatment of dermatophytosis. Reprintedwith permission from the Turkish Historical Society.

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Rashid al-Din played a major role in the transmissionof 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 thefirst is extant (ie, the Introduction section).19 A singlehandwritten copy from 1313 was kept in Istanbul.Tanksukname-i İlhan was a valuable source of Chinesemedicine because it includes information about fiveelements, 12 meridians and pulse diagnosis. In theIntroduction section, Rashid al-Din Fadlallah says that“Khitan people (ie, the Chinese) go too far in theapplication of cauterization. They even cauterize new-borns”. Sentences from the book provide good exam-ples that revealed the connection between thecauterization and acupuncture theories; for example,“Each meridian corresponds to an internal organ”;“Cauterization (along the meridians) can be seen asstopping the water flow from the fountain”;“(Harmful) bodily fluids (eg, blood, phlegm, etc)cannot move to a diseased organ when a specificmeridian is cauterized”; “In some instances, they cau-terize the left-hand side when the disease is on theright-hand side”; “They sometimes cauterize the dis-eased organs (areas)”; and “As we stated above, theKhitan people (ie, the Chinese) and Turks go too farin cauterization and they compiled books that illus-trate exact cauterization points”.19 We might assumethat Tanksukname-i İlhan was potentially a source forSabuncuo�glu because the Amasya Hospital (darüşşifa)in Anatolia where he worked was founded in 1308–1309 during the Ilkhanate period.1

In conclusion, Sabuncuo�glu compiled the surgicalknowledge of his day, which included both ancientGreek medicine and Central Asian medicine, in hisbook Cerrahiyetü’l-Haniyye. This book was the firstillustrated Turkish surgical textbook. Some new techni-ques, suggestions and original illustrations that werenot included in Al-Tasrif are contained inCerrahiyetü’l-Haniyye, although the general outline ofCerrahiyetü’l-Haniyye came from Albucasis’s Al-Tasrif.These added portions reflect Sabuncuo�glu’s ownknowledge and experiences. It is highly likely that thecontent that brings acupuncture medicine to thereader’s mind originated from the medical knowledgeof Central Asian Turkish people.

Acknowledgements The author thanks Associate Professor DrAhmet Acıduman for his valuable contribution to the analysesof sections of Cerrahiyetü’l-Haniyye, which was written in oldTurkish.

Competing interests None.

Provenance and peer review Not commissioned; externallypeer reviewed.

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