SEREFEDDIN SABUNCUO?LU’S FIRST ILLUSTRATED DESCRIPTIVE SURGICAL MANUSCRIPT, CERRAH?YETÜ’L HAN?YYE (IMPERIAL SURGERY) REFLECTS SHOULDER REDUCTION IN 15TH CENTURY IN ANATOLIA.Abstract Serefeddin Sabuncuoglu (AD 1385-1470) one of the most famous Turkish physician contributed in many surgical fields such as obstetrics, gynecology,thoracic, vascular surgery, nerve surgery, ophthalmology, oncology, dentistry, traumatology and plastic surgery. Cerrahiyyetü’l Haniyye (Imperial Surgery) is the first colored illustrations of surgical methods, manipulation and instruments in 15th centruies in 1465, Manuscript is compose of three chapter and 193 sections in detailed illness by treatment cauterization, surgical interventions, and fractures and dislocations. The third chapter including is fractures and dislocation relevant to orthopaedic and traumatology. ?n each sections, description,classification, treatment and surgical practice with instruments in colored illustrations is unique. we present in this study is to examine, detail, and interpret the miniatures finding in this 550-year-old book.IntroductionSerefeddin Sabuncuoglu (AD 1385–1470) was a surgeon who lived in Amasya, which is in the northern part of middle Anatolia, in the 15th century during the period of the Ottoman Empire(1,2 3.4) During his lifetime, he wrote detailed explanations of surgical methods and used miniatures to demonstrate these methods.(4,5,6) He wrote the manuscript in Arabic letters (in old Turkish alphabet) in Turkish; during that time, because of spoken commonly language was Turkish. But the commonly used scientific language was Arabic. Further, it was written in the period for public works. Therefore, Sabuncuoglu was sufficiently unrecognized in literature. (1)Sabuncuoglu declared in his foreword that he dedicated his book Ottoman Empire Sultan Mehmed Khan who admired and apprenciated the scientific work. Because of presenting, he named Haniyye as known emperor and Cerrahi as known Surgery that called Cerrahiyyeü’l Haniyye.(1) Also, in 1930’s rediscovered by Ali Canip and Suheyle Unver, A Turkish medical historian first introduced the book called name Cerrahiyyetü’l Haniyye. Moreover, in 1960, Pierre Huard and Mirko G Grmek presented about this book translated ”La Chirurgie Imperiale” (?mperial Surgery) as a known the first illustrated surgical treatise in Turkish language(1). Cerrahiyyetü’l Haniyye (Imperial Surgery) has into different chapter (bab) and several section (fasl). Explained subjects were on personal experience, observation of training and evidence of Greek, Roman and Arab medicine.(1,7). His main book, Cerrahiyyet’ul Haniyye (Imperial Surgery), has three chapters: treatment by cauterization, surgical interventions, and fractures and dislocations. This manuscript consists of 193 sections and 412 pages in subject of surgery including obstetric and gynecology, ophthalmology, general surgery, pediatric surgery, neurosurgery, thoracic, vascular surgery, orthopaedic and traumatology.(8) In addition, it contains pictures of 134 surgical interventions and 156 surgical instruments. The book was written in 1465, and the main point making this book unique is the inclusion of miniature illustrations that explain these treatment methods in detail in Turkish in the Anatolian medical literature (9). There are three original handwritten copies: two in Istanbul in the Fatih Millet Library and the Library of Medical History at the Department of Istanbul University and one in the Bibliotheque Nationale in Paris(10,11)..The 3rd chapter of Sabuncuoglu’s manuscript’s, which works deals with fractures and dislocations, includes a very detailed classification, definition, and treatment with miniature illustrations(1,2) Serefeddin Sabuncuoglu also described similar several techniques for shoulder dislocation in the 26th section of the 3rd chapter of his manuscript Cerrahiyyet’ul Haniyye with or without using tools from simple and complex. Sabuncuo?lu’s description resembles Hippocrates methods. One of the techniques he described was to pull the hand of the patient in a downward motion while the surgeon pushes toward the joint by placing both thumbs in the axillary region of the patient.(1,2)In Sabuncuoglu’s manuscript, there are also attempts to reduce the shoulder using plants with known muscle relaxant properties and the muscle relaxant effect of heat. In one of these techniques, a knob or ball is placed in the axillary region of the patient while the patient lies in the supine position. Then, as an assistant pulls down the hand of the dislocated side, the surgeon pushes the ball upward using the palm.(1,2)?erefeddin Sabuncuo?lu’s Miniature in Section 26, ?t shows the cloth to be placed on the arm and forearm region to stabilize the upper extremity.Sabuncuo?lu described three person, two person should be taller than the patient and one should be of a heavy than patient. In each side of wooden shaft, assistant elevated. The patient is elevated from the ground with a wooden shaft put into the axillary region of the upper extremity with cloth bandage and longitudinal traction by third assistant until it is reduced(1,2). Even though the wooden shaft is shown to be located on the elbow, it is probably used to keep the shoulder in the abduction position (See the Figure).DiscussionHistory medicine has progresive many years with different culture and civilisations for centuries.(12).And also,surgery history of develepment is old as much as humanity. Ancient Egypt, had specialist in field of medicine nearly 5000 years ago (13,14) The history of science has course from west and east assosiated with establisment of educational instutions as a schools and hospitals. (15).On each of the Aegean Sea, in builting temple priest-physicians healed in name of god, Ascepius in ancient Greece. Heybeli. Hippocrates, was born on island of Cos, the father of modern medicine who lived between 460 B.C. and 377 B.C. All of around each civilisations were affected by Hippocrates. (15). Galen (AD 129-210),Greek physician borned in Pergamon,West Anatolia (now ?zmir, Turkey), dominated his medical knowledge and practice in Pergamon School during Roman Empire.(16).His works and theories were written manuscripts and followers had translated from Greek in Arabic.(16). Paul Aegineta(AD 625-690) was the last major ancient medical encyclopedist, a Greek physician influenced in his own era and also such as Rhazes, Haly Abbas, Albucasis, Avicenna.(17,18). The Greek and Roman civilization were promoted that several contributions to humanity in the field of science, philosophy and medicine. After the Roman Empire fell in AD 476, cultural and scientific developments regressed in Western science in Medieval Age. Many textbook refers the Dark Age in which any significant scientific evolvement through the fall of the Roman Empire and beginning the European Renaissence from AD 500 to AD1500. Between ancient civilisation of Egypt, Greek, Rome, Persian, India and Renaissance period in Europe, as known ”the dark age”, Arab and Muslims kept alive knowledge of medicine. From 7th and 13th centuries, Islamic medicine, achieved with significant developments , later affected medical education and practice in Europe The nomenclature, the golden age” refers Islamic civilizations, science was actively involved by many scientist. (3,14,15). Cause of the golden age was that Muslims followed the guidelines of Prophet working and searching for knowledge, communication improved since the empire United extensive geographic areas with Arabic language happened connective factor, and people travelled to teach,learn and share ideas. The other reasons was many source of Greek, Latin and Chinese translations into Arabic during that time. (15)During the Golden Age of Islam, Arab autors translated textbook and medicine book from Greek and Latin into Arabic langauge..(3). After 9th centuries, Muslims who influenced by Greek, Roman, ?ndian, Chinese and Persian, progressed astonishly to experienced in various fields of medicine. Al-Razi (Rhazes, 854-925 AD?) has medical works collected in Kitab al-Hawi fi al-tibb (The Comprehensive Book on Medicine). The medicine encyclopedia Al Tasrif wrote by Ebu al Kas?m Al Zahrawi (Abulcasis,AD 936-1013) and and Al-Qanun fi’t Tibb (The Canon of Medicine) wrote by Ibn-i Sina(Avicenna, 981-1037 AD). Their masterpiece were accepted as the most significant medical books until the European Renaissance.(19,20,21) In Medieval Age, major surgical medicine reference source were books of Hippocrates, Galen, Avicenna and Albucasis.In ?slamic medicine, surgical education base on not only carefull observation, experience and taught in master-apprentice but also worked in the hospital in medieval age, Ottomans physicians followed Islamic medicine. (15,22).Sabuncuoglu’s Cerrahiyyet’ul Haniyye was translated from Abuclasis’s Al-Tasrif (Textbook of Surgery) as a main book,which was one of the important source dominance European, Arabic, Persian schools until Renaissence. it was claimed that not only translated from Abulcasis’s Al-Tasrif. Despite of some similarities, there are 137 different observations, ,recommedations and detailed colored miniatures in Serefeddin Sabuncuoglu’s manuscript. (2,21,23). Moreover, surgical techniques and colored pictures or miniatures containing the position of patients and physicians were added by Sabuncuoglu himself. in other word, Sabuncuoglu contributed to Greek, Roman, Arabic And Turkish medicine inheritage. Moreover, a combination of all Greek, Roman, and Arabic medical knowledge and Turkish surgery techniques is important for contribute and original remarks in his book. (1,24)Further, his book was the first illustrated, Turkish-written, surgical textbook in Anatolian medicine.(10,14,23,24) Sabuncuoglu was a master of Turkish, his mother language. Although he knew Arabic, Greek, and Persian, he consciously wrote his book in Turkish because most physicians and majority of the Anatolian public spoke Turkish at that time. Serefeddin Sabuncuoglu states in Cerrahiyyetul Haniye ; ”i wrote this book Turkish. The reason is that people of Anatolia speak Turkish and majority of physicians of our time are illiterate. Those who are literate, can only read Turkish.(1)And also, he translated and wrote into Turkish for followers who did not know Arabic, Persian and Latin, to prevent medical fault and wrong on patient. The other reason was that medical books were commonly written in other languages; thus, the public of Anatolia was deprived of this knowledge in his era. Conclusion One of the most important aspects in the book of Serefeddin Sabuncuoglu was the detailed explanations of surgeries and medical practice and the illustrations of those with miniatures. Most of these illustrations show the position of the surgeon and the patient and also include the instruments or tools and technique used during surgery in detail. It has a similar approach to modern medical writings in terms of the detailed writing, classification, and illustration of the techniques. Therefore, it could be one of the earliest written colored illustrated scientific content in Middle Age.Another distinctive feature in Sabuncuoglu’s manuscript is the drawing of human pictures and figures, which were not found in previous Islamic medical manuscripts such as Al-Tasrif and Canon of Medicine during that era. This absence of illustrations in previous manuscripts can be explained by the Islamic ban on paintings human figures and illustrations. Along with the Renaissance period, detailed pictures, illustrations, and drawing instead of miniatures. Serefeddin Sabuncuoglu described their treatments in detail, illustrated with colored miniatures. It is also possible, he made a trailblazing contribution to field of surgical at that time, influencing the resurgence of paintings and illustrations in medical manuscripts and articles in Europe that rise up with the Renaissance period and continued throughout the Age of Enlightenment. Also, combining to knowledge Greek, Roman, Arabic Turkish with original contribution physician Serefeddin Sabuncuoglu is common heritage in the surgical history .References1. Uzel ?, Cerrahiyetü’l Haniyye, 1 st Ed. Ankara: Türk Tarih Kurumu Yayinlari,1992.2. Sarban S, Aksoy S, Uzel, I, Iskan, U. E., & Atik, S. (2005). Orthopaedic Techniques of Sabuncuoglu in the 15th Century Ottoman Period. Clin Orthop Relat Res 2005; 439, 253-259.3. Turgut, M. Illustrations of neurosurgical techniques in early period of Ottoman Empire by ?erefeddin Sabuncuo?lu. Acta neurochirurgica 2007; 149(10), 1063-1069.4. Kaya SO, Karatepe M, Tok T, Onem G, Dursunoglu N, Goksin I. Were pneumothorax and its management known in 15th-century anatolia?. Texas Heart Institute Journal 2009; 36(2), 152-153.5. Elcioglu O, Ozden H, Guven G, Kabay S. Urinary bladder stone extraction and instruments compared in textbooks of Abul-Qasim Khalaf Ibn Abbas Alzahrawi (Albucasis)(930–1013) and Serefeddin Sabuncuoglu (1385–1470). Journal of endourology 2010; 24(9), 1463-1468.6. Turgut M. Pediatric neurosurgical techniques in the 15th century. Journal of Clinical Neuroscience 2008, 15(10), 1085-1090.7. Bat?rel, HF, Yüksel M. Thoracic surgery techniques of ?erefeddin Sabuncuo?lu in the fifteenth century. Ann Thorac Surg 1997; 63(2), 575-577.8. Bekraki, A,Gorkey S, Aktan, AÖ. Anal surgical techniques in early Ottoman period performed by ?erefeddin Sabuncuo?lu. World J Surg 2000; 24(1), 130-132.9. Naderi, S. Acar, F, Arda, MN. History of spinal disorders and Cerrahiyetül Haniye (Imperial Surgery) Historical vignette. J Neurosurg: Spine 2002; 96(3), 352-356. 10. Bademci, G. Batay, F,Sabuncuoglu H. First detailed description of axial traction techniques by Serefeddin Sabuncuoglu in the 15th century. European Spine Journal, 2005; 14(8), 810-812.11. Elmaci, I. Color illustrations and neurosurgical techniques of ?erefeddin Sabuncuo?lu in the 15th century. Neurosurgery 2000;47(4), 951-95512. Kafali, H, Aksoy S Atmaca F, San, I. Colored illustrations of obstetrics manipulations and instrumentation techniques of a Turkish surgeon Serafeddin Sabuncuoglu in the 15th century. Eur J Obstet Gynecol Reprod Biol 2002; 105(2), 197-202.13. Said GZ. Orthopaedic in the dawn of civilisation, practices in ancient Egypt. International Orthopaedics(SICOT) 2004. 38:905-909.14. San I, Oguz H, Kafali H. Colored illustrations of pediatric otorhinolaryngologic surgical techniques of a Turkish surgeon, Serefeddin Sabuncuoglu, in the 15th century. Int J Pediatr Otorhinolaryngol 2005; 69(7), 885-891.15. Heybeli, N. Sultan Bayezid II Külliyesi: One of the Earliest Medical Schools—Founded in 1488. Clin Orthop Relat Res 2009; 467(9), 2457-2463.16. Ajita, R. Galen and his contribution to anatomy: A Review. J of Evolution of Med and Dent Sci 2015;4(26), 4509-4516.17. Er U, Naderi S. Paulus aegineta: review of spine-related chapters in “Epitomoe medicoe libri septem”. Spine 2013; 38(8), 692-695.18. Gurunluoglu R, Gurunluoglu A. Paul of Aegina: landmark in surgical progress. World J Surg 2003; 27(1), 18-25.19. Afshar, A. Concepts of orthopedic disorders in Avicenna’s Canon of Medicine. Arch Iran Med 2011; 14(2), 157-159.20. Kahya, E. ?bni Sina El-Kanun fi’t-T?bb (Birinci Kitap) (in Turkish). Ankara: Atatürk Kültür Dil ve Tarih Kurumu Press,1995:103.21. Aygen, G, Karasu, A, Ofluoglu AE, Pait, G. Toplamaoglu, H. The first Anatolian contribution to treatment of sciatica by Serefeddin Sabuncuoglu in the 15th century. Surgical neurology 2009; 71(1), 130-133.22. Majeed, A. How Islam changed medicine. BMJ 2005; 2005;24;331:1486-1487. 23. Sabuncuoglu O, Ekinci O. Comment on the Cover. Clin Infect Dis 2008; 47(1), 146-146.24. Oguz, H, San I, Verit A, Uzel I. Ophthalmic techniques described by ?erefeddin Sabuncuo?lu (1385? 1468 ad). Clin Experiment Ophthalmol 2004; 32(2), 192-195. Figure 1. This illustrated by Serefeddin Sabuncuoglu in the miniature; the following is shown; the senior surgeon associate with three additional contributors (assistants) carrying the long wooden shaft and elevated the ground. The assistant applied longitudinal traction for reduction. (Reprinted with permission from Prof. Dr. Ilter Uzel. Copyright T.C. Ataturk Kultur, Dil ve Tarih Yuksek Kurumu. Turk Tarih Kurumu Baskanl??? Ankara, Turkey).