EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Objectives: Şerefeddin Sabuncuoğlu (1385-1465) is a medical scholar who wrote the first illustrated surgical book (Cerrahiyetü’l Haniyye [Imperial Surgery]) in the history of Turkish and Islamic medicine. Sabuncuoğlu benefited from the books of medical scholars before him and translated the book et-Tasreef of Abul-Qasim Khalaf Ibn Abbas Alzahrawi (Albucasis), which was the most important surgical book of its time. In this study, the urinary system disease sections of the textbook by Şerefeddin Sabuncuoğlu were examined. Materials and Methods: Cerrahiyetü’l Haniyye and et-Tasreef were evaluated by comparative textual analysis methodology in terms of urinary system diseases and its treatments. Results: The textbooks contain the same definitions of the cauterization of the kidney, cauterization of the urinary bladder, the treatment of urine retention, bladder irrigation with the syringe, and the forms of the instruments for the extraction of a stone from men and women. Şerefeddin Sabuncuoğlu made additions to the kidney and bladder cauterization and bladder irrigation sections. Colorful miniatures containing images of the procedures performed on the patients are found in Cerrahiyetü’l Haniyye. Conclusions: The urinary system disease section in Cerrahiyetü’l Haniyye is a translation of et-Tasreef in general, with some additional information and drawings. The surgical instruments and procedures described by both physicians have reached the present day with changes.

Key words : Cerrahiyetü’l Haniyye, Şerefeddin Sabuncuoğlu, Surgery, Treatment, Urinary tract

Şerefeddin Sabuncuoğlu (Şerefeddin bin Ali bin el-Hac İlyas Sabuncuoğlu, 1386-1468?) is one of the 15th century Turkish physicians. Sabuncuoğlu published Cerrahiyetü’l Haniyye (Imperial Surgery), the Turkish translation of the surgical section of Al-Zahrawi’s “Kitâb e’t Tasîf li men Acize an e’t Te’lif” (et-Tasreef) in 1465.^1-3

Şerefeddin Sabuncuoğlu was born in Amasya, located in Central Anatolia in today’s Turkey. Coming from a family with a medicine tradition, Sabuncuoğlu worked as a physician and manager at Amasya Dar al-shifas (hospital) for 14 years. Sabuncuoğlu, who spoke Arabic, Persian, and Greek in addition to his mother tongue Turkish, was a good clinician, researcher, and educator. Other works of Sabuncuoğlu are Terceme-i Akrabadin, a “pharmacology” book that deals with the indications for the use and administration of drugs, and Mücerrebname (Book of Experiences), which examines drug trials on animals and humans.^1,2,4 In his works, he included guiding sections on the ethical principles of medicine.^1-3,5-7

Sabuncuoğlu’s prestigious work titled Cerrahiyetü’l Haniyye was prepared as 412 pages. The book consists of 3 chapters (Cauterization, Surgical Procedures, Orthopedic Treatment) and 191 subtopics dealing with all kinds of surgery, including the urinary system. Sabuncuoğlu created good educational material by visualizing 136 surgical interventions, 164 instruments, and 14 incisions with the miniatures and figures that he drew.^4,8 The surgical instrument drawings in Al-Zahrawi’s work are illustrated by him in a more subtle and refined way. With this feature, the book has an important place in the history of medical illustration and Islamic medicine. The second important feature of this work in the cultural context is that it was written in Turkish. Sabuncuoğlu wrote the book in Turkish because the current language in Anatolia was Turkish and most of the surgeons at that time were illiterate and preferred, if they could read and write, to read Turkish. He mentioned that the subjects can be learned in depth with a Turkish source so that physicians can avoid erroneous practices and patients can be protected from complications.^1-3,5,6,9

There are 3 copies of Cerrahiyetü’l Haniyye: Paris Bibliothèque Nationale Supplement 963, Istanbul National Library 79/353, and Istanbul University Çapa Medical Faculty 263. Sabuncuoğlu originally wrote the “Paris” and “Millet” copies of the book, and the “Faculty” copy was written later in the 18th century. Ruscuklu Hakki was the first scientist to give information about Sabuncuoğlu in 1920. In 1939, Süheyl ünver published the first book in Turkish literature, including Haniyye’s miniatures. Three original handwritten copies of Sabuncuoğlu’s book were examined by Uzel and were republished in 1992.^1-3,10

In the literature, many studies have examined the subjects in Cerrahiyetü’l Haniyye by medical disciplines.³ There are 4 studies in the literature on the treatment of urinary system diseases. The first study was published by Dr. Fuat Kamil Beksan in 1935 in Zeitschrift für Urologie.¹¹ The other 3 studies were published in the early 2000s. These articles discuss urinary system diseases, pediatric urology, genital surgery, urinary retention, and bladder calculi treatment.^8,10-12 In addition, in the study from Elcioglu and colleagues, it was determined that urinary system diseases were examined only in terms of bladder stones by comparing the texts of et-Tasreef and Cerrahiyetü’l Haniyye.¹⁰ However, there is no comparative textual study about the kidney and bladder cauterization chapters in the first section of et-Tasreef and Cerrahiyetü’l Haniyye. This situation has been accepted as a missing point in the general evaluation of the works in the approach to urinary system diseases in terms of medical history.

This article evaluated the original contributions of Sabuncuoğlu’s study by comparing the urinary system diseases, kidney and bladder cauterization, urinary retention, and bladder irrigation chapters in both texts.

Materials and Methods

In this study, the comparative textual analysis method was used. For this method, et-Tasreef was chosen as the lens text for the comparison of et-Tasreef as the original document (document A)¹³ versus Cerrahiyetü’l Haniyye as the translated document (document B).¹

Section 1, Chapters 37 and 38, and Section 2, Chapters 58, 59, 60, and 61 of et-Tasreef and Cerrahiyetü’l Haniyye were analyzed using the comparative textual method. As a result of the examination, the original contributions identified in Cerrahiyetü’l Haniyye are shown with an asterisk (*) in the translation of the relevant section of document A.

The comparison of the preface texts of et-Tasreef and Cerrahiyetü’l-Haniyye showed that the books had different contents. The comparison of the index section showed that both texts’ main section titles and subtopics were the same, except for 2 titles.^1,13

The first part of both works is about the cauterization process. In the introductory text of the chapter, it is stated that cauterization is a universal practice within the paradigm of the period, and its advantages and disadvantages are discussed. It has been determined that this content is included in both texts in a one-to-one correspondence.^1,13

In Section 1, kidney and bladder cauterization occurs within the framework of urinary system diseases.

Section 1, Chapter 37: on cauterization of the kidney

Document A is as follows: “On cauterization of the kidney: When pain strikes the kidneys from chill or heavy vapor, the patient’s sexual vigor is impaired. (*) You should burn him right over the kidneys, once on each kidney, with the claviform cautery mentioned before. I have often burnt him with a third cauterization on the flat of the back, making three cauterizations in a line, which is most effective.”¹³

Document B is as follows: (*) The statement “if the drugs mentioned in the medication section do not help when used”¹ is not included in document A. Document B shows a descriptive miniature of the kidney cauterization process (Figure 1).¹

Section 1, Chapter 38: on cauterization of the urinary bladder

Document A is as follows: “When there occurs in urinary bladder weakness and relaxation due to chill and humidity so that the patient cannot retain his water, (*) cauterize him once below his navel, on the bladder, where the pubic hair begins; burn him once also on the right side and once on the left side of the navel, and let the distance of the burn from either side be the length of the joint of the thumb. Cauterize him also once on the lower part of the back or twice if you need. The cautery should be claviform, as described.”¹³

The statement from document B (*) “if the drugs mentioned in the medication section do not help when used”¹ is not included in document A. Document B illustrates the bladder cauterization (Figure 2).¹

The additional sentence (*) in both sections refers to the treatments specified in the pharmacopeia section at the end of text of document B. This title is not included in the text of document A. In the text of document B, there is a descriptive miniature of the operation. The cautery device specified in document A text is not included in document B text (Figure 3).¹³

Section 2, Chapter 58: urinary retention

When texts from documents A and B of this section are compared, both documents explain the use of a silver catheter (kasatir) (Figure 4). The process is determined to be the same in both texts. The information in document B describing the risk of infection that may occur because of incorrect application of the procedure could not be determined in document A text. In document B text, there is an illustration of the process (Figure 5).^1,13

In document A, “The operation is done in this manner because the passage by which the urine is excreted is curved. (*) Then withdraw rather firmly the thread with the wool plug attached, for the urine follows the wool; then pull it right out and the urine will pour out.”¹³ In document B, (*) “if the procedure is not done as described, the probe will touch the bladder wall and cause infection, causing harm to the patient, this should be considered.”¹

Section 2, Chapter 59: bladder irrigation

It is determined that the content of the section on bladder irrigation is similar in documents A and B. This section describes a type of injector named “zerraka” (Figure 6). Another instrument defined for bladder irrigation is the “mihkan” (Figure 7). In document B text, there is a descriptive miniature of the process (Figure 8).^1,13

In the bladder irrigation section, the drawings of the instruments are included in both texts. In document A text, in the use of “mihkan,” a camel bladder is recommended for the pouch in which the liquid is placed, while it has been determined that a lamb’s bladder is mentioned in document B text.^1,13

Section 2, Chapter 60: extraction of stone from the bladder

As a result of the examination of both texts, the text fully overlaps in terms of content. In this section, a special scalpel called “nechil” has been described for lithotripsy (Figure 9). Other instruments described in this section are strong forceps (kelbeteyn) to hold the stone and a thin tool with a curved tip (Figure 10*). For small stones in the urethra, a type of drill (miskab) made of steel is also identified (Figure 11). The drawings of the scalpel (nechil) and miskab (mishaab) are identified in document A and B texts. Document B includes the image of the curved tip tool. In text B, a miniature showing stone removal from the bladder is included (Figure 12).^1,13

Section 2, Chapter 61: bladder stone removal in women

As a result of the examination of both texts, the section is the same in terms of content.^1,13

Although Cerrahiyetü’l-Haniyye is a translation of et-Tasreef, in the studies carried out by different medical disciplines, attention was drawn to the original chapters in the work. Sabuncuoğlu’s work has 137 clinical observations and recommendations, unlike et-Tasreef.^1,3 The sections in Sabuncuoğlu’s work that are different from et-Tasreef are as follows: illustrations, surgical instruments drawn for the first time; transferring personal experiences in cases; cautery treatment of toothache, eczema, hemorrhoid, and dermatophytosis; leprosy treatment, and “pharmacopeia” section.^1,2 This study evaluated the original aspects of Sabuncuoğlu’s work by making a comparative textual analysis of the sections in which urinary system diseases are discussed.

In the parts of the Cerrahiyetü’l-Haniyye related to urinary system diseases, the cauterization process in the first section of the book was not specifically addressed. In Chapter 37 of Section 1, kidney cauterization is discussed within the framework of urinary system diseases; in Chapter 38, bladder cauterization is discussed. Our comparison showed that the same title and content were also found in et-Tasreef.^1,13 Al-Zahrawi explained in the intro-duction of his book that the cauterization process was addressed within the framework of the humoral pathology paradigm. He also stated that cautery treatment was successful in sudden and severe painful diseases caused by cold and steam. In the kidney cautery section, it was defined as a prerequisite that the disease was caused by cold and heavy steam. Cauterization has been suggested as a treatment for kidney pain symptoms and decreased potency. The procedure to be applied to the kidney lodge and back region has been defined. In the next section, the cold nature of the disease was emphasized in the same way in bladder cauterization. In both sections, the phrase “if the drugs mentioned in the treatment section are used and do not help”¹ was added to the text by Sabuncuoğlu. In the introduction to his work, Al-Zahrawi defined the risks of cautery and stated that drug therapy should be prioritized and that the invasive procedure is the last step (“we use cautery, which has proven to be effective, lastly, when various treatments are not successful for a particular disorder”).¹³ It is determined that the approach in Sabuncuoğlu’s statement is in line with Al-Zahrawi’s view. When the 2 sources are compared, miniatures describing kidney cauterization (Figure 1) and bladder cauterization (Figure 2) are seen as original contri-butions in Sabuncuoğlu’s work. In addition, cautery (mismārį ŧaġlaġu) and a kind of nail-like instrument used for cauterizing are included as a drawing in et-Tasreef (Figure 3).¹ To the best of our knowledge, an evaluation of this section in terms of the history of medicine is the first of its kind in the literature.

As a result of the examination of the “urinary retention” section (Section 2, Chapter 58), it was determined that Sabuncuoğlu made an additional contribution to the original text with the sentence “if the procedure is not performed as described, the probe will touch the bladder wall and cause infection, causing harm to the patient.”¹ In the urinary retention chapter context, this finding is the first in the literature (Figures 4 and 5). This statement of Sabuncuoğlu is considered a reflection of his experience during surgical practice. This attentive attitude toward protecting the patient has been evaluated as another example of his deontological approach.¹

In the “Extraction of Stone from the Bladder” chapter, which is another subject of the second chapter, the image of the curved-tipped instrument assisting in the use of forceps (Figure 10) and the miniature showing the stone removal process (Figure 12) are original content added to the et-Tasreef translation by Sabuncuoğlu.^8,10,12,14

A comparative textual analysis of the second part showed that the definition of the complication identified in the urinary retention chapter and the miniature additions examined in previous studies were considered as original contributions to Sabuncuoğlu’s work. Apart from this result, the sections of bladder irrigation, stone removal from the bladder, and removal of stones from the bladder in women overlapped almost exactly in Cerrahiyetü’l-Haniyye and et-Tasreef. Previous studies have evaluated this result.^8,10,12,14

In addition to medical history studies, Cerrahiyetü’l-Haniyye is an important source of information for different disciplines such as cultural history, fine arts, and literature. It is determined that Turkish vowel symbols are used meticulously in the work, reflecting the grammatical and phonetic features of Turkish people of the period with its plain and fluent style. This makes the work an important source for language history studies.^1,2,15

Another important feature of Cerrahiyetü’l Haniyye is its colorful illustrations. In the framework of the available evidence, it is stated that Cerrahiyetü’l Haniyye is the first illustrated medical book in Turkish and Islamic medical literature due to the work’s original drawings and human figurines. In this colorful illustrated surgical atlas made by Sabuncuoğlu, adult male, adult female, and pediatric patients, male and female physicians, and midwives are shown. It is known that the use of human figures in paintings was forbidden in the Islamic tradition during the period when the illustrations were made. When this situation is taken into consideration, it is seen that Cerrahiyetü’l Haniyye is a revolutionary work.^1,2,16-21 Thus, the historical value of the work is not limited to the Anatolian geography.

Our study showed that the original drawings are included in the urinary system diseases sections of Sabuncuoğlu’s work, some additions were made to the text, and the author’s experiences were briefly conveyed. In addition, we can say that the Cerrahiyetü’l-Haniyye is a translation of et-Tasreef, specific to the sections examined. In the final analysis, evaluating the Cerrahiyetü’l-Haniyye with the principles of research and publication ethics of today’s scientific world and accepting it as plagiarism will be an example of evaluating the historical phenomenon from an anachronistic point of view. This will lead to an erroneous analysis and conclusion in terms of historical methodology.

Volume: 21 Issue: 6 June 2023 - Supplement - 2

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