EXPERIMENTAL AND CLINICAL TRANSPLANTATION

The objective of the study is to discuss the question, “how did physicians come to grasp some facts in the absence of scientific experimentation and medical technology?” within the framework of examples from Ahı? Ahmed Çelebi’s fifteenth century Turkish treatise on the urinary calculus. Çelebi’s monograph on the urinary calculus in the kidneys and the bladder written in Turkish in Arabic alphabet is transliterated and studied within the framework of the medical theory of the period. The sample information for this study was randomly chosen. Examples of epidemiological information, diets against urinary calculus formation, diagnoses of kidney and urinary bladder calculi, and symptomatic therapies noted in Çelebi’s treatise are discussed, with results briefly compared with today’s data. The study of Çelebi’s treatise shows that it was possible to reach some medical facts with the methods of the period.

Key words : Ahı? A?med Çelebi, Bladder, Kidney, Turkish medical history

Major questions in medical history are, “who in history gave the first accurate medical information on a particular subject?” and “who was the first in history to perform a particular medical practice?”

In this study, the questions are “how did physicians come to grasp some facts in the absence of scientific research and medical technology?” and “how is it that some physicians in history have reached some medical facts without modern methods and tools?” The answers to these questions will be discussed within the framework of examples from Ahi Çelebi’s fifteenth century Turkish manuscript on urinary calculus.

The methods of obtaining information that might have been used in Çelebi’s era could be medical history taking, observation, physical examination, uroscopy, reasoning and analogy, classification, and discussion. Were these methods of acquiring information sufficient to reach some of the facts noted in the treatise that we can attain with advanced technology today? By searching similarities between information on urinary stones written by Çelebi 535 years ago and contemporary knowledge, the possibility of accessing some facts with the methods of Çelebi’s period will be discussed.

Materials and Methods

Ahi Ahmed Çelebi’s monograph titled “Treatise on the Urinary Calculus in the Kidneys and the Bladder” (Risaletü'l kilyeteyn ve'l-mesane or Risale-i hasatü'l kilye ve'l-mesane) dated 1487/1488 is the source of this research. The manuscript, written in Turkish in Arabic alphabet and registered as number 1491 in the Bağdatli Vehbi Efendi section of the Süleymaniye Library, was transliterated and studied.

The 180-page treatise is divided into 10 chapters. Chapters were read, and the factual information about the formation and treatment of kidney and bladder stones was randomly selected. The selected infor-mation was briefly associated with today’s literature.

Çelebi’s way of acquiring knowledge can be shown in his own statement: “I served in the hospital, consulted with the master doctors of the time, and learned the laws of medicine and medical practice. I took some of what I heard and what I experienced and wrote them down.” Thus, knowledge gained from Çelebi’s personal experience and his colleagues forms the basis of the information in his treatise.

The drawing of lessons from experiences among Ottoman medical practitioners was a common way of acquiring knowledge. Information claimed to have been experienced was to be trusted. Confidence in experience was emphasized with the expression “mücerrebdir.”¹ Knowledge derived from experience is empiricism. Is it possible to talk about “clinical objectivity” on behalf of empirical medical practice?

Epidemiological information

Foremost epidemiological information in Çelebi’s treatise draws attention. Epidemiology deals with the incidence and distribution of disease in a population. Epidemiological knowledge is observational, expe-riential, and retrospective. However, statistics are required for precise epidemiologic analysis. Because there was no idea of statistics in Çelebi’s day, can we talk about the objectivity of the epidemiological information in his treatise? Let’s take a look at the following examples.

For the first example, Ahi Çelebi states, “I wrote about the stone formed in the kidney and bladder because this ailment is very common in people. It is most common especially among the wealthy and the powerful, for abundance and prosperity are ample in these classes… They eat and drink too much… Urinary calculus formation occurs mostly in obese individuals.” Present studies report causal relations of metabolic syndrome and/or central obesity with kidney stone formation.²

As the second example, “Calculi are rarely formed in the urinary bladder of women, because of the female anatomy of the urinary tract.” Modern studies have shown that, in adults, there was higher prevalence of bladder stones in males (15.2%) than in females (2.1%), a ratio of 7.2:1. The presence of kidney stones in women is about half that in men.^3,4

For the third example, Ahi Çelebi also states, “Vesical calculus formation is higher in boys misfed until adolescence.” A recent study puts forth that “vesical calculi are commonly seen in developing countries in pediatric age group patients belonging to poor economic status.”⁵

As the final example, Ahi Çelebi states, “If animal or breast milk is of the bilious humor, the density causes calculus formation in boys. If the nature of milk is of the phlegm humor, the boy’s urine will be denser. The accumulation of humor leads to the hotness of the urinary bladder inducing calculus formation.” Although the quality of milk is explained according to the humoral theory, recent studies discuss the effects of different types of milk and the amount of milk intake on formation of stones.⁶

Testing of theory by practice: Experience and Reasoning

In Çelebi’s time, practice relied on a priori reasoning. The day-to-day impressions of experiences were evaluated with reasoning to show why an experience was bound to operate in such a way. The humoral theory was used to explain the empirical data. Can the medical information explained by humoral pathology be expressed with today’s medical views? Let’s take a look at the etiology of calculus formation in the urinary tract according to Çelebi: “Any humor (blood, phlegm, yellow bile, black bile) that decomposes has a tendency for calculus formation. Decomposed humors remaining in the kidneys give rise to stasis and humidity occurs, causing calculus formation.” Present-day studies reveal that urinary stasis does promote stone formation, and humidity is a risk factor for urolithiasis.^3,7 Theories change, but the facts remain.

Diets against urinary calculus formation

Çelebi’s views on prophylaxis against urinary calculus formation can be grouped under 3 main headings: (1) avoid food and drinks causing urinary calculus formation, (2) change attitude and behavior, and (3) evacuate substances that cause formation of calculus. Similar advice is found in today’s publications.⁸

Çelebi establishes a relationship between nutrition and urolithiasis. According to Çelebi, food that may lead to calculus formation are beef meat, fat, lamb, lamb’s head, camel meat, trotter, big fish, big aquatic birds, roasts, kabobs, animal products, rice with milk, and multi-cooked eggs. Contemporary studies show that animal protein can increase risk for urinary stone formation. Some meat products are lower in fat and have less calories (eg, white meat is a leaner source of protein, with a lower fat content).^4,7 Ahi Çelebi, knowing nothing of animal protein, stated that “easily digestible food should be consumed to prevent stone formation, for example, chicken-young chicken, house sparrow, pigeon, partridge, swallow, francolin, sheep, goat, and rabbit.” The humoral theory of his time establishes a fundamental relationship between the digestion of nutrients and health.

Ahi Çelebi also specifies several foods and drinks that may lead to calculus formation: unleavened flour products, vermicelli, shredded wheat, starch pudding, raw fruit, bitter orange, pear, apple, garlic, onion, spinach, old and intense syrup, and turbid water. Do these ingredients increase risk for urolithiasis? There is evidence that some of them lead to calculus formation, whereas some need to be further researched.^4,7

Ahi Çelebi asserts that several fruits and vegetables, such as fig, red grape, celery, carrots, Swiss chard, mallow, peppermint, and common fennel, protect against calculus formation. These ingredients have an alkaline pH level. Ahi Çelebi knew nothing of it. Today, we know that the acidity and alkalinity of fruits and vegetables (their varieties, way of cooking, and processing methods) have an effect on stone build-up. Ahi Çelebi also provides cooking recipes that would help prevent stone formation. Contemporary studies show that some fruits and vegetables influence urinary pH, causing further crystallization and increased risk for various types of urinary stone formation. For example, an alkaline pH favors the crystallization of stones containing calcium and phosphate, whereas acidic urine pH promotes uric acid or cystine stones.⁹ In Ahi Çelebi’s time, there was no knowledge of pH (discovered in 1909), whereas various medicinal effects of vegetables and fruits could be defined by the accumulation of empirical findings.

Further preventive measures against urolithiasis mentioned by Ahi Çelebi include, “Avoidance of exercise after eating, taking bath or sexual intercourse after eating that would cause sweating, and sleeping on warm mattresses so that the kidney will not get hot.” Today, heat-induced sweating is discussed as a cause of stone formation, although based on a cause-effect relationship different from the humoral theory.^9-11

Ahi Çelebi also mentions fluid intake in relation to formation of urinary stones: “If water is drunk in the middle of the meal from time to time, or drunk on an empty stomach, stone will not occur in the kidney, but it is wrong to drink water all the time just because it’s a good measure, for various harm arise from the excess of good precaution. Today, it is suggested that, “uncomplicated stones can be managed conservatively with adequate fluid intake.”^4,8

Diagnosis of kidney calculi

In premodern Ottoman medicine, diagnoses were determined according to symptoms and signs of disease. In Ahi Çelebi’s time, these hints were accessible by patient anamnesis, physical examination, and uroscopy. He writes, “A continuous feeling of heaviness is felt around the kidney… Normal urine flowing intensely starts to flow weak.” There is frequent mention of urine inspection in a flask, as it was of great diagnostic relevance. To what degree could urinary tract diseases be detected in the visual examination of the urine bottle? For example, quantity, color, odor, and sediment of urine give important clues about urinary stones.¹²

Pain is an important sign of kidney stones, as Çelebi cites, “Especially when fecal matter collects in the intestines, pain increases. After defecation, pain ceases or pain is relieved… Sometimes there will be abdominal colic… Sometimes, testis pain or thigh numbness are signs of kidney calculus.”

Although Çelebi did not know about kidney infection in today’s sense, he evaluated some symptoms such as high fever and chills as distinguished signs about the nature of kidney disease: “There would be fever and chills because of calculus in an overheated kidney disorder.”

Ahi Çelebi also made claims of a differential diagnosis between kidney colic and abdominal pain: “Abdominal pain is felt around the umbilical, sometimes in the upper or lower region of the navel. But, usually renal pain tends to be on the back, radiating to the side and is local.” This reminds us that urolithiasis should always be considered in the differential diagnosis of abdominal pain.¹³

Diagnosis of urinary bladder calculi

Bladder stone symptoms and signs (painful urination, increased frequency of urination, and weak urine stream), as described below for a male patient by Çelebi, indicate that he carefully observed and followed his patients: “If there is pain and heaviness in the loins downward toward the thighs, it is evidence that the calculus has descended into the urinary tract. When the stone reaches the bladder neck, it becomes painful and prevents urination. Later, if pain alleviates, the stone has descended into the urinary bladder. When the stone is in the bladder, pain, heaviness, and itching appear at the base of the penis. Sometimes pain is felt in the groins. The patient frequently handles his groin involuntarily. A man who has a bladder calculus will feel numbness in his penis while walking. If one who has a bladder calculus runs, there would be pain at the base of the penis. While walking fast or jumping causes pain at the base of the penis, when the patient lies curled up there is relief of pain at the base of the penis… Most of those who have a calculus in their bladder have difficulty in urination and feels for urination again after urination. Sometimes the patient urinates abruptly and this happens often after urination. In these patients the urinary bladder calculus is large and tortuous. Big and heavy stone makes it difficult to defecate. Sometimes it causes rectal prolapse.” These definitions also indicate that a differential diagnosis could be made between kidney and bladder stones.

Determining a remedy

In the time of Ahi Çelebi, treatment was tested by trial and error. Trial and error was useful but unverifiable. The frequent recovery of some and the death of others distinguished between the beneficial and the harmful effect of a medicine.¹⁴ Thus, in Çelebi’s time, there were no accurate tests of cure. However, judging the value of the treatment seems to have been highly successful. Çelebi recommended inorganic drugs (both metallic and nonmetallic minerals, fossilized organic substances) having active ingredients (ie, Lapis Judaicus) to prevent certain kidney stones. Randomized and double-blind clinical trials have put forth the safety and calcium kidney stone dissolving efficacy of Lapis Judaicus.¹⁵ The lithotriptic effects of several substances recorded in Çelebi’s treatise are the subject of research.

Drugs that provide symptomatic relief were valued in Ottoman medicine. Several formulas are prescribed in Çelebi’s treatise for the treatment of pain, inflammation (pus), fever, and bleeding. Could Çelebi’s medicine really relieve symptoms of vesical calculus obstruction and urinary tract infections? Various prescriptions are advised for the treatment of urinary tract infections and pain. Analgesics, sedatives, tranquilizers, soporifics, and drugs having antiseptic, anti-inflammatory, styptic, antipyretic, antispasmodic, and diuretic effects were prescribed (eg, opium, mandrake, lettuce seeds, sandalwood, pine, limestone, terra sigillata in sealed clay tablets, dragon’s blood resin, cannabis sativa, rose water).¹⁶

Ahi Çelebi’s treatise showed that it was possible to reach some facts in history through gaining experience by means of adequate medical observation, medical history taking, and physical examination in clinical practice. Although reasoning through simple observation is rarely efficient at advancing medical knowledge, a master physician like Ahi Çelebi was able to arrive at some facts from personal experiences and experiences of his colleagues as well as taking advantage of previous medical literature.

On the occasion of this study, I would like to draw attention to the rapidly developing diagnostic technology taking the place of medical history taking and physical examination. Relying mainly on laboratory and imaging techniques is insufficient in revealing the clinical picture. A medical education that enhances observing the signs and symptoms of disease, gaining clinical experience, and including reasoning should be encouraged and developed.

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

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